Unawarded Health Insurance Bids • Aick Fds
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POSTING
of
CITY OF OKEECHOBEE
HEALTH AND LIFE INSURANCE BID
FIN 02-32-06-01R
Date and time of posting: 7-27-01 2:30 P.M. By: BC
Three day period ends: 8-1-01 (&, 2:30 P M. By:
NOTE: Failure to file a protest within the time prescribed in s. 120.53(5), Florida Statutes, shall constitute
a waiver of proceedings under chapter 120, Florida Statutes. Offers from the vendors listed herein are the
only offers received timely as of the above opening date and time. All other offers submitted in response to
this solicitation, if any, are hereby rejected as late.,
TABULATION SHEET
FOR
INSURANCE PROPOSAL
FIN 02-32-06-01 (RE-BID)
Vendor/Policy Arthur J. Gallagher& Florida Health Care Sigma Group Insurance
Company Plans Solutions
Insurer Public Risk Management Same Same Blue Cross/Blue Shield
Preferred Provider Option(PPO)High
Deductible:
Calendar Year$100.00 (3 per family aggregate)
Per Admission $100.00 (Non PPC Hospital Only)
Employee Only $356.23 No Bid No Bid No Bid
Employee and Spouse $744.59 No Bid No Bid No Bid
Employee and Child $694.32 No Bid No Bid No Bid
Employee and Family $1,082.81 No Bid No Bid No Bid
Preferred Provider Option(PPO)Low
Deductible:
Calendar Year$500.00 ( 3 per family-aggregate)
Per Admission$500.00 (Non PPC Hospital Only)
Employee Only $317.91 No Bid No Bid No Bid
Employee and Spouse $658.42 No Bid No Bid No Bid
Employee and Child $614.35 No Bid No Bid No Bid
Employee and Family $954.97 No Bid No Bid No Bid
Preferred Provider Option (PPO)Traditional
Deductible:
Calendar Year $300.00
Hospital $300.00
Employee Only No Bid No Bid No Bid $378.99
Employee and Spouse No Bid No Bid No B id $741.04
Employee and Child No Bid No Bid No Bid $668.09
Employee and Family No Bid No Bid No Bid $1,030.31
Health Maintenance Organization Option Blue Care (HMO)
Employee Only $313.53 No Bid No Bid $250.35
Employee and Spouse $608.70 No Bid No Bid $516.06
Employee and Child $570.50 No Bid No Bid $457.93
Employee and Family $865.80 No Bid No Bid $723.64
.00% tegaotillEI\ 4151P,,
.1500 tolvi
.........................
CITY OF OKEECHOBEE - INVITATION TO BID
HEALTHAN - INSURANCE
Sealed PROPOSAL/BID(S) will be received by the City of Okeechobee,
General Services Office, City Hall, 55 SE 3rd Avenue, Rm 101 ,
Okeechobee, FL 34974, (863) 763-3372 until 3:00 pm on Monday, July..
201g0 at which time they will be publicly opened and read aloud. Any
PROPOSAUBID(S) received after the time specified will not be accepted.
Facsimile or e-mail PROPOSAUBID(S) will not be accepted.
PROPOSAUBID(S) may not be revoked after PROPOSAL/BID opening.
HEALTI-LAFE INSURANCE
FIN 02-32-06-01 (Re-Bid)
A complete set of this proposal/bid may be obtained from the Finance
Department, Rm 102, during normal office hours, Mon-Fri, 8:00 am to 4:30
pm.
The City of Okeechobee reserves the right to accept or reject any or all
PROPOSAUBID(S), with or without cause, to waive any technical errors or
informalities, or to accept the proposal/bid(s) deemed most advantageous
to the City.
Bill L. Veach, City Administrator
City of Okeechobee, Florida
•
II 11111
P 41.11 M MME!
11411 .N1A11.1(
POSTING
of
CITY OF OKEECHOBEE
HEALTH AND LIFE INSURANCE BID
FIN 02-32-06-01
Date and time of posting: 7-09-01 (&,4:00 P.M. By: LG
Three day period ends: 7-11-01 (a, 4:00 P M. By:
ALL BIDS WERE REJECTED. ITEM WILL BE RE-BID.
NOTE: Failure to file a protest within the time prescribed in s. 120.53(5), Florida Statutes, shall constitute
a waiver of proceedings under chapter 120, Florida Statutes. Offers from the vendors listed herein are the
only offers received timely as of the above opening date and time. All other offers submitted in response to
this solicitation, if any, are hereby rejected as late.,
ei"
GROUP INSURANCE
46 ee#e4, ate.
July 10, 2001
Ms Lola Parker
City of Okeechobee
55 SE 3rd Ave
Okeechobee FL 34972
Dear Ms Parker,
Enclosed is the comparison of the City's present Blue Cross plan and a Dual
Option renewal alternate.
The Employer cost illustration assumes that the City pays 100% of single
coverage and $70 per month toward the cost of dependent coverage. .
If you have any questions, please call.
Thank you.
. r.
I
Scott A Harris
18230 RIVER OAKS DRIVE • JUPITER,FL 33458 • PHONE 561-747-5636 • FAX 561-747-3524 • 800-972-0963
el
GROUP INSURANCE
Ggildatiek44, GtiIC
City of Okeechobee
August 1, 2001 Group Health Insurance
Blue Cross/ Blue Shield Renewal Comparison
Benefits Care Manager A16 HMO Bluecare 4 PPO Plan 107
Present Dual Option Renewal Alternate
HMO
Lifetime Maximum Unlimited Unlimited NA
Office Visit CoPay $ 5 $ 10 NA
Hospital CoPay $ 0 $ 10 NA
Emergency Room CoPay $ 25 $ 50 NA
Prescription CoPays $5 generic/ $10 name $5 gen/ $15 pref/ $30 non pref NA
Access to both plans all year? YES NO- insured selects HMO or PPO once a year
Traditional/PPO
Lifetime Maximum $ 1,000,000 NA $ 5,000,000
Calendar Year Deductible $ 300 NA $ 300
Hospital Deductible $ 300 NA $ 0
Co-Insurance 80 % NA 80 %par, 70 % non
Out of Pocket Limit $ 2,000 + deds on covered charges NA $ 1,500 +ded on coy charges
Prescription CoPays $5 generic/ $10 name NA $5 gen/ $15 pref/ $30 name
Rates Present Renewal HMO PPO
Employee Only (38) $ 230.10 $ 270.80 $ 250.35 $ 378.99
Employee/ Sp (8) 517.50 609.10 516.06 741.04
Employee/ Ch (9) 480.30 565.30 457.93 668.09
Family (4) 767.80 903.70 723.64 1,030.13
Annual Total (59) $ 243,338 $ 286,380 $ 247,891 $ 365,562
Total $ Change $ 43,042 $ 4,553 $ 122,224
Employer Cost $ 180,551 $ 209,366 $ 194,888 $ 285,965
Employer Cost$ Change $ 28,815 $ 14,337 $ 105,414
Employer Cost% Change 13.6 % 6.7 % 49.6 %
18230 RIVER OAKS DRIVE • JUPITER,FL 33458 • PHONE 561-747-5636 • FAX 561-747-3524 • 800-972-0963
:•. rf.
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CITY OF OKEECHOBEE - INVITATION TO BID
HEALTH AND LIFE INSURANCE
Sealed PROPOSAUBID(S) will be received by the City of Okeechobee,
General Services Office, City Hall, 55 SE 3rd Avenue, Rm 101 ,
Okeechobee, FL 34974, (863) 763-3372 until 3:00 pm on Monday, July 23,
2001 at which time they will be publicly opened and read aloud. Any
PROPOSAUBID(S) received after the time specified will not be accepted.
Facsimile or e-mail PROPOSAUBID(S) will not be accepted.
PROPOSAUBID(S) may not be revoked after PROPOSAUBID opening.
HEALTH AND LIFE INSURANCE
FIN 02-32-06-01 (Re-Bid)
A complete set of this proposal/bid may be obtained from the Finance
Department, Rm 102, during normal office hours, Mon-Fri, 8:00 am to 4:30
pm.
The City of Okeechobee reserves the right to accept or reject any or all
PROPOSAUBID(S), with or without cause, to waive any technical errors or
informalities, or to accept the proposal/bid(s) deemed most advantageous
to the City.
Bill L. Veach, City Administrator
City of Okeechobee, Florida
•
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facsimile
TRANSMITTAL
to: Independent Newspapers of Florida- Okeechobee News - Legal Ad Department
fax#: 1877-354-2424
from: City Clerk's Office 763-3372 ext. 215
re: Legal Advertisement - Invitation to Bid Health Insurance
date: May 17, 2002
pages: 2, including this sheet.
Please publish the following advertisement as a Legal on FRIDAY, MAY 24, 2002 Proof of
publication requested. Attached is our purchase requisition #11744:
INVITATION TO BID
HEALTH INSURANCE
FIN 01-00-05-02
Sealed PROPOSAUBID(S) will be received by the City of Okeechobee, General Services Office,
City Hall, 55 SE 3`d Avenue, Rm 101, Okeechobee, FL 34974, (863) 763-3372 until 3:00 pm on
Friday, July 5, 2002 at which time they will be publicly opened and read aloud. Any
PROPOSAUBID(S) received after the time specified will not be accepted. Facsimile or e-mail
PROPOSAL/BID(S) will not be accepted. PROPOSAUBID(S) may not be revoked after
PROPOSAL/BID opening.
HEALTH INSURANCE
FIN 01.00-02-02
A complete set of this proposal/bid may be obtained from the Finance Department, Rm 102, during
normal office hours, Mon-Fri, 8:00 am to 4:30 pm.
The City of Okeechobee reserves the right to accept or reject any or all PROPOSAUBID(S), with
or without cause, to waive any technical errors or informalities, or to accept the proposal/bid(s)
deemed most advantageous to the City.
Bill L. Veach, City Administrator
City of Okeechobee, Florida
G\y.\OF pKF‹c14
' 111!rk
; ,915*__ - City of Okeechobee
May 17, 2002
The City of Okeechobee would appreciate your assistance in
obtaining proposals for our Group health insurance . The ob-
jectives of the proposals are :
1 . To compare the cost and benefits of our current plan with
Plans that you represent . We would like to see if there would
be any way of saving any material premium expense with
comparable benefits .
2 . Not to place the City in any jeopardy of losing our present
insurance plan or increasing our present rate with Blue
Cross/ Blue Shield Insurance Co .
3 . Not to place in jeopardy any employee' s or dependent' s
current coverage with Blue Cross/ Blue Shield Insurance
Company, and to make sure that any Proposal that you might
Submit would include absolutely no loss of any Benefit for
any employee or their dependent due to a preexisting medical
condition.
4 . That current and future retired employees and their
dependents may stay on the plan. That current and future
retired Elected Officials that may leave office and their
dependents may stay on the plan.
5 . That the current and future retired City Attorney and their
dependents are eligible and may stay on the plan.
Enclosed are specifications of current insurance benefits, so
that you may submit a proposal with no lesser of a benefit
structure .
The City will not entertain any proposals from insurance carriers
who are not rated at least A+ or A++ by the A.M. Best Company. We
would appreciate receiving your proposals on or before Friday
July 5, 2002 at 3 : 00 P.M. .
Sincerely
Lola Parker
Account supervisor
55 S.E.Third Avenue•Okeechobee,Florida 34974-2932•(863)763-3372•Fax: (863)763-1686
HEALTH INSURANCE PROPOSAL MAINLING LIST MAY 17, 2002
1. CHPA ATTN: MAJORIE SILBERMAN
4152 WEST BLUE HERON BLVD, SUITE 226
RIVIERA BEACH, FL 334
2. MURRAY INSURANCE SERV. INC.
P.O. BOX 1417
OKEECHOBEE, FL 34973-1417
3. BERGER INSURANCE AGENCY
800 SOUTH PARROTT AVE
OKEECHOBEE, FL. 34974
4. SCOTT HARRIS, GROUP INS. SOLUTIONS
18230 RIVER OAK DRIVE
JUPITER, FL 33458
5. JOHN E. BURDESHAW INSURANCE
505 N.E. 4TH STREET
OKEECHOBEE, FL. 34972
6. DEAKINS-LAWRENCE INS. INC.
2020 SOUTH PARROTT AVE
OKEECHOBEE, FL. 34974
7. FARM BUREAU INS.
401 N.W. 4TH STREET
OKEECHOBEE, FL 34972
8. DAVID HESTER INS. AGENCY
204 N.E. 3RD STREET
OKEECHOBEE, FL. 34972
9. BRUCE HOMER INS. AGENCY
900 SOUTH PARROTT AVENUE
OKEECHOBEE, FL 34974
10. LAKE OKEECHOBEE INSURANCE
407 SOUTH PARROTT AVENUE
OKEECHOBEE, FL. 34974
11. PRITCHARDS & ASSOCIATES
3555 SOUTH 441
OKEECHOBEE, FL 34974
4'1
12. BILL LANE, FL HEALTH CHOICE PLAN
5300 WEST ATLANTIC AVENUE SUITE 302
DELRAY BEACH, FLORIDA 33484
13. MARC WEISS, ASSOCIATED FINANCIAL SERV. INC.
2699 STIRLING ROAD SUITE B 100
FT. LAUDERDALE, FL. 33312
14. AETNA HEALTH PLAN OF FLORIDA, INC.
4890 WEST KENNEDY BLVD SUITE 545
TAMPA, FL. 33609
15. CIGNA HEALTH CARE OF FL., INC.
COMPLIANCE & CONTRACT DEV.-C-38
HARTFORD, CT. 06152-1038 SP(
16. FLORIDA HEALTH CARE PLAN, INC. °+ vest)
P.O. BOX 9910 DAYTONA BEACH, FL. 32120 ( (e
17. BROWN & BROWN INSURANCE
P.O. BOX 1229 - -
TAMPA, FLORIDA 33601-1229
18. GARY LIVINGSTON
SENIOR ACCOUNT MANAGER
EOS/REVIEWCO 1240 MELISSA LANE
DAVIE, FLORIDA 3325
19. ON TARGET SOLUTIONS
ATTN: LYNN
182 COLLY WAY
NORTH LAUDERDALE, FL 33068
20. TRUST INSURANCE GROUP
5439 SW 148 PLACE
MIAMI, FL 33185-4029
21. ARTHUR J. GALLAGHER& CO.
1 BOCA PLACE SUITE 400E
2255 GLADES ROAD
BOCA RATON, FLORIDA 33431-7379
222 Mark Sittig (mailed out 6-25-02)
Membershiop Services Manager
c/o Florida Lueage of Cities , Inc .
P .O. Box 1757
Tallahassee , Florida 32302-1757
TABULATION SHEET EXHIBIT 3
for JUL 16 AGENDA
Health Insurance Proposal
FIN 01-00-05-02
Vendor/Policy Arthur J. Gallagher&Company Group Insurance Solutions
Insurer Public Risk Management Blue Cross/Blue Shield
Preferred Provider Option (PPO)High
Employee Only $545.55 $394.16
Employee and Spouse $1,162.30 $852.67
Employee and Child $1,082.45 $725.67
Employee and Family $1,699.39 $1184.18
Preferred Provider Option(PPO) Low
Employee Only $486.93 $367.89
Employee and Spouse $1,030.45 $795.88
Employee and Child $960.09 $672.27
Employee and Family _ $1,503.77 $1,100.26
Health Maintenance Organization Option Blue Care (HMO)
Basic High Low
Employee Only $485.80 $304.44 $297.09
Employee and Spouse $1,004.04 $658.00 $642.00
Employee and Child $936.95 $549.28 $536.45
Employee and Family $1,455.33 $902.80 $881.36
g;(1/6t/ i AetoiS 5439 SW 148`h Place
MIAMI, FL. 33185-4029
Correspondents Lloyd's of London • Tel.:(305) 559-0545 • Fax:(305) 207-9684
August 11, 1997
ATTENTION: PURCHASING DEPARTMENT
RE: CHANGE OF OUR ADDRESS IN YOUR BIDDER'S LIST
Dear Sir/Madam :
We are included in your Bidder's List to quote for INSURANCE COVERAGES (ALL TYPES).
Kindly, update your records with our NEW ADDRESS AND TELEPHONE NUMBERS.
TRUST INSURANCE GROUP
5439 SW 148 Place
Miami, Fl. 33185-4029
Telephone: (305) 559-0545
Fax: (305) 207-9684
Please, send us confirmation of the receipt of this communication. Thank you very much.
Kind regards,
a(4) /
CARLOS R. RAFFO
President
�II
j II
TABULATION SHEET
for
Health Insurance Proposal
FIN 01-00-05-02
Vendor/Policy Arthur J. Gallagher& Company Group Insurance Solutions
Insurer Public Risk Management Blue Cross/Blue Shield
Preferred Provider Option (PPO) High
Employee Only $545.55 $394.16
Employee and Spouse $1,162.30 $852.67
Employee and Child $1,082.45 $725.67
Employee and Family $1,699.39 $1184.18
Preferred Provider Option (PPO) Low
Employee Only $486.93 $367.89
Employee and Spouse $1,030.45 $795.88
Employee and Child $960.09 $672.27
Employee and Family $1,503.77 $1,100.26
Health Maintenance Organization Option Blue Care (HMO)
Basic High Low
Employee Only $485.80 $304.44 $297.09
Employee and Spouse $1,004.04 $658.00 $642.00
Employee and Child $936.95 $549.28 $536.45
Employee and Family $1,455.33 $902.80 $881.36
POSTING
of
City of Okeechobee
Health Insurance Bid
FIN 01-00-05-02
Date and time of posting: 7-9-02 (a, 8:32 a.m. By: CA
Three day period ends: 7-12-02 (a, 8:32 a.m. By: W.-
Note: Failure to file a protest within the time prescribed in s. 120.53(5),Florida Statutes,shall
constitute a waiver of proceedings under chapter 120,Florida Statutes. Offers from the vendors
listed herein are the only offers received timely as of the above opening date and time. All other
offers submitted in response to this solicitation,if any,are hereby rejected as late.
BID TABULATION SHEET
BID # , TITLE „
ITEM NO. & DESCRIPTION
c
TOTAL OFFER
TERMS
DELIVERY
RECOMMEND AWARD
•
May 30 03 12:46p Scott Harris
elBlue Cross ElueShield
of Florida
OM CM.* .4 OS Mold 41eallso
5/29/7003
JAMES KIRK
CITY Or OKE ECHOBEE
55 SE 3RD AVE
OKEECHOBEE, FL 34974 -2903
561- 747 -3524 P.2
770 Notihpoint Parkway, Suite 200
West Palm Brach, FL 33407
Anoiventary Date: 5/1/2003
Group Number: 90206
Product: B1ueCare NFQ LG Grp Plat► 4
wBlueCare Rs 5/15/30C
Dear JAMES KIRK:
Thank you fir being part of the one million plus Florida residents covered either by Blue Cross and Blue Shield of Florida, lac, or Health Options,
Inc. We Iook forward to continuing to provide your business with quality health cans coverage.
We have reviewed the futons that affect the cost of your group health benefits program. The new group rates noted op the enclosed documents ere
subject to Florida Department of Insurance approval and our policyholders will not be billed for these proposed rates until the Florida Department of
Insurance has issued approval.
Employee Only Emnleygj(raiNaae EmPloyes/glildfran) F.neoloyes/Fam0v
HMO 341.16 750.35 627.40 1030.79
The rates sasume that your group tree set qualify as a Small Group according to Section 627 .6699, Florida !tanned. In the event that your group
hen 50 or fewer eligible employers, (employees who worst 25 hours or molt per week), please contact our office immediately.
To continue group health benefits and to provide for smootb flow of claims proesadig for your eovcrsd employees and their covered
dependetta without intertvptton, please (1) complete and age an Enrollment Summary; (2) provide a topy e4 your'most recent Employer's
Quarterly Tax Report (UCT4] or IRS ton documentation appropriate to your bualam type. This may Include an IRS schedule C, 1120,
11105 aed K -1's, or 1065 and K -1's; then (3) return all of the above Information requested fa tilts notice by the 15th of the mend+ prior to
your regt val date.
sot return eh
• ..1.
aced bashes*
• I 1.141:
ntatlon rt
J.2
anal
s our cove
{
d as
of your scheduled ar! tsr dais. ,
If you decide to change to another plan design instead of the one shown above, a new True Group Application must be aignod and returned 15 days
prior to your anniversary date in order to assure a smooth transition.
Under the Health Insurance Portability and Accountability Act (i:iIPAA) your group is required to hold an annual open enrollment, Your group's
open enrollment period will begin 30 days prior to your anniversary date. Eligible employees and their eligible dependents who have satisfied their
waiting period can now enroll for coverage.
We would like to advise you that we can make available to you the following additional products:
Dental Voluntary • Life, STD, LTD
Short Term Disability Premium Conversion plan (Sec. 125)
Ling Term Disability Flexible Spending Accounts (FSAs)
Basic Life 4011(
meek you for the opportunity to save you and your employees. We value your company's business and look forward to working with you in the
future.
Sincerely,
Blue Croat Blue Shield of Plotida
LINDA C LOWERS
Account Repmeatativs
Cc. GROUP INSURANCE SOLUTIONS INC - 0714
561- 747 -5636 561 - 147-3534
1'd
1Sd 013IHS 3f11H SSOhD 3f119 WtiOP :60 E0. 0E .ltil•JJI.GIua
May 30 03 12:46p Scott Harris
561- 747 -3524 P.3
1;31tr+ u= 7that9hield
- of Florida
OP`s' ENROLLMENT SUMMARY
• R ' i• COMPLIANCE (CTRF_CTC APpitOFR1ATR BMA
11 Our company employed 20 or more full and/or part -time employees* during the previous calendar year and is subject to federal COBRA. All full
and part -time common law employees of en employer are considered in drtsrmining COBRA compliance. All full time ranployees are counted is
one employee and each part-time employee is counted as a fraction of an employee.
0 Our company employed fewer than 20 full andtor part -time employees* eluting tbepreviou3 calendar year and is subject to the Florida Health
Insurance Coverage Continuation Act ( °FHICCA "). All full and parr -time common law employees of an employer are considered in determining •
COBRA compliance. All full time eTOployam are counted as ooe employee and each pats -lino employee is counted oa a fraction of an employe.
"'For COBRA and FHICCA purposes, self- employed individuals, independent contractors and non - employee directors are not counted.
SECONDA ' V , p MPLT N . . , AhIPRO
ljou ars a s e employer plea:
❑Yea IIU No Our company employed 20 or more employees** eadt woridng day in 20 or more calendar weeks (does not have to be consecutive
weeks) doting the currant or preceding calendar year.
ryas are a Via employer, esadt4pls emptoysr or a seeki- ewrploysr plant:
❑ jies No Our company employed 100 or mare employees" on 50 percent or more elks business days du ring the preceding calendar year.
f II ore a Araltiph employer or a idid:11- employer playa;
Yee ❑ Ne Ali employer im ovr Grasp Health Plan (GHP) employed 20 or more etoployeuts ** for 20 or more consecutive weeks in either the
current or preceding calendar year.
❑ Yes ❑ No M least one of the employers in our GHP employ d 20 or more employees ** for 20 or more consecutive weeks in either the current
or preceding calendar year.
❑ Yes 0 No All employers in our GHP employed fewer than 20 employees *"' for 20 or more consecutive weeks in either the
current or preceding calcmder year.
* "Ion byeea" includes all full and/or part time a lo ma -_
It is important for the employer to have each employee who chooses not to participate, complete the refusal portion of the
appltcatloa anal returns use rerusar Inrm as parr oz tine srnpaoyee-a moral. tame separate Dmeee or paper u ncerevatrlr
1. Group Name CITY OF OKEECHOBEE
2. Group Number 90206
3. Group Sales Rep/Agent LINDA C LOWERS (S14)
4. Effective Date 06/01!2003 •
5. . .lo Contribution Toward E . • .lo -es Premium must be at least 50% for 1 -50 75% for 5l+
1. TOTAL EMPLOYEES ON PAYROLL I
T A. otal Part Time mp1oyeeN
B. Total New EmploysaM Sin Waiting Period)
C Total EtmpIo se(s) Not Actively At Work
l
FA
2. TOTAL INELIGIBLE EMPLOYEES (A THROUGH C)
S. TOTAL ELIGIBLE EMPLOYEES (l Minus 2) (DETERMINES GROUP SIZE & PRODUCT)
D. T o t a l Employee. wfdr O t h e r C o v e r a g e t. 4-i, rY 4 f' , 'hr I v y v 5 1 H14-6t Ak id
4. TOTAL !LIG= FOR PARIIQPATIONL Minus D) ki
E. Total Refusals
F. Total Absentee
,,,..el
5. TOTAL ENROLLED �l IQ
6. EMPLOYEE PART1CPATION (3 divided by 4) (75% IS REQULRED)
/ -- el `L
—,
It is important for the employer to have each employee who chooses not to participate, complete the refusal portion of the
appltcatloa anal returns use rerusar Inrm as parr oz tine srnpaoyee-a moral. tame separate Dmeee or paper u ncerevatrlr
EMPLOYEE NAME
REASON CODE
i through El
EMPLOYEE NAME
REASON CODE
(A through F2
fk- N'(s'c i< Jt- Nevi A•1e/
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7
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7423 541(Rsv 0x01)
E 'c
Title
Data
Ow does and ague Willa et Ronda, Inc anti Me1eh Orions, Inc. it IfgWordant Owlets oltA. olua Cross erne elut &lipid Aeeodeeen.
lSd Q13IHS 3(118 SS02O 3(1-18 Wd0P:60 E0. 06 k W
May 30 03 12:58p Scott Harris
•
561- 747 -3524 p.2
In witness whereof, Companies and agent have caused this agreement to be executed by their duty
authorized representatives as of the date set forth below,
Slue Cross and Blue Shield of Florida, Inc.
William W, Sharrett, Jr., Vice President, Sales and Sales Management
Blue Cross and Blue Shield of Florida, Inc.
Florida Ccnibined Life Insurance Company, Inc.
By
Randy Simmons, vice President
Florida Combined Life Insurance, Inc.
Health Options, Inc.
ay:
44441444(
William W. Sharrett, Jr.. Vice President, Sales and Sales Management
Agent
By;
Name:
Title:
SC tja r✓e'j
l�.9..D
Sf 3J3 3
Data
Appointed Representative(s) Date
Printed Name(s)
Apr Argeseht - owwr
Representative Code(s)
Rev. 09-27-02
E•d lSd O13IHS 3118 SS0213 3018 WEE:OI EO4 OE AdW
- UCConfirmation
Page 1 of 4
State of Florida
Wartment of Revenue
Unemployment Compensation - Click for HELP
CITY OF OKEECHOBEE
Employer's Quarterly Report (UCT -6)
Confirmation Number is: 20030505160294
DATE: 5 /5/2003 TIME: 17:14:21
Please Print this Page for Your Records.
Quarter Ending
Due Date
Penalty After Date
Account Number
March 31, 2003
April 01, 2003
April 30, 2003
9975445
1st Month Number
57
Tax Rate
.0000
2nd Month Number
56
F.E.I. Number
596000393
3rd Month Number
57
SSN
Last Name
First
MI
Gross Wages
559-99-7222
ARNOLD
C
$ 6206.26
161 -34 -5424
BAUGH
J
$ 9806.03
083 -40 -2017
BERMUDEZ
0
M
$ 11587.55
364-13-9564
BERRY
A
$ 5549.66
592 -78 -8971
BOURGAULT
K
D
$ 8743.96
267 -53 -1499
BROCK
R
L
$ 6206.23
266 -79 -0684
CALE
R
E
$ 8015.16
263 -65 -8841
CARLTON
W
D
$ 6117.53
263-39-0337
CHRISTOPHER
N
S
$ 6073.73
265-33-7713
CONROY
P
$ 7496.78
262-33-3117
DAVIS
D
$ 11690.77
262 -04 -6299
DOUGLAS
W
$ 10553.03
266 -90 -7056
FISHER
A
$ 7665.06
t+�-- ^•din ,i. >>n i- a net /(r,ltimf7rlitva7wC7cym1 dak551/UCConfirmation.aspx
5/5/03
UCConfirmation
Page 2 of 4
261-71-2388
FUSCO
J
J
$ 8273.03
595-44-9443
GAMIOTEA
S
L
$ 477.40
265-45-3882
GARCIA
T
$ 6073.73
266-49-0255
GOULD
C
R
$ 6143.81
262 -79 -0213
HAGAN
D
$ 9477.35
266-74-1064
HANCOCK
L
S
$ 1928.29
595-60-4604
HATHAWAY
R
C
$ 7853.57
267-83-7662
HICKMAN
W
W
$ 7589.75
589 -26 -4791
HILL
C
G
$ 8177.82
263-75-6669
HILL
W
H
$ 9290.99
264-37-8148
HODGES
G
$ 8692.21
592-88-9982
JONES
C
H
$ 2612.41
267-60-9677
LAMB
P
C
$ 7910.22
263-90-8529
LAN N I NG
D
L
$ 1 124.44
265 -65 -3304
LOWE
B
0
$ 8015.16
593-58-2157
MCCRARY
P
S
$ 5054.52
266 -92 -1305
MERRY
C
$ 8924.50
592-60-6671
MOBLEY
T
M
$ 6098.95
237 -19 -9844
PADGETT
D
B
$ 6108.77
261 -23 -7816
PARKER
L
B
$ 7944.67
224-17-1335
PETERSON
R
$ 10192.86
266-15-2149
RAULERSON
J
$ 10136.88
589 -40 -2468
REVELS
A
D
$ 1111.71
262 -88 -1661
REYNOLDS
D
V
$ 6073.73
325-50-3916
ROBARDS
M
J
$ 5389.53
266 -57 -1052
ROBERTS
M
L
$ 6073.73
420-66-4314
ROBERTSON
D
R
$ 10051.99
289-68-0053
ROBERTSON
P
M
$ 5924.67
hops: / /florida.uc. bswa.net/(pltjmfzpityszwgarn 1 dgk5 5 )/UCConfirmation.aspx 5/5/03
UCConfirmation
Page 3 of 4
262-53-5824
RUS
$ 0.00
262-81-0639
SANDERS
G
$ 8148.83
262.41.3828
SAUM
W
$ 8598.05
266.84.2401
SELF
F
$ 6108.76
594-18-7063
SHIREMAN
M
$ 8688.60
401-04-0798
SMITH
H
$ 10932.46
264-25-4162
SMITH
J
$ 9998.73
595-12-8911
SMITH
Z
J
$ 8276.38
595 -36 -6738
STOKES
B
$ 7434.68
184-42-1354
TARNER
T
$ 9340.89
261-23-8310
TAYLOR
B
$ 8663.95
306-42-8369
TOMEY
L
K
$ 11404.77
344-48-6873
VEACH
B
$ 14330.51
593-38-8367
VINSON
K
$ 2698.40
264-97-3321
WENDT
D
M
$ 8523.33
267-61-3917
WILBUR
D
$ 9921.88
593-54-6092
WILKERSON
P
J
$ 5793.72
265-49-1329
WILLIAMS
L
J
$ 6206.64
400-84-9965
WILLIAMS
V
$ 7796.24
266-67-3354
ZEIGLER
J
$ 9774.07
• Total Gross Wages Paid This Quarter
$451,079.33
• Wages Paid This Quarter in Excess of $7,000 per Employee This
Year. The excess amount is based on reports filed with UC.
Adjustment(s) will require contact with this agency.
$0.00
• Taxable Wages for this Quarter
$0.00
• Tax Due
$0.00
• Penalty Due
$0.00
5/5/03
https: // florida. uc.bswa.net /(pltjmfzpityszwggrnl dg(55)/UCConfiiniation.aspx
UCConfirmation
• Interest Due
• Total Amount Due to Florida U.C. Fund
(if less than $1.00 no payment necessary)
• Payment you have authorized
Please Print this Page for Your Records.
File Another Report ' LogOut
Maintained by Florida Department of Revenue
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$0.00
$0.00
https: / /florida.uc.bswa. net /(pltjmfzpityszwggrn1 dgk55)/UCConfirmation.aspx 5/5/03
UCConfirmation
Page 4 of 4
• Interest Due
$0.00
• Total Amount Due to Florida U.C. Fund
(if less than $1.00 no payment necessary)
$0.00
• Payment you have authorized
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File Another Report I LogOut
Maintained by Florida Department of Revenue
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HEALTH INSURANCE PROPOSAL MAINLING LIST +e'i /_ , 200
1. CHPA ATTN: MAJORIE SILBERMAN
4152 WEST BLUE HERON BLVD, SUITE 226
RIVIERA BEACH, FL 334
2. MURRAY INSURANCE SERV. INC.
P.O. BOX 1417
OKEECHOBEE, FL 34973 -1417
3. BERGER INSURANCE AGENCY
800 SOUTH PARROTT AVE
OKEECHOBEE, FL. 34974
4. SCOTT HARRIS, GROUP INS. SOLUTIONS
18230 RIVER OAK DRIVE
JUPITER, FL 33458
5. JOHN E. BURDESHAW INSURANCE
505 N.E. 4TH STREET
OKEECHOBEE, FL. 34972
6. DEAKINS — LAWRENCE INS. INC.
2020 SOUTH PARROTT AVE
OKEECHOBEE, FL. 34974
7. FARM BUREAU INS.
401 N.W. 4TH STREET
OKEECHOBEE, FL 34972
8. DAVID HESTER INS. AGENCY
204 N.E. 3RD STREET
OKEECHOBEE, FL. 34972
9. BRUCE HOMER INS. AGENCY
900 SOUTH PARROTT AVENUE
OKEECHOBEE, FL 34974
10. LAKE OKEECHOBEE INSURANCE
407 SOUTH PARROTT AVENUE
OKEECHOBEE, FL. 34974
11. PRITCHARDS & ASSOCIATES
3555 SOUTH 441
OKEECHOBEE, FL 34974
E/' D - O - 0y-
12. BILL LANE, FL HEALTH CHOICE PLAN
5300 WEST ATLANTIC AVENUE SUITE 302
DELRAY BEACH, FLORIDA 33484
13. MARC WEISS, ASSOCIATED FINANCIAL SERV. INC.
2699 STIRLING ROAD SUITE B 100
FT. LAUDERDALE, FL. 33312
14. AETNA HEALTH PLAN OF FLORIDA, INC.
4890 WEST KENNEDY BLVD SUITE 545
TAMPA, FL. 33609
15. CIGNA HEALTH CARE OF FL., INC.
COMPLIANCE & CONTRACT DEV. -C -38
HARTFORD, CT. 06152 -1038
5Pr
16. FLORIDA HEALTH CARE PLAN, INC. d° v,,d
P.O. BOX 9910 DAYTONA BEACH, FL. 32120 ()Kee
17. BROWN & BROWN INSURANCE
P.O. BOX 1229
TAMPA, FLORIDA 33601 -1229
18. GARY LIVINGSTON
SENIOR ACCOUNT MANAGER
EOS/REVIEWCO 1240 MELISSA LANE
DAVIE, FLORIDA 3325
19. ON TARGET SOLUTIONS
ATTN: LYNN
182 COLLY WAY
NORTH LAUDERDALE, FL 33068
20. TRUST INSURANCE GROUP
5439 SW 148 PLACE
MIAMI, FL 33185 -4029
21. ARTHUR J. GALLAGHER & CO.
1 BOCA PLACE SUITE 400E
2255 GLADES ROAD
BOCA RATON, FLORIDA 33431 -7379
22 Mark Sittig (mailed out 6- 25 -02)
Membershiop Services Manager
c/o Florida Lueage of Cities, Inc.
P.O. Box 1757
Tallahassee, Florida 32302 -1757
3,
JERRY CORZINE
HILB, ROGAL AND HAMILTON COMPANY
OF FORT MYERS
1614 COLONIAL BLVD
FT. MYERS, FLORIDA 33907
BILLY NELSON
309 US 27 SOUTH
LAKE PLACID, FL 33852
941 -939 -3813 HRH INS. FT. MYERS
FaX
513 F01/01 JUL 36 '9E 15:38
Hilb, Royal and Hamilton Company
of Fort Myers
1614 Colonial Boulevard
Fort Myers, Florida 33907
To: General Services From: Jerry Corzine
Phone* (941) 939 -1400
Fax* (941) 939 -3813
Company. Okeechobee Florida
Fax: 941 763 -1686 Pages including cover sheet: 1
Date: 7/5/98
Re: Placement on BID LIST for all Insurance Coverages
0 Comments:
Hilb , Rogal & Hamilton Co. is a National Insurance Broker with stock traded on
the N.Y. Exchange We have several agencies in Florida and have access to
very competitive Insurance Programs for Public Entities ,
Please place us on your bid list .
J ' Corzine
Vice President
If anv problems Pr n the receipt of this fax. please caII. This fax iiis confidential information intended
for the use of the •riduai or entity to which it is addressed. If you have received this in error lease
notify us and des" fiis fax. Thank vou.
FROM FAX- ON- DEMANG' MARKETING TO: 9,18637631686
New Medical Plan
Now Available!
$47.75 /month
Covers Entire Family
Save up to 80%
✓ Everyone `s Accepted (regardless of Medical History)
✓ Over 400,000 Providers Nationwide
✓ Doctors, Hospitals, Clinics, Chiropractors
✓ Prescription & Vision included
✓ Includes $2000 Accidental Injury
✓ Dental, Orthodontics Covered
✓ No Deductible
✓ Immediate Maternity coverage
✓ Available to Employer Groups
For More Information and Immediate Activation
Apply for your Card Today!
1 -866 -400 -7522
USA HEALTH BENEFITS
If you have received this fax in error and 'or would like to have your number
removed from our database , please call 832 -615 -1000
i
U60\. am; CAze
City of Okeechobee
March 27, 2003
The City of Okeechobee requests your assistance in obtaining proposals for our group health insurance.
The objectives of the proposals are as follows:
1. To compare the cost and benefits of our current plan with other plans that are represented by
your company. Our goal is to reduce material premium expense and maintain comparable
benefits.
2. To avoid jeopardizing our present coverage or increasing our current rate with Blue Cross /Blue
Shield Insurance Co.
3. To avoid jeopardizing our employees' or dependents' current coverage with Blue Cross /Blue
Shield Insurance Company. To make sure that any proposal that is submitted would include
absolutely no Toss of benefit for City employees or their dependents due to a pre- existing
medical condition.
4. That current and future retired employees and elected officials and their dependents may stay
on the plan.
5. That the current and future City Attorney and their dependents are eligible and may stay
on the plan.
Enclosed are specifications of the City's current insurance benefits. We request that your proposal
contain no lesser benefits than what the City currently has.
The City will not consider proposals from insurance carriers who are not rated at least A+ or A ++ by
the A.M. Best Company. We must receive proposals on or before Monday, June 2, 2003 by 3:00 P.M.
Sincerel
Lola Parker
Account Supervisor
55 S.E. Third Avenue • Okeechobee, Florida 34974 -2903 • (863) 763 -3372 • Fax: (863) 763 -1686
City ofOkeechobce Blue Cross Blue Shield Rate
Blue Care 111\10 Plan
111v10
Employee $ 297.09
Employee/ Spouse (142.00
Employee/ Ch 536.45
an►ily 881.36
Annual Total $ 288.3y3
City of Okeechobee blue Cross Blue Shield Benefit
I IMO Benefits/ Plan
1,il'ctin►e Maximum
1'('1' ()V Co Pay
Specialist OV Co Pay
1lospital Co Pay
1 ',n►ergency Room Co Pay
Prescription Drug Co Pays
Mail Order Prescriptions
Blue Care I'I<► !IMO 5
Unlimited
$ 10
It)
0
St)
5/1c/30
90 day's' 2 co p.► S
Grorap !Vurnt4T-
Group Name:
Paid Period:
Product:
Monitoring Report by rasa
nnnnr
CITY OF OKEECHOBEE
200208 Through 200302
HMO
Date: 03/26/2003
Contracts Capitation Hospital
Year/Mo Single Emp/Sp EmpICh Family Total Members Premium PCP Specialty Total Inpatient Outpatient Total Hospital Physician Other Pharmacy Dental TotaIFFS
Capitath
200208 0 0 0 0 0 0 60.00 6150.98 5719.44 $870.42 60.00 60.00 50.00 546.62 50.00 51,521.76 $0.00 52,438.
200209 48 10 7 1 66 93 524,154.21 - 5150.98 - 6553.58 - 5704.56 60.00 62249.55 52,249.55 5313.64 50.00 51,881.34 $0.00 53,739.
200210 48 9 9 1 87 100 524,775.23 5339.54 $1,246.20 51,585.74 519,099.25 53,785.11 522,884.36 66933.72 696681 56,395.75 50.00 638,766
200211 48 9 10 1 68 103 526,554.98 $320.90 5746.60 51,067.50 50.00 52,411.76 52,411.76 52,569.73 1102.12 $4,729.22 $0.00 510,880.
200212 47 9 9 1 66 98 525,690.00 $218.36 5703.50 5921.86 50.00 $338.12 1338.12 53,365.90 53,405.23 56,144.78 50.00 514,175.
200301 48 9 9 1 67 99 $26,044.82 5624.06 5412.10 51,036,16 50.00 511,608.23 511,608.23 54, 497.89 5680.96 56,020.63 50.00 523,843.
200302 47 9 9 1 66 98 525,450.64 5194.98 $701.90 $898.88 $12,321.97 58,807.82 521,129.79 511,255.03 51,176.46 $4,446.01 50.00 538,904,
Total: 286 55 53 6 400 591 5152,669.88 51, 697.84 53, 976.16 55, 674.00 531,421.22 329,200.59 $60,621.81 $28,962.53 $6,331.58 531,139.49 50.00 5132,749
Average: 41 6 8 1 57 84 $21,809.98 3242.55 5568.02 5810.57 34, 488.75 51,171.51 58,860.26 34,140.36 5904.51 34,448.50 50.00 518,964
1
"Contracts and Members do not reflect retroactive additions and terminations.
_`Experience Is reflective of both active and terminated members.
Contracts
monitoring rseport uy rata
Group Number: 90206
Group Name: CITY OF OKEECHOBEE
Paid Period: 200103 Through 200302
Product: NON -HMO
Capitation Hospital
Run Date. ag1?6/2003
Year/Mo Single Emp/Sp Emp/Ch Family Total Members Premium PCP Specialty Total Inpatient Outpatient Total Hospital Physklan Other Pharmacy Dental TotaIFFS
�
200103 43 8 9 4 64 92 521,888.40 51,860.07 $0.00 51,860.07 53,513.54 $6,065.11 59,578.65 5977.05 $339.73 $5,915.97 50.00 518,671.4
200104 42 8 9 4 63 91 521,658.30 5732.24 50.00 5732.24 59,333.92 53,091.64 $12,425.56 $4,351.04 5836.89 55,049.17 50.00 $23,394.9
200105 42 8 9 4 63 91 521,198.10 51,751.92 50.00 51,751.92 51,888.69 $1,216.27 53,104.96 52,589.13 5264.68 $4,062.52 50.00 511,773.2
200106 42 8 10 3 63 89 520,968.00 5703.14 50.00 $703.14 55,155.08 $2,333.43 57,488.51 $2,987.91 5664.88 53,547.36 50.00 515,391.8
200107 42 8 10 3 63 89 520,105.50 $681.84 50.00 5681.84 51,113.65 53,938.65 55,052.30 54,956.38 $433.62 55,520.00 50.00 $16,644.1
200108 46 7 8 3 64 87 525,341.52 5695.97 50.00 $695.97 $2,423.78 33,871.53 56,295.31 53,923.60 80.00 $6,690.43 50.00 $17,605.3
200109 47 7 7 3 64 86 $23,659.50 5625.67 50.00 5625.67 $2,611.97 512,237.50 814,849.47 55,561.46 3379.08 55,909.48 50.00 $27,325.1
200110 47 7 7 3 64 86 $23,365.00 5646.76 50.00 8646.76 54,068.23 51,749.89 55,818.12 517,715.80 $1,340.74 34,931.48 $0.00 $30.452.5
200111 50 7 7 3 67 89 523,635.80 5667.85 $0.00 $667.85 50.00 $3,290.17 $3,290.17 57,167.61 55,984.47 85,489.89 50.00 $22,599.5
200112 50 7 6 2 65 84 323,002.90 3623.04 $0.00 5623.04 834,765.75 52,123.89 536,889.64 35,059.17 $2,128.97 $5,571.20 50.00 $50,272.0
200201 49 7 5 2 63 81 $22,623.78 8539.22 50.00 $539.22 $27,500.64 55,213.55 $32,714.19 514,643.36 55,215.40 59,890.62 30,00 $63,002.;
200202 50 7 6 2 65 84 523,002.90 5565.29 $0.00 5565.29 35,722.00 $5,115.10 510,837.10 35,983.02 84,700.82 510,014.14 50,00 $32,100.:
200203 49 7 6 2 64 83 522,437.60 $584.32 50.00 5584.32 58,500.00 51,565.64 $10,065.64 $6,365.57 55,542.84 56,331.29 50.00 528,889.E
200204 49 7 6 2 64 83 522,732.10 5584.32 50.00 3584.32 $3,241.15 $9,498.91 512,740.06 59,043.79 52,837.43 $6,843.76 50.00 $32,049.:
200205 50 7 6 2 65. 84 522,732.10 5590.96 50.00 3590.96 33,712.50 '-5212.30" " ' 83,924.80 56,221.12 $2,214.83 57,189.96 $0.00 820,141.1
200206 52 7 5 2 66 84 $23,273.70 5624.16 50.00 $624.16 - 513,101.14 52,221.10 - 510,880.04 54,850.59 8250.00 58,015.68 $0.00 $2,860.:
200207 52 7 6 2 67 86 $23,520.80 $604.24 50.00 5604.24 $13,912.98 53,464.49 $17,377.47 511,488.80 $285.70 56,330.12 50.00 $36,086.:
200208 50 7 6 2 65 84 523,273.70 50.00 50.00 50.00 $1,264.92 32,096.66 33,361.57 $7,550.33 5706.52 $6,183.75 $0.00 517,802.'
200209 0 0 0 0 0 0 50.00 $1,188.56 $0.00 51,188,56 $635.19 570.01 5705.20 82,414.00 5817.01 $4,365.44 $0.00 59,490.:
200210 0 0 0 0 0 0 $0.00 - 5451.52 50.00 - 3451.52 $0.00 51,125.72 $1,125.72 51,456.69 50.00 •559.30 30.00 52,071.!
200211 0 0 0 0 0 0 50.00 50.00 $0.00 $0.00 50.00 53,6888.63 53,688.63 $788.14 50.00 50.00 50.00 $4,476.'
200212 0 0 0 0 0 0 $0.00 $0.00 50.00 50.00 $3,075.21 $73.04 53,148.25 $452.52 33,263.83 $0.00 30.00 36,864.'
1
*Contracts and Members do not reflect retroactive additions and terminations.
`Experience is reflective of both active and terminated members.
200302 0 0 0 0 0 0 $0.00 $0.00 $0.00 50.00 $0.00 $0.1.XJ $0.110 i[Se.w iv.w 4114.w wv.w
Total: 852 131 128 48 1159 1553 $408,419.70 513,818-06 50.00 513,818.06 5119,338.06 574,263.22 $193,60128 5128,015.83 538,243.18 5117,792.96 50.00 5491,474;
Average 36 5 5 2 48 65 517, 017.49 $675.75 50.00 $575.75 $4, 972.42 $3,094.30 58,066•72 56,33412 51,593.47 $4,900.04 $0.00 520,478.'
2
'Contracts and Members do not reflect retroactive additions and terminations.
'Experience is reflective of both active and terminated members.
B1ueCross B1ueShield
of Florida
M M.dspordra Mows d ar
Om tram and Blue BNeldAaaotlallon
0714
Includes any additional Insurance Coverages, where applicable (shown under "Other ").
offered through Florida Combined Life Insurance Company, Inc.
GROUP INVOICE
Page: 3
Group: 90206001
Invoice: 137159 01
Dist: SBR
Billed:
03/20/03
Due: 04/01/03
Pays To: 05/01/03
MSG
COD
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-;. ..HEALTH..;
CLASS
::: ::O THER, ; 7: >
:1'O'fAti`:.::.:`:;.'`:::
ARNOLD CAROLYN N
01
06
536.45
.00
536.45
BAUGH JEFF D
5-
01
01
297.09
.00
297.09
BERMUDEZ OSCAR
16 j
01
01
297.09
.00
297.09
BERRY ADRIANA
01
06
536.45
.00
536.45
BOURGAULT KEITH D
..a ..a.,1._
.. y
01
07
642.00
.00
642.00
BROCK ROBIN
01
01
297.09
.00
297.09
CALF RUSSELL
4_°s
01
01
297.09
.00
297.09
CARLTON WAYNE
01
01
297.09
.00
297.09
CHANDLER NOEL A
`.,
01
01
297.09
.00
297.09
CHRISTOPHER NANCY S
lI
01
01
297.09
.00
297.09
CONROY PHILLIP J
114.)
01
06
536.45
.00
536.45
COOK JOHN R
01
01
297.09
.00
297.09
DAVIS DENNIS W
11u
01
06
536.45
.00
536.45
DOUGLAS WILLIAM'L
.'O
01
01
297.09
.00
297.09
FISHER ALFRED L
."3
01
07
642.00
.00
642.00
FUSCO JAMES.
01
06
536.45
.00
'536.45
GAMIOTEA STEPHANIE L
y
01
06
536.45
.00
536.45
GARCIA TERISA
y Y
01
01
297.09
.00
297.09
GOULD CLINT R
01
01
297.09
.00
297.09
HAGAN DONALD C
01
07
642.00
.00
642.00
HATHAWAY RYAN C
3
01
01
297.09
.00
297.09
HICKMAN WILLIAM
31
01
01
297.09
.00
297.09
HILL CHRISTOPHE G
3/
01
06
536.45
.00
536.45
HILL WILLIAM H
g5
01
01
297.09
.00
297.09
HODGES GLENN W
34..
01
01
297.09
.00
297.09
JONES COURTNEY H
.2,
01
01
297.09
.00
297.09
KIRK JAMES E
(a i
01
01
297.09
.00
297.09
LAMB PALMER C
(oC)
01
07
642.00
.00
642.00
LOWE BRYAN 0
;27
01
01
297.09
.00
297.09
MARKHAM ROSCOE L
MCCRARY PHILIP
57
- erm/A -k t-el
01
01
01
01
297.09
297.09
.00
.00
297.09
297.09
MERRY CHARLIE T
611....
01
01
297.09
.00
297.09
MOBLEY TOMI M
;2y
01,
01
297.09
.00
297.09
PADGETT DANIEL B
y/
01,
01
297.09
.00
297.09
PARKER LOLA B
a
01,
01
297.09
.00
297.09
PETERSON ROBERT C
ti -a--
01
01
297.09
.00
297.09
RAULERSON JOHN T
hlir.
01
01
297.09
.00
297.09
REYNOLDS DONNA V
y
01
01
297.09
.00
297.09
ROBARDS MARY J
54
01
02
881.36
.00
881.36
ROBERTS MARVIN L
3f. -_
01
04
536.45
.00
536.45
ROBERTSON DONNIE R
53
01
01
297.09
.00
297.09
ROBERTSON PAULA M
1 3
01
01
297.09
.00
297.09
SANDERS GORDON L
3 Y
01
01
297.09
.00
297.09
SAUM WILLIAM J
4
01
01
297.09
.00
297.09
SELPH JOHN F
5
01
01
297.09
.00
297.09
SHIREMAN MARK A
3'
01
04
536.45
.00
536.45
SMITH HERBERT E
5/
.01
07
642.00
.00
642.00
SMITH JEROME
z/7
01
01
297.09
.00
297.09
SMITH ZACK J
01
01
297.09
.00
297.09
STOKES BRYAN
,,2
:33
01
01
297.09
.00
297.09
TARNER THOMAS A
01
01
297.09
.00
297.09
TAYLOR BETTYE
_-`',9-.
01
01
297.09
.00
297.09
TOMEY II LOUIS K
4, 6
01
07
642.00
.00
642.00
RG14- 03079 -06314
1
1
1
I) BlueCross BlueShield
of Florida
• M Indepondffll Llama' ol ihe
Oka Cross and Blue Meld Aroclation
0714
Includes any additional Insurance Coverages, where applicable (shown under "Other ").
offered through Florida Combined Life Insurance Company, Inc.
c
GROUP INVOICE
Page: 4
Group: 90206001
Invoice: 13715901
Dist: SBR
Billed:
Due:
03/20/03
04/01/03
Pays To: 05/01/03
RG14-03079-06315
?HR
TOTAL
VEACH BI LL L
4.2r
01
01
297.09
.00
297.09
-
VINSON KATRINA B
j-/
, .
01
01
297.09
.00
- 297.09
WATFORD DOWLING R
5")
01
01
297.09
.00
297.09
WENDT DAWN M
:34.
01
01
297.09
.00
297.09
WILBUR DAVID G
ii C
01
01
297.09
.00
297.09
WILKERSON PAMELA J
_40
01
01
297.09
.00
297.09
WILLIAMS LYDIA J
ii
01
01
297.09
.00
297.09
WILLIAMS VICTORIA
i../
01
01
297.09
.00
297.09
WILLIAMS JR DAVID C
1;1
01
07
642.00
.00
642.00
TOTAL
ZEIGLER JOHN P
Re uei e--) , 4,3h lse '7,
DUE THIS PERIOD
41 ")---
i 7
01
07
.
642.00
24,214.46
.00
.00
642.00
24,214.46
NUMBER
BILLED FOR THIS
PERIOD
1-PERSON FAMILY
2-PERSON EMP-CHLDRN
EMP-SPOUSE
OTHER
PKG
01 HEALTH MAINTENANCE
ORG
45
1
0
9
8 0
TOTAL
45
1
0
9
8 0
*******3101***********
*MEMBER
ADJUSTMENTS*
**********X*********
ADDITIONS:
EFF DATE
JONES COURTNEY H
030103
01
01
297.09
.00
297.09
*** NET MEMBER
ADJUSTMENTS
***
TOTAL: ADDITIONS
297.09
.00
297.09
CHANGES
.00
.00
.00
DELETIONS
.00
.00
.00
TOTAL GRP ADJUSTMENTS
297.09
.00
297.09
RG14-03079-06315
Blue Cross Blue Shield
of Florida
MWspordeallonwolft
MusCnommandOmillOMMmidlon
0714
Includes any additional Insurance Coverages, where applicable (shown under "Other ").
offered through Florida Combined Life Insurance Company, Inc.
cor
NUMHER
GROUP INVOICE
Page: 3
Group: 90206R01
Invoice: 13715900
Dist: SBR
A--)e, 41/ rt.
.
pi»
)1.
Billed: 03/20/03
Due: 04/01/03
Pays To: 05/01/03
cov
HEALTI
CIAS
CASTORINA NETTIE
JUAREZ AMADO S
MOBLEY LARRY
TOTAL DUE THIS PERIOD
NUMBER BILLED FOR THIS
PKG 01 HEALTH MAINTENA
10TAL
5q
PERIOD
NCE ORG
1-PERSON FA
3
3
01
01
01
MIL
0
0
01
01
01
297.09
297.09
297.09
891.27
2-PERSON EM
0
0
(/2rM
P-CHL
.00
.00
.00
.00
DRN EMP-
0
0
(1:777/0
297.09
297.09
297.09
891.27
SPOUSE OTHER
0 0
0 0
RG14-03079-06318
511 KIRK, JAMES E.
511 CHANDLER, NOEL
511 WILLIAMS, JR. DAVID C.
511 MARKHAM, ROSCOE L.
511 WATFORD JR., DOWLING
2512 GAMIOTEA, STEPHANE L.
2512 HSP. AM BERRY, ADRIANA
2512 VINSON, KATRINA
512
512
VEACH, BILL
BROCK, ROBIN
513 PARKER, LOLA B.
513 AM. IND. REYNOLDS, DONNA V.
513 AM. IND. WILLIAMS, LYDIA J.
519 HSP. AM ARNOLD, CAROLYN
519 VINSON, KATRINA
521 DAVIS, DENNIS W.
521 RAULERSON, JOHN T.
521 CALE, RUSSELL E.
521 HAGAN, DONALD C.
521 HILL CHRISTOPHER G.
521 HILL, WILLIAM H.
521 HICKMAN, WILLIAM
521 JONES, COURTNEY H.
521 HISP. AM LOWE, BRYAN O.
521 MERRY JR., CHARLIE
521 PETERSON. ROBERTC.
521 SAUM, WILLIAM J.
521 SHIREMAN, MARK
521 BLK/AM. SMITH, JEROME
521 TARNER, THOMAS A.
521 TAYLOR, BETTYE
521 WENDT, DAWN M.
521 WILBUR, DAVID G.
5�
521 WILLIAMS, VICTORIA L.
521 ZEIGLER, JOHN P.
521 HISP /AM GARCIA, TERISA G.
521 ROBARDS, MARY JO
521 LANNING, DONNA
522 MOBLEY, TOMI M.
522 ROBERTSON, PAULA M.
522 REVELS, ASHLEY
522 WILKERSON, PAMELA J.
522 TOMEY II, LOUIS K.
522 HANCOCK, LOUIS S.
522 BAUGH, JEFFREY D.
522 BOURGAULT, KEITH D.
522 CHRISTOPHER, NANCY S
522 CONROY, PHILLIP J.
522 HATHAWAY, RYAN
522 DOUGLAS, WILLIAM L.
522 HODGES, WILBUR GLEN
522 SANDERS, GORDON L.
522 SMITH, HERBERT E.
522 STOKES, BRYAN K.
522 FUSCO, JAMES J.
522 SMITH, ZACH J.
549 BERMUDEZ, OSCAR M.
541 ROBERTSON, DONNIE R.
541 LAMB, PALMER C.
541 FISHER, ALFRED L.
541 CARLTON, WAYNE D.
541 GOULD, CLINT
541 PADGETT, DANIEL B.
541 ROBERTS, MARVIN L.
541 SELPH, FLOYD
JUNE 17, 2003 - REGULAR MEETING • PAGE 7 OF 9
AGENDA
COUNCIL ACTION - DISCUSSION • VOTE
IX. NEW BUSINESS CONTINUED.
C. 2. c) Vote on motion.
VOTE
D. Consider Street and Alley Closing Application No. 69 submitted by
Okeechobee County and a request to waive the application fees -
City Clerk (Exhibit 4).
Consider proposals and award a health insurance contract - City
Administrator (Exhibit 5).
KIRK - YEA
CHANDLER • YEA
MARKHAM - YEA
WATFORD - YEA
WILLIAMS • YEA
MOTION CARRIED.
Council Member Markham moved to direct the Ci Attorne to draft an ordinance to close the r • uested
alleylstreets on Application No. 69 submitted by Board of County Commissioners, Okeechobee County,
Florida, to reserve an easement for a water line on the right -of -way of Northwest 3rd Streetforthe Okeechobee
Utility Authority, and to waive the Street!Alley closing fees; seconded by Chandler.
Mr. John Moaner, President of the Contractors Association was present, and addressed the Council by stating that
the intention was to build a very large community recreational facility, and hoped to seek the help of the City for
contributions in the future. Council agreed that this was a community effort to build this recreational facility for the
youth, and thanked everyone for joining their efforts to make this a reality.
Council MemberWatford moved to award a loneyearrHealth Insurance Bid to Group Insurance Solutions (Blue
Cross Blue Shield); seconded by Council Member Williams.
Administrator Veach stated that the City received four bids, one from Scott Harris of Group Insurance Solutions, who
currently is the health insurance provider for the City. The other was Florida League of Cities, who submitted three
proposals. He explained the contents of the proposals, including co- payments for visits to your primary physician,
emergency room, hospital stays, and prescriptions. He also compared prescription prices, and out of pocket expense.
VOTE
KIRK - YEA
CHANDLER - YEA
MARKHAM - YEA
WATFORD - YEA
WILLIAMS - YEA
MOTION CARRIED.
F MOM G
TIME EXPIRE
al& INT
TUE EXPI.11
.0:
IN 4
0 M04
r ATTMft
-,ocqiESS
tio if-ow- 3
CHPA ATTN: MAJORIE SILBERMAN
4152 WEST BLUE HERON BLVD, SUITE 22t,
RIVIERA BEACH, F
1
ur plc 11:0Ti 766}
AS AiiiMESSED,
FORWARDING
ORDER EXPIRED
AETNA HEALTH PLAN OF FLORIDA, INC.
4890 WEST KENNEDY BLVD SUITE 545
TAMPA, FL. 33609
r kPIS4...,-646-,?:'z,
4.
5 •.5 i
RECEIVED APR 0 8 2003
BELL LANE, FL HEALTH CHOICE PLAN
5300 WEST ATLANTIC AVENUE SUITE 302
DELRAY BEACH, FLORIDA 33484
JUN- 02-03 IN 02403 Pit FLORIDA LEAGUE
FAX N(, 407347'181 P. ?'
FLORIDA LEEJE Of CITIES, INC.
14 East COlon111 Drives 4 Pro Box 634065 4 ando, fl 3Z863N
P110 (401, 425414/ SEE 3441244FAK(4414243113 4
wean: :1 ,uaossrtx
X003FLCL9islativvkti iDay
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To Lola Fax: 883 783-1636
From: Joni Rochester Dan; 6/2/2003
Re: Health quote Paper: 2
CC:
O Urgent 0 For Review 0 Please Comment 0 Please Reply O Please Recycle
Please sail (407) 42641142 if you have eny goestions or any problems receiving this fax.
Confidentiality Notice: This fas and any flee transmitted with M am confidential and ere intended solely for the use of ths
individual er entity 10 which hiey sn eddnepd. If the reader of this fee a not the intended raciplont, yen are hereby
notified that tiny disseminated, ciatdbutton or envying of MN communication is steady prohibited, and that you have
neelved tine fns end any eeeempanNng Mee In VIOL You should notlN Flotilla League of Cities rmmedlaNly by replying
le Ihla he and destroyIng the Intennenon. Florida taken of Cities does net iooept responsibility for changes le faxes
tMe eenur Wier they/ins. aeon sem.
1RnidaLag alGSGu
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[- m-sr IZcg 11 am 1�Tel� orl'_c
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$91:27
57a6.4d
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5337_P
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$69,.19
11,1187:
5355695
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56.4 54
$1,056.9:
599,94164 God Plm
87,33757 God Flan
$6197.62 Gald Plr
$129116 € tdI1
$111,199 14 SaTawa
$6,694.97 Saws-Plan
56.29270 Siva Plea
51.146 73 Sdaz Ptan
576.776.60 DRAM PI=
SF,1 ^6.90 Broom Ply
35,000 90 11.9na Plan
$I,05E 95 Wane flan
5239,383 _66
S88 O5 _S7
582_771 .41
515„ 109_91
5218}389.71
580.328.80
$75,51 Z_36
313_784_ ?"7
3201,7121 _6c5
3'7-1_050_ :'8
569,6 1 0 _ "745
512_'70'7 _.47
S 11ver glary
Silver Playa
Silver plaza
Salvo Plan
Sroraze p1.9.aa
r3ron>_e 1=.1a
Broaaze Plan -w
f3roxaxc_ Plan
• An rarer alarm* . LU8e a.4, Oedurra nu ,aanptaue y eta tnpres Mop /,Kinea.r111.,,er■io.
^•Nrd.cnre SY. ie ent it mmlai4Jar eafi.el over ve 65
bd 5: PO NOV EO —Z7 —N f
18IGLICiL0t ON Xdd
❑ Administration/
Marketing
❑ Risk Control
❑ Underwriting
Property & Casualty
Health
iVr
Post Office Box 530065
125 East Colonial Drive
Orlando, FL 32853 -0065
800 - 445 -6248
407 - 425 -9142
Suncom 344 -0725
Fax 407 - 425 -9378
Health Claims
Post Office Box 538140
Orlando, FL 32853 -8140
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
❑ Workers'
Compensation Claims
Post Office Box 538135
Orlando, FL 32853 -8135
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
❑ Property & Liability
Claims
Post Office Box 538135
Orlando, FL 32853 -8135
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
FLORIDA LEAGUE OF CITIES, INC.
PUBLIC RISK SERVICES
May 30, 2003
City of Okeechobee
Procurement Management Office
55 S.E. Third Avenue
Okeechobee, FL 34974 -2903
Re: RFP - Group Health Insurance
Dear Procurement Management Office:
We appreciate the opportunity to provide you with this proposal of insurance for
employee benefits. Medical coverage has been proposed on a Point of Service
(POS) managed care basis through the Florida Municipal Insurance Trust, a non-
profit, non - accessible, group - pooled program.
The Trust also provides dental and short -term disability benefits and a prescription
drug card plan.
The Trust offers First Health to provide a statewide managed care network for its
participants. These Comprehensive networks of doctors and hospitals are available
in most regions.
All rates quoted are guaranteed for sixty (60) days from the date of the proposal.
The rates include costs of administration, reinsurance and estimated claims costs.
Monthly, quarterly and annual loss reports are provided at no additional charge.
We welcome the opportunity to further discuss our proposal and should you have
any questions, please contact me at 1- 800 - 445 -6248.
Sincerely,
Chuck Wilde
Marketing Representative
CW /jr
Enclosure
Florida Municipal Insurance Trust
❑ Administration/
Marketing
❑ Risk Control
❑ Underwriting
Property & Casualty
Health
id
Post Office Box 530065
125 East Colonial Drive
Orlando, FL 32853 -0065
800 - 445 -6248
407 - 425 -9142
Suncom 344 -0725
Fax 407 - 425 -9378
Health Claims
Post Office Box 538140
Orlando, FL 32853 -8140
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
❑ Workers'
Compensation Claims
Post Office Box 538135
Orlando, FL 32853 -8135
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
❑ Property & Liability
Claims
Post Office Box 538135
Orlando, FL 32853 -8135
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
FLORIDA LEAGUE OF CITIES, INC.
PUBLIC RISK SERVICES
PROPOSAL OF INSURANCE
FOR
CITY OF OKEECHOBEE
Effective Date: 10/01/2003
Provided by
Florida Municipal Insurance Trust
Administered by:
The Florida League of Cities, Inc.
PUBLIC RISK SERVICES
P.O. Box 530065
Orlando, FL 32853 -0065
407 - 425 -9142 or Toll Free 1- 800 - 445 -6248
May 30, 2003
Florida Municipal Insurance Trust
Florida League of Cities
Treasure Island
Medical/Rx
First Health Network
Contract Type
Enrollment
Current Rates
United Health Care
7/1/02 - 6/30/03
Monthly Premium
Annual Premium
Single
EE + Spouse
EE + Child(ren)
Family
87
8
2
15
$361.18
$774.73
$671.57
$1,096.12
$31,422.66
$6,197.84
$1,343.14
$16,441.80
$377,071.92
$74,374.08
$16,117.68
$197,301.60
.... „
Contract Type
Enrollment
Proposed PPO
Rates (FLC)
7/1/03 - 09/30/04
Monthly Premium
Annual Premium
Single
EE + Spouse
EE + Child(ren)
Family
Single
EE + Spouse
EE + Child(ren)
Family
Single
EE + Spouse
EE + Child(ren)
Family
"r" ,;:,;„,-.;7".!,,FH :,.:,4-
87
8
2
15
87
8
2
15
87
8
2
15
1,,,rmat,40,1.2.,',Arig,
'',
$470.38 Gold Plan
$1,006.64 Gold Plan
$938.44 Gold Plan
$1,474.70 Gold Plan
$429.23 Silver Plan
$918.56 Silver Plan
$856.33 Silver Plan
$1,345.67 Silver Plan
$395.59 Bronze Plan
$846.59 Bronze Plan
$789.23 Bronze Plan
$1,240.23 Bronze Plan
':'-'':-::r--.•,', ::--1.6.0:5,50:,''',,,:-.4i06.....1,',
-..:' ..-:-F,. -- si944eAsitianiii'
7.46,:„.5 : Ilivinze Plan
$40,923.40 Gold Plan
$8,053.16 Gold Plan
$1,876.89 Gold Plan
$22,120.55 Gold Plan
$37,342.60 Silver Plan
$7,348.51 Silver Plan
$1,712.66 Silver Plan
$20,185.00 Silver Plan
$34,416.58 Bronze Plan
$6,772.70 Bronze Plan
$1,578.46 Bronze Plan
$18,603.39 Bronze Plan
-:!' ,,:,‘ '‘10.4di
,:.,z, '`::::. 6X&77SilPisn
' ., : $64 71.4 Bronze Nan
$491,080.75 Gold Plan
$96,637.88 Gold Plan
$22,522.63 Gold Plan
$265,446.64 Gold Plan
$448,111.18 Silver Plan
$88,182.06 Silver Plan
$20,551.90 Silver Plan
$242,220.05 Silver Plan
$412,998.91 Bronze Plan
$81,272.46 Bronze Plan
$18,941.53 Bronze Plan
$223,240.62 Bronze Plan
:: ::: 0,99*5.2tiSilliirP14it -;
::: , : ',$736;453.52,Brenze Nati
**Medicare Supplement
$266.98
. -... ' .,j .:...: ..-.:-::.' ::
f':' .. . .,-::. 10.1*:n14P1kli
Notes:
All rates are subject to Large Claim Disclosure and acceptance by the League's stop loss insurance carrier.
**Medicare Supplement is available for retirees over age 65
***4% Commission included for Agent of Record
k:Florida League of Cities\ New City\Treasure Island\Treasure Island rating.xls
5/30/2003
GROUP DFNTAI
SCHEDULE OF BENEFITS
FLORIDA MUNICIPAL INSURANCE TRUST
GFNFRAL DFNTAL CARF BFNFFIT
Lifetime Maximum Benefit - Unlimited
Calendar Year Maximum Benefit -
$1,000 per individual
SUMMARY OF GFNFRAI CARF SFRVICF,S
1. Examinations and recall services, check -ups and
cleaning of teeth
2. Palliative treatment
3. Endodontic treatment
4. Space maintainer
5. X -rays
6. Oral surgery
7. Periodontal treatment
8. Normal extraction of teeth
9. Silver and synthetic permanent fillings, crowns
and jackets
10. Fixed bridges consisting of crowns or jackets
11. Dentures and removable bridges
J�FDl1CTIRl F
$50 per individual per calendar year.
COINSURANCF
Plan pays 80% of first $1,250 of eligible
expenses per calendar year.
DFNTAI RATFS (PFR MONTH)
Employee Dental
Dependent Dental
Family Dental
$28.91
S42 50
$71.41
ORTHODONTIC CARF BENFFIT
Lifetime Maximum Benefit - $1,000 per
individual.
SUMMARY OF ORTHODONTIC CARF
1. Diagnostic procedures
2. Appliances for tooth guidance and control of
harmful habits
3. Retention appliances
4. Comprehensive treatment with fixed and
removable appliances for correction of
malocclusion in permanent, primary and
mixed dentition
5. Orthodontic treatment must be completed
prior to attainment of age 19.
LIFFTIMF DFDIJCTIRI P
$50 per individual.
COINSI IRANCF
Plan pays 50% of first $2,000 of eligible
expenses per individual in their lifetime.
STAND Al ONF - (Without Health)
Employee Dental
Dependent Dental
Family Dental
$32.30
S47 60
$79.90
Dental coverage written in the Florida Municipal Insurance Trust is subject to a 25% participation of those
employees quoted.
* **
This summary was designed only to give you a brief description of benefits provided and does not
include all of the provisions, limitations or exclusions in the policies. In an actual claim situation,
the policy provisions, limitations, exclusions will apply. If this outline disagrees with the Plan
Document in any way, the Plan Document will govern.
FLORIDA MUNICIPAL INSURANCE TRUST
DENTAL BENEFIT PLAN SUMMARY
Reasonable and customary limits will apply to all covered eligible expenses.
GFNFRAI DFNTAI CARF
Calendar Year Maximum $1,000
Deductible $50 calendar year
After the deductible has been met, unless otherwise stated, the following coinsurance will apply:
This plan will pay 100% preventative services, not subject to the calendar year deductible, as follows:
1. Oral examinations
2. Dental X -rays (Bitewings twice per calendar year, Full Mouth or Panoramic once every 2 years)
3. Fluoride application (for dependents under age 15)
4. Prophylaxis
This plan will pay 80% for basic dental services as follows:
1. Emergency treatment for pain
2. Space maintainers
3. Dental X -rays
4. Biopsies of oral tissue
5. Pulp vitality tests
6. Fillings
7. Extractions
8. Oral Surgery
9. Endodontics
10. Periodontics
This plan will pay 50% for dental restorations and specialty services as follows:
1. Inlays, onlays
2. Crowns
3. Bridges, dentures
,SCHFIII II F OF ORTHODONTIC RFNFFIT (applies only to eligible dependents under age 19).
Lifetime maximum (per person)
Lifetime deductible
$1,000
$50 per person
Covered eligible expenses are payable after the deductible at 50 %.
1. Diagnostic procedures.
2. Appliances for tooth guidance and control of harmful habits.
3. Retention Appliances.
4. Comprehensive treatment with fixed and removable appliances for correction of
malocclusion in permanent, primary and mixed dentition.
These summaries are designed only to give you a brief description of the benefits provided and does not include all of the
provisions, limitations or exclusions in the policies. In an actual claim situation, the policy provisions, limitations,
exclusions will apply. If this outline disagrees with the Plan Document in any way, the Plan Document will govern.
CLAIM ADMINISTRATOR.
Florida League of Cities, Inc. Claims Center
P.O. Box 538135 (407) 245 -0725
Orlando, FL 32853 -8135 (800) 756 -3042
GROUP VISION
VISION SERVICE PLAN
SCHEDULE OF BENEFITS
DFDUCTIRI F
A deductible amount of $10.00 is required for any service(s) rendered payable out of pocket by the eligible person
to the panel doctor at the time of service.
COVERED EXPENSES
VISION EXAMINATION
The primary purpose of the Vision Service Plan is to provide for professional vision examination and care. This
examination comprises an analysis of the vision functions, including the prescription and supply of glasses where
indicated.
J FNSFS AND FRAMFS
A. LENSES - The VSP Panel Doctor will order the proper lenses from a VSP approved laboratory. VSP
provides any necessary lenses, including single vision, bifocal, trifocal or other more complex and
expensive lenses, when necessary for the patients visual welfare. This assures the finest American -
made lenses and quality workmanship. The doctor verifies the accuracy of the finished lenses.
B. FRAMES - The patient is assisted in the selection of frames. VSP provides a wide selection of quality
frames. Because of the cosmetic nature of frames and the rapidly changing styles, VSP has a limit on
the cost of the frames provided under the program. The limit is designed to cover a majority of frames in
current use. Patients who select frames that exceed the limit are required to pay the additional wholesale
cost, plus a modest additional fee.
C. MEDICALLY NECESSARY CONTACT LENSES - Contact lenses are allowed under the program in any
of these instances provided prior approval is obtained from VSP by your doctor with documentation.
1) Following cataract surgery.
2) When visual acuity cannot be corrected to 20/70 in the better eye except by use of contact
lenses.
3) Anisometropia of greater than 350 diopters and asthenopia or diplopia, with spectacles.
4) Keratoconus diagnosis where contact lenses is the treatment of choice.
5) Monocular aphakia and /or binocular aphakia where the doctor certifies medically necessary
contact lenses are necessary for safety and rehabilitation to an occupational productive life.
All five (5) categories of "medically necessary" contacts are subject to coordination of benefits with the
medical insurance carriers. VSP will provide the contacts or glasses, but not both.
D. COSMETIC CONTACT LENSES - When cosmetic contact lenses are selected, an indemnity allowance
will be made in lieu of all other services.
HOW OFTFN SFRVICFS ARF AVAII ARI F
A. A VISION EXAMINATION - is available to each covered person every 12 months.
B. LENSES - Are available every 12 months when required.
C. FRAMES - Are available every 24 months.
J IMITATIONS
EXTRA COST - The plan is designed to cover visual needs rather than elective materials. If any of the following
are selected and the VSP doctor does not receive prior authorization, there will be an extra charge:
a) Oversized lenses
b) A frame costing more than plan allowance
c) Tinted or photochromic lenses (other than Pink 1 and 2)
d) Coated lenses
e) No -line bifocals (blended type) and progressive lenses
f) Cosmetic Faceting
g) Other cosmetic items.
ITEMS NOT COVERED:
a) Orthoptics or vision training
b) Subnormal vision aids
c) Aniseikonia lenses
d) Two pair of glasses in lieu of bifocals
e) Plano (non - prescription) lenses
f) Cosmetic contact lenses.
Replacement or repair of lost or broken lenses and frames, except at normal intervals.
Medical or surgical treatment of the eyes.
Services or materials provided as a result of any Workers' Compensation Law, or similar legislation, or obtained
through or required by any government agency or program whether Federal, State or any subdivision thereof.
Any eye examination required by an employer as a condition of employment, unless agreed upon in writing by
VSP and included in the original contract.
DI IAI CHOICF COVFRAGF
Eligible persons not wishing to secure services from a Vision Service Plan Doctor may secure services from a
non - participating doctor and submit bills for reimbursement. The amounts reimbursed are limited and may not
cover the full charges.
Fl IGIBILITY
Each group electing vision care must maintain their vision care coverage for a minimum of one year from the time
of inception. All employees and dependents who meet the eligibility requirements of their enrolled group are
covered for vision care benefits.
Neither employees nor dependents have the right to individually select vision care coverage. Requirements for
participation are:
a) 100% of all city employees, or
b) 100% of all City employees carrying any coverages with FMIT.
FRFMII JM RATFS
Employee $ 5.74
Dependent $ 8.4:3
Family Total $14.17
..1
THE FIRST HEALTH NETWORK
Internet Provider Directory
City of Okeechobee
Current As Of: May 30, 2003
?First Health.
This Provider Directory is provided by First Health Group Corp. to present to you information on hospitals, physician and other providers who have agreed
to provide their usual services to you at specially contracted rates of payment. All decisions about the type of care you receive are the responsibility of you
and the physician whom you select. The quality and results of the care provided are the responsibility of the physician. Some health services may be provided
by resident physicians under the supervision of the listed physicians. While First Health Group Corp. makes every effort to maintain accurate and up- to-date
information, we cannot be responsible for any omissions or errors after publication. Please confirm provider participation prior to your visit.
Okeechobee County Hospitals
Okeechobee County Hospitals
The First Health® Network
Internet Provider Directory
Current As Of: May 30, 2003
9First Health
This Provider Directory is provided by First Health Group Corp. to present to you information on hospitals, physicians and other providers who have agreed to provide their usual services
to you at specially contracted rates of payment All decisions about the type of care you receive are the responsibility of you and the physician whom you select. The quality and results of
the care provided are the responsibility of the physician. Some health services may be provided by resident physicians under the supervision of the listed physicians. While First Health
Group Corp. makes every effort to maintain accurate and up -to -date information, we cannot be responsible for any omissions or errors after publication. Please confirm provider
participation prior to your visit.
Okeechobee County Hospitals
Directory Criteria
Product: FIRST HEALTH HOSPITAL NETWORK
Sorted By: City
Counties Included: OKEECHOBEE
States Included: FLORIDA
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited
2
Okeechobee County Hospitals
OKEECHOBEE
OKEECHOBEE HOSPITAL INC
DBA RAULERSON
HOSPITAL
(863) 763-2151
1796 HIGHWAY 441 N
OKEECHOBEE, FL 34973
THIS LIST IS SUBJECT TO CHANGE
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited.
3
Okeechobee County Facilities
Okeechobee County Facilities
The First Health® Network
Internet Provider Directory
Current As Of: May 30, 2003
QFirst Health.
This Provider Directory is provided by First Health Group Corp. to present to you information on hospitals, physicians and other providers who have agreed to provide their usual services
to you at specially contracted rates of payment. All decisions about the type of care you receive are the responsibility of you and the physician whom you select. The quality and results of
the care provided are the responsibility of the physician. Some health services may be provided by resident physicians under the supervision of the listed physicians. While First Health
Group Corp. makes every effort to maintain accurate and up -to -date information, we cannot be responsible for any omissions or errors after publication. Please confirm provider
participation prior to your visit.
1
Okeechobee County Facilities
Directory Criteria
Product: FIRST HEALTH FACILITY CARE NETWORK
Sorted By: City
Counties Included: OKEECHOBEE
States Included: FLORIDA
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited
2
Okeechobee County Facilities
OKEECHOBEE
LAB CORP FLORIDA
(863) 357-7715
1008 N PARROTT AVE
OKEECHOBEE, FL 34972
LAKE OKEECHOBEE
REGIONAL CANCER
CENTER
(863) 763-7100
301 NE 19TH DR
OKEECHOBEE, FL 34972
LOOKADOO SKYLINE LAB
(863) 357-2666
1006 N PARROTT AVE
OKEECHOBEE, FL 34972
MEDFOCUS FLORIDA
(800) 398-8999
204 SE PARK ST
OKEECHOBEE, FL 34972
MEDFOCUS FLORIDA
(800) 398-8999
115 NE 3RD ST #A
OKEECHOBEE, FL 34972
ONCOLOGY ASSOCIATES
FL
(863) 763-7100
301 NE 19TH DR
OKEECHOBEE, FL 34972
OPEN MRI OF
OKEECHOBEE
(863) 824-6736
115 NE 3RD ST
OKEECHOBEE, FL 34972
SURGERY CENTER OF
OKEECHOBEE INC
(863) 357-6220
1655 US HIGHWAY 441
OKEECHOBEE, FL 34972
THIS LIST IS SUBJECT TO CHANGE
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibiter.
3
Okeechobee County Physicians
Okeechobee County Physicians
The First Health® Network
Internet Provider Directory
Current As Of: May 30, 2003
9First Health®
This Provider Directory is provided by First Health Group Corp. to present to you information on hospitals, physicians and other providers who have agreed to provide their usual services
to you at specially contracted rates of payment. All decisions about the type of care you receive are the responsibility of you and the physician whom you select. The quality and results of
the care provided are the responsibility of the physician. Some health services may be provided by resident physicians under the supervision of the listed physicians. While First Health
Group Corp. makes every effort to maintain accurate and up -to -date information, we cannot be responsible for any omissions or errors after publication. Please confirm provider
participation prior to your visit.
1
Okeechobee County Physicians
Directory Criteria
Product: FIRST HEALTH OUTPATIENT CARE NETWORK
Sorted By: Specialty, City
Counties Included: OKEECHOBEE
States Included: FLORIDA
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited
2
Okeechobee County Physicians
ANESTHESIOLOGY
OKEECHOBEE
MID FLORIDA ANESTHESIA
ASSOCIATES
(863) 763-7015
1655 US HIGHWAY 441
OKEECHOBEE, FL 34972
MID FLORIDA ANESTHESIA
ASSOCIATES
(863) 763-7015
1796 US HIGHWAY 441
OKEECHOBEE, FL 34972
MID FLORIDA ANESTHESIA
ASSOCIATES
(863) 763 -7015
300 NW 5TH ST #312
OKEECHOBEE, FL 34972
CARDIOVASCULAR
DISEASE
OKEECHOBEE
ARAIN, SHAKOOR A
(863) 467-9400
1600B SW 2ND AVE
OKEECHOBEE, FL 34974
RIAZ, MOHAMMAD
(863) 467-1156
204 NE I9TH DR
OKEECHOBEE, FL 34972
CHIROPRACTIC
MEDICINE
OKEECHOBEE
DOUGLAS, EDWARD W
(863) 763-4320
916 NW PARK ST
OKEECHOBEE, FL 34972
PLATT, KEVIN
(863) 763 -2400
280 SW 32ND ST
OKEECHOBEE, FL 34974
STEPHENS, PETER W
(863) 763-0880
375 SW 32ND ST
OKEECHOBEE, FL 34974
CRITICAL CARE
MEDICINE
OKEECHOBEE
SHAKOOR, ARIF
(863) 357-2300
265 NE 19TH DR
OKEECHOBEE, FL 34972
DERMATOLOGY
OKEECHOBEE
SCHIFF, THEODORE A
(863) 467 -6767
301 NE I9TH DR
OKEECHOBEE, FL 34972
EAR NOSE & THROAT
(OTOLARYNGOLOGY)
OKEECHOBEE
BEQUER, NAPOLEON C
(863) 357-3333
212 NE 19TH DR
OKEECHOBEE, FL 34972
EAR NOSE & THROAT
(OTOLARYNGOLOGY)
OKEECHOBEE
BERGHASH, LESLIE R
(863) 357-7791
1916 US HIGHWAY 441
OKEECHOBEE, FL 34972
EAR NOSE & THROAT
(OTOLARYNGOLOGY)
OKEECHOBEE
LANZA, JOHN T
(863) 357-7791
1916 US HIGHWAY 441
OKEECHOBEE, FL 34972
EMERGENCY
MEDICINE
OKEECHOBEE
SCOTT, JOSEPH A
(863) 763-2151
1796 US HIGHWAY 441
OKEECHOBEE, FL 34972
FAMILY PRACTICE
OKEECHOBEE
ARAGON, GLORIA R
(863) 763-6496
1004 N PARROTT AVE
OKEECHOBEE, FL 34972
HELLER, LELAND M
(863) 467-8771
109 NE 19TH DR
OKEECHOBEE, FL 34972
SWEDA, STANLEY H
(863) 763 -1107
204 SE PARK ST
OKEECHOBEE, FL 34972
GENERAL PRACTICE
OKEECHOBEE
CROUCH, JOHN C
(863) 357-3600
115NE 3RD ST #C
OKEECHOBEE, FL 34972
GENERAL VASCULAR
SURGERY
OKEECHOBEE
KOTHALANKA, RAMA
(863) 467 -5873
107 NE 19TH DR
OKEECHOBEE, FL 34972
GERIATRIC MEDICINE
OKEECHOBEE
MAVROIDES, CHRISTOPHER
J
(863) 763-5666
1922 US HIGHWAY 441
OKEECHOBEE, FL 34972
GYNECOLOGY (NO
OB)
OKEECHOBEE
COLLINS, EVAN M
(772) 219-1080
250 NE 2ND AVE
OKEECHOBEE, FL 34972
GYNECOLOGY (NO
OB)
OKEECHOBEE
DELOACH, VICTOR E
(863) 763-7481
308 NW 5TH AVE
OKEECHOBEE, FL 34972
GYNECOLOGY (NO
OB)
OKEECHOBEE
GARCIA, TRINIDAD E
(863) 763 -6427
GASTROENTEROLOGY 306 NE 19TH DR
OKEECHOBEE, FL 34972
OKEECHOBEE
CHANG, JOHN
(863) 357-0888
235 NE 19TH DR
OKEECHOBEE, FL 34972
HAAS, KENNETH F
(863) 357-7447
1930 US HIGHWAY 441
OKEECHOBEE, FL 34972
GYNECOLOGY (NO
OB)
OKEECHOBEE
HUSAIN, SURAIYA
(863) 763-8000
1300 N PARROTT AVE
OKEECHOBEE, FL 34972
GYNECOLOGY (NO
OB)
OKEECHOBEE
THOMSON JR, ALTON
(561) 219-1080
250 NE 2ND AVE
OKEECHOBEE, FL 34972
HEAD & NECK
SURGERY
OKEECHOBEE
BERGHASH, LESLIE R
(863) 357-7791
1916 US HIGHWAY 441
OKEECHOBEE, FL 34972
LANZA, JOHN T
(863) 357-7791
1916 US HIGHWAY 441
OKEECHOBEE, FL 34972
HEMATOLOGY
OKEECHOBEE
AKHTAR, VASEEM S
(863) 467 -9000
1101 N PARROTT AVE
OKEECHOBEE, FL 34972
INTERNAL MEDICINE
OKEECHOBEE
AHMED, IQBAL
(863) 357-6030
202 NE 19TH DR
OKEECHOBEE, FL 34972
AKHTAR, VASEEM S
(863) 467-9000
1101 N PARROTT AVE
OKEECHOBEE, FL 34972
ARAGON, CANDID() P
(863) 763 -6496
1004 N PARROTT AVE
OKEECHOBEE, FL 34972
ARAIN, SHAKOOR A
(863) 467-9400
1600B SW 2ND AVE
OKEECHOBEE, FL 34974
BERGER, JAY S
(863) 467 -1117
1105 N PARROTT AVE
OKEECHOBEE, FL 34972
CHAUDHARY, MUHAMMAD
A
(863) 763-1917
206 NE I9TH DR
OKEECHOBEE, FL 34972
HAAS, KENNETH F
(863) 357-7447
1930 US HIGHWAY 441
OKEECHOBEE, FL 34972
KHAN, SAEED A
(863) 467-4788
1924 US HIGHWAY 441
OKEECHOBEE, FL 34972
KOTHALANKA,
JANIKAMMA
(863) 467 -5873
107 NE 19TH DR
OKEECHOBEE, FL 34973
LADIA, FELIPE P
(863) 763 -6431
210 NE 19TH DR
OKEECHOBEE, FL 34972
LADIA, LILIA D
(863) 763 -6431
210 NE 19TH DR
OKEECHOBEE, FL 34972
MAVROIDES, CHRISTOPHER
J
(863) 763 -5666
1922 US HIGHWAY 441
OKEECHOBEE, FL 34972
MEHANNI, MAGED A
(863) 763-3622
300 NW 5TH ST #300
OKEECHOBEE, FL 34972
NAEEM, TAHIR
(863) 357-0104
1924 US HIGHWAY 441
OKEECHOBEE, FL 34972
RIAZ, 11.10HAMMAD
(863) 467 -1156
204 NE I 9TH DR
OKEECHOBEE, FL 34972
SHAKOOR, ARIF
(863) 357-2300
265 NE I9TH DR
OKEECHOBEE, FL 34972
MEDICAL ONCOLOGY
OKEECHOBEE
AKHTAR, VASEEM S
(863) 467-9000
1101 N PARROTT AVE
OKEECHOBEE, FL 34972
MULTISPECIALTY
CLINIC
OKEECHOBEE
JUPITER HAND
REHABILITATION CENTER
INC
(863) 357-4994
210 NE 3RD AVE
OKEECHOBEE, FL 34972
MULTISPECIALTY
FACILITY
OKEECHOBEE
ALLIANCE ANESTHESIA P A
(863) 763-7015
300 NW 5TH ST #312
OKEECHOBEE, FL 34972
FLORIDA COMMUNITY
HEALTH CENTERS INC
(863) 763-1951
1100 N PARROTT AVE
OKEECHOBEE, FL 34972
THIS LIST IS SUBJECT TO CHANGE
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited
3
Okeechobee County Physicians
FLORIDA COMMUNITY
HEALTH CENTERS INC
(863) 763-7481
308 NW 5TH AVE
OKEECHOBEE, FL 34972
NEUROLOGY
OKEECHOBEE
ALDANA, PETER R
(863) 763 -5181
115 NE 3RD ST #C
OKEECHOBEE, FL 34972
ALI, ABULFAZAL S
(863) 357-2777
225 NE I9TH DR
OKEECHOBEE, FL 34972
OBSTETRICS &
GYNECOLOGY
OKEECHOBEE
COLLINS, EVAN M
(772) 219-1080
250 NE 2ND AVE
OKEECHOBEE, FL 34972
GONZALEZ, PABLO R
(863) 763-7481
308 NW 5TH AVE
OKEECHOBEE, FL 34972
THOMSON JR, ALTON
(561) 219-1080
250 NE 2ND AVE
OKEECHOBEE, FL 34972
OCCUPATIONAL
THERAPY
OKEECHOBEE
DURAND, DONNA
(863) 357-4994
210 NE 3RD AVE
OKEECHOBEE, FL 34972
WILLETTE, MICHAEL
(863) 357-4994
210 NE 3RD AVE
OKEECHOBEE, FL 34972
OPHTHALMOLOGY
OKEECHOBEE
ESPIRITU, MIGUEL A
(863) 467-0533
304 NE 19TH DR
OKEECHOBEE, FL 34972
KELLY, KEVIN T
(863) 467-4111
710 S PARROTT AVE
OKEECHOBEE, FL 34974
KELLY, KEVIN T
(863) 467-4111
8551 W SUNRISE BLVD
OKEECHOBEE, FL 34974
ORTHOPEDIC
SURGERY
OKEECHOBEE
SLUTSKY, BRADFORD A
(863) 763 -8100
1920 US HIGHWAY 441
OKEECHOBEE, FL 34972
PAIN MANAGEMENT
OKEECHOBEE
MID FLORIDA ANESTHESIA
ASSOCIATES
(863) 763-7015
1655 US HIGHWAY 441
OKEECHOBEE, FL 34972
MID FLORIDA ANESTHESIA
ASSOCIATES
(863) 763-7015
1796 US HIGHWAY 441
OKEECHOBEE, FL 34972
MID FLORIDA ANESTHESIA
ASSOCIATES
(863) 763 -7015
300 NW 5TH ST #312
OKEECHOBEE, FL 34972
PATHOLOGY
OKEECHOBEE
HUSSAIN, MUSHTAQ
(863) 467-7084
210 NW PARK ST #204
OKEECHOBEE, FL 34972
SCHIFF, THEODORE A
(863) 467-6767
301 NE 19TH DR
OKEECHOBEE, FL 34972
PEDIATRICS
OKEECHOBEE
ARAGON, GLORIA R
(863) 763-6496
1004 N PARROTT AVE
OKEECHOBEE, FL 34972
BROWN, FRED D
(863) 763-1951
1100 N PARROTT AVE
OKEECHOBEE, FL 34972
HUSSAIN, ANJUM P
(863) 467-8398
255 NE I9TH DR
OKEECHOBEE, FL 34972
ROBSHAW, CHRISTOPHER
(863) 357-1117
1100 N PARROTT AVE
OKEECHOBEE, FL 34972
PHYSICAL THERAPY
OKEECHOBEE
KIRTON, CHERYL L
(863) 467-6669
332 SW 32ND ST
OKEECHOBEE, FL 34974
NEW AMERICAN PHYSICAL
THERAPY
(863) 763-7773
1103 N PARROTT AVE
OKEECHOBEE, FL 34972
NOORUDDIN, MUHAMMAD
S
(863) 763 -7733
1103 N PARROTT AVE
OKEECHOBEE, FL 34972
PODIATRIC SURGERY
OKEECHOBEE
GARVIN, MICHAEL A
(863) 357 -1166
105 NE 19TH DR
OKEECHOBEE, FL 34972
PARRATTO, SCOTT F
(863) 467-4311
1105 N PARROTT AVE
OKEECHOBEE, FL 34972
PSYCHIATRY
OKEECHOBEE
ALI, ABULFAZAL S
(863) 357-2777
225 NE 19TH DR
OKEECHOBEE, FL 34972
PULMONARY DISEASE
OKEECHOBEE
MEHANNI, MAGED A
(863) 763-3622
300 NW 5TH ST #300
OKEECHOBEE, FL 34972
SHAKOOR, ARIF
(863) 357 -2300
265 NE 19TH DR
OKEECHOBEE, FL 34972
RADIATION
ONCOLOGY
OKEECHOBEE
HARTER, DAVID J
(863) 467-9500
1115 N PARROTT AVE
OKEECHOBEE, FL 34972
KRIMSLEY, ALAN S
(863) 467-9500
1115 N PARROTT AVE
OKEECHOBEE, FL 34972
KUMAR, RAMESH T
(863) 467-9500
1115 N PARROTT AVE
OKEECHOBEE, FL 34972
WOODY III, RONALD H
(863) 467-9500
1115 N PARROTT AVE
OKEECHOBEE, FL 34972
REHAB &
OCCUPATIONAL
MEDICINE CTR
OKEECHOBEE
JUPITER HAND
REHABILITATION CENTER
INC
(863) 357-4994
210 NE 3RD AVE
OKEECHOBEE, FL 34972
SURGERY
OKEECHOBEE
HUSAIN, MUZAFFAR
(863) 763 -8000
1300 N PARROTT AVE
OKEECHOBEE, FL 34972
KURTIN, ADAM D
(772) 219 -4026
250 NE 2ND AVE
OKEECHOBEE, FL 34972
SANTELICES, ARMANDO A
(863) 467-8181
212 NE 19TH DR
OKEECHOBEE, FL 34972
UROLOGY
OKEECHOBEE
PANGILINAN, TRISTAN H
(863) 467-7666
200 NE I9TH DR
OKEECHOBEE, FL 34972
SIGALOW, DAVID A
(863) 763-0217
215 NE 19TH DR
OKEECHOBEE, FL 34972
YOUNG, MARVIN J
(863) 467-0909
245 NE I9TH DR
OKEECHOBEE, FL 34972
WORK HARDENING
CENTER
OKEECHOBEE
JUPITER HAND
REHABILITATION CENTER
INC
(863) 357-4994
210 NE 3RD AVE
OKEECHOBEE, FL 34972
THIS LIST IS SUBJECT TO CHANGE
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited
4
Dental Plan
Florida Municipal Insurance Trust
1
Summary of Benefits
Calendar Year Deductible
Calendar Year Maximum
Per Covered Participant
$50
$1,000
Type A: Preventive Dental Services
Oral examinations, dental x -rays, prophylaxis, and fluoride and sealant applications (for dependents under age 15)
♦ 100% of covered expenses, no deductible
Type B: Basic Dental Services
Emergency treatment for pain, space maintainers, dental x -rays, biopsies of oral tissue, pulp vitality tests,
fillings, extractions, oral surgery, endodontics, periodontics
♦ 80% of covered expenses, after deductible
Type C: Dental Restorations and Specialty Services
Inlays, onlays, crowns, bridges, dentures
♦ 50% of covered expenses, after deductible
Type D: Orthodontia Services
Diagnostic procedures, comprehensive treatment, appliances
♦ 50% of covered expenses, after deductible ♦ $1,000 lifetime maximum per person
♦ $50 lifetime deductible per person ♦ Eligible dependents under age 19 only
(This is intended as a Summary of Benefits and does not include all of the benefits, limitations,
and exclusions of the plan. Complete terms of the plan are contained in the Master Plan of Benefits.)
Florida Municipal Insurance Trust
Certificate of Coverage
This Dental Master Plan of Benefits ( "Plan ") sets forth your rights and obligations as a
participant. It is important that you READ YOUR Plan FULLY 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 dental services, subject to the terms, conditions, exclusions and limitations of
the plan. The plan is issued on the basis of the Participation Agreement of the employer
and payment of the required plan charges. The employer's application is made a part of
the contract.
The Trust shall not be deemed or construed as an employer for any purpose with respect to
the administration or provision of benefits under the employer's benefit plan. The Trust
shall not be responsible for fulfilling any duties or obligations of an employer with respect
to the employer's benefit plan.
The Trust has sole and exclusive discretion in interpreting the benefits covered under the
plan and the other terms, conditions, limitations and exclusions set out in the plan and in
making factual determinations related to the plan and its benefits. The Trust may, from
time to time, delegate discretionary authority to other persons or entities providing
services in regard to the plan.
The Trust reserves the right to change, interpret, modify, withdraw or add benefits or
terminate the policy, in its sole discretion, without prior notice to or approval by
participants. No person or entity has any authority to make any oral changes or
amendments to the policy.
Please show your plan identification card each time you request health care services.
This is to ensure that the providers know that you are part of the plan; otherwise you
may receive a bill for health care services.
This plan shall take effect on the date specified and will be continued in force by the timely
payment of the required plan charges when due, subject to termination of the plan as
provided. All coverage under the plan shall begin at 12:01 a.m. and end at 12:00 midnight
Eastern Time.
IMPORTANT NOTICE REGARDING AMENDMENT AND TERMINATION
The Policyholder expects and intends to continue the Plan indefinitely. However, the Policyholder
reserves the right to amend or terminate the Plan at any time and for any reason. If the Plan is
amended or terminated, you and other active employees may not receive benefits as described in
other sections of this certificate. You may be entitled to receive difference benefits, or benefits under
different conditions. However, it is possible that you will lose all benefit Coverage. This may
happen at any time, if the Policyholder decides to terminate the Plan or your Coverage under the
Plan. In no event will you become entitled to any vested rights under this Plan. Further, the
provisions of this paragraph cannot be modified in any manner except by resolution of the
Policyholder.
SCHEDULE OF INSURANCE
Calendar Year Deductible $ 50 per covered participant
Calendar Year Maximum $1,000 per covered participant
Deductible and Insured Percentages
Type of Covered Expense Does the Deductible Apply? Insured
Percentage
Type A - Preventive Dental No 100%
Services
Type B - Basic Dental Services Yes 80%
Type C - Dental Restorations and Yes 50%
Specialty Services
Type D - Orthodontia Services: Yes 50%
Lifetime deductible - $50
Lifetime maximum -
$1,000
Orthodontia Services
apply to eligible
Dependents under age 19
only
Section
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
TABLE OF CONTENTS
Heading Page
I. DEFINITIONS 1
II. ELIGIBILITY AND ENROLLMENT ------------- --- - -4
III. DEDUCTIBLES AND MAXIMUMS 10
IV. COVERED DENTAL EXPENSES 10
V. EXCLUSIONS AND LIMITATIONS ------------------------------------- - - - -12
VI. COORDINATION OF BENEFITS - ----------- - - - -14
VII. CONDITIONS FOR RENDERING SERVICE--------- __-- _— __— ____— ____15
VIII. TIME OF PAYMENT, GRACE PERIOD - - -------------- - - - - -- ----- - - - -16
IX. EMPLOYER'S TERMINATION AND RENEWAL -- -16
X. PARTICIPANT'S TERMINATION OF COVERAGE— - - -- - ---- - - -17
XI. CONTINUATION OF COVERAGE - COBRA - -- - - - - -17
XII. GENERAL PROVISIONS 20
XIII. GRIEVANCE PROCEDURE - 22
XIV. SUBROGATION _ ___— _______________________ - -22
XV. NOTICE — ______ -23
Florida Municipal Insurance Trust Dental Master Plan of Benefits
SECTION I — DEFINITIONS
Accident means a non - occupational, unforeseeable, unintentional and unplanned event, other
than the acute onset of a bodily disease or infirmity, resulting in a traumatic injury to a
Participant while this Plan is in force. Injury or illness resulting from the acts of
bending, stooping, lifting, stretching or standing is covered as a Sickness.
Adopted Child means a child who, before attaining 18 years of age, has been lawfully adopted
by the Employee under State Laws and the Employee has established a legal
relationship with the child in which the State of Florida declares and recognizes the
child to be legally the child of the Employee and the Employee's heir at law and legally
entitled to all the rights and privileges and subject to all the obligations of a child born
to such Employee in lawful wedlock.
Annual Enrollment Period means a 30 -day period commencing on the date as specified by
the Employer's Participation Agreement during which each Employee is given an
opportunity to select coverage from among the alternatives offered under the
Employer's health benefit program.
Benefits shall mean the payment or reimbursement by the Plan of a portion of a Medical
Expense incurred by a Participant.
Calendar Year means a period of twelve (12) consecutive months commencing on January 1
and ending on December 31 of a given year. For participants enrolling during a
Calendar Year, the "Calendar Year" begins on the Effective Date of the Participant's
enrollment and ends on December 31 of the same year.
Calendar Year Deductible means the amount stated in the Schedule of Benefits the
Participant is required to pay to a Provider for Benefits in each Calendar Year before
the Trust will pay for Benefits provided under the Plan in the same Calendar Year.
COBRA means the federal continuation of Coverage requirements of the Consolidated
Omnibus Budget Reconciliation Act of 1985, as amended, also known as s. 4980B of
the Internal Revenue Code of 1986.
Coverage(s) or Covered Services or Covered Expenses means the services and supplies
specifically outlined in Sec. VI of this Plan and not otherwise excluded under this Plan,
when Medically Necessary and rendered within the scope of the license of an
appropriately licensed Provider, for which payment will be made by the Trust to, or
on behalf of, a Participant.
Dentist means a person licensed as such by the State of Florida when providing dental services
within the scope of the person's license and in accordance with State Laws.
Dental Services means those dental services for which benefits are provided under this Plan as
set forth in Section IV.
Dependent means the legal, married spouse of an Employee and /or the eligible legal,
unmarried (never married) Dependent children, as hereinafter described, who
continue(s) to meet this Plan's applicable eligibility requirements and who is actually
"Unless otherwise stated in the Schedule of Benefits trey. 08021
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Florida Municipal Insurance Trust
Dental Master Plan of Benefits
covered under this Plan. The Employee's child is a Dependent child if the child meets
all of the following conditions: (1) the child is a natural child, step - child, Adopted
Child, Foster Child or a child who has been placed in the court - ordered temporary or
other legal custody of the Employee, and (2) the child is in the custody of and
financially dependent upon the Employee. Condition (2) is waived if the Employee is
required to provide Coverage to the child due to court order or divorce decree. A
newborn child of a Dependent child having Dependent coverage is entitled to the same
benefits as the Dependent child; provided, however, a Dependent child shall not be
entitled to maternity benefits under this Plan, and with respect to a newborn child of a
Dependent child, Coverage under the Plan for the newborn child 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 the age of 19;
provided, however, that if such child is dependent upon the Employee for support, and
is living in the household of the Employee or is enrolled in and attending an accredited
school, college, or university, Coverage will continue until the end of the Calendar
Year in which the child reaches the age of 25, or upon the marriage of such child,
whichever event shall first occur. 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 a mental or physical disability that was
diagnosed while the Dependent child was covered under this Plan; and (2) chiefly
dependent upon the Employee for support and maintenance.
Upon attaining the eligibility limiting age, it is the Participant's sole responsibility to
establish that a child meets the applicable requirements for continued eligibility. The
burden is on the Participant to establish such Dependent meets or continues to meet
the applicable requirements for continued eligibility. The Trust may, at any time,
require reasonably reliable and acceptable documentation that a child meets and
continues to meet such requirements. Upon request by the Trust, the Participant must
provide a sworn and properly executed affidavit, which states the Dependent,
continues to meet the applicable requirements for eligibility. A Dependent's continued
eligibility does not modify any eligibility requirements other than the limiting age
requirement. Continued eligibility shall terminate on the last day of the month in
which the child does not meet the requirements of continued eligibility.
Dependent also may include individuals on short term sick or disability leave, FMLA
Leave, USERRA Leave or occupational /vocational (Workers' Compensation) leave
(for non occupational illness or injuries only) and who otherwise meet the
requirements of this definition.
Effective Date means, with respect to this entire Plan, and to Participants properly enrolled
when this Plan first becomes effective, 12:01 a.m. on the date specified on the
Participation Agreement; and, with respect to a Participant who is subsequently
enrolled in this Plan, 12:01 a.m. on the date on which Coverage will commence for the
Participant under the terms of this Plan.
Employee means an officer or employee of the Employer or any class or classes of such
employees, regularly working twenty -five (25) or more hours a week, who is eligible
"Unless otherwise stated in the Schedule of Benefits treu.08021
Page 2
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
for Coverage hereunder, who has been so designated by the Employer and who holds a
valid Social Security Number. Employee also includes the elected or appointed
officials of the Employer, employees who have retired and are receiving retirement
benefits pursuant to a retirement plan lawfully established and maintained by the
Employer and employees who are eligible for Medicare, but who nonetheless continue
to satisfy the first sentence of this definition. Employee also may include individuals
on short term sick or disability leave, FMLA Leave, USERRA Leave or
occupational /vocational (Workers' Compensation) leave (for non occupational illness
or injuries only) and who otherwise meet the requirements of this definition.
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 Participation
Agreement, and who has agreed to be bound by all the terms and provisions of the
Trust Agreement, the Participation Agreement, this Plan and the rules and regulations
adopted by the Trustees in the administration of the Trust.
Initial Enrollment Period means the 30 -day period of time immediately following the initial
dates an Employee or Dependent is first eligible to become a Participant under the
terms of this Plan.
Late Enrollee means a Participant who enrolls in the Plan at any time other than the Initial
Enrollment Period or the Special Enrollment Period.
Lifetime Maximum means the maximum liability of the Trust for Benefits provided under
this Plan to each Participant covered under this Plan, during the entire period such
Participant is covered under this Plan. Lifetime Maximum may refer to the maximum
amount stated in the Schedule of Benefits or to the maximum amount specified in
specific Benefits provided under Section VI of this Plan.
New Employee means an Employee who has never been previously employed by the
Employer prior to the Effective Date of this Plan and who is employed by the
Employer on or after the Effective Date of this Plan, or an Employee who was
employed by the Employer prior to the Effective Date of this Plan and was ineligible
to participate in the Employer's prior plan because the Employee had not completed
the period of continuous employment and hours requirement with the Employer as set
forth in such plan, if any, to qualify to participate in such plan.
Participant means and includes the Employee and any Dependent of the Employee who is
actually enrolled and covered under this Plan. Participant also means and includes
those Employees and their Dependents that qualify for continuation of coverage under
COBRA.
Plan means this Medical Master Plan of Benefits, the Dental Master Plan of Benefits, the
Employer's Participation Agreement, the Employer's Schedule of Benefits, the
Agreement and Declaration of Trust creating the Trust, the rules, regulations and
resolutions adopted by the Trust, the Employer's Group Application, the Employee's
Enrollment Forms, any Endorsements in effect, the identification cards issued to
Employees and Dependents indicating they are Participants, any arrangement between
"Unless otherwise stated in the Schedule of Benefits (rev. 08023
Page 3
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
the Trust and a network of health care providers, and any other agreement between
the Trust and the Employer by virtue of which the Employer and its eligible
Employees and their Dependents participate in the Trust and this Plan.
Provider means a person or facility defined herein when providing Benefits within the scope
of the person or facility's license and in accordance with State Laws.
Reasonable Fee means the maximum benefit allowance the Trust will pay for Benefits
provided to a Participant. Benefit allowances will be determined solely by the Trust.
The basis for the benefit allowance 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, including pre- negotiated payment amounts, diagnostic related groupings, relative
value scales, and /or the usual and customary charges for providing the medical service
or supply. These studies are used to develop benefit value schedules, which are
updated on a routine basis. Any charges above the amount determined to be a
Reasonable Fee shall be the responsibility of the Participant.
Single Procedure means a dental procedure to which a separate procedure number is assigned
by the Trust.
Special Enrollment Period means the 30 -day period of time specified in this Plan when an
Employee and /or Dependent may be eligible to enroll in this Plan outside of the Initial
Enrollment Period and the Annual Enrollment Period.
State Laws means the laws of the State of Florida and all rules, regulations, ordinances and
directives promulgated there under.
Treatment Plan means a written report showing the recommended treatment of any dental
disease, defect or injury for a Participant prepared by a Dentist as a result of any
examination made by such Dentist while Coverage under this Plan is in effect for the
Participant.
Trust means the Florida Municipal Insurance Trust, its Trustees and individuals or
organizations designated by the Trustees to act on behalf of the Trust.
Waiting Period means the period specified in the Participation Agreement that must pass
before an Employee or Dependent is eligible to become a Participant under the terms
of this Plan, less any Applicable Credit that must be given if the Participant has
satisfied a similar Waiting Period provision under a prior health insurance plan that
was replaced by this Plan.
SECTION II — ELIGIBILITY AND ENROLLMENT
Commencement of Coverage - Subject to any Waiting Period set forth under this Plan and
to any other condition of commencement expressed in this Plan, coverage hereunder
shall commence as follows:
"Unless otherwise stated in the Schedule of Benefits tree. 08021
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Florida Municipal Insurance Trust Dental Master Plan of Benefits
(1) In the event an Employer had no group dental insurance plan covering its
Employees and their Dependents in effect immediately prior to the Effective
Date of this Plan, all Employees of such Employer on the Effective Date, and
their eligible Dependents shall be eligible to participate in this Plan. Coverage
shall commence as of the Effective Date of the Plan without proof of
insurability provided the Trust receives a properly and accurately completed
and executed enrollment form and any required medical statement application
during the Initial Enrollment Period. If application is not received on or before
the expiration of the Initial Enrollment Period, any application for coverage by
an Employee, or the Employee's eligible Dependents, will be accepted only
during an Annual Open Enrollment Period or a Special Enrollment Period.
(2) In the event an Employee, or the Employee's eligible Dependents, were validly
covered under a group dental insurance plan issued to the Employer and in
effect immediately prior to the Effective Date of this Plan and such plan is
discontinued and replaced with this Plan, all such Employees and eligible
Dependents actually covered under such prior plan shall be eligible to
participate in this Plan, without interruption of coverage and without proof of
insurability, unless such Employee or Dependent is entitled to any extension of
benefits in accordance with S. 627.667, F.S., under the terms of the prior plan,
and provided the Trust receives a properly and accurately completed and
executed enrollment form, and any required medical statement application,
during the Initial Enrollment Period. 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 Dependent shall be
entitled to participate in this Plan without interruption of coverage and without
proof of insurability provided the Trust receives an accurately completed and
executed enrollment form, and any required medical statement application,
during the Initial Enrollment Period; however, the level of benefits under this
Plan shall be no more than the applicable level of benefits under this Plan,
reduced by any benefits payable under the prior plan. Upon request, the
Employer, Employee and /or Dependent shall provide the Trust all information
as is reasonably necessary, including specific coverage or claim information
from the prior plan, for the Trust to coordinate the level of benefits payable
under this Plan and under the prior plan, for the Trust to verify the level of
benefits provided under the prior plan, and for the Trust to determine each
Employee and Dependent who was validly covered under the prior plan
immediately prior to the Effective Date of this Plan. If application is not
received on or before the expiration of the Initial Enrollment Period, any
application for Coverage by an Employee, or the Employee's eligible
Dependents, will be accepted only during an Annual Enrollment Period or a
Special Enrollment Period.
Eligibility - Employees and eligible Dependents shall be eligible for Coverage on or after the
Effective Date of this Plan if:
(1) They fall within the classification set forth in the Employer's Participation
Agreement; and
"Unless otherwise stated in the Schedule of Benefits frev. 08021
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Florida Municipal Insurance Trust
Dental Master Plan of Benefits
(2) They have completed the period of continuous employment with the Employer
as set forth in such classification.
An Employee shall not be eligible as a Dependent under the same Employer group
except when both spouses are eligible Employees and desire dependent child(ren)
coverage. In that case, one Employee may cover the spouse and children as
Dependents for health Benefits and the spouse may be covered as a single Employee for
other employee coverage(s).
Enrollment - Employees and Dependents may enroll for Coverage under the Plan by
completing and submitting to the Employer an accurately completed and executed
enrollment form provided by the Trust, as specified below:
(1) Initial Enrollment Period - within 30 days of satisfaction of the Plan Waiting
Period.
(a) New Employees, and their Dependents shall be eligible to participate in
this Plan without proof of insurability subject to the exclusions
contained herein for Totally Disabled individuals. Participation in the
Plan shall commence on the first of the month following satisfaction of
the eligibility requirements set forth above. If the enrollment form is
not received on or before the expiration of the Initial Enrollment 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 Dependent is hospital confined, on
sick /short term disability leave or Family Medical Leave as defined by
the Family Medical Leave Act of 1993 (FMLA) when Coverage would
otherwise begin, Coverage will commence 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.
"Unless otherwise stated in the Schedule of Benefits (rev. 08021
Page 6
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
(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.
(2) Open Enrollment /Re- enrollment Period - within 30 days after the Employer's
Plan's policy renewal anniversary as specified in the Employer's Participation
Agreement, or as agreed to in writing by the Trust and the Employer. All Plan
Participant's must re- enroll by submitting a newly signed completed enrollment
application. Eligible Employees can enroll in the Plan or terminate Coverage
during the Open Enrollment Period. If application is received 30 days or more
following the Plan's policy renewal anniversary, any application for coverage
by an Employee or Dependents will be governed by the provisions set forth in
Paragraph (4) of this section except in the case of re- enrollment. Failure to re-
enroll in the Plan will result in suspended claim payment until a signed
completed enrollment application is received by the Trust.
Special Enrollment Period - within 30 days of certain events or loss of coverage
as outlined below:
(3)
(a) Employees and /or Dependents may utilize the Special Enrollment
Period if:
1) covered under another health benefit plan as an employee or
dependent, or COBRA continuation of coverage at the time of
initial eligibility to enroll for Coverage under this Plan; and
2) when offered Coverage under this Plan at the time of initial
eligibility, stated, in writing, that coverage under another health plan
was the reason for declining enrollment; and
3) demonstrated that loss of coverage under an individual or group
health benefit plan occurred as a result of legal separation, divorce,
death, termination of employment, reduction in the number of
hours of employment, or the coverage was terminated as a result of
the termination of employer contributions toward such coverage;
and
4) the required showing regarding loss of coverage and an enrollment
application is received by the Trust within thirty (30) days after the
termination of coverage under another health benefit plan.
"Unless otherwise stated in the Schedule of Benefits [rev. 0802)
Page 7
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
(b) A newly eligible Dependent acquiring such newly eligible status as a
result of marriage, birth, adoption or placement for adoption, legal
guardianship or court order, may utilize the Special Enrollment Period
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 specified herein, any application for Coverage will
be governed by Paragraph (4) of this Section.
1) In the event of marriage, the Effective Date of Coverage for such
Dependent shall be the first day of the month following receipt of
notification by the Trust.
2) In the event of a newborn, Coverage for such Dependent will take
effect on the date of birth. The Participant must provide a written
enrollment form to the Trust to notify the Trust of the birth of the
child within a notice period of thirty (30) days after the birth. If
timely notice is received by the Trust, the Trust will not charge an
additional premium for coverage of the newborn child for the
duration of the notice period. If timely notice is not received by the
Trust, the Trust may charge an additional premium from the date of
birth. If notice is given within 60 days of the birth of the child, the
Trust may not deny coverage of the child due to the failure of the
Participant to timely notify the Trust of the birth of the child.
Following this 60 -day period wherein no enrollment form is
received by the Trust, the Participant may only establish coverage
for such newborn Dependent(s) by utilizing the Annual Open
Enrollment Period.
Coverage for a newborn child of a Covered Dependent terminates
under the Plan eighteen months after the birth of the newborn child.
3) 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 accompany the Employee's
supplemental application for Coverage for such Dependent child. In
the case of an adopted newborn child, Coverage begins at the
moment of birth if a written agreement to adopt the child has been
entered into by the Participant prior to the birth of the 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
"`Unless otherwise stated In the Schedule of Benefits (ree. 08021
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Florida Municipal Insurance Trust
Dental Master Plan of Benefits
Trust, under oath, such information as is reasonably necessary to
keep the Trust apprised of the status of the adoption proceeding. See
subsection 5 hereunder for further relevant information.
4) In the event of an adoption or placement for adoption (other than
newborn), legal guardianship or court order, the Effective Date of
Coverage shall be from the date of the child's placement in the
Employee's residence or date specified by court order. The
Participant must provide a written enrollment to the Trust to notify
the Trust of the placement or adoption of the chilled within a notice
period of thirty (30) days after the adoption or placement for
adoption. If timely notice is received by the Trust, the Trust will
not charge an additional premium for coverage of the child for the
duration of the notice period. If timely notice is not received by the
Trust, the Trust may charge an additional premium from the date of
placement or adoption. As a condition of Coverage, the Employee
shall provide the Trust with a certified copy of the judgment of
adoption, guardianship of court order. See subjection 5 hereunder
for further relevant information.
5) In order to be covered under the Plan, the adopting Participant must
provide the Trust with written notice of the birth (in the case of a
newborn adoptee) or placement of the adopted Dependent, including
an enrollment form, within thirty (30) days of the birth or
placement. If timely notice is received by the Trust, the Trust may
not charge an additional premium for coverage of the newborn of
adopted child for the duration of the notice period. If timely notice
is not received by the Trust, the Trust may charge an additional
premium from the date of birth or placement. If notice is given
within 60 days of the birth or placement of the child, the Trust may
not deny coverage of the child due to the failure of the Participant to
timely notify the Trust of the birth or placement of the child.
However, in no event will adopted Dependent Coverage continue
beyond sixty (60) days after birth (in the case of a newborn adoptee)
or placement, without receipt of application and enrollment form by
the Trust. Following this 60 -day period wherein no enrollment
form is received by the Trust, the Participant may only establish
Coverage for such newborn Dependent(s) by utilizing the Annual
Open Enrollment Period.
It is the responsibility of the Participant to provide the Trust
appropriate written documentation demonstrating the child is an
Adopted Child, including proof of final adoption, a Foster Child, or
a child placed in the court - ordered temporary or other custody of
the Participant. It is the further responsibility of the Participant to
notify the Trust if an Adopted Child is not ultimately lawfully
placed in the Participant's residence, if and when the Foster Child is
no longer in the care of the Participant, or if and when a child is no
"Unless otherwise stated in the Schedule of Benefits trey. 08021
Page 9
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
longer in the court - ordered temporary or other custody of the
Participant.
The child's Coverage under the Plan will terminate at the end of the
month in which the Trust is notified the adoption could not be
legally completed, the Participant's status as a Foster Parent is
terminated, or the Participant's court- ordered temporary or other
custody of the child is terminated.
(c) An individual who loses coverage as a result of failure to pay premiums
on a timely basis, or the discontinuance of any contributions toward the
dental 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 a loss of eligibility for coverage or loss of
coverage entitling an Employee or Dependent to utilize the Special
Enrollment Period.
In the event a participant drops coverage, he /she and eligible dependents may not re-
enroll in the dental plan until the end of thirteen (13) months.
SECTION III — DEDUCTIBLES AND MAXIMUMS
The Calendar Year Deductible is waived for all Type A- Preventive Dental Services.
Only one Calendar Year Deductible applies if both Type B -Basic Dental Services and Type
C- Dental Restorations and Specialty Services expenses are incurred. Such deductible
amounts shall be satisfied on the basis of the first Covered Services rendered and by
application of the Reasonable Fee for such services.
Type D- Orthodontia Services is limited to a $50 lifetime deductible. The maximum benefit
payable for all Type D- Orthodontia Services expenses to a Participant rendered during that
Participant's lifetime shall not exceed $1,000.
The maximum benefit payable for all (Type A- Preventive Dental Services, Type B -Basic
Dental Services, Type C- Dental Restorations and Specialty Services, and Type D-
Orthodontia Services) expenses rendered to a Participant during any one calendar year shall
not exceed $1,000.
SECTION IV - COVERED DENTAL EXPENSES
Subject to the limitations, exclusions and other terms and conditions of this Plan, Benefits to
the extent hereinafter set forth shall be provided for Basic Dental and Orthodontia Services set
forth below when rendered by a Dentist.
In the event a Participant shall incur expenses for Covered Dental Services on or after his /her
effective date of Coverage hereunder, Benefits will be provided as follows for such expenses
(except for any amount in excess of a reasonable fee):
"Unless otherwise stated in the Schedule o1 Benefits Ireu. 08021
Page 10
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
Type A - Preventive Dental Services
Preventive Dental Services expenses are payable at 100% of the Reasonable Fee. No
deductible need be met for these services. Preventive Dental Services are defined as:
(1)
(2)
(3)
Oral examinations - limited to two (2) visits every Calendar Year.
Prophylaxis - limited to two (2) visits every Calendar Year.
X-rays -
a) Bite Wing - limited to two (2) visits per Calendar Year.
b) Panoramic or Full Mouth - limited to one (1) every 24 months. More
than 14 intraoral periapical x -rays are deemed a full mouth x -ray.
Fluoride and sealant applications - limited to two (2) visits every Calendar Year. This benefit
applies to Dependents under age 15 only.
Type B - Basic Dental Services
Basic Dental Services expenses are payable at 80% of the Reasonable Fee, after the Calendar
Year Deductible has been met. Basic Dental Services are defined as:
(1) Palliative treatment - temporary treatment of pain.
(2) Endodontic treatment - including root canals.
(3) Space maintainers - This benefit applies to Dependents under age 15 only.
(4) X -rays - other than full mouth, panoramic, or bite wing.
(5) Silver and synthetic permanent fillings - except when used in conjunction with
straightening teeth.
(6) Oral Surgery.
(7) Periodontal treatment.
(8) Normal extraction of teeth.
Type C - Dental Restorations and Specialty Services
Dental Restorations and Specialty Services expenses are payable at 50% of the Reasonable Fee,
after the Calendar Year Deductible has been met. Dental Restorations and Specialty Services
are defined as:
(1) Crowns and jackets - except when used in conjunction with straightening teeth.
(2) Gold fillings, crowns, onlays or inlays - will be paid at the recommended
allowance (reasonable fee) for a similar porcelain, silver or alloy filling crown,
onlay or inlay.
(3) Fixed bridges - consisting of crowns or jackets and the artificial teeth.
(4) Dentures and removable bridges - including adjustments and repairs.
"Unless otherwise stated in the Schedule of Benefits free. 08021 Page 11
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
Type D — Orthodontia Services (applies only to Dependent children under age 19)
Orthodontia Services expenses are payable at 50% of the Reasonable Fee, after the
Orthodontia Lifetime Deductible has been met. Benefits are only paid for services at the time
they are rendered. In no event will the total Benefit be payable in one sum at the start of
treatment. Orthodontia Services are defined as:
(1) Diagnostic procedures.
(2) Appliances for tooth guidance and control of harmful habits.
(3) Retention appliances.
(4) Comprehensive treatment — with fixed and removable appliances for correction
of malocclusion in permanent, primary and mixed dentition.
Pre - Treatment Estimate
If Covered Expenses for a course of treatment are expected to be more than $300, a Treatment
Plan must be submitted to the Trust before treatment begins. If the Trust determines that
alternate procedures, services or courses of treatment can be performed to correct a dental
condition, payment will be considered for the least costly procedure that will produce a
professionally satisfactory result.
SECTION V — EXCLUSIONS AND LIMITATIONS
No Benefits shall be provided under this Plan on account of:
(1) Services, care or treatment received from a dental or medical department
maintained by or on the behalf of an Employer, a mutual benefit association,
labor union, trustee or similar person or group.
(2) Services, care or treatment with respect to congenital malformations or
primarily for cosmetic or esthetics purposes.
(3) Services, care or treatment furnished or available to a Participant in whole in
part under the laws of the United States, or any state, or political subdivision
thereof, or for which the Participant would have no legal obligation to pay in
the absence of this or any similar Coverage.
(4) Services, care or treatment to the extent Coverage is available to the Participant
under any other Dental Care Plan.
(5) Services, care or treatment not specifically listed under Section IV.
(6) Expenses incurred for procedures, appliances or restorations necessary to
increase vertical dimension or restore occlusion or for purposes of splinting.
(7) Expenses incurred for the replacement of any prosthetic appliance or fixed
bridge within five (5) years following the date of the last replacement of such
appliance, crown or bridge.
"Unless otherwise stated in the Schedule of Benefits free. 08021
Page 12
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
(8)
(9)
Expenses incurred for lost or stolen appliance.
Expenses incurred for initial placement of any prosthetic appliance or fixed
bridge unless such placement is necessitated by the extraction of one or more
natural teeth while covered under this Plan. Any such appliance or fixed bridge
must include the replacement of the extracted tooth or teeth.
(10) Expenses for the replacement of denture or bridgework or temporary appliance
unless one or more natural teeth were extracted after Coverage began, and /or
the appliance is at least five (5) years old and cannot be made serviceable.
(11) Expenses incurred for any procedure begun before Coverage was in effect.
(12) Services rendered or supplies furnished after the date the Participant ceases to be
covered hereunder; or for any prosthetic dental appliances finally installed or
delivered more than thirty (30) days after the participant's Coverage terminates.
(13) Expenses by a Dentist for broken appointments or for completion of Dental
Claim Forms.
(14) Any services, care or treatment that do not meet the standards set by the
American Dental Association or which are not reasonably necessary or
customarily used for dental care.
(15) Preventive Services performed more than twice in a Calendar Year period or
for fluoride application(s) and sealants performed on Participants over the age
of 15.
(16) Charges made by a Dentist or dental hygienist who normally lives in the
Participants home or is a member of the Participant's immediate family.
(17) Services, care or treatment for which Coverage is available to the Participant, in
whole or part, under any Workers' Compensation Law or similar legislation,
whether or not the Participant claims compensation or receives benefits there
under and whether or not any recovery is had by the Participant against a third
party for damages resulting from a condition, disease, ailment or accidental
injury necessitating such Services.
(18) Dental care resulting from any injury sustained as a result of war, declared or
undeclared, or any action of war or any resistance to armed invasion or
aggression or international police action.
(19) Dental care resulting from any injury which is self - inflicted or not caused by an
Accident.
(20) Dental care resulting from participation in the commission of a felony.
(21) Services for the replacement of teeth using implant procedures or any services
on such implants.
"Unless otherwise stated in the Schedule of Benefits [rev. 0802]
Page 13
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
SECTION VI — COORDINATION OF BENEFITS
The purpose of dental care coverage is to help meet actual expenses. In line with that purpose,
this Plan contains a non - profit provision coordinating it with other plans, including group
plans under which a Participant is covered, so that the total Benefits available will not exceed
100% of the allowable expenses.
Primary Coverage — A plan without a coordination of benefits provision is always the
primary plan. If all potentially applicable plans have this provision:
(1) the plan covering the person as an employee rather than as a dependent is
primary;
(2) the plan covering the person as an active employee or as a dependent of an
active employee rather than Medicare is primary;
if a dependent child is covered under both parents' plans, the plan for the
parent with the earliest birth date 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. However, if a plan subject to the foregoing rule based on the
birthday of the parents coordinates with an out -of -state plan which contains
provisions under which the benefits cover a person as a dependent of a male are
determined before those of a person covered as a dependent of a female, and, if
as a result, the plans do not agree on the order of benefits, the provisions of the
other plan shall determine the order of benefits.
if a dependent child is covered under both parents' plans, and the parents are
divorced or separated, the primary plan will be determined in the following
order:
(3)
(5)
• 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;
and
• Third, the plan of the parent not having custody of the child; unless the
specific terms of a court decree state that one of the parents is responsible
for the health care expenses of the child in which case the plan covering
such parent is primary. A copy of the court decree must be furnished to
the Trust;
(6) The Plan covering an employee, or the employee's dependents, rather than a
retiree, or the retiree's dependents, is primary;
The Plan covering a person as an employee who has not retired, or as the
employee's dependents, rather than the plan covering a person, or the person's
dependents, as a retiree, is primary;
(7)
"Unless otherwise stated in the Schedule of Benefits (rev. 0802)
Page 14
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
(8)
The Plan covering a person as an employee, or the employee's dependents,
rather than a plan covering the person, or the person's dependents, under
COBRA, shall be primary.
If none of the above rules apply, the plan that covered an employee or dependent for a
longer period of time is primary.
Secondary Coverage — Services and Benefits under this Plan will be coordinated with, and
this Plan is hereby deemed secondary to plans providing coverage for services, supplies
or benefits furnished to a Participant or paid under any of the following plans of
insurance coverage:
(1) any plan, program or insurance policy providing dental benefits including, but
not limited to, policies issued to any health maintenance organization or any
entity to which such policies may legally be issued in the State of Florida for
the purpose of insuring a group of individuals;
(2) any plan, program or insurance policy and /or Personal Injury Protection
automobile insurance as required and defined in the Florida Statutes or policy
of No -Fault Insurance as defined by any other applicable state laws or
provisions, which provide benefits or makes payments to or on behalf of a
participant for hospital, medical and /or health care expenses;
(3) any group contract issued to this Trust;
(4) any dental coverage under a plan or law of any federal, state or local
government or any political subdivision thereof, including but not limited to,
coverage under Medicare 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 Section. The Participant shall provide, execute and deliver such
information, instruments and papers, and do whatever else is necessary to
secure the instruments and papers, and the Trust's rights under this paragraph.
(5)
SECTION VII - CONDITIONS FOR RENDERING SERVICE
Benefits will not be paid for any one item of expense under more than one provision of the
Plan. All related dental expenses will be part of the most comprehensive procedure and only
the Benefit for such procedure will be payable.
The Participant shall present proper identification issued by the Trust when applying for
dental services covered under this Plan.
The Plan does not confer upon the Trust any rights to select a Dentist for the Participant.
The Participant shall be at liberty to elect his or her Dentist. Nothing contained herein shall
interfere with the ordinary relationship between the Participant and the Dentist selected by
"Unless otherwise stated in the Schedule of Benefits [rev. 08021
Page 15
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
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 Covered Services
to the Participant to the extent herein specified. The Trust shall not, in any event, be liable
for any negligence, misfeasance, nonfeasance, malfeasance, malpractice or any act of
commission or omission on the part of any dental service Provider.
SECTION VIII — TIME OF PAYMENT, GRACE PERIOD
All contributions are due and payable on the first day of each month for which Coverage
under this Plan is provided. If the Employer fails to pay the contributions to the Trust within
twenty (20) days after they become due and payable, the Plan is automatically terminated
effective the first day of the month in which such contributions were due and payable and no
Participant shall thereafter be entitled to any further Benefits hereunder.
In the event this Plan terminates for any reason, the Employer shall be liable for all
contributions due and unpaid as of the date of termination in the event that claims were paid
after the contributions became due and payable.
The Trust must give an employer forty -five (45) days written notice of any change in the
monthly rate of contribution or any changes in this Plan's terms or Benefits.
SECTION IX — EMPLOYER'S TERMINATION AND RENEWAL
Except as provided in Section VIII, 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 is terminated.
(2) On the expiration date as provided in Section VIII, if the Employer fails to
make the required contributions.
All claims must be submitted no later than ninety (90) days after the date of termination of the
policy in order to be eligible for payment.
"Unless otherwise stated in the Schedule of Benefits frev. 08021
Page 16
Florida Municipal Insurance Trust Dental Master Plan of Benefits
SECTION X — PARTICIPANT'S TERMINATION OF COVERAGE
Unless a Participant qualifies for and elects continuation of Coverage pursuant to and in the
manner provided in Section XI of the Plan:
(1) Coverage for any Participant shall terminate automatically at the end of the
month for which payment of the contributions specified herein shall have been
made by the Employer for such Participant, in the event the Employer notifies
the Trust that the Coverage of such Participant under this Plan is to be
terminated.
(2) Coverage of the spouse of an Employee shall automatically cease upon a legal
separation of the spouse and Employee or termination of the marriage between
the spouse and Employee.
Coverage of the spouse and Dependents of an Employe shall automatically
cease upon the death of the Employee.
(4) Coverage of a Dependent child of an Employee shall automatically cease as
provided under Section I - Dependent Definition.
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.
(3)
(5)
SECTION XI — CONTINUATION OF COVERAGE - COBRA
The Plan provides an election for continuation of Coverage to qualified beneficiaries who
would otherwise lose Coverage under the Plan as a result of a qualifying event.
A qualified beneficiary means the Dependent spouse or Dependent child of an Employee who
is a Participant in the Plan on the day before the qualifying event. In the case of termination
(other than for gross misconduct), the term also includes the Employee. One exception to this
rule is when a child is born to (or placed for adoption with) an Employee during the COBRA
continuation period. These children will receive all rights of a qualified beneficiary
throughout the COBRA continuation period.
A qualifying event means the occurrence of any of the following events, which would result in
the loss of Coverage to:
(1)
Employee:
(a) Termination of employment for any reasons other than gross
misconduct.
(b) Reduction of work hours.
"Unless otherwise stated In the Schedule of Benefits (rev. 08021
Pagel]
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
(2)
(3)
Continuation
requirements.
is as follows:
(1)
(2)
(3)
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.
Dependent:
(a) Termination of Employee's employment.
(b) Reduction of Employee's work hours.
(c) Death of Employee.
(d) Divorce or legal separation from Employee.
(e) Employee becomes enrolled in Medicare.
(f) Dependent child ceases to be an eligible Dependent as defined by the
Plan.
of Coverage is conditioned upon satisfaction of the following notice
The notice requirement relating to election Coverage by qualified beneficiaries
In the event of an Employee's death, termination of employment or Medicare
eligibility, the Employer shall notify the Trust within sixty (60) 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.
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.
Notice hereunder to Employees or qualified beneficiaries shall be by First Class
Mail to their last known address; notice to the Trust shall be by First Class Mail
to the Board of Trustees of the Florida Municipal Insurance Trust.
A qualified beneficiary's election of continuation of Coverage must be made within sixty (60)
days following notice of continuation rights being provided 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.
If any other qualifying event occurs, the election of continuation of Coverage by the spouse
shall be deemed to include an election of continuation Coverage on behalf of any other
qualified beneficiary who would lose Coverage under the Plan by reason of the qualifying
event.
"Unless otherwise stated In the Schedule of Benefits trey. 08021 Page 18
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
The cost of Coverage to the qualified beneficiary shall be 102% of the cost of providing
Coverage for such period to a similarly situated Participant under the Plan to whom a
qualifying event has not occurred. In the event the qualifying event entitling the qualified
beneficiary to continuation of Coverage is the covered beneficiary's disability as defined by
the Social Security Act, the cost of Coverage to the qualified beneficiary for any month after
the 18th month of continuation Coverage following the date of termination shall be 150% of
the cost of providing Coverage for such period to a similarly situated Participant under the
Plan to whom the qualifying event has not occurred. The cost of Coverage shall be paid
directly to the Employer in monthly installments.
In the event of a covered Employee's termination, the period of continuation of Coverage is:
(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 a 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.
Up to twenty -nine (29) months from the date of such termination for such
Employee and such Employee's qualified beneficiaries, if it is determined, under
Title II or XVI of the Social Security Act, the covered Employee was disabled
on the date of termination. The Employee must notify the Trust of said
determination within sixty (60) days of said determination and within eighteen
(18) months of the date of termination. In the event another qualifying event
occurs during the eighteen (18) months following the date of the Employee's
termination, the period of continuation of Coverage is up to thirty -six (36)
months from the date of termination for such Employee and his qualified
beneficiaries.
(5)
A qualified beneficiary's continuation of Coverage shall cease on the earliest of the 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 VIII, if the qualified beneficiary fails to pay
contributions within thirty (30) days after they become due;
(4) The date the qualified beneficiary becomes covered under another group health
plan (as an employee or otherwise) with similar coverage, which does not
contain any exclusions or limitations for pre- existing conditions, and if there is
any pre- existing condition exclusion or limitation, coverage shall terminate on
the date such limitation or exclusion ends;
The date the qualified beneficiary becomes entitled to Medicare benefits;
(5)
"Unless otherwise stated in the Schedule of Benefits trey. 08021
Page 19
Florida Municipal Insurance Trust
Dental Master Plan of 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.
Notwithstanding the above, in no event shall said Coverage extend beyond the
twenty -nine (29) month Coverage period.
If COBRA is elected and the eighteen (18) or thirty -six (36) months maximum time frame is
exhausted, the qualified beneficiary may be eligible for Coverage under an individual plan
(through an insurer of their choice) on a guaranteed issue basis without any pre- existing
condition limitations.
In the event the Plan offers a conversion privilege, the qualified beneficiary shall be entitled to
said conversion privilege provided the qualified beneficiary applies for such conversion plan
during the last 180 days of the period of continuation Coverage.
Coordination of Benefits with other plans for COBRA recipients will follow current National
Association of Insurance Commissioners (NAIC) recommendations.
SECTION XII — GENERAL PROVISIONS
The Trust will issue to the Employer for delivery to each participating Employee covered
hereunder, a Schedule of Benefits, a copy of this Plan and appropriate identification cards,
which the Employee or eligible covered Dependents can present to a Dentist in claiming
Benefits due under this Plan. It shall be the Employer's responsibility to disseminate to the
Employee the Schedule of Benefits, a copy of this Plan and 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.
No representative has authority to change this Plan or waive any of its provisions. No change
in this Plan shall be valid unless approved by the Board of Trustees.
"Unless otherwise stated in the Schedule of Benefits trey. 08021
Page 20
Florida Municipal Insurance Trust Dental Master Plan of Benefits
Written proof of claim for services must be furnished to the Trust within 365 days after the
date of such services.
Benefits provided in this Plan would be payable to the Dentist rendering service under this
Plan or to the Participant upon receipt, by the Trust, of paid bills in acceptable form.
No action at law or in equity shall be brought to recover under this Plan prior to the
expiration of sixty (60) days written notice to the Trust. No such action shall be brought after
the expiration of the specified statute of limitations on such action. Such notice to the Trust
shall be sufficient if given to:
The Florida Municipal Insurance Trust
Attention: Health Department
125 E. Colonial Drive
Orlando, Florida 32801
An Employee applying for Coverage under this Plan for himself /herself or eligible
Dependents and the Participant and /or each Dependent of the Participant agrees that, as a
condition of payment of Benefits, Services and supplies, any Provider that has made or may
hereafter make a diagnosis, render service, attendance or treatment of or to a Participant, may
furnish and is authorized to furnish to the Trust at any time upon its request, a report
containing all information and records or copies of records pertaining to diagnosis, attendance,
service or treatment. The applicant or Participant and /or each Dependent of the applicant or
Participant agree 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 Participant sustained on or before the Participant'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 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.
"Unless otherwise stated in the Schedule of Benefits (rev. 08021
Page 21
Florida Municipal Insurance Trust
Dental Master Plan of Benefits
SECTION XIII — GRIEVANCE PROCEDURE
There are situations when Participants have questions about their Coverage or are dissatisfied
with Plan services. Such inquiries and complaints will be handled in a timely manner.
In the event that a claim is denied and the Participant disagrees with the denial, a re-
determination may be requested in writing detailing the reasons for the disagreement. This
request must be received within sixty (60) days of the initial claim denial. The Plan will
respond with a written decision, within sixty (60) days from receipt of the request.
SECTION XIV — SUBROGATION
If any payments are made to or on behalf of a Participant and such payments arise as a result
of an injury, illness or other condition for which the Participant has, or may have, or asserts
any claim or right of recovery (including, without limitation, claims for pain and suffering,
loss of consortium, consequential, punitive, exemplary or other damages) against a third party
or parties, then any benefits advanced by the Trust for such medical expenses shall be made on
the condition and with the agreement and understanding that the Participant shall reimburse
the Trust to the extent of (but not exceeding) any amount or amounts recovered by or on
behalf of the Participant (including the Participant's estate) from any third party by way of
settlement or in satisfaction of any judgment relating to said claim. The Trust shall maintain a
hen on any such recovery and be entitled to reimbursement in full in accordance with this
Section irrespective of whether the Participant has been fully compensated for all or any of
said claims. The Trust shall be entitled to such reimbursement from first dollar recovery
amounts received by the Participant. As security for the Trust's rights to such reimbursements
the Trust shall be subrogated to all claims, demands, actions or rights of recovery of the
Participant against any third party or parties (or their insurers) to the extent of any and all
benefits advanced by the Trust; and any Participant that takes any action prejudicing or
otherwise impairing the subrogation rights of the Trust shall be liable to the Trust for any
losses to the Trust caused by such action. Any action prejudicing or otherwise impairing the
subrogation rights of the Trust made by the Participant shall also terminate the Trust's
obligation to advance benefits to or on behalf of the Participant. The Trust shall withhold
payments of claims made under this Plan, to the extent that the Trust has reason to believe
that said claims arise as a result of any act of a third party, until the Participant or the
Participant's legal representative executes a subrogation agreement.
The subrogation rights of the Trust, as set forth in this Section, also apply to payments made
by the Participant's own auto insurance (with the exception of payment for property damage).
For purposes of this Section and any subrogation agreement executed pursuant hereto, the
term Participant shall include the heirs, guardians, executors or other representatives of the
Participant.
For purposes of this Section and any subrogation agreement executed pursuant hereto, the
spouses, children and other Dependents as Participants under the Plan are third party
"Unless otherwise stated in the Schedule of Benefits [rev. 08021
Page 22
Florida Municipal Insurance Trust Dental Master Plan of Benefits
beneficiaries under the Plan and therefore subject to the same duties and obligations as
Employees who are Participants under the Plan. If the Participant is a minor, any amount
recovered by or on behalf of such minor- Participant shall be subject to this provision, to the
fullest extent permissible under State Law.
The Trust shall have no obligation to share the cost of, or pay any part of, the Participant's
attorney fees and costs incurred in obtaining any recovery against the third party.
The Trust retains the right, at its sole discretion, to sue third parties on behalf of the
Participant should the Participant not commence lawsuit within a reasonable period of time.
The Trust reserves the right to make changes to this provision, as necessary, provided
appropriate advance notice is given to the Participant.
SECTION XV — NOTICE
Notice to an Employer given under the Plan shall be sufficient if given to the Employer when
addressed to its office location stated in the Participation Agreement. Notice to the Trust,
except as otherwise herein expressly provided, shall be sufficient if given to:
The Florida Municipal Insurance Trust
Attention: Health Department
125 E. Colonial Drive
Orlando, Florida 32801
"Unless otherwise stated in the Schedule of Benefits freu.08021
Page 23
I
Florida Municipal Insurance Trust
Major Plan Benefit
Calendar Year Deductible:
Individual
Family
Maximum Out of Pocket:
Individual
Family
Lifetime Maximum
In Network
0
0
$2,000
$4,000
$1,000,000
Out of Network
$500
$1,500
$3,000
$6,000
$1,000,000
♦ Inpatient
Services
♦ Outpatient
Services
♦ Emergency Room
Services
• Preventative Care
• Routine Services
• Well Child Care
• Specialty Care
• OB /GYN Care
• Allergy Injections
• Surgical Expense
• Maternity Care
Hospital Services
$100.00 Co -Pay per Day for
days 1 -5, then 70 %
of covered expenses
$100.00 Co -Pay, then 70%
of covered expenses
$100.00 Co -Pay, then 100%
of covered expenses
Physician Services
$30.00 Co -Pay **
$30.00 Co -Pay **
$30.00 Co -Pay **
$30.00 Co -Pay **
$30.00 Co -Pay **
$30.00 Co -Pay **
70%
$30.00 Co -Pay,
1St Visit, then 100%
$500.00 Co -Pay, then 50% of
reasonable charges
after deductible
$100.00 Co -Pay, then 50% of
reasonable charges
after deductible
$100.00 Co -Pay, then 100%
of reasonable charges
Not Covered
50% of reasonable charges
50% of reasonable charges
50% of reasonable charges
50% of reasonable charges
50% of reasonable charges
50% of reasonable charges
50% of reasonable charges
* *Co -Pay applies to office visit charge only - all other In Network in office services paid at 70%
MBF FLC -MS09B REV 10/01
Florida Municipal Insurance Trust
i
Other Health Care Services
♦ Prescription Drugs
(Express Scripts))
In Network
10.00 Generic
20.00 Preferred Brand
35.00 Non Preferred Brand
♦ Mental & Nervous Disorder
• Inpatient Services
(30 days per calendar year maximum)
• Outpatient Services
$1,000 calendar year maximum
♦ Alcohol and Drug Dependency
• Individual Visit
$2,000 lifetime maximum
$35.00 per visit maximum
(44 outpatient visits lifetime maximum)
♦
Hospice Care
(6 month maximum care)
$6,000 lifetime maximum
♦ Home Health Care
$1,000 calendar year maximum
♦ Physical Therapy
$2,000 calendar year maximum
♦ Skilled Nursing Facility
(60 days per year maximum)
♦ Chiropractic Services
♦ Routine X -Rays, Lab Tests,
Diagnostic Services
$100.00 Co -Pay,
then 70%
$30.00 Co -Pay,
then 100%
$30.00 Co -Pay
then 70%
Out of Network
Wholesale Price, less 13 %,
less In Network Co -Pay
$500.00 Co -Pay, then
50% of reasonable charges
50% of reasonable charges
$50.00 per visit maximum
50% of reasonable charges
70% 50% of reasonable charges
70% 50% of reasonable charges
70% 50% of reasonable charges
70% 50% of reasonable charges
$30.00 Co -Pay,
then 70%
50% of reasonable charges
$40.00 per visit maximum
70% 50% of reasonable charges
All surgical procedures over $500.00 must be pre- authorized. Failure to obtain a pre- authorization will result in a denial of benefits.
All emergency and non - emergency hospital stays must be pre- certified. Failure to obtain pre - certification will result in a 20% penalty.
All Out of Network Benefits are covered at 50% 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.
Co -Pays do not apply to the annual maximum out of pocket expenses.
The hospital Co -Pay for Out of Network confinement due to an emergency does not apply.
All charges exceeding reasonable charges are patient responsibility.
(This is intended as a Summary of Benefits and does not include all of the benefits, limitations,
and exclusions of the plan. Complete terms of the plan are contained in the Master Plan of Benefits.)
MBF FLC -MS09B REV 10/01
Florida Municipal Insurance Trust
I
Major Plan Benefit
Calendar Year Deductible:
Individual
Family
Maximum Out of Pocket:
Individual
Family
Lifetime Maximum
In Network
0
0
$1,500
$3,000
$1,000,000
Out of Network
$500
$1,500
$2,500
$5,000
$1,000,000
• Inpatient
Services
• Outpatient
• Emergency Room
Services
• Preventative Care
• Routine Services
• Well Child Care
• Specialty Care
• OB /GYN Care
• Allergy Injections
• Surgical Expense
• Maternity Care
Hospital Services
$250.00 Co -Pay, then 80%
of covered expenses
$100.00 Co -Pay, then 80%
of covered expenses
$100.00 Co -Pay, then 100%
of covered expenses
Physician Services
$25.00 Co -Pay **
$25.00 Co -Pay **
$25.00 Co -Pay **
$25.00 Co -Pay **
$25.00 Co -Pay **
$25.00 Co -Pay **
80%
$25.00 Co -Pay,
1st Visit, then 100%
$500.00 Co -Pay, then 60% of
reasonable charges
after deductible
$100.00 Co -Pay, then 60% of
reasonable charges
after deductible
$100.00 Co -Pay, then 100%
of reasonable charges
Not Covered
60% of reasonable charges
60% of reasonable charges
60% of reasonable charges
60% of reasonable charges
60% of reasonable charges
60% of reasonable charges
60% of reasonable charges
* *Co -Pay applies to office visit charge only - all other In Network in office services paid at 80%
MBF FLC -MSO9S REV 10/01
1
Florida Municipal Insurance Trust
Other Health Care Services
♦ Prescription Drugs
(Express Scripts)
In Network
Out of Network
$10.00 Generic Wholesale Price, less 13 %,
$20.00 Preferred Brand less In Network Co -Pay
$35.00 Non Preferred Brand
♦ Mental & Nervous Disorder
• Inpatient Services
(30 days per calendar year maximum)
• Outpatient Services
$1,000 calendar year maximum
♦ Alcohol and Drug Dependency
• Individual Visit
$2,000 lifetime maximum
$35.00 per visit maximum
(44 outpatient visits lifetime maximum)
♦ Hospice Care
(6 month maximum care)
$6,000 lifetime maximum
♦ Home Health Care
$1,000 calendar year maximum
♦ Physical Therapy
$2,000 calendar year maximum
♦ Skilled Nursing Facility
(60 days per year maximum)
♦ Chiropractic Services
♦ Routine X -Rays, Lab Tests,
Diagnostic Services
$100.00 Co -Pay,
then 80%
$25.00 Co -Pay,
then 100%
$25.00 Co -Pay
then 80%
$500.00 Co -Pay, then
60% of reasonable charges
60% of reasonable charges
$50.00 per visit maximum
60% of reasonable charges
80% 60% of reasonable charges
80% 60% of reasonable charges
80% 60% of reasonable charges
80% 60% of reasonable charges
$25.00 Co -Pay,
60% of reasonable charges
then 80% $40.00 per visit maximum
80% 60% of covered charges
All surgical procedures over $500.00 must be pre- authorized. Failure to obtain a pre- authorization will result in a denial of benefits.
All emergency and non - emergency hospital stays must be pre- certified. Failure to obtain pre - certification will result in a 20% penalty.
All Out of Network Benefits are covered at 60% 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.
Co -Pays do not apply to the annual maximum out of pocket expenses.
The hospital Co -Pay for Out of Network confinement due to an emergency does not apply.
All charges exceeding reasonable charges are patient responsibility.
(This is intended as a Summary of Benefits and does not include all of the benefits, limitations,
and exclusions of the plan. Complete terms of the plan are contained in the Master Plan of Benefits.)
MBF FLC -MSO9S REV 10/01
1
Florida Municipal Insurance Trust
Major Plan Benefit
Calendar Year Deductible:
Individual
Family
Maximum Out of Pocket:
Individual
Family
Lifetime Maximum
In Network
0
0
$1,000
$2,000
$1,000,000
Out of Network
$300
$900
$2,000
$4,000
$1,000,000
♦ Inpatient
Services
♦ Outpatient
Services
♦ Emergency Room
Services
• Preventative Care
• Routine Services
• Well Child Care
• Specialty Care
• OB /GYN Care
• Allergy Injections
• Surgical Expense
• Maternity Care
Hospital Services
$100.00 Co -Pay, then 90%
of covered expenses
$100.00 Co -Pay, then 90%
of covered expenses
$100.00 Co -Pay, then 100%
of covered expenses
Physician Services
$20.00 Co -Pay **
$20.00 Co -Pay **
$20.00 Co -Pay **
$20.00 Co -Pay **
$20.00 Co -Pay **
$20.00 Co -Pay **
90%
$20.00 Co -Pay,
1St Visit, then 100%
$500.00 Co -Pay, then 70% of
reasonable charges
after deductible
$100.00 Co -Pay, then 70% of
reasonable charges
after deductible
$100.00 Co -Pay, then 100%
of reasonable charges
Not Covered
70% of reasonable charges
70% of reasonable charges
70% of reasonable charges
70% of reasonable charges
70% of reasonable charges
70% of reasonable charges
70% of reasonable charges
* *Co -Pay applies to office visit charge only - all other In Network in office services paid at 90%
MBF FLC -MS090 REV 10 /01
1
Florida Municipal Insurance Trust
Other Health Care Services
• Prescription Drugs
(Express Scripts)
In Network
$10.00 Generic
$20.00 Preferred Brand
$35.00 Non Preferred Brand
• Mental & Nervous Disorder
• Inpatient Services
(30 days per calendar year maximum)
• Outpatient Services
$1,000 calendar year maximum
• Alcohol and Drug Dependency
• Individual Visit
$2,000 lifetime maximum
$35.00 per visit maximum
(44 outpatient visits lifetime maximum)
• Hospice Care
(6 month maximum care)
$6,000 lifetime maximum
• Home Health Care
$1,000 calendar year maximum
• Physical Therapy
$2,000 calendar year maximum
• Skilled Nursing Facility
(60 days per year maximum)
$100.00 Co -Pay,
then 90%
$20.00 Co -Pay,
then 100%
$20.00 Co -Pay
then 90%
Out of Network
Wholesale Price, less 13 %,
Tess In Network Co -Pay
$500.00 Co -Pay, then
70% of reasonable charges
70% of reasonable charges
$50.00 per visit maximum
70% of reasonable charges
90% 70% of reasonable charges
90% 70% of reasonable charges
90% 70% of reasonable charges
90% 70% of reasonable charges
• Chiropractic Services $20.00 Co -Pay,
70% of reasonable charges
then 90% $40.00 per visit maximum
• Routine X -Rays, Lab Tests, 90% 70% of reasonable charges
Diagnostic Services
All surgical procedures over $500.00 must be pre- authorized. Failure to obtain a pre- authorization will result in a denial of benefits.
All emergency and non - emergency hospital stays must be pre - certified. Failure to obtain pre - certification will result in a 20% penalty.
All Out of Network Benefits are covered at 70% 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.
Co -Pays do not apply to the annual maximum out of pocket expenses.
The hospital Co -Pay for Out of Network confinement due to an emergency does not apply.
All charges exceeding reasonable charges are patient responsibility.
(This is intended as a Summary of Benefits and does not include all of the benefits, limitations,
and exclusions of the plan. Complete terms of the plan are contained in the Master Plan of Benefits.)
MBF FLC -MS09G REV 10/01
Florida Municipal Insurance Trust
Master Plan Document
This Medical Master Plan of Benefits ( "Plan ") sets forth your rights and obligations as a
participant. It is important that you READ YOUR Plan FULLY and familiarize
yourself with its terms and conditions.
The Plan may require that the participant contribute to the required premiums.
Information regarding the premium and any portion of the premium cost a participant
must pay can be obtained from your employer.
Florida Municipal Insurance Trust ( "Trust ") agrees with your employer to provide
coverage for medical services, subject to the terms, conditions, exclusions and limitations
of the plan. The plan is issued on the basis of the Participation Agreement of the
employer and payment of the required plan charges. The employer's application is made
a part of the contract.
The Trust shall not be deemed or construed as an employer for any purpose with respect
to the administration or provision of benefits under the employer's benefit plan. The
Trust shall not be responsible for fulfilling any duties or obligations of an employer with
respect to the employer's benefit plan.
The Trust has sole and exclusive discretion in interpreting the benefits covered under the
plan and the other terms, conditions, limitations and exclusions set out in the plan and
in making factual determinations related to the plan and its benefits. The Trust may,
from time to time, delegate discretionary authority to other persons or entities providing
services in regard to the plan.
The Trust reserves the right to change, interpret, modify, withdraw or add benefits or
terminate the policy, in its sole discretion, without prior notice to or approval by
participants. No person or entity has any authority to make any oral changes or
amendments to the policy.
Please show your plan identification card each time you request health care services.
This is to ensure that the providers know that you are part of the plan; otherwise you
may receive a bill for health care services.
This plan shall take effect on the date specified and will be continued in force by the
timely payment of the required plan charges when due, subject to termination of the
plan as provided. All coverage under the plan shall begin at 12:01 a.m. and end at 12:00
midnight Eastern Time.
Florida Municipal Insurance Trust
Medical Master Plan of Benefits
TABLE OF CONTENTS
Section Heading
I. DEFINITIONS
Pa_e
1
II. DEDUCTIBLES 13
III. LIFETIME MAXIMUM AND RESTORATION OF BENEFITS 13
IV. MAXIMUM EXPENSE TO PARTICIPANTS 13
V. ELIGIBILITY AND ENROLLMENT 14
VI. COVERED SERVICES 20
VII. HOSPITAL BILL SELF -AUDIT 37
VIII. EXCLUSIONS AND LIMITATIONS 37
IX. COORDINATION OF BENEFITS 43
X. PRE- EXISTING CONDITIONS LIMITATIONS 48
XI. TIME OF PAYMENT, GRACE PERIOD 49
XII. CONDITIONS FOR RENDERING SERVICE 49
XIII. EMPLOYER'S TERMINATION AND RENEWAL 49
XIV. PARTICIPANT'S TERMINATION OF COVERAGE 50
XV. CONTINUATION OF COVERAGE - COBRA 52
XVI. PRESCRIPTION DRUGS 55
XVII. GENERAL PROVISIONS 56
XVIII. PAYMENT OF BENEFITS, ASSIGNMENT 58
XIX. GRIEVANCE PROCEDURES 58
XX. SUBROGATION 58
XXI. NOTICE 59
Florida Municipal Insurance Trust Medical Master Plan of Benefits
SECTION I — DEFINITIONS
Accident means a non - occupational, unforeseeable, unintentional and unplanned event, other
than the acute onset of a bodily disease or infirmity, resulting in a traumatic injury to a
Participant while this Plan is in force. Injury or illness resulting from the acts of
bending, stooping, lifting, stretching or standing is covered as a Sickness.
Acquired Immune Deficiency Syndrome or (AIDS) means the human immunodeficiency
virus identified as the causative agent of acquired immune deficiency syndrome, the
syndrome itself, an acquired immune deficiency syndrome - related complex, or a
Sickness or medical condition derived from the human immune deficiency virus or
AIDS.
Adopted Child means a child who, before attaining 18 years of age, has been lawfully adopted
by the Employee under State Laws and the Employee has established a legal
relationship with the child in which the State of Florida declares and recognizes the
child to be legally the child of the Employee and the Employee's heir at law and legally
entitled to all the rights and privileges and subject to all the obligations of a child born
to such Employee in lawful wedlock.
Advanced Registered Nurse Practitioner means a person licensed as such by the appropriate
governmental or regulatory authority as reasonably determined by the Trust when
providing services within the scope of the person's license and in accordance with State
Laws.
Ambulatory Surgical Center means a facility, other than a facility that is part of a Hospital
or Birth Center, licensed as such by the appropriate governmental or regulatory
authority as reasonably determined by the Trust, the primary purpose of which is to
provide elective surgical care in which the Participant is admitted to and discharged
from the facility within the same working day and is not permitted to stay overnight.
Annual Open Enrollment Period means a 30 -day period commencing on the date as
specified by the Employer's Participation Agreement during which each Employee is
given an opportunity to select coverage from among the alternatives offered under the
Employer's health benefit program.
Benefits shall mean the payment or reimbursement by the Plan of a portion of a Medical
Expense incurred by a Participant.
Billing Date represents the first of the month.
Birth Center means any facility, institution, or place, other than an Ambulatory Surgical
Center or a Hospital, licensed as such by the appropriate governmental or regulatory
authority as reasonably determined by the Trust at which births are planned to occur
away from the mother's usual residence following a normal, uncomplicated, low -risk
pregnancy.
Board - Certified Endocrinologist means a Physician who has received formal recognition as a
specialist in endocrinology from the specialty board of the American Board of Medical
Specialties or from another recognizing agency approved by the Board of Medicine.
Board of Medicine means the board established under s. 458.307, F.S.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 1
Florida Municipal Insurance Trust
Medical Master Plan of Benefits
Bone Marrow Transplant means human blood precursor cells administered to a Participant
to restore normal hematological and immunological functions following ablative
therapy with curative intent. Human blood precursor cells may be obtained from the
Participant in an autologous transplant or from a medically acceptable related or
unrelated donor, and may be derived from bone marrow, circulating blood, or a
combination of bone marrow and circulating blood. If chemotherapy is an integral
part of the treatment involving bone marrow transplantation, the term "bone marrow
transplant" includes both the transplantation and the chemotherapy.
Breast Reconstructive Surgery means surgery to reestablish symmetry between two breasts.
Calendar Year means a period of twelve (12) consecutive months commencing on January 1
and ending on December 31 of a given year. For a Participant enrolling during a
Calendar Year, the "Calendar Year" begins on the Effective Date of the Participant's
enrollment and ends on December 31 of the same year.
Calendar Year Deductible means the amount stated in the Schedule of Benefits the
Participant is required to pay to a Provider for Benefits in each Calendar Year before
the Trust will pay for Benefits provided under the Plan in the same Calendar Year.
Cast means a solid mold used to immobilize fractures, dislocations, and other severe injuries.
Certified Diabetes Educator means a person properly certified as such by the appropriate
governmental or regulatory authority as reasonably determined by the Trust to
supervise diabetes outpatient self- management training and educational services when
performing said services within the scope of the person's license and in accordance
with State Laws.
Certified Nurse Midwife means a person who is licensed as an Advanced Registered Nurse
Practitioner by the appropriate governmental or regulatory authority as reasonably
determined by the Trust and who is certified to practice midwifery by the American
College of Nurse Midwives when practicing midwifery within the scope of the
person's license and in accordance with State Laws.
Child Health Supervision Services means the following Physician- delivered or Physician -
supervised services provided to a Dependent child from moment of birth to 16 years of
age: a history, physical examinations, developmental assessments, anticipatory
guidance, oral and /or injectable immunizations, and laboratory tests normally
performed for a well child.
Clinical Social Worker means a person licensed as such by the appropriate governmental or
regulatory authority as reasonably determined by the Trust when providing clinical
social services within the scope of the person's license and in accordance with State
Laws.
Condition means an Accident or a Sickness.
COBRA means the federal continuation of coverage requirements of the Consolidated
Omnibus Budget Reconciliation Act of 1985, as amended, also known as s. 4980B of
the Internal Revenue Code of 1986.
Co- Insurance means the charge set forth in the Schedule of Benefits the Participant is
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 2
Florida Municipal Insurance Trust Medical Master Plan of Benefits
required to pay for Benefits provided under the Plan. Co- Insurance is usually
expressed as a percentage rather than as a dollar amount and constitutes a sharing of the
Reasonable Fees for Benefits between the Trust and the Participant. After the
Participant's Deductible requirement is met, the Trust will pay the percentage of the
Reasonable Fees for Benefits set forth in the Schedule of Benefits.
Co- Payment means the charge set forth in the Schedule of Benefits the Participant is required
to pay for Benefits at the time of service. The Co- Payment is usually expressed as a
dollar amount rather than as a percentage and is paid directly to the Provider at the
time of service.
Contract means this agreement between the Trust and the Employer by virtue of which the
Employer and its eligible Employees and their Dependents become Participants; the
Participation Agreement of the employer; the Agreement and Declaration of Trust
creating the Health Benefit Trust; the rules, regulations and resolutions adopted by the
Board of Trustees; the attached endorsements and riders, if any; the individual
applications of the Employees; and the identification cards issued to Employees
indicating their participation in the coverage provided hereunder.
Coverage(s) or Covered Services or Covered Expenses means the services and supplies
specifically outlined in Sec. VI of this Plan and not otherwise excluded under this Plan,
when Medically Necessary and rendered within the scope of the license of an
appropriately licensed Provider, for which payment will be made by the Trust to, or
on behalf of, a Participant.
Creditable Coverage means the period of time a Participant is covered under any of the
following:
1. A group health plan;
2. Health insurance coverage;
3. Part A and Part B of Title XVIII of the Social Security Act (Medicare);
4. Title XIX of the Social Security Act (Medicaid, other than coverage consisting
solely of benefits under Sec. 1928 of the program for distribution of pediatric
vaccines);
5. Ch. 55 of Title X, United States Code (medical and dental care for members
and certain former members of the uniformed services and their dependents);
6. A medical care program of the Indian Health Service or of a tribal organization;
7. The Florida Comprehensive Health Association or another similar state health
benefit risk pool;
8. A health plan offered under Ch. 89 of Title V, United States Code;
9. A public health plan; and
10. A health benefit under Sec. 5(e) of the Peace Corps Act (22 U.S.C.s. 2504(e)).
Dependent means the legal, married spouse of an Employee and /or the eligible legal,
unmarried (never married) Dependent children, as hereinafter described, who
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 3
Florida Municipal Insurance Trust Medical Master Plan of Benefits
continues to meet this Plan's applicable eligibility requirements and who is actually
covered under this Plan. The Employee's child is a Dependent child if the child meets
all of the following conditions: (1) the child is a natural child, step - child, Adopted
Child, Foster Child or a child who has been placed in the court - ordered temporary or
other legal custody of the Employee, and (2) the child is in the custody of and
financially dependent upon the Employee. Condition (2) is waived if the Employee is
required to provide coverage to the child due to court order or divorce decree. A
newborn child of a Dependent child having Dependent coverage is entitled to the same
benefits as the Dependent child; provided, however, a Dependent child shall not be
entitled to maternity benefits under this Plan, and with respect to a newborn child of a
Dependent child, coverage under the Plan for the newborn child 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 the age of 19;
provided, however, that if such child is dependent upon the Employee for support, and
is living in the household of the Employee or is enrolled in and attending an accredited
school, college, or university, coverage will continue until the end of the Calendar
Year in which the child reaches the age of 25, or upon the marriage of such child,
whichever event shall first occur. 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 a mental or physical disability that was
diagnosed while the Dependent child was covered under this Plan; and (2) chiefly
dependent upon the Employee for support and maintenance.
Upon attaining the eligibility limiting age, it is the Participant's sole responsibility to
establish that a child meets the applicable requirements for continued eligibility. The
burden is on the Participant to establish such Dependent meets or continues to meet
the applicable requirements for continued eligibility. The Trust may, at any time,
require reasonably reliable and acceptable documentation that a child meets and
continues to meet such requirements. Upon request by the Trust, the Participant must
provide a sworn and properly executed affidavit, which states the Dependent,
continues to meet the applicable requirements for eligibility. A Dependent's continued
eligibility does not modify any eligibility requirements other than the limiting age
requirement. Continued eligibility shall terminate on the last day of the month in
which the child does not meet the requirements of continued eligibility.
Dependent also may include individuals on short term sick or disability leave, FMLA
Leave, USERRA Leave or occupational /vocational (Workers' Compensation) leave
(for non occupational illness or injuries only) and who otherwise meet the
requirements of this definition.
Dietitian means a person licensed as such by the appropriate governmental or regulatory
authority as reasonably determined by the Trust to engage in dietetics and nutrition
practices or nutritional counseling when performing said services within the scope of
the person's license and in accordance with State Laws.
Durable Medical Equipment means medical equipment designated for repeated use and
which is Medically Necessary to improve the functioning of a malformed body
member, or to prevent further deterioration of the Participant's medical condition.
Effective Date means, with respect to this entire Plan, and to Participants properly enrolled
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 4
Florida Municipal Insurance Trust Medical Master Plan of Benefits
when this Plan first becomes effective, 12:01 a.m. on the date specified on the
Participation Agreement; and, with respect to a Participant who is subsequently
enrolled in this Plan, 12:01 a.m. on the date on which coverage will commence for the
Participant under the terms of this Plan.
Emergency means a Condition manifesting itself by acute symptoms of sufficient severity,
which may include severe pain or other acute symptoms, such that the absence of
immediate medical attention could reasonably be expected to result in serious jeopardy
to the Participant's health, including a pregnant Participant or her fetus; serious
impairment to bodily functions; or serious dysfunction of a bodily organ or part.
With respect to a pregnant Participant, Emergency also means there is inadequate time
to effect safe transfer to another Hospital prior to delivery, a transfer may pose a threat
to the health and safety of the pregnant Participant or her fetus, or there is evidence of
the onset and persistence of uterine contractions or rupture of the membranes. Any
purported Emergency Condition is subject to determination as such based on the
average, reasonable person facing the same or substantially similar acute medical
symptoms.
Employee means an officer or employee of the Employer or any class or classes of such
employees, regularly working twenty -five (25) 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. Employee also includes the elected or appointed
officials of the Employer, employees who have retired and are receiving retirement
benefits pursuant to a retirement plan lawfully established and maintained by the
Employer and employees who are eligible for Medicare, but who nonetheless continue
to satisfy the first sentence of this definition. Employee also may include individuals
on short term sick or disability leave, FMLA Leave, USERRA Leave or
occupational /vocational (Workers' Compensation) leave (for non occupational illness
or injuries only) and who otherwise meet the requirements of this definition.
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 Participation
Agreement, and who has agreed to be bound by all the terms and provisions of the
Trust Agreement, the Participation Agreement, this Plan and the rules and regulations
adopted by the Trustees in the administration of the Trust.
Experimental or Investigational means any evaluation, treatment, therapy, or device which
involves the application, administration, or use of procedures, techniques, equipment,
supplies, products, remedies, vaccines, biological products, drugs, pharmaceuticals, or
chemical compounds if, as determined solely by the Trust.
a. such evaluation, treatment, therapy, or device is not the standard treatment,
therapy, or device utilized by practicing Physicians in treating other patients with
the same or similar Condition;
b. such evaluation, treatment, therapy, or device is provided pursuant to a written
protocol which describes as among its objectives determinations of safety, efficacy,
or efficacy in comparison to the standard evaluation, treatment, therapy or device;
c. such evaluation, treatment, therapy or device has not been proven safe and effective
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 5
Florida Municipal Insurance Trust Medical Master Plan of Benefits
for treatment of the Condition in question, as evidenced in the most recently
published medical literature in the United States, Canada, or Great Britain, using
generally accepted scientific, medical or public health methodologies or statistical
practices;
d. there is no consensus among practicing Physicians that the treatment, therapy, or
device is safe and effective for the Condition in question; or
e. it has not been approved as a safe, effective and usual treatment method for the
specific Condition by the appropriate federal regulatory agency, including, but not
limited to, the U.S. Food and Drug Administration (FDA) and the Health Care
Financing Administration (HCFA).
Facility means an establishment that can include a Hospital or Ambulatory Surgical Center
where Covered Services are provided.
Foster Child means a child who, before attaining 18 years of age, is recognized as such by the
appropriate state authority and is lawfully placed in the Employee's residence and care
by the Florida Department of Children and Family Services.
Foster Parent means the Participant who is legal required to maintain the care and custody of
a Foster Child.
Fraud is the intentional deception or misrepresentation that an individual knows to be false
or does not believe to be true and makes, knowing that the deception could result in
some unauthorized benefit to himself /herself or some other person. Under the broad
definition of fraud are violations including the offering or acceptance of kickbacks,
waiver of deductible, coinsurance and co- payments.
Genetic Information means information about genes, gene products and inherited
characteristics that may derive from the Participant or a family member of the
Participant. It includes information regarding carrier status and information derived
from laboratory tests that identify mutations in specific genes or chromosomes,
physical medical examinations, family histories and direct analysis of genes or
chromosomes.
High -Risk Participants means estrogen- deficient Participants who are at clinical risk for
osteoporosis, Participants who have vertebral abnormalities, Participants who are
receiving long -term glucocorticoid (steroid) therapy, Participants who have primary
hyperparathyroidism, and Participants who have a family history of osteoporosis.
Home Health Agency means any public agency or private organization licensed as such by
the appropriate governmental or regulatory authority as reasonably determined by the
Trust to provide Home Health Services.
Home Health Aide means a person licensed as such by the appropriate governmental or
regulatory authority as reasonably determined by the Trust who, within the scope of
the person's license and in accordance with State Laws, provides hands -on personal
care, performs simple procedures as an extension of therapy or nursing services, assists
in ambulation or exercises, or assists in administering medications.
Home Health Services means the following services and supplies furnished to a Participant
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust Medical Master Plan of Benefits
by a Home Health Agency in a place of residence used as the Participant's home
including: 1) part -time or intermittent nursing care provided by a Registered Nurse or
a Licensed Practical Nurse; 2) physical therapy provided by a Physical Therapist,
subject to the limitations provided in Section VI, occupational therapy provided by an
Occupational Therapist, respiratory care services by a Respiratory Therapist or a
Respiratory Care Practitioner, or speech therapy provided by a Speech Therapist,
when related to a cleft lip or cleft palate Condition; 3) services of a Home Health Aide;
4) dietetics and nutrition practice and nutrition counseling; 5) medical supplies,
restricted to drugs and biologicals prescribed by a Physician. Home Health Services do
not include homemaker services, domestic maid services, sitter services, companion
services, or services and supplies rendered by an employee or operator of an adult
congregate living facility, an adult foster home, an adult daycare center, a nursing
home facility, or similar facilities.
Hospice Care means care, meeting the standards established by the National Hospice
Association, given to a terminally ill Participant by or under arrangements with a
Hospice Care Agency.
Hospice Care Agency means an organization, licensed as such by the appropriate
governmental or regulatory authority as reasonably determined by the Trust, which:
(1)
(2)
(3)
(4)
(5)
has twenty -four (24) hour Hospice Care available; and
provides skilled nursing_ services, medical social services, psychological and
dietary counseling; and
provides Physician services, services of a Physical Therapist, services of a part -
time Home Health Aide and Inpatient care; and
keeps medical records; and
has a full -time administrator.
Hospital means an establishment licensed as such by the appropriate governmental or
regulatory authority as reasonably determined by the Trust that offers services more
intensive than those required for room, board, personal services, and general nursing
care, that offers facilities and beds for use beyond 24 hours by a Participant requiring
diagnosis, treatment, or care for illness, injury, deformity, infirmity, abnormality,
disease, or pregnancy, and that regularly makes available at least clinical laboratory
services, diagnostic X -ray services, and treatment facilities for surgery or obstetrical
care, or other definitive medical treatment of similar extent. The term Hospital does
not include an Ambulatory Surgical Center, a Skilled Nursing Facility, a Birth Center,
a facility for the diagnosis, care, and treatment of Mental and Nervous Disorders or
Substance Abuse, a convalescent, rest or nursing home, or a facility which primarily
provides custodial, educational, or rehabilitative care.
Hospital Per Admission Co- Payment means the amount stated in the Schedule of Benefits
the Participant is required to pay upon admission as an Inpatient to a Hospital.
Initial Enrollment Period means the 30 -day period of time immediately following the initial
dates an Employee or Dependent is first eligible to become a Participant under the
terms of this Plan.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Pagel
Florida Municipal Insurance Trust Medical Master Plan of Benefits
Inpatient means a patient who has been admitted upon order of a Physician as a bed patient
for treatment in a Hospital and who has been charged for room and board.
Late Enrollee means a Participant who enrolls in the Plan at any time other than the Initial
Enrollment Period or the Special Enrollment Period.
Lifetime Maximum means the maximum liability of the Trust for Benefits provided under
this Plan to each Participant covered under this Plan, during the entire period such
Participant is covered under this Plan. Lifetime Maximum may refer to the maximum
amount stated in the Schedule of Benefits or to the maximum amount specified in
specific Benefits provided under Section VI of this Plan.
Marriage and Family Therapist means a person licensed as such by the appropriate
governmental or regulatory authority as reasonably determined by the Trust when
providing therapy services within the scope of the person's license and in accordance
with State Laws.
Massage Therapist means a person properly licensed to administer massages, pursuant to
Chapter 480 of the Florida Statutes, or other states' applicable law.
Mastectomy means the removal of all or part of a breast for Medically Necessary reasons.
Medically Necessary means treatment, care, services, or supplies that are consistent with the
diagnosis and treatment of the Participant, that comply with acceptable medical
standards, that are widely accepted by the Provider's peer group as efficacious and
reasonably safe based upon scientific evidence, that are universally accepted in clinical
use such that omission raises questions regarding the accuracy of the diagnosis or the
appropriateness of the treatment, that are not primarily for the convenience of the
Participant, the Participant's family, the Physician, or other health care Provider, that
are not experimental or investigational, that are not for cosmetic purposes, and that are
the most appropriate level of treatment, care, services, or supplies which can be safely
provided the Participant. When applied to Inpatient care, it means the care cannot be
safely provided on an Outpatient basis. Care that has not received federal approval by
the appropriate federal regulatory agency, including without limitation, the United
States Food and Drug Administration (FDA) and the Health Care Financing
Administration (HCFA) as a safe, effective and usual treatment for the specific
Condition will not be considered Medically Necessary.
Mental and Nervous Disorder means a disorder set forth in the diagnostic categories of the
most recently published edition of the American Psychiatric Association's Diagnostic
and Statistical Manual of Mental Disorders, regardless of the underlying cause or effect
of the disorder. Examples include attention - deficit hyperactivity, anorexia nervosa,
bulimia, bipolar effective disorder, autism, mental retardation, and Tourette's disorder.
Mental Health Counselor means a person licensed as such by the appropriate governmental
or regulatory authority as reasonably determined by the Trust when providing
counseling services within the scope of the person's license and in accordance with
State Laws.
Midwife means a person, other than a Physician or a Certified Nurse Midwife, licensed as
such by the appropriate governmental or regulatory authority as reasonably
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust Medical Master Plan of Benefits
determined by the Trust when practicing midwifery within the scope of the person's
license and in accordance with State Laws.
New Employee means an Employee who has never been previously employed by the
Employer prior to the Effective Date of this Plan and who is employed by the
Employer on or after the Effective Date of this Plan, or an Employee who was
employed by the Employer prior to the Effective Date of this Plan and was ineligible
to participate in the Employer's prior plan because the Employee had not completed
the period of continuous employment and hours requirement with the Employer as set
forth in such plan, if any, to qualify to participate in such plan.
Occupational Therapist means a person licensed as such by the appropriate governmental or
regulatory authority as reasonably determined by the Trust when practicing
occupational therapy within the scope of the person's license and in accordance with
State Laws.
Orthotic Device means a rigid or semi -rigid device needed to support a weak or deformed
body member or to restrict or eliminate body movement.
Outpatient means a patient who has not been admitted to a Hospital as an Inpatient and who
has not been charged for room and board.
Outpatient Services Co- Payment means the amount stated in the Schedule of Benefits the
Participant is required to pay upon receipt of any services received as an Outpatient.
Partial Hospitalization Services means treatment in which the Participant receives at least 7
hours of institutional care during a portion of a 24 -hour period and returns home or
leaves the treatment facility during any period in which treatment is not scheduled. A
Hospital shall not be considered a "home." Partial Hospitalization Services shall
include care rendered under the direction of a Physician for a Mental or Nervous
Disorder. For each fourteen (14) hour period of Partial Hospitalization Services
received for a Mental or Nervous Disorder, the Participant's available Mental and
Nervous Disorder Benefit for the extant Calendar Year shall be reduced by one (1) day.
Participant means and includes the Employee and any Dependent of the Employee who is
actually enrolled and covered under this Plan. Participant also means and includes
those Employees and their Dependents that qualify for continuation of coverage under
COBRA.
Participating Network Transplant Center of Excellence, or In Network means, in regard
to any Tissue or Organ Transplant Benefit supply or service, a licensed healthcare
facility that has entered in to a participation agreement at fee arrangements as
established with the participating network approved by the Trust to provide
transplant - related health services to the Trust.
Physical Therapist means a person licensed as such by the appropriate governmental or
regulatory authority as reasonably determined by the Trust when practicing physical
therapy within the scope of the person's license and in accordance with State Laws.
Physician means a doctor of medicine (M.D.) or a doctor of osteopath (D.O.), licensed as such
by the appropriate governmental or regulatory authority as reasonably determined by
the Trust to practice medicine and perform surgery. Doctors of dental surgery
**Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust Medical Master Plan of Benefits
(D.D.S.), doctors of dental medicine (D.M.D.), doctors of podiatry (D.P.M.), doctors
of chiropractic (D.C.), and doctors of optometry (O.D.), when practicing within the
scope of their licenses, are deemed to be Physicians.
Plan means this Medical Master Plan of Benefits, the Dental Master Plan of Benefits, the
Employer's Participation Agreement, the Employer's Schedule of Benefits, the
Agreement and Declaration of Trust creating the Trust, the rules, regulations and
resolutions adopted by the Trust, the Employer's Group Application, the Employee's
Enrollment Forms, any Endorsements in effect, the identification cards issued to
Employees and Dependents indicating they are Participants, any arrangement between
the Trust and a network of health care providers, and any other agreement between
the Trust and the Employer by virtue of which the Employer and its eligible
Employees and their Dependents participate in the Trust and this Plan.
Pre - Authorization means the process of notifying FMIT of any impending non - inpatient
requests for treatment services or supplies to assess for coverage and medical necessity.
All Inpatient hospitalizations, Alternate Level of Care, Skilled Nursing Facilities,
Outpatient Surgery performed either in a Hospital or a Physician's office, all MRI, CT
scans, Cardiac Stress Tests, Diagnostic Sleep Disorder Studies, Durable Medical
Equipment over $500, allergy testing and injectable medications (except insulin) must
be Pre - Authorized by the Managed Care Department of the Trust. Failure to obtain a
Pre - Authorization will result in a complete denial of Benefits for the subject services.
No authorizations for treatment or services after the treatment or services have been
rendered (Post- Authorization) will be permitted, where the Participant was required to
obtain Pre - Authorization, except at the absolute discretion of the Trust.
To avoid any forfeiture of Benefits, all questions pertaining to whether Pre -
Authorization for certain treatment or services is required should be directed to
the Trust's Customer Service Department at 1 (800) 756 -3042. Services requiring
Pre - Authorization are subject to change at any time at the sole discretion of the
Trust.
Pre - Certification means the process of notifying FMIT of any impending elective and /or
scheduled admission to a hospital or alternate level of care in order for FMIT to assess
for coverage and medical necessity. Pre - Certification notice to FMIT also includes
providing notice to FMIT of all Emergency services within 48 hours of receipt of
service.
Pre - Existing Condition means any condition, regardless of the cause of the condition, for
which medical advice, diagnosis, care, or treatment was recommended or received
within the 6 -month period ending on the first day of a Participant's Waiting Period for
Participants who enroll during the Initial Enrollment Period or within the 6 -month
period ending on the Participant's Effective Date for Participants who enroll during
the Special Enrollment Period or the Annual Enrollment Period. Pre - Existing
Condition excludes a Participant's pregnancy, generic information about the
Participant in the absence of a diagnosis of a Condition, routine follow -up care for
breast cancer after the Participant was determined to be free of breast cancer, or a
Condition arising from domestic violence committed against the Participant.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 10
Florida Municipal Insurance Trust
Medical Master Plan of Benefits
Preventative Care means services and supplies ordered and /or provided by or under the
direction of a Physician for which there is no medical diagnosis or for which the
Physician does not seek to diagnose, treat, or cure a Sickness or injury.
Prosthetic Device means a device, which replaces all or part of a body part or an internal
body organ or replaces all or part of the functions of a permanently inoperative or
malfunctioning body part or body organ.
Provider means a person or facility defined herein when providing Benefits within the scope
of the person or facility's license and in accordance with State Laws.
Psychologist means a person licensed as such by the appropriate governmental or regulatory
authority as reasonably determined by the Trust when practicing psychology within
the scope of the person's license and in accordance with State Laws.
Reasonable Fee means the maximum benefit allowance the Trust will consider for Benefits
provided to a Participant. Benefit allowances will be determined solely by the Trust.
The basis for the benefit allowance 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, including pre- negotiated payment amounts, diagnostic related groupings, relative
value scales, and /or the usual and customary charges for providing the medical service
or supply. These studies are used to develop benefit value schedules, which are
updated on a routine basis. Any charges above the amount determined to be a
Reasonable Fee shall be the responsibility of the Participant.
Registered Nurse or Licensed Practical Nurse means a person licensed as such by the
appropriate governmental or regulatory authority as reasonably determined by the
Trust when engaged in the practice of nursing within the scope of the person's license
and in accordance with State Laws.
Rehabilitative Services means health care service designed or provided to restore functional
defects.
Respiratory Care Practitioner means a person licensed as such by the appropriate
governmental or regulatory authority as reasonably determined by the Trust when
delivering respiratory care services within the scope of the person's license and in
accordance with State Laws.
Respiratory Therapist means a person licensed as such by the appropriate governmental or
regulatory authority as reasonably determined by the Trust when practicing
respiratory therapy within the scope of the person's license and in accordance with
State Laws.
Routine Care means services and supplies ordered and /or provided by or under the direction
of a Physician for the purpose of the diagnosis, treatment, or cure of a Sickness or
injury.
Schedule of Benefits means the Benefits provided to the Participant based on the Plan
selected by the Employer (i.e. POS Gold, Silver, Bronze, or Indemnity). It
encompasses the network of Providers offered to the Group, (i.e. First Health). Each
network of Providers is subject to an established fee schedule for all Providers within a
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 11
Florida Municipal Insurance Trust
Medical Master Plan of Benefits
particular network. Out -of- network and Indemnity fee schedules are based upon
Medicare usual and customary fee allowances for various services.
Second Surgical Opinion means the second opinion contained in a written statement on the
necessity for the performance of a covered surgical operation given by a board - certified
specialist who, by the nature of the Physician's specialty, qualifies the Physician to
provide the surgical opinion being proposed and who is not associated with the
Physician initially recommending the surgical operation.
Sickness means a disease, illness, infirmity, injury, bodily disorder, bodily dysfunction
(including a Mental or Nervous Disorder), or pregnancy of a Participant occurring
while this Plan is in force.
Skilled Nursing Facility means a facility licensed as such by the appropriate governmental or
regulatory authority as reasonably determined by the Trust, which provides 24 hour
nursing care for a Participant whose Condition does not warrant hospitalization. The
facility can operate independently or as part of a Hospital.
Special Enrollment Period means the 30 -day period of time specified in this Plan where an
Employee and /or Dependent may be eligible to enroll in this Plan outside of the Initial
Enrollment Period and the Annual Enrollment Period.
Speech Therapist means a person licensed as such by the appropriate governmental or
regulatory authority as reasonably determined by the Trust when practicing speech
therapy within the scope of the person's license and in accordance with State Laws.
Splint means an appliance used for fixation, union or protection of an injured part of the
body.
State Laws means the laws of the State of Florida and all rules, regulations, ordinances and
directives promulgated there under.
Substance Abuse means a Participant chronically and habitually uses alcoholic beverages to
the extent that it injures the Participant's health, to the extent it substantially interferes
with the Participant's social or economic functioning, or to the extent the Participant
has lost the power of self - control with respect to the use of such beverages, or means a
Participant is dependent upon, or by reason of repeated use is in imminent danger of
becoming chemically dependent upon, or addicted to, any legal or illegal substance
controlled under Ch. 893, F.S.
Total Disability means a medically determinable physical or mental impairment that renders
a Participant so incapacitated as to be unable to engage in any gainful occupation
within the range of his /her normal ability, taking into consideration the Participant's
education, training and work experience.
Truss means a device worn to hold a hernia in place.
Trust means the Florida Municipal Insurance Trust, its Trustees and individuals or
organizations designated by the Trustees to act on behalf of the Trust.
Waiting Period means the period specified in the Participation Agreement that must pass
before an Employee or Dependent is eligible to become a Participant under the terms
of this Plan, less any Applicable Credit that must be given if the Participant has
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust
Medical Master Plan of Benefits
satisfied a similar Waiting Period provision under a prior health insurance plan that
was replaced by this Plan.
SECTION II — DEDUCTIBLES
Individual Deductible – In any Calendar Year the Participant incurs expenses for Covered
Services on or after the Participant's Effective Date, such expenses shall be subject to
the Calendar Year Deductible set forth in the Schedule of Benefits.
Family Deductible – In any Calendar Year, all Participants within a family shall be subject to
the maximum accumulative Calendar Year Deductible set forth in the Schedule of
Benefits.
Deductible Credit from Employer's Prior Coverage – In the event a Participant has
incurred and paid Covered Expenses during the 90 days preceding the initial Effective
Date of this Plan under any other group health insurance plan issued to the Employer
which was in effect immediately prior to the Participant's coverage under this Plan,
then, upon receipt of written evidence submitted in manner satisfactory to the Plan,
the amount of such Covered Expenses actually incurred and applied toward the
deductible provisions of the Participant's other group health insurance plan shall be
credited toward the Participant's Calendar Year Deductible under this Plan in the
Calendar Year of the Participant's initial Effective Date.
SECTION III — LIFETIME MAXIMUM AND RESTORATION OF
BENEFITS
Each Participant is entitled to the Benefits specified in Section VI of this Plan when incurred
while the Plan is in force and when the Benefits are necessary and consistent with the
Condition for which the Participant is being treated.
Subject to the provisions of this Section, the Lifetime Maximum for each Participant during
the entire period such Participant is covered under this Plan shall be the amount specified in
the Schedule of Benefits.
(1)
If, during any one Calendar Year, more than $1,000 in Benefits have become
payable on behalf of a Participant, said Participant shall automatically be
entitled to $1,000 in restored Benefits commencing with the next Calendar
Year, regardless of whether the Lifetime Maximum in the Schedule of Benefits
has been reached.
Subsection (1) of this Section does not pertain to the specific Lifetime Maximums of limited
Benefits specified in Section VI of this Plan.
SECTION IV — MAXIMUM EXPENSE TO PARTICIPANTS
When the Covered Expenses of a Participant reach the amount specified in the Schedule of
Benefits, subject to the co- insurance requirements stated in the Schedule of Benefits, all further
Covered Expenses for that Calendar Year will be considered at 100% of the actual Reasonable
Fees, up to the Lifetime Maximum stated in the Schedule of Benefits.
"Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 13
Florida Municipal Insurance Trust Medical Master Plan of Benefits
SECTION V — ELIGIBILITY AND ENROLLMENT
Commencement of Coverage - Subject to any Waiting Period set forth under this Plan and
to any other condition of commencement expressed in this Plan, coverage hereunder
shall commence as follows:
(1) In the event an Employer had no group health insurance plan covering its
Employees and their Dependents in effect immediately prior to the Effective
Date of this Plan, all Employees of such Employer on the Effective Date, and
their eligible Dependents shall be eligible to participate in this Plan. Coverage
shall commence as of the Effective Date of the Plan without proof of
insurability provided the Trust receives a properly and accurately completed
and executed enrollment form and any required medical statement application
during the Initial Enrollment Period. If application is not received on or before
the expiration of the Initial Enrollment Period, any application for coverage by
an Employee, or the Employee's eligible Dependents, will be accepted only
during an Annual Open Enrollment Period or a Special Enrollment Period.
(2) In the event an Employee, or the Employee's eligible Dependents, were validly
covered under a group health insurance plan issued to the Employer and in
effect immediately prior to the Effective Date of this Plan and such plan is
discontinued and replaced with this Plan, all such Employees and eligible
Dependents actually covered under such prior plan shall be eligible to
participate in this Plan, without interruption of coverage and without proof of
insurability, unless such Employee or Dependent is entitled to any extension of
benefits in accordance with S. 627.667, F.S., under the terms of the prior plan,
and provided the Trust receives a properly and accurately completed and
executed enrollment form, and any required medical statement application,
during the Initial Enrollment Period. 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 Dependent shall be
entitled to participate in this Plan without interruption of coverage and without
proof of insurability provided the Trust receives an accurately completed and
executed enrollment form, and any required medical statement application,
during the Initial Enrollment Period; however, the level of benefits under this
Plan shall be no more than the applicable level of benefits under this Plan
reduced by any benefits payable under the prior plan. Upon request, the
Employer, Employee and /or Dependent shall provide the Trust all information
as is reasonably necessary, including specific coverage or claim information
from the prior plan, for the Trust to coordinate the level of benefits payable
under this Plan and under the prior plan, for the Trust to verify the level of
benefits provided under the prior plan, and for the Trust to determine each
Employee and Dependent who was validly covered under the prior plan
immediately prior to the Effective Date of this Plan. If application is not
received on or before the expiration of the Initial Enrollment Period, any
application for coverage by an Employee, or the Employee's eligible
Dependents, will be accepted only during an Annual Enrollment Period or a
Special Enrollment Period.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 14
Florida Municipal Insurance Trust Medical Master Plan of Benefits
(3)
In the event an Employee was 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, the
Employee's eligible Dependents not covered under the previous plan may
utilize the medical statement application process contained in Paragraph (4) of
this section and have Coverage commence accordingly, in lieu of the Open
Enrollment Period.
Eligibility - Employees and eligible Dependents shall be eligible for coverage on or after the
Effective Date of this Plan if:
(1) They fall within the classification set forth in the Employer's Participation
Agreement; and
(2) They have completed the period of continuous employment with the Employer
as set forth in such classification.
An Employee shall not be eligible as a Dependent under the same Employer group
except when both spouses are eligible Employees and desire dependent child(ren)
coverage. In that case, one Employee may cover the spouse and children as
Dependents for health Benefits and the spouse may be covered as a single Employee for
other employee coverage(s).
Enrollment - Employees and Dependents may enroll for Coverage under the Plan by
completing and submitting to the Employer an accurately completed and executed
enrollment form provided by the Trust, as specified below:
(1)
Initial Enrollment Period - within 30 days of satisfaction of the Plan Waiting
Period.
(a) New Employees, and their Dependents shall be eligible to participate in
this Plan without proof of insurability subject to the exclusions
contained herein for Totally Disabled individuals. Participation in the
Plan shall commence on the first of the month following satisfaction of
the eligibility requirements set forth above. If the enrollment form is
not received on or before the expiration of the Initial Enrollment 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 Dependent is hospital confined, on
sick /short term disability leave or Family Medical Leave as defined by
the Family Medical Leave Act of 1993 (FMLA) when Coverage would
otherwise begin, Coverage will commence 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. Any period of delayed commencement contained herein is subject
to a reduction based on the amount of any prior Creditable Coverage.
This subsection does not apply to a newborn child of an employee
covered for dependent coverage at the time of birth.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 15
Florida Municipal Insurance Trust Medical Master Plan of Benefits
(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 Condition limitations will apply to the Initial Enrollment
Period, as outlined in Section X.
(2) Open Enrollment /Re- enrollment Period - within 30 days after the Employer's
Plan's policy renewal anniversary as specified in the Employer's Participation
Agreement, or as agreed to in writing by the Trust and the Employer. All Plan
Participant's must re- enroll by submitting a newly signed completed enrollment
application. Eligible Employees can enroll in the Plan or terminate Coverage
during the Open Enrollment Period. Pre - Existing Condition limitations will
apply to the Open Enrollment Period, as outlined in Section X. If application
is received 30 days or more following the Plan's policy renewal anniversary,
any application for coverage by an Employee or Dependents will be governed
by the provisions set forth in Paragraph (4) of this section except in the case of
re- enrollment. Failure to re- enroll in the Plan will result in suspended claim
payment until a signed completed enrollment application is received by the
Trust.
(3)
Special Enrollment Period - within 30 days of certain events or loss of coverage
as outlined below:
(a) Employees and /or Dependents may utilize the Special Enrollment
Period if:
1) covered under another health benefit plan as an employee or
dependent, or COBRA continuation of coverage at the time of
initial eligibility to enroll for Coverage under this Plan; and
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 16
Florida Municipal Insurance Trust Medical Master Plan of Benefits
2) when offered Coverage under this Plan at the time of initial
eligibility stated, in writing, that coverage under another health plan
was the reason for declining enrollment; and
3) demonstrated that loss of coverage under an individual or group
health benefit plan occurred as a result of legal separation, divorce,
death, termination of employment, reduction in the number of
hours of employment, or the coverage was terminated as a result of
the termination of employer contributions toward such coverage;
and
4) the required showing regarding loss of coverage and an enrollment
application is received by the Trust within thirty (30) days after the
termination of coverage under another health benefit plan.
(b) A newly eligible Dependent, acquiring such newly eligible status as a
result of marriage, birth, adoption or placement for adoption, legal
guardianship or court order, may utilize the Special Enrollment Period
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 specified herein, any application for Coverage will
be governed by Paragraph (4) of this Section.
1) In the event of marriage, the Effective Date of coverage for such
Dependent shall be the first day of the month following receipt of
notification by the Trust.
2) In the event of a newborn, Coverage for such Dependent will take
effect upon receipt of an enrollment application for such newborn.
If the enrollment application is received within thirty (30) days of
the birth of the newborn, coverage will be considered effective from
the newborn's date of birth. If an enrollment form is not received
by the Trust during the initial 30 -day period, the Trust reserves the
right to charge a premium for Coverage of such newborn Dependent
during the initial thirty (30) day period following the birth, along
with the ordinary premium that would apply to such newborn
Dependent from the 31" day following the birth through the date of
receipt of application and enrollment forms. However, in no event
will newborn Dependent Coverage continue beyond sixty (60) days
after the birth without receipt of application and enrollment forms
by the Trust. Following this 60 -day period wherein no enrollment
application is received by the Trust, the Participant must attempt to
establish coverage for such newborn Dependent(s) by utilizing the
Annual Open Enrollment Period explained in subsection (2) of the
Enrollment section.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust Medical Master Plan of Benefits
Coverage for a newborn child of a Covered Dependent terminates
under the Plan eighteen months after the birth of the newborn child.
3) 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 accompany the Employee's
supplemental application for Coverage for such Dependent child. In
the case of an adopted newborn child, Coverage begins at the
moment of birth if a written agreement to adopt the child has been
entered into by the Participant prior to the birth of the 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 status of the adoption proceeding. See
subsection 5 hereunder for further relevant information.
4) In the event of an adoption or placement for adoption (other than
newborn), legal guardianship or court order, the Effective Date of
Coverage shall be from the date of the child's placement in the
Employee's residence or date specified by court order. The
Participant must provide a written enrollment to the Trust to notify
the Trust of the placement or adoption of the child within a notice
period of thirty (30) days after the adoption or placement for
adoption. If timely notice is received by the Trust, the Trust will
not charge an additional premium for coverage of the child for the
duration of the notice period. If timely notice is not received by the
Trust, the Trust may charge an additional premium from the date of
placement or adoption. As a condition of Coverage, the Employee
shall provide the Trust with a certified copy of the judgment of
adoption, guardianship or court order. See subjection 5 hereunder
for further relevant information.
5) In order to be covered under the Plan, the adopting Participant must
provide the Trust with written notice of the birth (in the case of a
newborn adoptee) or placement of the adopted Dependent, including
an enrollment form, within thirty (30) days of the birth or
placement. If timely notice is received by the Trust, the Trust may
not charge an additional premium for coverage of the newborn or
adopted child for the duration of the notice period. If timely notice
is not received by the Trust, the Trust may charge an additional
premium from the date of birth or placement. If notice is given
within 60 days of the birth or placement of the child, the Trust may
not deny coverage of the child due to the failure of the Participant to
timely notify the Trust of the birth or placement of the child.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 18
Florida Municipal Insurance Trust Medical Master Plan of Benefits
However, in no event will adopted Dependent Coverage continue
beyond sixty (60) days after birth (in the case of a newborn adoptee)
or placement, without receipt of application and enrollment form by
the Trust. Following this 60 -day period wherein no enrollment
form is received by the Trust, the Participant may only establish
Coverage for such newborn Dependent(s) by utilizing the Annual
Open Enrollment Period.
It is the responsibility of the Participant to provide the Trust
appropriate written documentation demonstrating the child is an
Adopted Child, including proof of final adoption, a Foster Child, or
a child placed in the court- ordered temporary or other custody of
the Participant. It is the further responsibility of the Participant to
notify the Trust if an Adopted Child is not ultimately lawfully
placed in the Participant's residence, if and when the Foster Child is
no longer in the care of the Participant, or if and when a child is no
longer in the court - ordered temporary or other custody of the
Participant.
The child's Coverage under the Plan will terminate at the end of the
month in which the Trust is notified the adoption could not be
legally completed, the Participant's status as a Foster Parent is
terminated, or the Participant's court - ordered temporary or other
custody of the child is terminated.
(c) An individual who loses coverage as a result of failure to pay premiums
on a timely basis, or the discontinuance of any contributions toward the
health Coverage plan by the employer or for cause does not have the
right to Special Enrollment under this Plan. Voluntary termination of
coverage does not constitute a loss of eligibility for coverage or loss of
coverage entitling an Employee or Dependent to utilize the Special
Enrollment Period.
(d) Pre - Existing Condition limitations will apply to the Special Enrollment
Period, as outlined in Section X, except in the case of newborn and
adopted Dependents.
(4) Medical Statement Application Enrollment - Those eligible Employees who
refuse Coverage for themselves or their Dependents under this Plan, those
Employees applying for Coverage, including Dependent Coverage, under this
Plan subsequent to the Effective Date of the Participation Agreement of the
Employer, or those Employees and Dependents who do not satisfy the
Coverage provisions specified in Paragraphs (1), (2), and (3) of this Section may
apply for Coverage at a later date by medical statement application. Such
Employee, on behalf of himself /herself or his /her Dependents, shall provide
the Trust with a completed medical statement application. 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. Pre - Existing Condition
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust
Medical Master Plan of Benefits
limitations will apply, as outlined in Section X.
The Employer shall submit such form and any required medical statement application,
as a prerequisite to the Coverage of such Employee(s) or Dependent(s) 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 Employee and /or the Employee's
Dependents.
The Employer does not act as an agent of the Trust in the enrollment and withdrawal
of its Employees and their Dependents. Notwithstanding, and in addition to, any
other conditions expressed herein for Coverage or payment of Benefits and Covered
Services, Coverage for each Employee and Dependent 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.
SECTION VI — COVERED SERVICES
If the Employer and the Participant have satisfied the terms and conditions provided in this
Plan for coverage and for the payment of Benefits, the Participant is entitled to the Benefits
listed below when incurred while the Plan is in force and when Medically Necessary and
consistent with the Participant's Condition. The Trust will base its reimbursements for
benefits on Reasonable Fees for such Benefits, unless otherwise expressly provided herein,
shall be subject to the Hospital Per Admission Deductible, the Calendar Year Deductible, the
Co- Payment, and the Co- Insurance requirements shown on the Schedule of Benefits, and to
the pre - existing exclusion section in this Plan. Unless otherwise expressly provided herein,
Benefits shall be paid up to the Lifetime Maximum shown on the Schedule of Benefits or
under the specific Benefit, or to the end of the Calendar Year, whichever first occurs.
(A) Hospital Pre - Admission Certification — Except in the case of an Emergency, the
attending Physician must receive certification from the Trust for all Inpatient
admissions to a Hospital. Certification must be received no less than 7 days prior to a
planned Inpatient admission. Emergency admissions must be certified within 48 hours
following Emergency admission or no later than the first business day following
admission, whichever is later. Pre - Admission Certification is not required for an
admission for the birth of a child, provided the Hospital or Birth Center length of stay
does not exceed 48 hours following a vaginal delivery or 96 hours following a cesarean
delivery. Certification by the Trust must be received following a vaginal delivery or a
cesarean delivery if the length of stay exceeds 48 hours or 96 hours, respectively.
Additionally, if a newborn is required to remain hospitalized after the birth mother is
discharged, the hospital must provide notice of such to FMIT's managed care nurses.
Certifications made by the Trust are made only to determine the appropriateness of
care and the appropriateness of setting for the care delivered to the Participant for
purposes of payment for Benefits under this Plan. Failure to timely obtain
certification will result in a 20% reduction in benefits paid under this Plan.
Services requiring Pre - Admission Certification are subject to change at any time at the
sole discretion of the Trust. The Trust will provide notification prior to any changes.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust Medical Master Man of Benefits
(B) Inpatient Hospital Services — The Plan will base its reimbursements for benefits on
Reasonable Fees for the following care, treatment, services and supplies when provided
to the Participant as an Inpatient at the Hospital
(1) Hospital room and board, not to exceed the average rate for a semi - private room.
(2) Intensive care unit (including cardiac and neonatal care units), not to exceed
three (3) times the average rate for a semi - private room.
Progressive care unit, not to exceed one and one -half (11h) times the average rate
of a semi - private room and only if incurred immediately following a
confinement in an intensive care unit.
(3)
(4) Miscellaneous services and supplies, such as use of operating, recovery and
emergency rooms, x -ray and other diagnostic procedures, laboratory tests,
pathological services, intravenous solutions, medications and dressings.
Transfusion services and supplies, including blood administration expenses, but
excluding blood, blood plasma and /or blood derivatives unless otherwise
specifically stated in this Plan.
Oxygen therapy, diathermy and physiotherapy.
Chemotherapy treatment, when such treatment is in connection with proven
malignancies.
Services of a Physical Therapist or Occupational Therapist (in connection with
a covered Condition).
Other Medically Necessary Services and Supplies
(5)
(6)
(7)
(8)
(9)
(C) Physician Services — The Plan will base its reimbursements for benefits on Reasonable
Fees for the following Physician care, treatment, and services.
(1) Surgical Services — wherever performed, limited to operative procedures for the
treatment of a Condition. 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
Participant and the type of eligible surgery performed require such assistance.
Consultations — which are Medically Necessary due to complications,
complexity or different diagnosis. A consultation report must be part of the
hospital medical records.
(4) Professional Component Expenses — of radiology, pathology ultrasound, allergy
testing and laboratory.
Medically Necessary Visits — while the Participant is an Inpatient in a Hospital,
while the Participant is in a Skilled Nursing Facility, while the Participant is in
an Ambulatory Surgical Center or while the Participant is an Outpatient (e.g.,
office visits), but not including visits for post- operative treatment.
(3)
(5)
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust Medical Master Plan of Benefits
(6) Medically Necessary Care and Treatment - rendered outside of the Hospital.
Expenses for routine physical examinations are not covered, unless otherwise
specifically stated in the Schedule of Benefits.
Concurrent Physician Care - Provided the concurrent Physician care is provided
by a Physician that actively participates in the care and treatment of the
Participant, the Condition involves more than one body system or is so severe
or complex that one Physician cannot provide the care and treatment
unassisted, and the Physicians have different specialties or have different sub-
specialties within the same specialty.
(D) Other Medical Services - The Plan will base its reimbursements for benefits on
Reasonable Fees for the following services and supplies.
(1) Alternative Treatment Provision - The Trust may, in its sole discretion, modify
some Plan provisions, if a Medically Necessary and a less costly alternative
Course of Treatment is available.
(7)
(2) Ambulance Transportation Services and Supplies - from a Hospital which is
unable to provide proper care and treatment to the nearest Hospital that can
provide proper care and treatment, from a Hospital to the Participant's nearest
home or to a Skilled Nursing Facility, or from the place where an Emergency
occurs to the nearest Hospital that can provide proper care and treatment.
Ambulance services by boat, airplane, or helicopter will be paid at the benefit
amount allowable for ground transportation unless, in the judgment of the
Trust, the pick -up point is inaccessible by ground vehicle, the speed in excess of
ground vehicle speed is critical to the care and treatment of the Participant, or
the travel distance in getting the Participant to the nearest Hospital that can
provide proper care and treatment is too far for the medical safety of the
Participant. Transportation services and supplies for a newborn child to and
from the nearest available facility appropriately staffed and equipped to treat
the newborn child's condition, when the necessity of such transportation is
certified by the attending physician as necessary to protect the health and safety
of the newborn child, shall be covered. In no event shall the benefits for
transportation services and supplies under this Plan exceed the sum of $1,000
per incident, or exceed $3,000 per incident in the event of aircraft ambulance
services.
(3)
Anesthesia - The administration of, including supplies and equipment charges,
for regional, intravenous, inhalation, intraspinal and caudal anesthesia services
when performed by a qualified anesthesiologist (which may be defined as a
Physician or Certified Registered Nurse Anesthetist) in connection with a
covered surgical service and not administered by the operating surgeon or
surgical assistant.
(4) Prosthetic, Orthotic and Other Devices - initial (under this Plan) appliances,
crutches, braces, cardiac pacemakers, standard model wheelchairs, or other
mechanical appliances Medically Necessary for the correction of conditions
arising out of an Accident or Sickness, including a Prosthetic Device following
"Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 22
Florida Municipal Insurance Trust Medical Master Plan of Benefits
(5)
a covered Mastectomy, and services to fit, adjust, and repair such devices,
provided the devices and services are prescribed by a Physician and the devices
and services do not, in whole or in part, serve as a comfort or convenience item.
Pre - authorization must be obtained by the Trust for any devices and services
the cost of which exceed $500. The Trust shall have the right to buy or rent
such devices as it may elect.
Splints, Casts, Trusses — which are medically necessary for the care and treatment
of a covered condition.
(6) Other Durable Medical Equipment Rental — required for temporary therapeutic
use, 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. Pre -
Authorization must be obtained by the Trust for equipment the cost of which
exceeds $500. The Plan will consider reasonable fees for rental, however,
cannot exceed the purchase price for any Durable Medical Equipment.
Initial Eye Glasses or Contact Lens — resulting only from cataract or glaucoma
surgery (including those surgically implanted), subject to a limit of $150.
Radiology, Anesthesiology, and Pathology Benefits — Where radiology,
anesthesiology, or pathology services (RAP) are to be performed at a Facility,
the Plan provides coverage at the in- network level of benefits, subject to the
required in- network Co- Insurance, and without being subject to the Calendar
Year Deductible, provided the Facility is within the relevant provider network
approved by the Trust. However, the Plan will only pay the usual and
customary fees for such RAP services, according to the CPT Code submitted.
If the Facility is outside the relevant provider network approved by the Trust,
the Plan will pay for radiology, anesthesiology, or pathology services at the out -
of- network benefit level.
(7)
(8)
(E) Multiple Surgical Procedures - Multiple Surgical Procedures performed by one or
more qualified Physicians during the same operative session will be covered according
to the following guidelines:
(1) The lesser of the actual charges or the amount stated in the Schedule of Benefits
will be allowed for the primary surgical procedure.
(2) 50% of the lesser of the actual charge or the amount stated in the Schedule of
Benefits will be allowed for other secondary Covered surgical procedures.
Bilateral Surgical Procedures - Bilateral Surgical Procedures performed by one or
more qualified Physicians during the same operative session will be covered according
to the following guidelines:
(F)
(1)
(2)
The lesser of the actual charges or the amount stated in the Schedule of Benefits
will be allowed for the primary surgical procedure.
50% of the lesser of the actual charges or the amount stated in the Schedule of
Benefits will be allowed for the secondary Covered surgical procedure.
Bilateral Surgical Procedures when preformed in combination with Multiple Surgical
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 23
Florida Municipal Insurance Trust Medical Master Plan of Benefits
Procedures will be reimbursed according to the application of the reimbursement
conventions enumerated in Section (E) above and the application of this Section (F)'s
reimbursement conventions.
(G) Assistant Surgeon - A Physician who actively assists the operating surgeon in
rendering a Covered surgical service to a Participant. Benefits are payable only if an
intern, resident, or Hospital staff member is not available. No Benefits are payable for
surgical assistance rendered by an intern, resident, or Hospital staff member. Assistant
surgeons will be reimbursed at the lesser of the assistant surgeon's charges or 20 percent
of the covered reimbursement amount of the operating surgeon.
(H) Clinical Claim Audits - Medical and surgical services rendered by a qualified Provider
to a Participant in or out of a Hospital may be subject to a Clinical Claims Audit to
determine appropriateness of the Provider's billing. Such claims will be audited for the
following billing practices:
(1) Upcoding: Upcoding is the term for the practice of billing the Plan using a
billing code that provides a higher payment rate than the billing code intended
for use with the item or service furnished to the Participant. Claims determined
by the Plan to be upcoded shall be reassigned and reimbursed according to the
appropriate billing code intended for use with the item or service provided.
(2) Unbundling: is the practice of billing separately for services when a global
billing code is provided and billing under the global billing code would result in
a lower payment rate. Claims determined by the Plan to be unbundled shall be
reassigned and reimbursed according to the appropriate billing code intended
for use with the item or service provided.
(I) Supplemental Accident Benefit - The expenses incurred for services or supplies to
treat injuries resulting from an Accident will be paid, up to the maximum stated in the
Schedule of Benefits, provided such expenses are incurred within ninety (90) days of
the Accident. Such expenses shall be subject to the Hospital Per Admission
Deductible, but shall not be subject to the Calendar Year Deductible, the Co-
Insurance, or the Co- Payment requirements stated in the Schedule of Benefits.
Expenses incurred in excess of the maximum stated in the Schedule of Benefits or
incurred after the ninety (90) day period set forth above shall be subject to the
Calendar Year Deductible, the Co- Payment and the Co- Insurance requirements stated
in the Schedule of Benefits.
(1)
Supplemental Accident Dental Benefit - The expenses incurred for services and
supplies to treat damage to natural (not artificial) teeth, not previously compromised
by decay or periodontal disease, and to treat damage to immediate adjacent structures
(e.g., periodontium) resulting from an Accident will be paid, provided such treatment
is initiated within ninety (90) days of the Accident. An unexpected event while
chewing food which causes traumatic injury to natural teeth is not an Accident.
(K) Diagnostic X -ray, Laboratory and Pathological Services Benefit - The Plan will
consider the Reasonable Fees for Outpatient Hospital and Physician services for
diagnostic x -ray, laboratory and pathology services required for the treatment of a
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 24
Florida Municipal Insurance Trust
Medical Master Plan of Benefits
Sickness up to the amount specified in the Schedule of Benefits.
(L) Ambulatory Surgical Center Benefit — The Plan will consider the Reasonable Fees
for the following services and supplies when such services and supplies are provided at
an Ambulatory Surgical Center:
(1) Miscellaneous services and supplies, such as use of operating and recovery
rooms, x -ray and other diagnostic procedures, laboratory tests, pathological
services, intravenous solutions, medications and dressings.
(2) Transfusion supplies and services, including blood administration expenses, but
excluding blood, blood plasma and /or blood derivatives unless otherwise
specifically stated in this Plan.
Anesthesia services, including supplies, equipment and Physician charges for
regional, intravenous, inhalation, intraspinal and caudal anesthesia services
when performed in connection with surgical, obstetrical, electro- shock, or
dental services covered under this Plan.
(M)
(N)
(3)
(4) Oxygen therapy, diathermy, and physiotherapy.
(5) Chemotherapy treatment, when such treatment is in connection with proven
malignancies.
(6) Other Medically Necessary services or supplies.
Chiropractic Services Benefit — The Plan will consider the Reasonable Fees for the
services of a Doctor of Chiropractic (DC) when performing services within the scope
of the doctor's license.
Outpatient Therapeutic Services Benefit — The Plan will consider the Reasonable
Fees for the following therapeutic services and supplies.
(1) Physical therapy services provided by a Physician or a Physical Therapist,
limited to 40 visits, up to a $2,000 per Calendar Year maximum;
(2) Chemotherapy treatment for proven malignant diseases;
(3) X -ray, cobalt, or other acceptable forms of radiation therapy for treatment of
proven malignant diseases;
(4) Allergy immunotherapy; and
(5) Electroshock therapy services when performed by a Physician.
(6) Occupational Therapy, which will result in significant clinical improvement in
a patient's condition. Significant clinical improvement is solely determined by
the Florida Municipal Insurance Trust, and must occur within 60 days from the
date of the first treatment. A written treatment plan must be submitted for
approval. The patient's participation in Occupational Therapy must relate to a
current health condition, and have a reasonable chance for improvement. The
Trust will not pay for vocational rehabilitation, maintenance, job training, or
those services that fall under the Workers' Compensation benefit. This benefit
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 25
Florida Municipal Insurance Trust
Medical Master Plan of Benefits
(7)
shall be limited up to $2,000 per Calendar Year maximum;
Speech Therapy, which can result in a significant clinical improvement in a
patient's condition. Significant clinical improvement is solely determined by
the Florida Municipal Insurance Trust, and must occur within 60 days from the
date of the first treatment. A written treatment plan must be submitted for
approval. The patients participation in Speech Therapy must relate to a current
health condition, and have a reasonable chance for improvement. This benefit
shall be limited up to $2,000 per Calendar Year maximum.
(0) Second Surgical Opinions - Second Surgical Opinions may be obtained from a
Physician prior to surgery for the following surgical procedures:
(1) Arthoplasty - plastic operation on a joint or the formation of an artificial joint
when performed on the knee or hip;
(2) Arthroscopy - internal examination performed by the use of a scope, when
performed on the knee;
(3) Cholecystectomy - removal of the gall bladder;
(4) Coronary Bypass and Pacemaker Insertion;
(5) Dilation and Curettage (D &C);
(6) Hemorrhoidectomy - removal of a mass of swollen varicose veins in the rectal
mucous membrane;
(7) Hysterectomy - removal of the uterus by excision;
(8) Laminectomy or Laminotomy - removal of or incision into a disk;
(9) Prostatectomy - excision of the prostrate gland;
(10) Subcutaneous Mastectomy - excision of cyst, tumor, or lesion of the breast;
(11) Submucous resection /rhinoplasty - surgical correction of deviated septum, plastic
surgery on the nose;
(12) Tonsillectomy /adenoidectomy - removal of the tonsils and adenoids.
(13) Bunionectomy - surgical removal of the bunion.
(14) Cataract removal - removal of the opacity of the crystalline lens of the eye.
The Second Surgical Opinion must be obtained from a Physician that specializes in the
surgical procedure and who is not associated with the attending Physician.
Services available under the Second Surgical Opinion Benefit are subject to change at
any time at the sole discretion of the Trust.
In addition, the Trust has the discretion to request a Second Surgical Opinion as part
of their clinical review process for additional surgical procedures not included on the
above list.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust
Medical Master Plan of Benefits
(P)
(Q)
Mental and Nervous Disorder Benefit - The Plan will consider the Reasonable Fees
for services and supplies to treat a Mental and Nervous Disorder, subject to the
following terms, conditions and limitations:
(1) Inpatient benefits shall be limited to 30 days per Calendar Year.
(2) Outpatient benefits shall be provided under the direction of a Physician, shall
be limited to $1,000 per Calendar Year, and shall be limited to consultations
with a Physician, a Psychologist, a Mental Health Counselor, a Marriage and
Family Therapist, or a Clinical Social Worker.
In no event shall the Reasonable Fees for Partial Hospitalization Services or a
combination of Inpatient and Partial Hospitalization Services exceed the cost of
30 days of Inpatient benefits measured by the usual and customary daily cost of
Inpatient hospitalization in the community in which the Partial Hospitalization
Services are rendered.
(3)
Medicare Supplement Benefits - A Participant over the age of 65 who retires from
the employ of the Employer while this Plan is in force is only eligible for the Medicare
Supplement Benefits of this Plan. Medicare Supplement Benefits are limited to the
following:
(1) For initial Hospital expenses for confinement as a Hospital Inpatient, the Plan
will pay the Part A Medicare deductible.
(2) For Hospital expenses from the 61st day through 150th day as a Hospital
Inpatient, the Plan will pay the amount of the daily Medicare coinsurance.
(3) The Medicare Part B deductible is paid by the Plan at 100% per Calendar Year.
(4) The Medicare Part B co- insurance is paid by the Plan for eligible reasonable fees
incurred as determined by Medicare.
Prescription Medicines - When ordered by a Physician, consistent with the
treatment of a specific diagnosis, when dispensed by a licensed pharmacist, and
when obtained through the mandatory prescription program provided in
Section XVI of this Plan. Vitamins, minerals and over - the - counter medications
are not eligible expenses. Expenses are subject to the individual Calendar Year
Deductible, Co- Insurance and Co- Payment requirements set forth in the former
Employer's Schedule of Benefits.
Home Health Services performed by a Home Health Agency, subject to the
terms, conditions, and limitations contained in Section VI (w) of this Plan.
The Lifetime Maximum for all Medicare Supplement benefits is $1,000,000.
(5)
(6)
(7)
(R) Substance Abuse Benefit - As used in this Section, `substance abuse' means the use of
alcoholic beverages or any psychoactive or mood altering substance in such a manner
as to induce mental, emotional or physical problems and cause socially dysfunctional
behavior.
The Plan will base its reimbursements for Substance Abuse benefits on Reasonable
Fees incurred as a result of necessary care and treatment subject to the following terms,
conditions and limitations:
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 21
Florida Municipal Insurance Trust
Medical Master Plan of Benefits
Care and treatment must be provided by, provided under the supervision of, or
prescribed by a Physician or Psychologist licensed as such by the appropriate
governmental or regulatory authority as reasonably determined by the Trust;
(1) Care and treatment must be pursuant to a program accredited by the Joint
Commission on Accreditation of Hospitals or approved by the appropriate
governmental or regulatory authority as reasonably determined by the Trust;
(2) The Lifetime Maximum number of Outpatient visits shall be 44 and the
maximum benefit payable for each Outpatient visit shall be $35.00.
Detoxification will not be considered a benefit under an Outpatient program.
(3)
(4)
The Lifetime Maximum Benefit shall be $2,000.00.
(S) Maternity Care Benefit - The Plan will consider the Reasonable Fees for the services
and supplies for maternity care provided to a Participant other than a Dependent child
by a Physician, a Hospital, a Birth Center, a Midwife, or a Certified Nurse Midwife,
including prenatal care, delivery and postpartum care rendered within 24 hours of
delivery. Maternity care for a mother and her newborn child includes a postpartum
assessment and newborn assessment, a physical assessment of the newborn and the
mother, and any Medically Necessary clinical tests and immunizations called for under
then prevailing medical standards. Maternity care must be provided at a Hospital, a
Birth Center, an attending Physician's office, and Outpatient maternity center, or in
the home by a qualified licensed health care professional trained in care for a newborn
child and mother.
(T)
Maternity care benefits are not provided for a Dependent child. Maternity care
does not include care and treatment for complications of pregnancy or care and
treatment for false labor, occasional spotting, bed rest prescribed by a Physician,
morning sickness, pre - eclampsia (protein in urine, sudden increase in weight, continual
increase in blood pressure without convulsions), or similar problems associated with a
difficult pregnancy. Maternity care benefits are not subject to the pre- existing
exclusion section in this Plan.
Care for Complications of Pregnancy - The Plan will consider the Reasonable Fees
for services and supplies to treat complications of pregnancy. Coverage for
complications of pregnancy is limited to services and supplies to treat the Sickness
caused by the complication. "Complications of pregnancy" means a Sickness, which is
diagnosed as separate from a normal, uncomplicated, low -risk pregnancy.
Complications of pregnancy include, but are not limited to:
(1) Acute nephritis;
(2) Nephrosis;
(3) Cardiac decompensation;
(4) Eclampsia (toxemia with convulsions);
(5) Uncontrolled vomiting requiring fluid replacement;
(6) Therapeutic abortion (i.e., termination of pregnancy before the time of fetal
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 28
Florida Municipal Insurance Trust
Medical Master Plan of Benefits
(7)
viability due to danger to the pregnant Participant or when the pregnancy
would result in the birth of an infant with grave malformation);
Conditions which may require other than a vaginal delivery, such as:
a. Uterine wound separation.
b. Premature labor unresponsive to tocolytic therapy.
c. Failed trial labor.
d. Dystocia (i.e., cephalopelvic disproportion, failure to progress,
dysfunctional labor).
e. Fetal distress requiring neonatal support /intervention.
f. Breech presentation where external version is unsuccessful.
g. Active clinical herpes at delivery.
h. Placenta previa.
i. Transverse lie where external version is unsuccessful.
j. Presence of fetal anomaly.
Tubal pregnancy;
Miscarriages; or
Sicknesses of similar severity.
Complications of pregnancy do not include false labor, occasional spotting, bed rest
prescribed by a Physician, morning sickness, pre - eclampsia (protein in urine, sudden
increase in weight, continual increase in blood pressure without convulsions) or similar
problems associated with a difficult pregnancy. Maternity care is not included in care
for complications of pregnancy unless delivery is required to resolve the complication.
The Plan will not consider the Reasonable Fees for services or supplies to treat the
complication of pregnancy of a Dependent child.
(U) Newborn Children Care Benefit — The Plan will consider the Reasonable Fees for
the necessary care and treatment of a Participant's newborn child from the moment of
birth. Newborn children care will include the necessary care and treatment of
medically diagnosed congenital defects, birth abnormalities, prematurity, and
transportation costs of a newborn to and from the nearest available facility
appropriately staffed and equipped to treat the newborn's Condition; however, any
such transportation costs must be certified by the attending Physician as necessary to
protect the health and safety of the newborn child and transportation costs shall be
limited to Reasonable Fees, not to exceed $1,000.
(V) Child Health Supervision Services Benefit — The Plan will consider the Reasonable
Fees for Child Health Supervision Services, subject to the following terms, conditions
and limitations:
(1) Child Health Services Benefit shall include Physician visits to accomplish a
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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(W)
history, physical examination, a developmental assessment and anticipatory
guidance, appropriate immunizations and lab tests. All such services provided
under this benefit shall be provided in accordance with and not to exceed the
prevailing medical standards consistent with the Recommendations for
Preventative Pediatric Health Care of the American Academy of Pediatrics.
(2) Benefits are limited to one visit payable to one Physician for all services
provided at that visit.
Child Health Supervision Services are not subject to the Calendar Year Deductible, but
are subject to the Co- Insurance and Co- Payments requirements stated in the Schedule
of Benefits.
Hospice Care Benefit — A Participant will be eligible for Hospice Care 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 the Participant is terminally ill,
(2) and attesting the Participant has a life expectancy of six (6) months or less, and
(3) the range of and charges for services that will or could be rendered to the
Participant.
Hospice Care is for Reasonable Fees incurred for the palliation or management of
terminal illness. Benefits shall be payable for routine and continuous home care.
Hospice care will only be approved once for a Participant.
(X) TMJ Benefit — The Plan will consider the Reasonable Fees for diagnostic or surgical
procedures involving bones or joints of the jaw and facial region if, under accepted
medical conditions, such procedures are Medically Necessary to treat conditions caused
by congenital or developmental deformity, disease or injury. This Benefit shall not
cover the care or treatment of the teeth or gums, intraoral prosthetic devices or
procedures for cosmetic purposes.
(Y) Acquired Immune Deficiency Syndrome Benefit — The Plan will consider the
Reasonable Fees for services and supplies related to the care and treatment of Acquired
Immune Deficiency Syndrome up to the Lifetime Maximum Benefit.
(Z) Cardiac Rehabilitation Benefit — The Plan will consider the Reasonable Fees for the
services of a Cardiac Rehabilitation Facility for cardiac rehabilitation on an Outpatient
basis provided such services are prescribed by a Physician and are provided under the
direct supervision of a Physician, and provided the Participant meets the following
criteria:
(1) Myocardial Infarction - post myocardial infarction, Participant may enter the
program anytime at the discretion and referral of the Physician;
(2) Post -op Cardiovascular Surgery - a minimum of three weeks aorta - coronary
bypass surgery, or at the discretion and referral of the Physician;
Adequate control of complications, i.e., angina, congestive heart failure or
(3)
"Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Medical Master Plan of Benefits
arrhythmias;
(4) Pacemaker patients with any of the above diagnosis and /or decreasing
functional capacity.
(AA) Home Health Care Benefit — The Plan will consider the Reasonable Fees, up to a
maximum of $1,000 per Calendar Year, for Home Health Services performed by a
Home Health Agency, provided the services are necessitated by an Accident or
Sickness, subject to the following terms, conditions and limitations: the services must
be performed pursuant to a written plan of treatment prescribed by a Physician, the
plan of treatment must be Pre - Authorized, and the Participant must be confined to
home and unable to carry out the basic activities of daily living.
(BB) Skilled Nursing Facility Benefit - The Plan will consider the Reasonable Fees for the
following services and supplies when furnished to a Participant while an Inpatient in a
Skilled Nursing Facility.
(1) Room and board, not to exceed the average rate of a semi - private room;
(2) Respiratory therapy (e.g., oxygen);
(3) Drugs and medicines administered while an Inpatient;
(4) Intravenous solutions;
(5) Dressings, including ordinary casts;
(6) Transfusion supplies and equipment, including blood administration expenses,
but excluding blood, blood plasma and /or blood derivatives unless otherwise
specifically stated in this Plan;
(7) Diagnostic services, including radiology, ultrasound, laboratory, pathology and
approved machine testing (e.g., electrocardiogram);
(8) Chemotherapy treatment for proven malignant disease;
(9) Services of a Occupational, Physical or Speech Therapist (in connection with a
covered Condition); and
(10) Other Medically Necessary services and supplies.
The services and supplies must be provided pursuant to a written plan of treatment
prescribed by a Physician and Pre - authorized by the Trust. Benefits shall be limited to
a maximum stay in the Skilled Nursing Facility of 60 days per Calendar Year.
(CC) Mastectomy Benefit — The Plan will consider the Reasonable Fees for services and
supplies for a Mastectomy, for Breast Reconstructive Surgery incident to a
Mastectomy, and for the Outpatient post - surgical follow -up care following Breast
Reconstructive Surgery. Post - surgical follow -up care shall be provided at the most
medically appropriate setting, which may include the Hospital, the treating Physician's
office, an Outpatient facility, or the home of the Participant. All services and supplies
must be Medically Necessary and related to the Mastectomy.
(DD) Mammogram Benefit — The Plan will consider the Reasonable Fees for the following
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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mammogram screening services, subject to the following terms, conditions and
limitations:
(1) Coverage for mammograms is limited to one base line mammogram, with or
without prescription, for a Participant who is 35 years of age or older, but
younger than 40 years of age; a mammogram every 2 years, with or without a
prescription, or more frequently if prescribed by the Participant's Physician, for
a Participant who is 40 years of age or older, but younger than 50 years of age; a
mammogram, with or without prescription, every year for a Participant who is
50 years of age or older; and one or more mammograms a year, based upon a
Physician's recommendation, for a Participant who is at risk of breast cancer
because of a personal or family history of breast cancer, because of a history of
biopsy- proven benign breast disease, because the Participant's mother, sister, or
daughter has or has had breast cancer, or because a Participant has not given
birth before the age of 30.
(2) Except for mammograms done more frequently than every two years for
women 40 years of age or older, but younger than 50 years of age, the Plan will
consider the Reasonable Fees for mammogram screening services only when the
Participant obtains a mammogram in a medical office, medical treatment
facility or through a health testing service that uses radiological equipment
registered with the Florida Department of Children and Family Services for
breast cancer screening.
Unless otherwise stated in the Schedule of Benefits, mammogram- screening services
shall be subject to the Calendar Year Deductible, Co- Insurance and Co- Payment
requirements stated in the Schedule of Benefits.
(EE) Diabetes Treatment Benefit — The Plan will consider the Reasonable Fees for
Medically Necessary and appropriate equipment, supplies, and diabetes outpatient self -
management training and educational services used to treat diabetes, subject to the
following terms, conditions and limitations:
(1) All diabetes treatment services shall be performed pursuant to a written plan of
treatment prescribed and approved by a Physician.
(2) A licensed Dietician shall provide any associated nutritional counseling.
(3) All diabetes outpatient self- management training and educational services shall
be provided under the direct supervision of a Certified Diabetes Educator or a
Board - Certified Endocrinologist.
(4) All diabetes outpatient self- management training and educational services shall
conform to standards adopted by the Florida Agency for Health Care
Administration.
Diabetic Supplies do not require pre - authorization.
(FF) Dental Care Benefit — The Plan will consider the Reasonable fees for general
anesthesia and hospitalization services Medically Necessary to assure the safe delivery
of necessary dental care to a Participant in a Hospital or Ambulatory Surgical Center,
subject to the following terms, conditions, and limitations:
**Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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(1) The Plan shall not pay for fees incurred in the diagnosis or treatment of a dental
disease, including any decay or periodontal disease, and the Participant must
comply with the Trust's pre- admission hospital certification program; and
(2) The services must be provided to a Participant under eight (8) years of age and a
licensed dentist and the Participant's Physician must have either determined
dental treatment in a Hospital or Ambulatory Surgical Center is necessary due
to a significantly complex dental condition or determined the Participant has a
developmental disability that makes patient management in the dental office
ineffective; or
The Participant has one or more medical conditions that would create a
significant or undue medical risk for the Participant in the course of delivery of
the necessary dental treatment or surgery if not rendered in a Hospital or an
Ambulatory Surgical Center.
Covered services otherwise shall not include the diagnosis or treatment of a dental
disease, including any decay or periodontal disease and the Patient must comply with
the Trust's Hospital Pre - Admission Certification guidelines contained in Section VI.
(GG) Osteoporosis Screening, Diagnosis, Treatment and Management Benefit — The
Plan will consider the Reasonable Fees for the Medically Necessary diagnosis and
treatment of osteoporosis for High -Risk Participants.
(HH) Cleft Lip and Cleft Palate Benefit — The Plan will consider the Reasonable Fees for
the Medically Necessary care and treatment of a Participant, under the age of 18, for
cleft lip or cleft palate, including medical, dental, speech therapy, audiology, and
nutrition services and supplies, provided the care and treatment is pursuant to a
written plan of treatment prescribed and certified by the treating Physician.
(II) Tissue or Organ Transplant Benefit — The Plan will consider the Reasonable Fees for
services and supplies connected with the following transplants, including services and
supplies relating to pre - transplant, transplant, post- discharge, and complications after
transplantation, subject to the terms, conditions and limitations described below:
(1) Bone Marrow Transplants specifically approved by Florida's Agency for Health
Care Administration and listed in Ch. 59B- 12.001, Florida Administrative
Code;
(2) Heart transplants;
(3) Lung transplants;
(4) Corneal transplants;
(5) Kidney transplants;
(6) Pancreas transplants;
(7) Liver transplants;
Transplants are subject to the following terms, conditions and limitations:
(1) Expenses incurred in connection with any organ or tissue transplant listed in
(3)
` *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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this provision will be covered subject to referral and to pre- authorization by the
Trust's authorized review specialist. (Kidney and cornea transplants are not
subject to the provision, but will be considered on the same basis as any other
medical expense coverage under the Plan. Tissue or Organ Transplant
Coverage is offered under the Plan through a preferred provider network of
duly licensed facilities and by duly credentialed Physicians acceptable to the
Trust. Tissue or Organ Transplant Coverage must be pre- authorized by the
Trust and /or its designated medical review and pre- authorization specialist to
receive Coverage at the level reserved for utilization of the preferred provider
network benefits.
As soon as reasonably possible, but in no event more than ten (10) days after a
Participant's attending Physician has indicated that the Participant is a potential
candidate for a transplant, the Participant or his /her Physician should contact
the Trust for referral to the network's medical review specialist for evaluation
and pre- authorization. A comprehensive treatment plan must be developed for
review by the Trust's medical review specialist, and must include such
information as diagnosis, the nature of the transplant, the setting of the
procedure, (i.e. the name and address of the hospital), any secondary medical
complications, a five (5) year prognosis, two (2) qualified opinions confirming
the need for the procedure, as well as a description and the estimated cost of the
proposed treatment. (The Trust's medical review specialist may waive one or
both confirming second opinions). Additional attending Physician's statements
may be required. Pre - authorization approval will result in the Participant being
asked to obtain transplant services in network at a Participating Network
Transplant Center of Excellence.
Failure to pre- authorize a transplant procedure will result in the application of a
$5,000 deductible to all Covered Expenses incurred as a result of the transplant.
This deductible is in addition to any other plan Deductible, Co- payment,
and /or Co- insurance requirements that would normally be applicable to the
transplant procedure.
(2) The Coverage is also provided for transplant services obtained outside of the
preferred provider network, though, at limited benefit levels as described
below. As a condition of such non - network Coverage, the Participant's
Physician must provide the Trust with advance notification of the Participant's
initial evaluation for the transplant procedure and the Trust must be given a
reasonable opportunity to evaluate the clinical results of the Participant's initial
evaluation and all applicable protocols. Additionally, the Trust must advise
such non - network Physician the extent to which the proposed transplant is
covered by the Plan.
If a transplant is performed out of network, but the Participant has received
approval from the Trust's medical review specialist for out of network services,
then network benefits will apply to the transplant and its related expenses. If
services are provided out of network without approval from the Trust's medical
review specialist, then limited, non - network benefits will apply.
(3) The respective Tissue and Organ Transplant Network and Non - Network
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Schedule of Benefits is as follows:
(a) Heart: Network Benefits - 100% of eligible charges
Non - Network Benefits - 100% of eligible charges, up to
an overall maximum of $110,000 including a Physician's
maximum of $20,000.
(b) Lung: Network Benefits - 100% of eligible charges
Non - Network Benefits - 100% of eligible charges up to
an overall maximum of $155,000 including a Physician's
maximum of $20,000.
(c) Bone Marrow: Network Benefits - 100% of eligible charges
Non - Network Benefits - 100% of eligible charges up to
an overall maximum of $130,000, including a Physician's
maximum of $20,000.
(d) Liver: Network Benefits -, 100% of eligible charges
Non - Network Benefits - 100% of eligible charges, up to
an overall maximum of $130,000 including a Physician's
maximum of $20,000.
(e) Heart /Lung: Network Benefits - 100% of eligible charges
Non - Network Benefits - 100% of eligible charges, up to
an overall maximum of $150,000 including a Physician's
maximum of $20,000
(f) Pancreas: Network Benefits - 100% of eligible charges;
Non - Network Benefits - 100% of eligible charges up to
an overall maximum of $70,000 including a Physician's
maximum of $20,000.
(g) Kidney: Network Benefits - 100% of eligible charges;
Non - network Benefits - 100% of eligible charges, up to an
overall maximum of $55,000 including a Physician's
maximum of $20,000.
(4) Covered Transplant Expenses will accumulate during a Transplant Benefit
Period, and will be charged toward the transplant benefit period maximums, if
any, shown in the Transplant Schedule of Benefits. The term "Transplant
Benefit Period" means the period that begins on the date of the initial
evaluation establishing potential transplantation candidacy and ends on the
date, which is twelve consecutive months following the date of the transplant.
(If the transplant is a bone marrow transplant, the date the marrow is reinfused
is considered the date of the transplant).
Covered Transplant Expenses, with respect to transplants, includes the
(5)
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Reasonable Fees for services and supplies covered under the Plan (or which are
specifically identified as covered only under this provision) and which are
Medically Necessary and appropriate to the transplant. Benefits will be limited
to the following expenses and costs:
(a) Charges incurred in the evaluation, screening, and candidacy
determination process.
(b) Charges incurred for organ transplantation.
(c) Charges for organ procurement, including donor expenses not covered
under the donor's plan of benefits.
(1) Coverage for organ procurement from a non - living donor
will be provided for costs involved in removing,
preserving and transporting the organ.
(2) Charges for organ procurement for a living screening the
potential donor, transporting the donor to and from the
site of the transplant, as well as for medical expenses
associated with removal of the donated organ and the
medical services provided to the donor in the interim and
for follow -up care.
If the transplant procedure is a bone marrow transplant,
coverage will be provided for the cost involved in the
removal of the patient's bone marrow, (autologous) or
donated marrow (allogenic). Pursuant to State Law,
Coverage will also include the reasonably necessary costs
associated with the donor - patient to the same extent and
limitations as costs associated with the Participant, except
the covered reasonably necessary costs associated with
any donor search are limited in scope to the tissue or
organ recipient- Participant's immediate family members
and the National Bone Marrow Donor Program.
(d) Charges incurred for follow -up care, including immuno- suppressant
therapy.
(e) Charges for transportation to and from the site of the covered organ
transplant procedure for the Participant- recipient and one other
individual, or in the event that the recipient- Participant is a minor, two
(2) other individuals. In addition, all reasonable and necessary lodging
and meal expenses incurred during the Transplant Benefit Period will be
covered up to a maximum of $10,000 per transplant period.
(6) Retransplantation will be covered up to two retransplants, for a total of three
transplants per Participant, per lifetime. Each transplant and retransplant will
have a new benefit period and a new maximum benefit.
(7) Accumulation of Expenses incurred during any one Transplant Benefit Period
for the Participant- recipient will apply towards the Participant- recipient's
(3)
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust Medical Master Plan of Benefits
(8)
(9)
(10)
transplant Benefit and will be included in the Plan's overall Maximum Lifetime
Benefit.
Donor Expenses, to the extent reasonable and Medically Necessary, will be
covered under this provision to the extent that they are not covered elsewhere
under the Plan or any other benefit plan covering the donor. In addition,
medical expense benefits for a donor who is not a Participant under this plan
are limited to a maximum of $10,000 per transplant benefit period when the
transplant services are provided out of network. This does not include the
donor's transportation and lodging expenses.
The Plan's Pre - Existing Condition Limitation shall apply to transplant charges.
Extended Benefits in the event of termination shall be provided. In the event of
termination of the Plan, or of the Participant- recipient's termination of
membership in an eligible class, if a transplant treatment program had
commenced while coverage was in force and benefits had not been exhausted,
then benefits will be paid for expenses related to the same organ transplant
which are incurred during the lesser of the remainder of that Transplant Benefit
Period or one month after termination of the Plan or membership in an eligible
class, as though Coverage had not ended.
SECTION VII — HOSPITAL BILL SELF -AUDIT
The Trust will provide a payment to the Participant in the amount of 50% of the savings (the
total dollar difference between the original Hospital bill and the revised Hospital bill), not to
exceed $1,000.
The Participant will receive a payment from the Trust for any errors that the Participant
identifies and the Hospital corrects.
The Participant must take the following steps 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 the Participant.
(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).
Send the revised bill to the Trust with a letter outlining the Participant's
actions, the amount of savings and the Participant's request for payment.
SECTION VIII — EXCLUSIONS AND LIMITATIONS
Unless otherwise expressly covered in Section VI of the Plan and then only to the extent of
such Coverage, Coverage under this Plan for Participants is subject to the following exclusions
and limitations for which no benefits will be paid:
(5)
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust Medical Master Plan of Benefits
(1) Services or supplies to improve the appearance or self - perception of a
Participant, including without limitation, procedures or supplies to correct hair
loss or skin wrinkling, and cosmetic surgery unless the cosmetic surgery is:
(a) necessitated by an Accident while covered under this Plan and
performed within six (6) months of the Accident, or
(b) required to restore a normal bodily function or to correct a deformity.
(2) Services or supplies that are custodial in nature, including without limitation,
services or supplies provided in rest homes, nursing homes, sanitariums, health
spas, health resorts, places of rest, institutions or homes for the aged, drug
addicts, or alcoholics, or places for the treatment of pulmonary tuberculosis or
mental or nervous disorders, domestic maid services, services of home health
aides, sitters, or home mothers, or any other services or supplies designed
primarily to assist the Participant in the activities of daily living.
Services or supplies to prevent the development of a Sickness, including
without limitation, surgical removal of tissue or organs solely because of the
probability of developing a malignancy, periodic health assessments, or routine
physical examinations, except as provided under the Child Health Supervision
Benefit and except as otherwise specifically stated in this Plan.
Services or supplies to a Participant hospitalized primarily for respite care, rest
or rest /cure.
(3)
(4)
(5)
Services or supplies to diagnose or treat an injury or a Sickness resulting,
directly or indirectly, from or in connection with drug or alcohol abuse by a
Participant, or resulting, directly or indirectly from or in connection with the
Participant being under the influence of drugs or alcohol.
(6) Services or supplies to diagnose or treat vision or hearing problems, including
without limitation, eye refractions, keratotomies, lasik surgery, eye glasses,
contact lenses, fitting of such glasses or lenses, eye examinations, eye exercise,
visual training or orthoptics, hearing aids, external or implanted hearing
devices, and any service or supply in connection with the fitting of such aids or
devices. This exclusion shall not apply to initial eyeglasses or contact lenses
(including those surgically implanted) provided to a Participant immediately
following cataract or glaucoma surgery covered under this Plan.
Travel expenses, whether or not recommended, ordered or prescribed by a
Physician.
Services or supplies provided a Participant in a Hospital after the attending
Physician advises further Inpatient care and treatment is no longer necessary.
Dental care and treatment of the teeth and their supporting structures and
gums, including without limitation, removal or addition of teeth, teeth fillings,
crowns or other materials, bridges, teeth cleaning, dental implants, dentures,
intraoral prosthethic devices, palatal expansion devices, bruxism appliances,
dental x -rays, oral surgery for cosmetic purposes, oral surgery, or any services
for orthodontia, prosthodontia or periodontia, except services and supplies
(7)
(8)
(9)
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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expressly provided under the Supplemental Accident Dental Care Benefit, the
TMJ Benefit, the Dental Care Benefit, and the Cleft Lip and Cleft Palate
Benefit.
(10) Massage, whether or not the massage is recommended, ordered or prescribed by
a Physician.
(11) Training or educational programs or materials, including without limitation,
programs or materials for pain management, vocational rehabilitation, and
management of diabetes, except as provided under the Diabetes Treatment
Benefit.
(12) Rehabilitative Services, except as provided under the Inpatient Hospital Services
Benefit, the Ambulatory Surgical Center Benefit, the Therapeutic Services
Benefit, the Skilled Nursing Facility Care Benefit and the Home Health Care
Benefit.
(13) Services or supplies provided by an Occupational Therapist, including
occupational therapy, for vocational rehabilitation, maintenance, job training,
or those services that fall under the Workers' Compensation benefit.
(14) Services or supplies provided by a Speech Therapist, including speech therapy,
to treat either a lisp or stuttering.
(15) Services or supplies provided by a Physical Therapist, including physical
therapy, except as provided under the Hospital Care Benefit, the Hospice Care
Benefit, the Therapeutic Services Benefit, the Skilled Nursing Facility Care
Benefit, and the Home Health Care Benefit.
(16) Services or supplies, including without limitation, surgery or psychiatric
services, related to sexual disorders, impotence, whether organic in origin or
not, or to sexual reassignments, reconstructions or modifications.
(17) Services or supplies connected with sterilization or reverse sterilization,
including without limitation, tubal ligations and vasectomies and reversals of
tubal ligations and vasectomies.
(18) Services or supplies connected with the treatment of infertility or any form of
artificial fertilization, including without limitation, medications, artificial
insemination, in -vitro fertilization, gamete intra - fallopian transfer, and any
other form of artificial impregnation.
(19) Contraceptive devices, appliances, medications or other services or supplies
used for contraception. This exclusion does not apply to oral contraceptives for
female Participants.
(20) Services or supplies connected with abortions, including the abortion, unless
the Physician certifies to the Trust the pregnancy would constitute a danger to
the health of the pregnant woman or the pregnancy would result in the birth of
an infant with grave malformation.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust
Medical Master Plan of Benefits
(21) Services or supplies connected with an autopsy or postmortem examination,
including the autopsy.
(22) Blood, blood plasma and /or blood derivatives.
(23) Services or supplies to lose, gain, or maintain weight, including without
limitation, gastric bypasses, gastric balloons, stomach stapling, jejunal bypasses,
jaw wiring, weight control /loss programs, food /nutritional supplements,
appetite suppressants, and exercise programs, equipment or memberships.
(24) Private duty nursing services.
(25) Services and supplies connected with Biofeedback and other forms of self -care
or self -help, including without limitation, any related diagnostic testing,
exercise programs, hypnosis or meditation.
(26) Services or supplies for routine foot care including but not limited to the
removal of warts, corns, calluses, the cutting and trimming of toe nails, flat feet,
fallen arches, chronic foot strain, or other foot care, except where the need for
professional performance of the service is required due to an underlying severe
systemic disease affecting the feet.
(27) Services or supplies to reduce or eliminate addiction to or dependency on
tobacco, including without limitation, nicotine withdrawal programs and
nicotine products such as nicotine gum or transdermal patches.
(28) Services or supplies connected with any transplant, except as provided under
the Tissue or Organ Transplant Benefit, including without limitation any
services or supplies connected with the implant of an artificial organ, including
the implant of the artificial organ; any organ, tissue, marrow, or stem cells
which are sold rather than donated to the Participant; any Bone Marrow
Transplant not specifically listed in Ch. 59B- 12.001, F.A.C.; any service or
supply connected with the identification of a donor from a local, state or
national listing; any transportation costs for the Participant to and from a
facility approved to perform the transplant; and any direct, non - medical costs
for the immediate family for transportation to and from the facility approved
to perform the transplant or for temporary lodging.
(29) Services or supplies determined by the Trust to be Experimental or
Investigational as defined by the appropriate federal regulatory agency,
(including without limitation, the U.S. Food and Drug Administration (FDA)
and the Health Care Financing Administration (HCFA))
(30) Services and supplies which, in the opinion of the Trust, are not Medically
Necessary for the diagnosis, care or treatment of an Accident or a Sickness.
The fact a Physician may prescribe, order, recommend, or approve a service or
supply does not in and of itself make it Medically Necessary.
(31) Services or supplies provided by a Provider who is related to the Participant by
blood or by marriage.
(32) Services or supplies obtained without cost to the Participant, or services or
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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Florida Municipal Insurance Trust
Medical Master Plan of Benefits
supplies the cost of which is discounted or waived to satisfy the Calendar Year
Deductible, Co- Insurance, or Co- Payment requirements stated in the Schedule
of Benefits.
(33) Service or supplies furnished to a Participant or paid under any of the following
plans or insurance coverages:
(a) any plan, program or insurance policy providing benefits for hospital,
medical and /or other health care expenses under a group master policy
including, but not limited to, policies issued to any health maintenance
organization or any entity to which such policies may legally be issued
in the State of Florida for the purpose of insuring a group of individuals;
(b) any plan, program or insurance policy, and /or Personal Injury
Protection automobile insurance required and defined under Florida
law, which provides benefits or makes payments to or on behalf of a
Participant for hospital, medical and /or other health care expenses;
(c) any group contract issued to this Trust;
(d) any coverage under a plan or a law of any federal, state or local
government or any political subdivision thereof, including but not
limited to, coverage under Medicare, 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 paragraph. The Participant shall provide, execute and deliver such
information, instruments and papers, and do whatever else is necessary to
secure the instruments and papers, and the Trust's rights under this paragraph.
(34) Services and supplies covered under Parts A and B of Medicare if the Participant
is not an active Employee or the Dependent of an active Employee.
(35) Services or supplies received in a veterans hospital or other government facility
due to an armed forces or military service connected Accident, Sickness or
disability.
(36) Services or supplies provided before Coverage commences or after Coverage
terminates 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 of the Plan.
(37) Services or supplies primarily for the personal comfort or convenience of the
Participant, including without limitation, beauty and barber services, radios,
televisions, telephone charges, take -home supplies, guest meals, and lodging
accommodations.
(38) Services or supplies not expressly covered under this Plan.
(39) Services or supplies to diagnose or treat any Accident or Sickness which,
directly or indirectly, resulted from or is in connection with the Participant's
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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participation in, or commission of, any act punishable by law as a felony. This
exclusion will not be imposed on injuries resulting from domestic violence.
(40) Services or supplies to diagnose or treat any Accident or Sickness which,
directly or indirectly, resulted from or is in connection with a riot, rebellion, or
war or act of war, whether or not declared.
(41) Pre - existing conditions except to the extent and in the manner provided in
Section X.
(42) Services or supplies for care or treatment to the extent the Participant is
covered or required to be covered by the workers' compensation laws of the
State of Florida, for the care or treatment of any occupational condition,
ailment or injury arising out of or in the course of employment or other
endeavor for wage, profit or gain, or for services or supplies furnished to a
Participant under the laws of the United States or any state or political
subdivision thereof, all of which are excluded under this Plan, even though the
Participant elects to waive the right to such services or supplies.
(43) Services or supplies for care or treatment resulting directly or indirectly from
self - inflicted or self - induced injury or illness. This exclusion will not be
imposed on injuries resulting from an underlying medical condition.
(44) Services or supplies for care or treatment resulting directly or indirectly from
the Participant's participation in or incitement of an altercation. This exclusion
will not be imposed on injuries resulting from domestic violence.
(45) Services or supplies for care and treatment resulting directly or indirectly from
or in connection with the Participant's service in the armed forces, including
the reserves and /or the National Guard.
(46) Services or supplies for care and treatment resulting directly or indirectly 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 care and
treatment resulting from the Participant's participation in sponsored sporting
events or traditional recreational activities.
(47) Services or supplies for care and treatment of complications which result from
or arise out of the provision of services or supplies that are excluded under this
Section.
(48) Fees in excess of the percentage specified in the Schedule of Benefits, or in
excess of Reasonable Fees.
(49) Services or supplies connected with acupuncture, including acupuncture,
whether or not recommended, prescribed, or ordered by a Physician.
(50) Services or supplies for the care and treatment of temporomandibular joint
dysfunction (TMJ), including without limitation, Phase II treatments, except as
provided under the TMJ Benefit.
(51) Services or supplies provided to a Participant as a result of or in connection
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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with a court order, unless the services or supplies are otherwise expressly
covered under Section VI.
(52) Equipment, other than equipment provided under the Durable Medical
Equipment Benefit, including, without limitations, modifications to motor
vehicles and /or homes such as wheelchair lifts or ramps, water therapy devices
such as Jacuzzis or hot tubs, and exercise equipment. In addition, maintenance
on purchased equipment is excluded under this plan.
(53) In the event a Participant suffers receives brain damage, brain injury, or any
brain Condition related to head trauma following a motorcycle Accident, the
amount of available Benefits related to such condition shall be reduced by 50 %,
where police or medical reports indicate that a helmet or other generally
recommended headgear or head safety equipment was not utilized by the
Participant.
(54) Services or supplies required in relation to a Total Disability for which a prior
health insurer, health maintenance organization, or policy is required to
provide an extension of benefits pursuant to section 627.667, Florida Statutes.
(55) Laboratory handling and material conveyance fees.
(56) Fees or charges designated as after -hours fees or charges or reasonably
understood to be after -hours fees or charges.
(57) Charges related to medical testimony of any Physician or Provider.
(58) Educational supplies except those related to a diabetic Condition.
(59) School, sports, travel and employment - related physical examinations.
(60) Vaccinations or immunizations related or required to undertake any travel.
(61) Any claim for services submitted to the Trust more than 365 days after the date
of service.
(62) Charges related to "no shows ". This is where the patient does not show for a
scheduled appointment.
(63) Ambulance Service for non - emergency transport.
(64) Services and supplies for future dates.
Benefits payable under this Plan will be limited to services and supplies provided and expenses
incurred within the continental United States. Any expenses incurred by a Participant outside
the continental United States will be subject to approval by the Trust.
SECTION IX — COORDINATION OF BENEFITS
The purpose of health care coverage is to help meet actual expenses. In line with that purpose,
this Plan contains a non - profit provision coordinating it with other plans, including group
plans under which a Participant is covered, so that the total Benefits available will not exceed
100% of the allowable expenses.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01 /03)
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Primary Coverage — A plan without a coordination of benefits provision is always the
primary plan. If all potentially applicable plans have this provision:
(1) the plan covering the person as an employee rather than as a dependent is
primary;
(2) the plan covering the person as an active employee or as a dependent of an
active employee rather than Medicare is primary;
if a dependent child is covered under both parents' plans, the plan for the
parent with the earliest birth date 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 . However, if a plan subject to the foregoing rule based on the
birthday of the parents coordinates with an out -of -state plan which contains
provisions under which the benefits cover a person as a dependent of a male are
determined before those of a person covered as a dependent of a female, and, if
as a result, the plans do not agree on the order of benefits, the provisions of the
other plan shall determine the order of benefits.
if a dependent child is covered under both parents' plans, and the parents are
divorced or separated, the primary plan will be determined in the following
order:
(3)
(5)
• 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;
and
• Third, the plan of the parent not having custody of the child; unless the
specific terms of a court decree state that one of the parents is responsible
for the health care expenses of the child in which case the plan covering
such parent is primary. A copy of the court decree must be furnished to
the Trust;
(6) The Plan covering an employee, or the employee's dependents, rather than a
retiree, or the retiree's dependents, is primary;
The Plan covering a person as an employee who has not retired, or as the
employee's dependents, rather than the plan covering a person, or the person's
dependents, as a retiree, is primary;
The Plan covering a person as an employee, or the employee's dependents,
rather than a plan covering the person, or the person's dependents, under
COBRA, shall be primary.
If none of the above rules apply, the plan that covered an employee or dependent for a
longer period of time is primary.
Secondary Coverage — Services and benefits under this Plan will be coordinated with, and
this Plan is hereby deemed secondary to plans providing coverage for services, supplies
or benefits furnished to a participant or paid under any of the following plans of
(7)
(8)
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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insurance coverage:
(1) 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 the State of Florida for
the purpose of insuring a group of individuals;
(2) any plan, program or insurance policy and /or Personal Injury Protection
automobile insurance as required and defined in the Florida Statutes or policy
of No -Fault Insurance as defined by any other applicable state laws or
provisions, which provide benefits or makes payments to or on behalf of a
participant for hospital, medical and /or health care expenses;
(3) any group contract issued to this Trust;
(4) any coverage under a plan or law of any federal, state or local government or
any political subdivision thereof, including but not limited to, coverage under
Medicare 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 Section. The Participant shall provide, execute and deliver such
information, instruments and papers, and do whatever else is necessary to
secure the instruments and papers, and the Trust's rights under this paragraph.
Medicare Coverage -- Secondary Payer Provisions -
(1) When a Participant or Dependent becomes covered under Medicare and
continues to be eligible and covered under this Plan, the Coverage hereunder
shall be primary, and the Medicare benefits shall be secondary, as set forth
below, but only to the extent required by law. In all other instances, Coverage
hereunder shall be secondary to any Medicare benefits.
To assure compliance with the Medicare statute, the Employer shall advise the
Trust, without delay, of any Employees and /or their Dependent spouses, age 65
or older, who are covered under Medicare prior to or immediately following
the date such Employee or Dependant spouse became covered under Medicare
(such information shall be provided to the Trust prior to the Employee or
Dependent spouse's 65th birthday). Additionally, the Employer shall advise the
Trust, without delay, of the Medicare status of any Medicare beneficiary who
applies for Coverage, prior to such individual's Effective Date under this Plan.
Pursuant to federal law, in any circumstance under which the Medicare statute
requires that the benefits under this Plan be primary for any Employee or
Dependent spouse, the Employer may not offer, subsidize, procure or provide a
Medicare supplement policy to such Employee or the Employee's Dependent
spouse. Additionally, the Employer may not induce such Employee or
Dependent spouse to decline or terminate his or her Coverage under this Plan
and elect Medicare as a primary source of health benefit coverage.
(5)
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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(2) If the Employer employs /employed twenty (20) or more Employees for twenty
(20) or more weeks of the current or preceding Calendar Year, this Plan will
provide primary Coverage for an Employee and /or the Employee's Dependent
spouse, age 65 or older, regardless of their eligibility for Medicare, provided
they are not eligible for Medicare due to end stage renal disease (ESRD),
pursuant to the following terms:
A. The Employer shall provide the Trust, without delay, the names and
other identifying information regarding Employees: (1) who are covered
under the Plan; (2) who are employed (not retired); (3) who have not
elected Medicare as primary payer of their health care claims; and (4)
who are not eligible for Medicare due to ESRD.
B. The Employer shall provide the Trust, without delay, the names of
Employees and /or any Dependent spouses, age 65 or older: (1) who are
covered under the Plan; (2) who have not elected Medicare as the
primary payer of their health insurance claims; and (3) who are not
eligible for Medicare due to ESRD.
This information shall be provided to the Trust on or before the 65th
birthday of the Employee or Dependent spouse, or on such later date
when the Employee or Dependent spouse enrolls under this Plan.
C. For an Employee or Dependent spouse who meets one of the
descriptions set forth above in A. or B., the Plan shall provide primary
coverage beginning the first day of the month in which the individual
attains age 65 or beginning on the Effective Date if the individual is 65
or older at the time of enrollment.
D. Individual entitlement to primary coverage under this sub - section will
automatically terminate:
(1) for a current Employee, age 65 or older, when he or she elects
Medicare as the primary payer or when he or she becomes
eligible for Medicare due to ESRD;
(2) for the Dependent spouse, age 65 or older, of a current
Employee, when the Dependent spouse elects Medicare as the
primary payer or when the Dependent spouse becomes eligible
for Medicare due to ESRD.
(3)
for the Employee and Dependent spouse, when the Employee is
no longer an active Employee, as defined in this Plan.
The Employer shall provide the Trust, without delay, the names and any other
identifying information of such Employees, or Dependent Spouses of such Employees,
age 65 or older, who choose Medicare as primary payer of their health care claims,
who become eligible for Medicare due to ESRD, or who are no longer active
Employees, as defined in this Plan.
It is the Employer's sole responsibility to notify the Trust if the number of its
employees changes from twenty (20) or more employees to less than twenty (20)
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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employees or from fewer than twenty (20) employees to twenty (20) or more
employees.
(3)
The Plan will provide primary Coverage for a Participant who is entitles to
Medicare coverage solely because of ESRD, subject to the following terms,
conditions and limitations:
A. The Employer must provide the Trust without delay, the names of a
Participant who is or will be undergoing a regular course of renal
dialysis or will receive or already has received a kidney transplant, the
beginning date of such dialysis or the date of such transplant, and any
other identifying information requested by the Trust.
B. The Plan will provide primary Coverage for such Participant for a
period of thirty (30) months, beginning the earlier of the month in
which the Participant became entitled to Medicare Part A ESRD
benefits or the first month in which the Participant would have become
entitled to Medicare Part A ESRD benefits if the Participant had made
timely application for the benefits.
If Medicare was the primary coverage prior to the Participant becoming entitled to
Medicare Part A ESRD benefits, then Medicare will remain the primary coverage of the
Participant. If this Plan was the primary Coverage for the Participant prior to the
Participant becoming entitled to Medicare Part A ESRD benefits, then this Plan will
remain the primary Coverage of the Participant for the ESRD 30 -month coordination
period.
(4) Medicare may become the primary coverage for Employees and /or their
Dependent spouses aged 65 or older, when the employer employs fewer than
twenty (20) employees, and the Medicare Administration (HCFA) grants
approval for such primary Medicare coverage.
Medicare Coverage -- Disabled Individuals -
(1) If the Employer employs 100 or more Employees for at least 50% of its regular
business days during the previous Calendar Year, this Plan will provide
primary Coverage to a Participant who is entitled to Medicare coverage because
of disability, provided the disability is not due to ESRD and subject to the
following terms, conditions and limitations:
A. The Employer must provide the Trust, without delay, the name of a
Participant who is entitled to Medicare because of disability (other than
disability due to ESRD) who has not elected Medicare as primary
coverage. Together with any other identifying information requested
by the Trust.
B. The Plan will provide primary Coverage for the Participant during the
month in which the Participant remains entitled to Medicare coverage
because of disability (other the disability due to ESRD).
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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C. The Plan's primary Coverage shall automatically terminate on the date
the Participant turns 65 years of age, on the date the Participant no
longer qualifies for Medicare coverage because of disability, or on the
date the Participant elects Medicare as primary coverage. The Employer
shall notify the Trust, without delay, of the occurrence of any of the
events listed herein.
It is the Employer's sole responsibility to notify the Trust that it employed 100 or more
Employees at least 50% of its regular business days during the previous Calendar year.
The Trust shall not be liable to the Employer or to any Participant for the non - payment
of primary benefits if the non - payment resulted from the failure of the Employer to
perform the Employer's obligations under this Medicare Coverage sub - section of the Plan.
Should the Trust make primary payments for services rendered a participant in a period
prior to receipt of the information required from the Employer under the terms of this
sub- section, the Trust may require the Employer to reimburse the Trust for such
payments. In the alternative, the Trust may require the Employer to pay the rate
differential that resulted from the Employer's failure to timely discharge any of its
obligations hereunder.
The Employer shall indemnify and hold the Trust harmless to the extent of any
liability, including attorneys fees and costs, that result directly or indirectly from the
Employer's failure to notify the Trust as required herein.
SECTION X — PRE- EXISTING CONDITIONS LIMITATIONS
There is no coverage under this Plan for services or supplies to treat a Pre - Existing Condition
or Conditions arising from a Pre - Existing Condition, until the Participant has been
continuously covered under this Plan:
(1)
for a 12 month period beginning on the date of hire for Employees and their
Dependents who enroll in the Plan during the initial enrollment period, and
(2) for a 12 month period beginning on the Effective Date for Employees and
their Dependents who enroll in the Plan during the Open 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 similar to or exceeded the Coverage provided under this Plan and
the previous coverage was continuous to a date not more than 62 days prior to the
Participant's Effective Date of Coverage under this Plan, exclusive of any Waiting Period
under this Plan.
No Pre - Existing Condition 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 day break in coverage prior to the participant's effective date of coverage under
this Plan, exclusive of any waiting period under this Plan.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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The eligible Participant may prove periods of Creditable Coverage by providing a certificate
of Creditable Coverage, which includes periods of coverage and benefit coverage levels. If
there was a break in coverage of 63 days or more, no credit will be given for prior Creditable
Coverage.
SECTION XI — TIME OF PAYMENT, GRACE PERIOD
All contributions are due and payable on the first day of each month for which Coverage
under this Plan is provided. If the Employer fails to pay the contributions to the Trust within
twenty (20) days after they become due and payable, the Plan is automatically terminated
effective the first day of the month in which such contributions were due and payable; no
Participant shall thereafter be entitled to any further Benefits hereunder.
In the event this Plan terminates for any reason, the Employer shall be liable for all
contributions due and unpaid as of the date of termination in the event that claims were paid
after the contributions became due and payable.
The Trust must give an Employer forty -five (45) days written notice of any change in the
monthly rate of contribution or any changes in this Plan's terms or benefits.
SECTION XII — CONDITIONS FOR RENDERING SERVICE
The participant shall present proper identification issued by the Trust when applying for
Hospital, Physician, pharmacy or other Covered Services 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 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 Covered Services
to the Participant to the extent herein specified. The Trust shall not, in any event, be liable
for any negligence, misfeasance, nonfeasance, malfeasance, malpractice or any act of
commission or omission on the part of any Physician, Hospital or other Provider or the agent
or employee of any Physician, Hospital or 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:
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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(1) On the date Coverage is terminated.
(2) On the expiration date as provided in Section XI, if the Employer fails to make
the required contributions.
All claims must be submitted no later than ninety (90) days after the date of termination of the
policy in order to be eligible for payment.
SECTION XIV — PARTICIPANT'S TERMINATION OF
COVERAGE
Unless a Participant qualifies for and elects continuation of Coverage pursuant to and in the
manner provided in Section XV of the Plan:
(1) Coverage for any Participant shall terminate automatically at the end of the
month for which payment of the contributions specified herein shall have been
made by the Employer for such Participant, in the event the Employer notifies
the Trust that the Coverage of such Participant under this Plan is to be
terminated.
(2) Coverage of the spouse of an Employee shall automatically cease upon a legal
separation of the spouse and Employee or termination of the marriage between
the spouse and Employee.
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
provided under the definition of Dependent in Section I.
Subject to the provisions of Paragraphs (1) and (2) of Section III, the Coverage
of any Participant shall terminate automatically when the maximum benefits
for which such Participant is eligible have been paid. Coverage for any
remaining family Participants shall, unless otherwise terminated in accordance
with provisions hereof, continue so long as payment of required contributions
is timely made.
A certificate of Creditable Coverage will be issued to all Participants whose Coverage
terminates. The certificate will be sent by First Class Mail to the Participant's last known
address. In addition, the Trust shall issue a certificate of Creditable Coverage to a Participant
upon request, for up to 24 months following the end of the Participant's Coverage under this
Plan.
(3)
(5)
Conversion Privilege on Termination of Eligibility
(1) A Participant whose Coverage under this Plan is terminated for any reason and
who has been validly and continuously covered under this Plan for at least
three (3) months immediately prior to such termination shall be entitled to
purchase a converted policy, providing benefits that may differ from but in no
event shall exceed those of the Plan. The Participant must apply to the Trust
for the converted policy in writing and must pay the first premium attributable
to the converted policy not later than sixty -three (63) days after termination of
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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the Participant's Coverage. 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 Department of Insurance. The
converted policy will be issued without evidence of insurability and will be
effective on the day following the termination of Coverage under this Plan.
(2) A Participant is not entitled to a converted policy:
(a) If termination is the result of the Participant or Employer's failure to
timely pay a required contribution.
(b) If any discontinued Coverage under this Plan is replaced by similar
group coverage within thirty -one (31) days of the date of termination of
this Plan.
(3)
(c) If the Participant is covered or eligible to be covered by Medicare.
(d) If the Participant 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 over
insurance, according to standards utilized by the Trust.
The terms and coverage conditions in and benefits provider under the
converted policy will be designed to comply with section 627.6675, Florida
Statutes, and the terms of section 627.6675, Florida Statutes, shall prevail to the
extent of any conflict with the terms of this Plan.
(4) An authorized insurer selected by the Trust to provide conversion coverage
may issue the converted policy.
The Trust may request and the Participant shall provide the Trust with
reasonable information sufficient to determine whether the Participant is
covered for similar benefits by another medical insurance policy or by any
arrangement of coverage for individuals in a group, whether on an insured or
uninsured basis.
(6) A Participant's failure to provide any information requested regarding
subsection (5) hereinabove, any fraud or intentional misrepresentation by the
Participant, or any over insurance resulting from any available coverages
referenced in subsection (5) hereinabove, will serve as a basis for the Trust's
non - renewal of a converted policy.
The converted policy may not exclude a pre - existing condition not excluded
under the Plan coverage or policy from which conversion is made. However,
the converted policy shall not provide coverage duplicative of any Coverage
otherwise payable under the Plan after the termination of Coverage under the
Plan.
(5)
(7)
(8)
A Participant who retires prior to his or her coverage or eligibility for coverage
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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(9)
under Medicare, shall be entitled to the converted policy privileges described
herein. However, upon coverage or eligibility for coverage under Medicare, the
available benefits under a converted policy may be reduced to the extent
Medicare or any other state or federal law provides benefits similar to those
provided by the converted policy.
This conversion privilege may be exercised by the Dependents (including
spouse and children) of a deceased Participant, when coverage for such
Dependents would otherwise immediately terminate and following the
expiration of any period of Continuation of Coverage as outlined in Section
XV under this Plan.
(10) The former spouse of a Participant whose coverage would otherwise terminate
due to annulment or dissolution of marriage may exercise this conversion
privilege, if the former spouse seeking a converted policy is dependent for
financial support upon the Participant.
(11) This conversion privilege may be exercised by a child of a Participant by reason
of ceasing to be an eligible Dependent under the Plan.
Extended Coverage for Total Disability
A temporary extension of Benefits, only for treatment of the Condition causing Total
Disability shall be available to a Participant who is Totally Disabled as a result of an Accident
or Sickness incurred while the policy was in effect. Coverage provided by the Plan shall
remain in effect until the Total Disability ceases, the Lifetime Maximum has been received,
the Participant becomes covered under a replacement contract or policy without limit as to
the disabling condition, or until the expiration of twelve (12) months following the date of
discontinuance, whichever occurs first. Extended coverage for Total Disability is subject to all
other terms, conditions, exclusions and limitations of the Plan.
SECTION XV — CONTINUATION OF COVERAGE - COBRA
The Plan provides an election for continuation of Coverage to qualified beneficiaries who
would otherwise lose Coverage under the Plan as a result of a qualifying event.
A qualified beneficiary means the Dependent spouse or Dependent child of an Employee who
is a Participant in the Plan on the day before the qualifying event. In the case of termination
(other than for gross misconduct), the term also includes the Employee. One exception to this
rule is when a child is born to (or placed for adoption with) an Employee during the COBRA
continuation period. These children will receive all rights of a qualified beneficiary
throughout the COBRA continuation period.
A qualifying event means the occurrence of any of the following events, which would result in
the loss of Coverage to:
(1) Employee:
(a) Termination of employment for any reasons other than gross
misconduct.
(b) Reduction of work hours.
(2) Spouse:
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
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(3)
Continuation
requirements.
beneficiaries is
(1)
(a)
(b)
(c)
(d)
(e)
(i
Termination of Employee's employment.
Reduction of Employee's work hours.
Death of Employee.
Divorce or legal separation from Employee.
Employee becomes enrolled in Medicare.
A Dependent child ceases to be a Dependent under the Plan.
Dependent:
(a) Termination of Employee's employment.
(b) Reduction of Employee's work hours.
(c) Death of Employee.
(d) Divorce or legal separation from Employee.
(e) Employee becomes enrolled in Medicare.
(f) Dependent child ceases to be an eligible Dependent as defined by the
Plan.
of Coverage is conditioned upon satisfaction of the following notice
The notice requirement relating to election of Coverage by qualified
as follows:
In the event of an Employee's death, termination of employment or Medicare
eligibility, the Employer shall notify the Trust within sixty (60) 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.
(3)
Notice hereunder to Employees or qualified beneficiaries shall be by First Class
Mail to their last known address; notice to the Trust shall be by First Class Mail
to the Board of Trustees of the Florida Municipal Insurance Trust.
A qualified beneficiary's election of continuation of Coverage must be made within sixty (60)
days following notice of continuation rights being provided 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.
If any other qualifying event occurs, the election of continuation of Coverage by the spouse
shall be deemed to include an election of continuation Coverage on behalf of any other
qualified beneficiary who would lose Coverage under the Plan by reason of the qualifying
event.
The cost of Coverage to the qualified beneficiary shall be 102% of the cost of providing
Coverage for such period to a similarly situated participant under the Plan to whom a
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 53
Florida Municipal Insurance Trust
Medical Master Plan of Benefits
qualifying event has not occurred. In the event the qualifying event entitling the qualified
beneficiary to continuation of Coverage is the covered beneficiary's disability as defined by
the Social Security Act, the cost of Coverage to the qualified beneficiary for any month after
the 18th month of continuation Coverage following the date of termination shall be 150% of
the cost of providing Coverage or such period to a similarly situated participant under the
Plan to whom the qualifying event has not occurred. The cost of Coverage shall be paid
directly to the Employer in monthly installments.
In the event of a covered employee's termination, the period of continuation of Coverage is:
(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.
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.
Up to twenty -nine (29) months from the date of such termination for such
Employee and such Employee's qualified beneficiaries, if it is determined, under
Title II or XVI of the Social Security Act, the covered employee was disabled
on the date of termination. The Employee must notify the Trust of said
determination within sixty (60) days of said determination and within eighteen
(18) months of the date of termination. In the event another qualifying event
occurs during the eighteen (18) months following the date of the employee's
termination, the period of continuation of Coverage is up to thirty -six (36)
months from the date of termination for such Employee and his qualified
beneficiaries.
(3)
(5)
A qualified beneficiary's continuation cif Coverage shall cease on the earliest of the 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;
As provided in Section XI, if the qualified beneficiary fails to pay contributions
within thirty (30) days after they become due;
(4) The date the qualified beneficiary becomes covered under another group health
plan (as an employee or otherwise) with similar coverage, which does not
contain any exclusions or limitations for pre - existing conditions, and if there is
any pre- existing condition exclusion or limitation, coverage shall terminate on
the date such limitation or exclusion ends;
(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
(3)
**Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 54
Florida Municipal Insurance Trust Medical Master Plan of Benefits
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.
Notwithstanding the above, in no event shall said Coverage extend beyond the
twenty -nine (29) month Coverage period.
A certificate of Creditable Coverage will be issued at the end of the continuation of Coverage
period. The certificate will be sent by First Class Mail to the Participant's last known address.
In addition, the Trust shall issue a certificate of Creditable Coverage to a Participant upon
request, for up to 24 months following the end of the Participant's Coverage under this Plan.
If COBRA is elected and the eighteen (18) or thirty -six (36) months maximum time frame is
exhausted, the qualified beneficiary may be eligible for Coverage under an individual plan
(through an insurer of their choice) on a guaranteed issue basis without any pre- existing
condition limitations.
In the event the Plan offers a conversion privilege, the qualified beneficiary shall be entitled to
said conversion privilege provided the qualified beneficiary applies for such conversion plan
during the last 180 days of the period of continuation Coverage.
Coordination of Benefits with other plans for COBRA recipients will follow current National
Association of Insurance Commissioners (NAIC) recommendations.
SECTION XVI — PRESCRIPTION DRUGS
Coverage is provided for prescription medications prescribed by a Physician that is intended
for use outside a Hospital, Skilled Nursing Facility or treatment facility. Benefits will be paid
at the coverage level shown on the Schedule of Benefits. Presenting your prescription
identification card each time you request a prescribed medication will ensure that the Provider
knows that you are part of the. Plan. A generic prescription drug will be provided unless the
prescribing Physician specifies a brand name drug.
In addition to the applicable exclusions specified in Section VIII, no Coverage is provided for:
(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 and
Ziban.
(5) Viagra and other similar virility enhancement drugs.
(6) Rogaine and other similar medications for baldness.
(7) Anorexics (appetite depressants such as "diet pills ").
(8) Diabetic Test Strips and glucometors.
(9) Over the Counter medications and supplies.
(10) Over the Counter Vitamins.
(11) Drug prescriptions of thirty (30) or more days' duration.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 55
Florida Municipal Insurance Trust
Medical Master Plan of Benefits
A Prescription Mail Program is available to meet the maintenance drug prescription needs of a
Participant. Only maintenance drug prescriptions of over thirty (30) days and less than
ninety -one (91) days' duration are eligible for this program. No Coverage is provided for the
exclusions specified in Section VIII, and Items (1) through (11) listed above.
SECTION XVII — GENERAL PROVISIONS
The Trust will issue to the Employer for delivery to each participating Employee covered
hereunder, a Schedule of Benefits, a copy of this Plan and appropriate identification cards,
which the Employee or eligible covered Dependents can present to a Hospital, Physician, or
other service Provider in claiming Benefits due under this Plan. It shall be the Employer's
responsibility to disseminate to the eligible Employee the Schedule of Benefits, a copy of this
Plan and the appropriate identification cards. The Employee's Benefits are non - assignable
prior to a claim. If any amendment to this Plan shall materially affect any Benefits, the
amendment, a new Schedule of Benefits and an updated copy of this Plan shall be delivered to
the participating Employer to be 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.
No representative has authority to change this Plan or waive any of its provisions. No change
in this Plan shall be valid unless approved by the Board of Trustees.
Written proof of a claim for services must be furnished to the Trust within 365 days after the
date of such services.
Benefits provided in this Plan would be payable to the Hospital, Physician, or other service
Provider rendering service under this Plan or to the Participant upon receipt, by the Trust, of
paid bills in acceptable form.
No action at law or in equity shall be brought to recover under this Plan prior to the
expiration of sixty (60) days written notice to the Trust. No such action shall be brought after
the expiration of the specified statute of limitations on such action. Such notice to the Trust
shall be sufficient if given to:
The Florida Municipal Insurance Trust
Attention: Health Department
125 E. Colonial Drive
Orlando, Florida 32801
An Employee applying for Coverage under this Plan for himself /herself or eligible
"Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 56
Florida Municipal Insurance Trust Medical Master Man of Benefits
Dependents and the Participant and /or each Dependent of the Participant agrees that, as a
condition of payment of Benefits, services and supplies, Hospital, Physician, or other Provider
that has made or may hereafter make a diagnosis, render service, attendance or treatment of or
to a Participant, may furnish and is authorized to furnish to the Trust at any time upon its
request, a report containing all information and records or copies of records pertaining to
diagnosis, attendance, service or treatment. The applicant or Participant and /or each
Dependent of the applicant or Participant agree 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 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.
To ensure any Provider is in the Employee /Participant's network of approved Providers, the
Employee /Participant should check the label affixed to his or her identification card. This
label identifies the network to which the Employee /Participant's Employer belongs. The
Trust recommends the Employee /Participant call the number(s) listed below with inquiries
for either network:
FIRST HEALTH
(800) 778 -1463
If an Employee /Participant's identification card does not identify the network to which his or
her Employer Belongs, Please contact the Trust's Customer Service Department at 1 (800) 756-
3042 for assistance.
DO NOT RELY UPON THE PROVIDER DIRECTORY FOR CONFIRMATION OF
NETWORK PROVIDERS. THE ULTIMATE RESPONSIBILITY TO ENSURE A
PROVIDER IS WITHIN A GIVEN NETWORK RESTS WITH THE
EMPLOYEE /PARTICIPANT.
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 57
Florida Municipal Insurance Trust
Medical Master Plan of Benefits
SECTION XVIII — PAYMENT OF BENEFITS, ASSIGNMENT
Benefits provided under this Plan for a specified injury or Condition may be paid to the
Participant or to the 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 Provider, Benefits may be paid directly to the Provider or to any
person or institution appearing to assume responsibility for the expense, and such payment
shall discharge the Trust's obligation for such expense.
SECTION XIX — GRIEVANCE PROCEDURE
There are situations when Participants have questions about their Coverage or are dissatisfied
with Plan services. Such inquiries and complaints will be handled in a timely manner.
In the event that a claim is denied and the Participant disagrees with the denial, a re-
determination may be requested in writing detailing the reasons for the disagreement. This
request must be received within sixty (60) days of the initial claim denial. The Plan will
respond with a written decision, within sixty (60) days from receipt of the request.
SECTION XX — SUBROGATION
If any payments are made to or on behalf of a Participant and such payments arise as a result
of an injury, illness or other condition for which the Participant has, or may have, or asserts
any claim or right of recovery (including, without limitation, claims for pain and suffering,
loss of consortium, consequential, punitive, exemplary or other damages) against a third party
or parties, then any benefits advanced by the Trust for such medical expenses shall be made on
the condition and with the agreement and understanding that the Participant shall reimburse
the Trust to the extent of (but not exceeding) any amount or amounts recovered by or on
behalf of the Participant (including the Participant's estate) from any third party by way of
settlement or in satisfaction of any judgment relating to said claim. The Trust shall maintain a
lien on any such recovery and be entitled to reimbursement in full in accordance with this
Section irrespective of whether the Participant has been fully compensated for all or any of
said claims. The Trust shall be entitled to such reimbursement from first dollar recovery
amounts received by the Participant. As security for the Trust's rights to such reimbursements
the Trust shall be subrogated to all claims, demands, actions or rights of recovery of the
Participant against any third party or parties (or their insurers) to the extent of any and all
benefits advanced by the Trust; and any Participant that takes any action prejudicing or
otherwise impairing the subrogation rights of the Trust shall be liable to the Trust for any
losses to the Trust caused by such action. Any action prejudicing or otherwise impairing the
subrogation rights of the Trust made by the Participant shall also terminate the Trust's
obligation to advance benefits to or on behalf of the Participant. The Trust shall withhold
payments of claims made under this Plan, to the extent that the Trust has reason to believe
that said claims arise as a result of any act of a third party, until the Participant or the
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 58
Florida Municipal Insurance Trust Medical Master Plan of Benefits
Participant's legal representative executes a subrogation agreement.
The subrogation rights of the Trust, as set forth in this Section, also apply to payments made
by the Participant's own auto insurance (with the exception of payment for property damage).
For purposes of this Section and any subrogation agreement executed pursuant hereto, the
term Participant shall include the heirs, guardians, executors or other representatives of the
Participant.
For purposes of this Section and any subrogation agreement executed pursuant hereto, the
spouses, children and other Dependents as Participants under the Plan are third party
beneficiaries under the Plan and therefore subject to the same duties and obligations as
Employees who are Participants under the Plan. If the Participant is a minor, any amount
recovered by or on behalf of such minor- Participant shall be subject to this provision, to the
fullest extent permissible under State Law.
The Trust shall have no obligation to share the cost of, or pay any part of, the Participant's
attorney fees and costs incurred in obtaining any recovery against the third party.
The Trust retains the right, at its sole discretion, to sue third parties on behalf of the
Participant should the Participant not commence lawsuit within a reasonable period of time.
The Trust reserves the right to make changes to this provision, as necessary, provided
appropriate advance notice is given to the Participant.
SECTION XXI — NOTICE
Notice to an Employer given under the Plan shall be sufficient if given to the Employer when
addressed to its office location stated in the Participation Agreement. Notice to the Trust,
except as otherwise herein expressly provided, shall be sufficient if given to:
The Florida Municipal Insurance Trust
Attention: Health Department
125 E. Colonial Drive
Orlando, Florida 32801
* *Unless otherwise stated in the Schedule of Benefits (rev. 01/03)
Page 59
❑ Administration/
Marketing
❑ Risk Control
❑ Underwriting
Property & Casualty
Health
Post Office Box 530065
125 East Colonial Drive
Orlando, FL 32853 -0065
800 - 445 -6248
407 - 425 -9142
Suncom 344 -0725
Fax 407 - 425 -9378
Health Claims
Post Office Box 538140
Orlando, FL 32853 -8140
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
❑ Workers'
Compensation Claims
Post Office Box 538135
Orlando, FL 32853 -8135
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
❑ Property & Liability
Claims
Post Office Box 538135
Orlando, FL 32853 -8135
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
FLORIDA LEAGUE OF CITIES, INC.
PUBLIC RISK SERVICES
May 30, 2003
City of Okeechobee
Procurement Management Office
55 S.E. Third Avenue
Okeechobee, FL 34974 -2903
Re: RFP - Group Health Insurance
Dear Procurement Management Office:
We appreciate the opportunity to provide you with this proposal of insurance for
employee benefits. Medical coverage has been proposed on a Point of Service
(POS) managed care basis through the Florida Municipal Insurance Trust, a non-
profit, non - accessible, group - pooled program.
The Trust also provides dental and short -term disability benefits and a prescription
drug card plan.
The Trust offers First Health to provide a statewide managed care network for its
participants. These Comprehensive networks of doctors and hospitals are available
in most regions.
All rates quoted are guaranteed for sixty (60) days from the date of the proposal.
The rates include costs of administration, reinsurance and estimated claims costs.
Monthly, quarterly and annual loss reports are provided at no additional charge.
We welcome the opportunity to further discuss our proposal and should you have
any questions, please contact me at 1- 800 - 445 -6248.
Sincerely,
Chuck Wilde
Marketing Representative
CW /jr
Enclosure
Florida Municipal Insurance Trust
❑ Administration/
Marketing
❑ Risk Control
❑ Underwriting
Property & Casualty
Health
vf
Post Office Box 530065
125 East Colonial Drive
Orlando, FL 32853 -0065
800 - 445 -6248
407 - 425 -9142
Suncom 344 -0725
Fax 407 - 425 -9378
Health Claims
Post Office Box 538140
Orlando, FL 32853 -8140
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
❑ Workers'
Compensation Claims
Post Office Box 538135
Orlando, FL 32853 -8135
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
❑ Property & Liability
Claims
Post Office Box 538135
Orlando, FL 32853 -8135
800 - 756 -3042
407 - 245 -0725
Suncom 344 -0725
Fax 407 - 425 -9378
FLORIDA LEAGUE OF CITIES, INC.
PUBLIC RISK SERVICES
PROPOSAL OF INSURANCE
FOR
CITY OF OKEECHOBEE
Effective Date: 10/01/2003
Provided by
Florida Municipal Insurance Trust
Administered by:
The Florida League of Cities, Inc.
PUBLIC RISK SERVICES
P.O. Box 530065
Orlando, FL 32853 -0065
407 - 425 -9142 or Toll Free 1- 800 - 445 -6248
May 30, 2003
Florida Municipal Insurance Trust
Florida League of Cities
City of Okeechobee
MedicaURx
First Health Network
Contract Type
Enrollment
Current Rates
Monthly Premium
Annual Premium
Single
47
$297.09
$13,963.23
$167,558.76
EE + Spouse
8
$642.00
$5,136.00
$61,632.00
EE + Child(ren)
9
$536.45
$4,828.05
$57,936.60
Family
1
$881.36
$881.36
$10,576.32
4-.,--, ,, '3.-fi,-:;:.-',''
Proposed PPO
Rates (FLC)
Contract Type
Enrollment
10/1/03 - 9/30/04
Monthly Premium
Annual Premium
Single
47
$424.44 Gold Plan
$19,948.64 Gold Plan
$239,383.66 Gold Plan
EE + Spouse
8
$917.20 Gold Plan
$7,337.57 Gold Plan
$88,050.87 Gold Plan
EE + Child(ren)
9
$766.40 Gold Plan
$6,897.62 Gold Plan
$82,771.41 Gold Plan
Family
1
$1,259.16 Gold Plan
$1,259.16 Gold Plan
$15,109.91 Gold Plan
Single
47
$387.22 Silver Plan
$18,199.14 Silver Plan
$218,389.71 Silver Plan
EE + Spouse
8
$836.76 Silver Plan
$6,694.07 Silver Plan
$80,328.80 Silver Plan
EE + Child(ren)
9
$699.19 Silver Plan
$6,292.70 Silver Plan
$75,512.36 Silver Plan
Family
1
$1,148.73 Silver Plan
$1,148.73 Silver Plan
$13,784.77 Silver Plan
Single
47
$356.95 Bronze Plan
$16,776.80 Bronze Plan
$201,321.66 Bronze Plan
EE + Spouse
8
$771.36 Bronze Plan
$6,170.90 Bronze Plan
$74,050.78 Bronze Plan
EE + Child(ren)
9
$644.54 Bronze Plan
$5,800.90 Bronze Plan
$69,610.76 Bronze Plan
Family
1
$1,058.95 Bronze Plan
s4.28 GdPlis '41:
$1,058.95 Bronze Plan
„;i.:', $3.,e10.99, 00jd Plaii -
$12,707.44 Bronze Plan
0 fl' 3' - ,,-,
1,1D,:lt:::45. , "‘...!..t
'Z'''''';'-t-': : .':::: . '„ PIan
S32,334 .64;$1iverylin -,,,i:
-,;:. :. -'" . Silver PIan . :
,
iiAtita:,. ..;.;i;".•', ‘,. ' r117:
'10,-3, :5 ',65D-il:',":?:..
,F:: -.;i-f.:::, ,. ziiiiwiiiplan
s . .:: S2,807.02Broni Mari' , .,.
_."2 ;1'.' -272 ition4
k... : ' ' ' . ',--;
T.7,11:',WL':. 'Z-5-,'::-
.;,-. - z
0.4iii... kit. itingik7a
iik,-,i-a-21i.!;..;j2::':,.4--:
,,:-.'i: 7::Ilkidiii,,,z,--
..'. :7 :,7: -.:'-"--.-':- -- -
' -::.:7 -:;_ _. erJn ......r..
PiWireiiiiiiii,:::I
' ri,„:°K:',,!!:=',I.:::. !,i'i
if-'. f.'" ''',.:•"-..:'',.' ..]?-:-:;,'k.:,. .:ii-g'.::'
a: i:- .'_„-::-::,:;:,,,:i,:!,:, :::: ,-.,::::
**Medicare Supplement
$256.30
* All rates are subject to Large Claim Disclosure and acceptance by the League's stop loss insurance carrier.
** Medicare Supplement is available for retirees over age 65
GROUP f)FNTAI
SCHEDULE OF BENEFITS
FLORIDA MUNICIPAL INSURANCE TRUST
GFNFRAL DFNTAL CARF BFNFFIT
Lifetime Maximum Benefit - Unlimited
Calendar Year Maximum Benefit -
$1,000 per individual
SUMMARY OF GFNFRAL CARF SFRVICFS
1. Examinations and recall services, check -ups and
cleaning of teeth
2. Palliative treatment
3. Endodontic treatment
4. Space maintainer
5. X -rays
6. Oral surgery
7. Periodontal treatment
8. Normal extraction of teeth
9. Silver and synthetic permanent fillings, crowns
and jackets
10. Fixed bridges consisting of crowns or jackets
11. Dentures and removable bridges
DFll1CTIRI E
$50 per individual per calendar year.
COINS' IRANCF
Plan pays 80% of first $1,250 of eligible
expenses per calendar year.
DFNTAI RATFS (PFR MONTH)
Employee Dental
Dependent Dental
Family Dental
$28.91
S42.50
$71.41
ORTHODONTIC CARE BFNFFIT
Lifetime Maximum Benefit - $1,000 per
individual.
SUMMARY OF ORTHODONTIC CARF
1. Diagnostic procedures
2. Appliances for tooth guidance and control of
harmful habits
3. Retention appliances
4. Comprehensive treatment with fixed and
removable appliances for correction of
malocclusion in permanent, primary and
mixed dentition
5. Orthodontic treatment must be completed
prior to attainment of age 19.
J IFFTIMF DFDl1CTIRI F
$50 per individual.
COINS( JRANCF
Plan pays 50% of first $2,000 of eligible
expenses per individual in their lifetime.
STAND ALONE - (Without Health)
Employee Dental
Dependent Dental
Family Dental
$32.30
S47 60
$79.90
Dental coverage written in the Florida Municipal Insurance Trust is subject to a 25% participation of those
employees quoted.
* **
This summary was designed only to give you a brief description of benefits provided and does not
include all of the provisions, limitations or exclusions in the policies. In an actual claim situation,
the policy provisions, limitations, exclusions will apply. If this outline disagrees with the Plan
Document in any way, the Plan Document will govern.
FLORIDA MUNICIPAL INSURANCE TRUST
DENTAL BENEFIT PLAN SUMMARY
Reasonable and customary limits will apply to all covered eligible expenses.
GFNFRAI DFNTAI CARF
Calendar Year Maximum $1,000
Deductible $50 calendar year
After the deductible has been met, unless otherwise stated, the following coinsurance will apply:
This plan will pay 100% preventative services, not subject to the calendar year deductible, as follows:
1. Oral examinations
2. Dental X -rays (Bitewings twice per calendar year, Full Mouth or Panoramic once every 2 years)
3. Fluoride application (for dependents under age 15)
4. Prophylaxis
This plan will pay 80% for basic dental services as follows:
1. Emergency treatment for pain
2. Space maintainers
3. Dental X -rays
4. Biopsies of oral tissue
5. Pulp vitality tests
6. Fillings
7. Extractions
8. Oral Surgery
9. Endodontics
10. Periodontics
This plan will pay 50% for dental restorations and specialty services as follows:
1. Inlays, onlays
2. Crowns
3. Bridges, dentures
SCHFfIII F OF ORTHODONTIC RFNFFIT (applies only to eligible dependents under age 19).
Lifetime maximum (per person)
Lifetime deductible
$1,000
$50 per person
Covered eligible expenses are payable after the deductible at 50 %.
1. Diagnostic procedures.
2. Appliances for tooth guidance and control of harmful habits.
3. Retention Appliances.
4. Comprehensive treatment with fixed and removable appliances for correction of
malocclusion in permanent, primary and mixed dentition.
These summaries are designed only to give you a brief description of the benefits provided and does not include all of the
provisions, limitations or exclusions in the policies. In an actual claim situation, the policy provisions, limitations,
exclusions will apply. If this outline disagrees with the Plan Document in any way, the Plan Document will govern.
CLAIM ADMINISTRATOR.
Florida League of Cities, Inc. Claims Center
P.O. Box 538135 (407) 245 -0725
Orlando, FL 32853 -8135 (800) 756 -3042
GROUP VISION
VISION SERVICE PLAN
SCHEDULE OF BENEFITS
f)FDL JCTIRI F
A deductible amount of $10.00 is required for any service(s) rendered payable out of pocket by the eligible person
to the panel doctor at the time of service.
COVFRFD FXPFNSFS
VISION EXAMINATION
The primary purpose of the Vision Service Plan is to provide for professional vision examination and care. This
examination comprises an analysis of the vision functions, including the prescription and supply of glasses where
indicated.
J ENSFS AM") FRAMFS
A. LENSES - The VSP Panel Doctor will order the proper lenses from a VSP approved laboratory. VSP
provides any necessary lenses, including single vision, bifocal, trifocal or other more complex and
expensive lenses, when necessary for the patient's visual welfare. This assures the finest American -
made lenses and quality workmanship. The doctor verifies the accuracy of the finished lenses.
B. FRAMES - The patient is assisted in the selection of frames. VSP provides a wide selection of quality
frames. Because of the cosmetic nature of frames and the rapidly changing styles, VSP has a limit on
the cost of the frames provided under the program. The limit is designed to cover a majority of frames in
current use. Patients who select frames that exceed the limit are required to pay the additional wholesale
cost, plus a modest additional fee.
C. MEDICALLY NECESSARY CONTACT LENSES - Contact lenses are allowed under the program in any
of these instances provided prior approval is obtained from VSP by your doctor with documentation.
1) Following cataract surgery.
2) When visual acuity cannot be corrected to 20/70 in the better eye except by use of contact
lenses.
3) Anisometropia of greater than 350 diopters and asthenopia or diplopia, with spectacles.
4) Keratoconus diagnosis where contact lenses is the treatment of choice.
5) Monocular aphakia and /or binocular aphakia where the doctor certifies medically necessary
contact lenses are necessary for safety and rehabilitation to an occupational productive life.
All five (5) categories of "medically necessary" contacts are subject to coordination of benefits with the
medical insurance carriers. VSP will provide the contacts or glasses, but not both.
D. COSMETIC CONTACT LENSES - When cosmetic contact lenses are selected, an indemnity allowance
will be made in lieu of all other services.
HOW OFTFN SFRVICFS ARF AVAII ARI F
A. A VISION EXAMINATION - is available to each covered person every 12 months.
B. LENSES - Are available every 12 months when required.
C. FRAMES - Are available every 24 months.
1 IMITATION
EXTRA COST - The plan is designed to cover visual needs rather than elective materials. If any of the following
are selected and the VSP doctor does not receive prior authorization, there will be an extra charge:
a) Oversized lenses
b) A frame costing more than plan allowance
c) Tinted or photochromic lenses (other than Pink 1 and 2)
d) Coated lenses
e) No -line bifocals (blended type) and progressive lenses
f) Cosmetic Faceting
g) Other cosmetic items.
ITEMS NOT COVERED:
a) Orthoptics or vision training
b) Subnormal vision aids
c) Aniseikonia lenses
d) Two pair of glasses in lieu of bifocals
e) Plano (non - prescription) lenses
f) Cosmetic contact lenses.
Replacement or repair of lost or broken lenses and frames, except at normal intervals.
Medical or surgical treatment of the eyes.
Services or materials provided as a result of any Workers' Compensation Law, or similar legislation, or obtained
through or required by any government agency or program whether Federal, State or any subdivision thereof.
Any eye examination required by an employer as a condition of employment, unless agreed upon in writing by
VSP and included in the original contract.
Di JAI CHOICF C:OVFRAC=,F
Eligible persons not wishing to secure services from a Vision Service Plan Doctor may secure services from a
non - participating doctor and submit bills for reimbursement. The amounts reimbursed are limited and may not
cover the full charges.
Fl IGIRILITY
Each group electing vision care must maintain their vision care coverage for a minimum of one year from the time
of inception. All employees and dependents who meet the eligibility requirements of their enrolled group are
covered for vision care benefits.
Neither employees nor dependents have the right to individually select vision care coverage. Requirements for
participation are:
a) 100% of all city employees, or
b) 100% of all City employees carrying any coverages with FMIT.
PRFMIUM RATFS•
Employee $ 5.74
Dependent $ 8 43
Family Total $14.17
THE FIRST HEALTH NETWORK
Internet Provider Directory
City of Okeechobee
Current As Of: May 30, 2003
QFirst Health.
This Provider Directory is provided by First Health Group Corp. to present to you information on hospitals, physician and other providers who have agreed
to provide their usual services to you at specially contracted rates of payment. All decisions about the type of care you receive are the responsibility of you
and the physician whom you select. The quality and results of the care provided are the responsibility of the physician. Some health services may be provided
by resident physicians under the supervision of the listed physicians. While First Health Group Corp. makes every effort to maintain accurate and up- to-date
information, we cannot be responsible for any omissions or errors after publication. Please confirm provider participation prior to your visit.
Okeechobee County Hospitals
Okeechobee County Hospitals
The First Health® Network
Internet Provider Directory
Current As Of: May 30, 2003
QFirst Health®
This Provider Directory is provided by First Health Group Corp. to present to you information on hospitals, physicians and other providers who have agreed to provide their usual services
to you at specially contracted rates ofpayment. All decisions about the type of care you receive are the responsibility of you and the physician whom you select. The quality and results of
the care provided are the responsibility of the physician. Some health services may be provided by resident physicians under the supervision of the listed physicians. While First Health
Group Corp. makes every effort to maintain accurate and up -to -date information, we cannot be responsible for any omissions or errors after publication. Please confirm provider
participation prior to your visit.
1
Okeechobee County Hospitals
Directory Criteria
Product: FIRST HEALTH HOSPITAL NETWORK
Sorted By: City
Counties Included: OKEECHOBEE
States Included: FLORIDA
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited.
2
Okeechobee County Hospitals
OKEECHOBEE
OKEECHOBEE HOSPITAL INC
DBA RAULERSON
HOSPITAL
(863) 763-2151
1796 HIGHWAY 441 N
OKEECHOBEE, FL 34973
THIS LIST IS SUBJECT TO CHANGE
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited.
3
Okeechobee County Facilities
Okeechobee County Facilities
The First Health® Network
Internet Provider Directory
Current As Of: May 30, 2003
QFirst Health
This Provider Directory is provided by First Health Group Corp. to present to you information on hospitals, physicians and other providers who have agreed to provide their usual services
to you at specially contracted rates of payment All decisions about the type of care you receive are the responsibility of you and the physician whom you select. The quality and results of
the care provided are the responsibility of the physician. Some health services may be provided by resident physicians under the supervision of the listed physicians. While First Health
Group Corp. makes every effort to maintain accurate and up -to -date information, we cannot be responsible for any omissions or errors after publication. Please confirm provider
participation prior to your visit.
7
Okeechobee County Facilities
Directory Criteria
Product: FIRST HEALTH FACILITY CARE NETWORK
Sorted By: City
Counties Included: OKEECHOBEE
States Included: FLORIDA
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited
2
Okeechobee County Facilities
OKEECHOBEE
LAB CORP FLORIDA
(863) 357-7715
1008 N PARROTT AVE
OKEECHOBEE, FL 34972
LAKE OKEECHOBEE
REGIONAL CANCER
CENTER
(863) 763-7100
301 NE 19TH DR
OKEECHOBEE, FL 34972
LOOKADOO SKYLINE LAB
(863) 357-2666
1006 N PARROTT AVE
OKEECHOBEE, FL 34972
MEDFOCUS FLORIDA
(800) 398-8999
204 SE PARK ST
OKEECHOBEE, FL 34972
MEDFOCUS FLORIDA
(800) 398-8999
115 NE 3RD ST #A
OKEECHOBEE, FL 34972
ONCOLOGY ASSOCIATES
FL
(863) 763-7100
301 NE 19TH DR
OKEECHOBEE, FL 34972
OPEN MRI OF
OKEECHOBEE
(863) 824-6736
115 NE 3RD ST
OKEECHOBEE, FL 34972
SURGERY CENTER OF
OKEECHOBEE INC
(863) 357-6220
1655 US HIGHWAY 441
OKEECHOBEE, FL 34972
THIS LIST IS SUBJECT TO CHANGE
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited
3
Okeechobee County Physicians
Okeechobee County Physicians
The First Health® Network
Internet Provider Directory
Current As Of: May 30, 2003
9First Health.
This Provider Directory is provided by First Health Group Corp. to present to you information on hospitals, physicians and other providers who have agreed to provide their usual services
to you at specially contracted rates of payment. All decisions about the type of care you receive are the responsibility of you and the physician whom you select. The quality and results of
the care provided are the responsibility of the physician. Some health services may be provided by resident physicians under the supervision of the listed physicians. While First Health
Group Corp. makes every effort to maintain accurate and up -to -date information, we cannot be responsible for any omissions or errors after publication. Please confirm provider
participation prior to your visit.
Okeechobee County Physicians
Directory Criteria
Product: FIRST HEALTH OUTPATIENT CARE NETWORK
Sorted By: Specialty, City
Counties Included: OKEECHOBEE
States Included: FLORIDA
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited
2
Okeechobee County Physicians
ANESTHESIOLOGY
OKEECHOBEE
MID FLORIDA ANESTHESIA
ASSOCIATES
(863) 763-7015
1655 US HIGHWAY 441
OKEECHOBEE, FL 34972
MW FLORIDA ANESTHESIA
ASSOCIATES
(863) 763-7015
1796 US HIGHWAY 441
OKEECHOBEE, FL 34972
MW FLORIDA ANESTHESIA
ASSOCIATES
(863) 763-7015
300 NW 5TH ST #312
OKEECHOBEE, FL 34972
CARDIOVASCULAR
DISEASE
OKEECHOBEE
ARAIN, SHAKOOR A
(863) 467-9400
1600B SW 2ND AVE
OKEECHOBEE, FL 34974
RIAZ, MOHAMMAD
(863) 467 -1156
204 NE 19TH DR
OKEECHOBEE, FL 34972
CHIROPRACTIC
MEDICINE
OKEECHOBEE
DOUGLAS, EDWARD W
(863) 763 -4320
916 NW PARK ST
OKEECHOBEE, FL 34972
PLATT, KEVIN
(863) 763-2400
280 SW 32ND ST
OKEECHOBEE, FL 34974
STEPHENS, PETER W
(863) 763-0880
375 SW 32ND ST
OKEECHOBEE, FL 34974
CRITICAL CARE
MEDICINE
OKEECHOBEE
SHAKOOR, ARIF
(863) 357-2300
265 NE I9TH DR
OKEECHOBEE, FL 34972
DERMATOLOGY
OKEECHOBEE
SCHIFF, THEODORE A
(863) 467-6767
301 NE 19TH DR
OKEECHOBEE, FL 34972
EAR NOSE & THROAT
(OTOLARYNGOLOGY)
OKEECHOBEE
BEQUER, NAPOLEON G
(863) 357-3333
212 NE I9TH DR
OKEECHOBEE, FL 34972
EAR NOSE & THROAT
(OTOLARYNGOLOGY)
OKEECHOBEE
BERGHASH, LESLIE R
(863) 357-7791
1916 US HIGHWAY 441
OKEECHOBEE, FL 34972
EAR NOSE & THROAT
(OTOLARYNGOLOGY)
OKEECHOBEE
LANZA, JOHN T
(863) 357-7791
1916 US HIGHWAY 441
OKEECHOBEE, FL 34972
EMERGENCY
MEDICINE
OKEECHOBEE
SCOTT, JOSEPH A
(863) 763-2151
1796 US HIGHWAY 441
OKEECHOBEE, FL 34972
FAMILY PRACTICE
OKEECHOBEE
ARAGON, GLORIA R
(863) 763 -6496
1004 N PARROTT AVE
OKEECHOBEE, FL 34972
HELLER, LELAND M
(863) 467-8771
109 NE 19TH DR
OKEECHOBEE, FL 34972
SWEDA, STANLEY H
(863) 763 -1107
204 SE PARK ST
OKEECHOBEE, FL 34972
GENERAL PRACTICE
OKEECHOBEE
CROUCH, JOHN C
(863) 357-3600
115 NE 3RD ST #C
OKEECHOBEE, FL 34972
GENERAL VASCULAR
SURGERY
OKEECHOBEE
KOTHALANKA, RAMA
(863) 467-5873
107 NE 19TH DR
OKEECHOBEE, FL 34972
GERIATRIC MEDICINE
OKEECHOBEE
MAVROIDES, CHRISTOPHER
J
(863) 763-5666
1922 US HIGHWAY 441
OKEECHOBEE, FL 34972
GYNECOLOGY (NO
OB)
OKEECHOBEE
COLLINS, EVAN M
(772) 219-1080
250 NE 2ND AVE
OKEECHOBEE, FL 34972
GYNECOLOGY (NO
OB)
OKEECHOBEE
DELOACH, VICTOR E
(863) 763-7481
308 NW 5TH AVE
OKEECHOBEE, FL 34972
GYNECOLOGY (NO
OB)
OKEECHOBEE
GARCIA, TRINIDAD E
(863) 763-6427
GASTROENTEROLOGY 306 NE I9TH DR
OKEECHOBEE, FL 34972
OKEECHOBEE
CHANG, JOHN
(863) 357-0888
235 NE 19TH DR
OKEECHOBEE, FL 34972
HAAS, KENNETH F
(863) 357-7447
1930 US HIGHWAY 441
OKEECHOBEE, FL 34972
GYNECOLOGY (NO
OB)
OKEECHOBEE
HUSAIN, SURAIYA
(863) 763-8000
1300 N PARROTT AVE
OKEECHOBEE, FL 34972
GYNECOLOGY (NO
OB)
OKEECHOBEE
THOMSON JR, ALTON
(561) 219-1080
250 NE 2ND AVE
OKEECHOBEE, FL 34972
HEAD & NECK
SURGERY
OKEECHOBEE
BERGHASH, LESLIE R
(863) 357-7791
1916 US HIGHWAY 441
OKEECHOBEE, FL 34972
LANZA, JOHN T
(863) 357 -7791
1916 US HIGHWAY 441
OKEECHOBEE, FL 34972
HEMATOLOGY
OKEECHOBEE
AKHTAR, VASEEM S
(863) 467-9000
1101 N PARROTT AVE
OKEECHOBEE, FL 34972
INTERNAL MEDICINE
OKEECHOBEE
AHMED, IQBAL
(863) 357-6030
202 NE I9TH DR
OKEECHOBEE, FL 34972
AKHTAR, VASEEM S
(863) 467 -9000
1101 N PARROTT AVE
OKEECHOBEE, FL 34972
ARAGON, CANDIDO P
(863) 763 -6496
1004 N PARROTT AVE
OKEECHOBEE, FL 34972
ARAIN, SHAKOOR A
(863) 467 -9400
1600B SW 2ND AVE
OKEECHOBEE, FL 34974
BERGER, JAY S
(863) 467-1117
1105 N PARROTT AVE
OKEECHOBEE, FL 34972
CHAUDHARY, MUHAMMAD
A
(863) 763-1917
206 NE 19TH DR
OKEECHOBEE, FL 34972
HAAS, KENNETH F
(863) 357-7447
1930 US HIGHWAY 441
OKEECHOBEE, FL 34972
KHAN, SAEED A
(863) 467-4788
1924 US HIGHWAY 441
OKEECHOBEE, FL 34972
KOTHALANKA,
JANIKAMMA
(863) 467-5873
107 NE I9TH DR
OKEECHOBEE, FL 34973
LADIA, FELIPE P
(863) 763-6431
210 NE 1 9TH DR
OKEECHOBEE, FL 34972
LADIA, LILIA D
(863) 763-6431
210 NE I9TH DR
OKEECHOBEE, FL 34972
MAVROIDES, CHRISTOPHER
J
(863) 763 -5666
1922 US HIGHWAY 441
OKEECHOBEE, FL 34972
MEHANNI, MAGED A
(863) 763 -3622
300 NW 5TH ST #300
OKEECHOBEE, FL 34972
NAEEM,TAHIR
(863) 357-0104
1924 US HIGHWAY 441
OKEECHOBEE, FL 34972
RIAZ, MOHAMMAD
(863) 467-1156
204 NE 19TH DR
OKEECHOBEE, FL 34972
SHAKOOR, ARIF
(863) 357-2300
265 NE 19TH DR
OKEECHOBEE, FL 34972
MEDICAL ONCOLOGY
OKEECHOBEE
AKHTAR, VASEEM S
(863) 467-9000
1101 N PARROTT AVE
OKEECHOBEE, FL 34972
MULTISPECIALTY
CLINIC
OKEECHOBEE
JUPITER HAND
REHABILITATION CENTER
INC
(863) 357-4994
210 NE 3RD AVE
OKEECHOBEE, FL 34972
MULTISPECIALTY
FACILITY
OKEECHOBEE
ALLIANCE ANESTHESIA P A
(863) 763 -7015
300 NW 5TH ST #312
OKEECHOBEE, FL 34972
FLORIDA COMMUNITY
HEALTH CENTERS INC
(863) 763-1951
1100 N PARROTT AVE
OKEECHOBEE, FL 34972
THIS LIST IS SUBJECT TO CHANGE
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited
3
Okeechobee County Physicians
FLORIDA COMMUNITY
HEALTH CENTERS INC
(863) 763-7481
308 NW 5TH AVE
OKEECHOBEE, FL 34972
NEUROLOGY
OKEECHOBEE
ALDANA, PETER R
(863) 763 -5181
115 NE 3RD ST #C
OKEECHOBEE, FL 34972
ALI, ABULFAZAL S
(863) 357-2777
225 NE 19TH DR
OKEECHOBEE, FL 34972
OBSTETRICS &
GYNECOLOGY
OKEECHOBEE
COLLINS, EVAN M
(772) 219-1080
250 NE 2ND AVE
OKEECHOBEE, FL 34972
GONZALEZ, PABLO R
(863) 763-7481
308 NW 5TH AVE
OKEECHOBEE, FL 34972
THOMSON JR, ALTON
(561) 219-1080
250 NE 2ND AVE
OKEECHOBEE, FL 34972
OCCUPATIONAL
THERAPY
OKEECHOBEE
DURAND, DONNA
(863) 357-4994
210 NE 3RD AVE
OKEECHOBEE, FL 34972
WILLETTE, MICHAEL
(863) 357-4994
210 NE 3RD AVE
OKEECHOBEE, FL 34972
OPHTHALMOLOGY
OKEECHOBEE
ESPIRITU, MIGUEL A
(863) 467-0533
304 NE 19TH DR
OKEECHOBEE, FL 34972
KELLY, KEVIN T
(863) 467-4111
710 S PARROTT AVE
OKEECHOBEE, FL 34974
KELLY, KEVIN T
(863) 467-4111
8551 W SUNRISE BLVD
OKEECHOBEE, FL 34974
ORTHOPEDIC
SURGERY
OKEECHOBEE
SLUTSKY, BRADFORD A
(863) 763-8100
1920 US HIGHWAY 441
OKEECHOBEE, FL 34972
PAIN MANAGEMENT
OKEECHOBEE
MID FLORIDA ANESTHESIA
ASSOCIATES
(863) 763-7015
1655 US HIGHWAY 441
OKEECHOBEE, FL 34972
MID FLORIDA ANESTHESIA
ASSOCIATES
(863) 763 -7015
1796 US HIGHWAY 441
OKEECHOBEE, FL 34972
MID FLORIDA ANESTHESIA
ASSOCIATES
(863) 763-7015
300 NW 5TH ST #312
OKEECHOBEE, FL 34972
PATHOLOGY
OKEECHOBEE
HUSSAIN, MUSHTAQ
(863) 467-7084
210 NW PARK ST #204
OKEECHOBEE, FL 34972
SCHIFF, THEODORE A
(863) 467-6767
301 NE 19TH DR
OKEECHOBEE, FL 34972
PEDIATRICS
OKEECHOBEE
ARAGON, GLORIA R
(863) 763 -6496
1004 N PARROTT AVE
OKEECHOBEE, FL 34972
BROWN, FRED D
(863) 763 -1951
1100 N PARROTT AVE
OKEECHOBEE, FL 34972
HUSSAIN, ANJUM P
(863) 467-8398
255 NE 19TH DR
OKEECHOBEE, FL 34972
ROBSHAW, CHRISTOPHER
(863) 357-1117
1100 N PARROTT AVE
OKEECHOBEE, FL 34972
PHYSICAL THERAPY
OKEECHOBEE
KIRTON, CHERYL L
(863) 467-6669
332 SW 32ND ST
OKEECHOBEE, FL 34974
NEW AMERICAN PHYSICAL
THERAPY
(863) 763-7773
1103 N PARROTT AVE
OKEECHOBEE, FL 34972
NOORUDDIN, MUHAMMAD
S
(863) 763 -7733
1103 N PARROTT AVE
OKEECHOBEE, FL 34972
PODIATRIC SURGERY
OKEECHOBEE
GARVIN, MICHAEL A
(863) 357 -1166
105 NE 19TH DR
OKEECHOBEE, FL 34972
PARRATTO, SCOTT F
(863) 467 -4311
1105 N PARROTT AVE
OKEECHOBEE, FL 34972
PSYCHIATRY
OKEECHOBEE
ALI, ABULFAZAL S
(863) 357-2777
225 NE 19TH DR
OKEECHOBEE, FL 34972
PULMONARY DISEASE
OKEECHOBEE
MEHANNI, MAGED A
(863) 763-3622
300 NW 5TH ST #300
OKEECHOBEE, FL 34972
SHAKOOR, ARIF
(863) 357-2300
265 NE I9TH DR
OKEECHOBEE, FL 34972
RADIATION
ONCOLOGY
OKEECHOBEE
HARTER, DAVID J
(863) 467-9500
1115 N PARROTT AVE
OKEECHOBEE, FL 34972
KRIMSLEY, ALAN S
(863) 467-9500
1115 N PARROTT AVE
OKEECHOBEE, FL 34972
KUMAR, RAMESH T
(863) 467-9500
1115 N PARROTT AVE
OKEECHOBEE, FL 34972
WOODY III, RONALD H
(863) 467-9500
1115 N PARROTT AVE
OKEECHOBEE, FL 34972
REHAB &
OCCUPATIONAL
MEDICINE CTR
OKEECHOBEE
JUPITER HAND
REHABILITATION CENTER
INC
(863) 357-4994
210 NE 3RD AVE
OKEECHOBEE, FL 34972
SURGERY
OKEECHOBEE
HUSAIN, MUZAFFAR
(863) 763 -8000
1300 N PARROTT AVE
OKEECHOBEE, FL 34972
KURTIN, ADAM D
(772) 219-4026
250 NE 2ND AVE
OKEECHOBEE, FL 34972
SANTELICES, ARMANDO A
(863) 467-8181
212 NE 19TH DR
OKEECHOBEE, FL 34972
UROLOGY
OKEECHOBEE
PANGILINAN, TRISTAN H
(863) 467-7666
200 NE 19TH DR
OKEECHOBEE, FL 34972
SIGALOW, DAVID A
(863) 763-0217
215 NE 19TH DR
OKEECHOBEE, FL 34972
YOUNG, MARVIN J
(863) 467-0909
245 NE 19TH DR
OKEECHOBEE, FL 34972
WORK HARDENING
CENTER
OKEECHOBEE
JUPITER HAND
REHABILITATION CENTER
INC
(863) 357-4994
210 NE 3RD AVE
OKEECHOBEE,FL34972
THIS LIST IS SUBJECT TO CHANGE
The information herein is protected proprietary information of First Health. Use of this information for any purpose other than for which it is provided is prohibited.
4
ORIGINAL
q1. i r =,
1sr ;��` t�
PUBLIC RISK MANAGEMENT OF FLORIDA
(PRM) HEALTH PLAN
Proposal for Group Health Insurance
For:
City of Okeechobee
Bid Number: FIN 01-00-05-02
July 5, 2002
Presented By:
RICHARD G.SCHELL
Area Assistant Vice President
Timothy R.Reynen
Account Executive
Arthur J. Gallagher&Co.
Gallagher Benefit Services
One Boca Place
2255 Glades Road, Suite 400E
Boca Raton,FL 33431
(561)995-6706
.
PUBLIC RISK MANAGEMENT
OF FLORIDA (PRM) HEALTH PLAN
TABLE OF CONTENTS
Section I Introduction
Section II Medical Plan
Section III Dental Plan
Section IV Life Insurance Plan
Section V Blue Cross Blue Shield of Florida
Gallagher Benefit Services
Section VI Current PRM Members
Section VII Agreement to Participate
PRM Bi-Laws
Section VIII Benefit Summary Comparison
AM Best Ratings
1
i t
PUBLIC RISK MANAGEMENT
OF FLORIDA (PRM) HEALTH PLAN
TABLE OF CONTENTS
Section I Introduction
Section II Medical Plan
Section III Dental Plan
Section IV Life Insurance Plan
Section V Blue Cross Blue Shield of Florida
Gallagher Benefit Services
Section VI Current PRM Members
Section VII Agreement to Participate
PRM Bi-Laws
Section VIII Benefit Summary Comparison
AM Best Ratings
1
t �
Gallagher Benefit Services, Inc.
A Subsidiary of Arthur J. Gallagher & Co.
July 3, 2002
Lola Parker, Account Supervisor
City of Okeechobee
55 S.E. Third Avenue
Okeechobee, PL 34974
Re: Public Risk Management Medical, Dental and Life Proposal
Dear Lola,
We appreciate the opportunity to present the enclosed Public Risk Management Health Trust
proposal. The proposal contains quotes for the High Option PPO, Low Option PPO, Blue Care
HMO as well as the PRM Dental and Life Insurance program.
The medical rates illustrated would be for the period August 1, 2002 through September 30,
2003, to coincide with the PRM plan year (a fourteen month contract). The Dental rates are
effective August 1, 2002 through September 30, 2002. The Life Insurance rates illustrated would
be from August 1, 2002 through September 30, 2004.
The PRM Health Trust, like the P&C Pool, will offer the City of Okeechobee increased value
and the opportunity to provide a more stable renewal process as health trends continue to
escalate. Groups with good claims experience receive additional credit at renewal.
The Trust requires a two-year commitment from the City of Okeechobee in order to participate.
The advantages of self-funding and the pooling concept are the results of long term commitment
as demonstrated by the continued success of the PRM program.
Should you have any questions, please contact me or Tim Reynen at 561-995-6706. Again,
thank you for the opportunity to provide the City of Okeechobee a proposal from the Public Risk
Management Health Trust.
Sincerely,
.AL-4.1 44e- 1 TR.
Richard G. Schell
Area Assistant Vice President
encl.
One Boca Place
2255 Glades Road, Suite 400 E
Boca Raton, FL 33431 /�
561.995.6706 G ,
Fax 561.995.6708
l I-:I.I.HK,1 i l;yl,7511.,�H
www.alg.com
9
' INTRODUCTION
Gallagher Benefit Services, a division of Arthur J. Gallagher & Co., is pleased to provide the enclosed
information on behalf of Public Risk Management of Florida concerning the benefit programs available
through the PRM Health Plan.
PRM is a purchasing cooperative of governmental agencies founded in 1988 for the purpose of banding
together to obtain the most competitive contracts for provision of Property & Casualty and Employee
Benefit insurances.
Arthur J. Gallagher & Co. acts as insurance consultant and broker to the PRM risk pools, working with
the membership and their individual consultants to provide quality programs to participating entities.
Members of the Property& Casualty risk pool have first hand knowledge of the expertise and
experience Arthur J. Gallagher & Co. brings to the membership. Gallagher Benefit Services brings the
same talents to the Employee Benefits arena, providing the PRM membership with expertise and
guidance through the quickly changing and heavily mandated employee benefits areas.
The PRM Health Plan is governed by a Board of Directors which meets quarterly to review plan
operation, financials, legislative issues and any other pertinent information. Each participating entity
delegates its' own Board Member, and each entity receives one vote. Each member has input regarding
the plan, future enhancements, funding levels, etc.
The plan year begins on October 1 of each year. Due to budgetary requirements, renewal discussions
begin in April and are finalized at the end of June each year. All contracts and funding levels are based
on an October 1 through September 30 plan year, although multi year rate guarantees are obtained from
the carriers whenever possible.
Medical coverage is required for participation in the PRM Health Plan. Other coverages offered as part
of the PRM Health Plan to participating entities are dental, life, AD&D and Dependent Life insurances.
These are offered for the convenience of the membership and are not required for participation.
Gallagher Benefit Services is also available for and happy to work with individual entities and their
advisors in the development of other additional employee benefits.
3
PR1VI MEDICAL PLAN
The Medical program provided through the Public Risk Management of Florida Health Plan is a self
funded plan using the Blue Cross Blue Shield of Florida network, administered by Blue Cross Blue
Shield of Florida and reinsured by Lincoln Re. At the close of each fiscal year an actuarial report is
submitted to the State of Florida pursuant to Florida Statute 112.08, and each year the State has
certified the Plan to be actuarially sound and fully reserved.
Administration/claims services, network access and excess reinsurance are negotiated by the PRM
Health Plan on behalf of its' members. This allows the Plan to utilize a larger purchasing group and
obtain more competitive rates than could be purchased individually. Any actual purchases must be
approved by the Board of Directors.
A choice of three medical plans is offered: A High Option PPO, a Low Option PPO, and an HMO.
Participating entities may select whichever plan, or combination of plans, best suit their needs. Plan
designs can be found on the following pages.
As PRM members are first and foremost individual entities, all Personnel parameters, i.e.; employee
eligibility for participation in the Plan, are decided by the individual entity. This allows the entities to
retain the personnel practices in place.
Prospective participants are initially underwritten based on individual group demographics and
experience.
5
PUBLIC RISK MANAGEMENT OF FLORIDA
SUMMARY OF BENEFITS
HIGH OPTION PPO
Lifetime Maximum $2,000,000
Copay $15 Per Office Visit at PPC
Physician's Office(Deductible and Coinsurance
Waived)
Deductibles
Calendar Year $200 (3 Per Family-Aggregate)
Per Admission(Non PPC Hospital Only) $100
Coinsurance 90%of PPC Schedule For Utilization of PPC
Providers; 70%Of Allowance For Utilization of Non-
PPC Providers
Prescription Drugs Rx Card(See Attached)
Maternity Delivery,Pre-and Postpartum Care Subject to
Deductible and Coinsurance
Adult Well Care $15 Copay per visit up to $250 combined adult
wellness and OB/GYN
Well Child Care $15 Copay Per Well Child Care Visit at PPC
Birth to Age 16 (18 Visits) Physician's Office; Out of Network, Deductible
Waived
Accident Care 90%of allowance(Deductible and Coinsurance
waived)
Mental Nervous
Inpatient -30 Days; 30 Visits $15 Copay Per Office Visit at PPC Physician's Office;
Per Calendar Year
Outpatient- Up to 20 Visits Per Out of Network, Subject to Deductible and
Calendar Year Coinsurance
Partial Hospitalization
Alcohol and Drug
$2,500 Lifetime Maximum $15 Copay Per Office Visit at PPC Physician's Office;
(Inpatient, Outpatient of any Combination) Out of network, Subject to Deductible and Coinsurance
Skilled Nursing Facility 60 Days Per Calendar Year
Home Health Care $12,000 Per Calendar Year
Hospice $7,500 Lifetime Maximum
Maximum Out-Of-Pocket
Coinsurance Expense $1,500 Per Person
Amount Per Calendar Year (Maximum 3 Per Family-Aggregate)
6
PUBLIC RISK MANAGEMENT OF FLORIDA
HIGH OPTION PPO
$7 GENERIC/$14 BRAND NAME PRESCRIPTION DRUG COVERAGE
BlueScriptsm Pharmacy Program
The cost of prescription drugs accounts for a significant share of your total health care expense. Blue Cross and Blue Shield
of Florida has developed the BlueScript Pharmacy Program in an effort to help control the increasing cost of prescription
drugs. BlueScript covers most medications, which,by law, may only be dispensed by a written prescription.
No claims to file. When your employees select a BlueScript participating pharmacy, they simply present their Blue Cross
and Blue Shield of Florida identification card and pay the applicable copayment amount for each covered prescription drug.
The participating pharmacy will file the claim for your employees.
Participating Pharmacies. More than 2,400 pharmacies participate in BlueScript statewide. Selection of a pharmacy for
participating in BlueScript is based on quality,service,competitive pricing, convenience to our customers,and ability to
provide all necessary information for claims filing. The pharmacy also must have on-line capability to provide timely
verification of eligibility,coverage and pricing information at the point-of-sale.
Non-Participating Pharmacies. Covered prescription drugs purchased at non-participating pharmacies are subject to the
copayment amount and reimbursed at a lower percentage. At the point-of-sale,your employees will pay the full cost of the
prescription drug and obtain an itemized receipt. It will be the employee's responsibility to complete a prescription drug
claim form, attach the itemized paid receipt, and submit both to Blue Cross and Blue Shield of Florida for payment. After
processing,payment will be made directly to the employee.
BlueScript Key Features:
• Broad accessibility with more than 2,400 participating pharmacies statewide,giving your employees more
choices with convenient locations.
• Participating pharmacies file claims for you, so you and your employees receive hassle-free service.
• Program flexibility with coverage designed to meet your needs at the point-of-sale.
• On-line claims information,providing quick answers on eligibility,pricing and coverage.
BlueScript provides hassle-fee service with no claims to file when using a participating pharmacy. It's another way Blue
Cross and Blue Shield of Florida is helping to control the high cost of health care.
sMService mark of Blue Cross and Blue Shield of Florida,Inc.
7
PUBLIC RISK MANAGEMENT OF FLORIDA
SUMMARY OF BENEFITS
LOW OPTION PPO
Lifetime Maximum $2,000,000
Copay $15 Per Office Visit at PPC
Physician's Office(Deductible and Coinsurance
Waived)
Deductibles
Calendar Year $500 (3 Per Family- Aggregate)
Per Admission(Non PPC Hospital Only) $500
Coinsurance 80%of PPC Schedule For Utilization of PPC
Providers; 60%Of Allowance For Utilization of Non-
PPC Providers
Prescription Drugs Rx Card(See Attached)
Maternity Delivery,Pre- and Postpartum Care Subject to
Deductible and Coinsurance
Adult Well Care $15 Copay per visit up to $250 combined adult
wellness and OB/GYN
Well Child Care $15 Copay Per Well Child Care Visit at PPC
Birth to Age 16 (18 Visits) Physician's Office;Out of Network,Deductible
Waived
Accident Care 80%of allowance(Deductible and Coinsurance
waived)
Mental Nervous
Inpatient -30 Days; 30 Visits $15 Copay Per Office Visit at PPC Physician's Office;
Per Calendar Year
Outpatient- Up to 20 Visits Per Out of Network,Subject to Deductible and
Calendar Year Coinsurance
Partial Hospitalization
Alcohol and Drug
$2,500 Lifetime Maximum $15 Copay Per Office Visit at PPC Physician's Office;
(Inpatient,Outpatient of any Combination) Out of network, Subject to Deductible and Coinsurance
Skilled Nursing Facility 60 Days Per Calendar Year
Home Health Care $2,500 Per Calendar Year
Hospice $7,500 Lifetime Maximum
Maximum Out-Of-Pocket
Coinsurance Expense $1,500 Per Person
Amount Per Calendar Year (Maximum 3 Per Family-Aggregate)
8
PUBLIC RISK MANAGEMENT OF FLORIDA
LOW OPTION PPO
$10 GENERIC/$25 BRAND NAME PRESCRIPTION DRUG COVERAGE
BlueScriptSm Pharmacy Program
The cost of prescription drugs accounts for a significant share of your total health care expense. Blue Cross and Blue Shield
of Florida has developed the BlueScript Pharmacy Program in an effort to help control the increasing cost of prescription
drugs. BlueScript covers most medications which, by law,may only be dispensed by a written prescription.
No claims to file. When your employees select a BlueScript participating pharmacy, they simply present their Blue Cross
and Blue Shield of Florida identification card and pay the applicable copayment amount for each covered prescription drug.
The participating pharmacy will file the claim for your employees.
Participating Pharmacies. More than 2,400 pharmacies participate in BlueScript statewide. Selection of a pharmacy for
participating in BlueScript is based on quality,service, competitive pricing, convenience to our customers, and ability to
provide all necessary information for claims filing. The pharmacy also must have on-line capability to provide timely
verification of eligibility,coverage and pricing information at the point-of-sale.
Non-Participating Pharmacies. Covered prescription drugs purchased at non-participating pharmacies are subject to the
copayment amount and reimbursed at a lower percentage. At the point-of-sale,your employees will pay the full cost of the
prescription drug and obtain an itemized receipt. It will be the employee's responsibility to complete a prescription drug
claim form,attach the itemized paid receipt, and submit both to Blue Cross and Blue Shield of Florida for payment. After
processing,payment will be made directly to the employee.
BlueScript Key Features:
• Broad accessibility with more than 2,400 participating pharmacies statewide, giving your employees more
choices with convenient locations.
• Participating pharmacies file claims for you,so you and your employees receive hassle-free service.
• Program flexibility with coverage designed to meet your needs at the point-of-sale.
• On-line claims information,providing quick answers on eligibility,pricing and coverage.
BlueScript provides hassle-fee service with no claims to file when using a participating pharmacy. It's another way Blue
Cross and Blue Shield of Florida is helping to control the high cost of health care.
sMService mark of Blue Cross and Blue Shield of Florida, Inc.
9
PUBLIC RISK MANAGEMENT OF FLORIDA
SUMMARY OF BENEFITS
HMO PLAN
Benefit Authorized
Out of Pocket Maximum
Individual $1,500
Family $3,000
Hospital per Admission Copay $250
Physician Office Services
Primary Care Physician $10 Copay
Specialist $10 Copay
Office Surgery $10 Copay
Routine Services $10 Copay
Preventive Care $10 Copay
Well Child Care $10 Copay
Allergy Testing $0 Copay
Allergy Immunization $10 Copay
Annual GYN exam $10 Copay
X-Ray& Lab $0 Copay
Infertility Services $10 Copay
Hospital Services:
Inpatient $250 per Admission Copay
Outpatient Hospital/Surgical $100 Copay
Emergency Room $50 Copay
Hospice Care $0 Copay
Home Health Care $0 Copay
$0 Copay
Skilled Nursing Facility 90 days/yr. max
Mental & Nervous
Inpatient $250 Copay/admission; 30 days/yr.
Outpatient $25 Copay/visit; 20 visits/yr.
Substance Abuse Inpatient/Outpatient
Inpatient $250 Copay/admission; Detox only
Outpatient $15 Copay/visit; 20 visits/yr.
Other Healthcare Providers(Ambulance,DME) $0 Copay
Prescription Drug Program
Drug Card: Generic $7.00 Copay
Brand $14.00 Copay
Mail Order: Generic $14.00 Copay
Brand $28.00 Copay
10
, .
City of Okeechobee
•
PRM Health Trust Rate Breakdown - Medical
Effective: 8/1/02 - 9/30/02
ft,7eferre4,PruyiderOjA.,.;,iii,; ,,,r"::: ',,:p,j:''.';'c:'%;z::::,1:: :Einploy,06',* '4EniplOyee,i lEinplayee
#iglidtiliOnV4:';NA'!::M: :AV:i6iiii14:60°i'AW;14.4,!A '2.:'4014,473/4;:;:.'siFinllY,
Attachment Factor $450.90 $1,014.19 $941.26 $1,504.72.
Specific Excess @ $80,000 $42.79 $96.25 $89.33 $142.81
Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $42.89 $42.89 $42.89 $42.89
PRM Administration $5.11 $5.11 $5.11 $5.11
Conversion $0.50 $0.50 $0.50 $0.50
Monthly Funding Rate $545.551 $1,162.301 $1,082.451 $1,699.39
Preferred Pr4A40P.,roic: ,,.: : 1,: .,:;:li,:sc:i;:,::::,-= 4:=: :: g'04)!oi-:'o:744 Employee Employee.
Low izili:::ii '', . J:::'''T,:-,::4,:fi'fs :',.cfl.:::iiiiiii4,-W,,,!.,, S,.::::ii,,,$ai44-1-:'1*.tii4; •:' *itio0
- ,
Attachment Factor $392.28 $882.34 $818.90 $1,309.10
Specific Excess @ $80,000 $42.79 $96.25 $89.33 $142.81
Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $42.89 $42.89 $42.89 $42.89
PRM Administration $5.11 $5.11 $5.11 $5.11
Conversion $0.50 $0.50 $0.50 $0.50
Monthly Funding Rate $486.93 $1,030.451 $960.09 $1,503.77
Health Maintenance ,.:::::::,,,:',
Organization Option ;, : ::;:-' ',-:,: ' ‘s,i-s,. :':;,'-''7!' .'-',, 1.'t' ,iiiiiiiiii4,4*: Employee e':: *,, ii-004
111u Car : : :‘ ,-• ' ': ':. : ': ' ,:", Enipi4ee,,', ;::'-'8piniSe:::'1' ;:A:Child'',' 4 Faintly
Attachment Factor $378.75 $851.92 $790.66 $1,263.96
Specific Excess @ $80,000 $36.08 $81.15 $75.32 $120.40
Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $62.00 $62.00 $62.00 $62.00
PRM Administration $5.11 $5.11 $5.11 $5.11
Conversion $0.50 $0.50 $0.50 $0.50
Monthly Funding Rate $485.80 $1,004.041 $936.95 $1,455.33
, • City of Okeechobee
PRM Health Trust Rate Breakdown - Medical
Effective: 10/1/02 - 9/30/03
E Pr,,,q0tqATTO14#1,S9RiNit'i,VF*M.. MI* P.,,P1::PiX0.# 'i:',";E#14,1t40,4440110i,
1000iiifiiii:::rAMig'C'Ai'':::P4; ;,''S':;: .' -i1ilti*4'-,4':&:si191401ii itikAn'0***:
Attachment Factor $450.90 $1,014.19 $941.26 $1,504.72
Specific Excess @ $80,000 $42.79 $96.25 $89.33 $142.81
Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $48.90 $48.90 $48.90 $48.90
PRM Administration $5.32 $5.32 $5.32 $5.32
Conversion $0.50 $0.50 $0.50 $0.50
Monthly Funding Rate I $551.77 $1,168.52 $1,088.67 $1,705.61
15' Cf0:•04Pro14071?r9: :: ,L;: -:';''':',:: '.,;,:: :::: , .!Pii0.19Y0:84i:;'';''PA401.00: ':AP4PA0):.0
Low Option ,1.: :::::,:f:: ,:;,,:''''::::::::, :'i' .:,iEnitilcii-e01:•: .: '::::N'5ii:$4gem:;14417ghttog '-:*****:
Attachment Factor $392.28 $882.34 $818.90 $1,309.10
Specific Excess @ $80,000 $42.79 $96.25 $89.33 $142.81
Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $48.90 $48.90 $48.90 $48.90
PRM Administration $5.32 $5.32 $5.32 $5.32
Conversion $0.50 $0.50 $0.50 $0.50
Monthly Funding Rate $493.15 $1,036.671 $966.31 $1,509.99
,) .:!,-,:: .,,i?„:. :,:;,::,4i554, , ,, ,, , ',040'St__,Ik.W'< 11. 1 :#44
grgoi.: 49!1:Poro,:: :,;‘;:''' !1: :::]-:•!?,gi,:gl :f;'::: :-'6-i:::gTntiv,Alif‘viA.9,„ :1,,„m.P41,,,. .
tiii'oloo ;s,t',i'.!,:i,$1;01011 140-44;WO**
Attachment Factor $378.75 $851.92 $790.66 $1,263.96
Specific Excess @ $80,000 $36.08 $81.15 $75.32 $120.40
Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $62.00 $62.00 $62.00 $62.00
PRM Administration $5.32 $5.32 $5.32 $5.32
Conversion $0.50 $0.50 $0.50 $0.50
Monthly Funding Rate $486.01 $1,004.25 $937.16 $1,455.54
i
Conditions and Limitations:
• Completion of Plan Sponsor Disclosure Form. Disclosure pertains to: 1) any claim relating
to a serious medical condition, 2) each claim in the last 12 months that has exceeded or
expected to exceed 50% of the specific deductible, 3) employees absent from work due to
disability and dependents, retirees or COBRA beneficiaries who are hospital confined.
• A Plan Document. The Excess Loss Policy cannot be issued until the Plan Document has
been received and approved by Lincoln Re Risk Management Services.
• Paid Claims experience from 4/1/02 — 9/30/02.
• A census of final enrollment. Terms are subject to change if final enrollment varies by more
than 15% from proposal assumptions.
• Capitation is included as an eligible expense under the aggregate.
• Minimum participation requirement is 75% of eligible employees. Employees who waive
coverage on this plan due to coverage elsewhere will be considered non participating.
• We assume implementation of the proposed PRM schedule of benefits with Blue Cross &
Blue Shield.
• The proposed program complies with State and Federal Statutes currently and in the future.
HIPAA compliance is included.
• Specific applies to all claims for all conditions for each individual.
• Specific applies to the mother and each child separately.
• The agent/broker is properly licensed and appointed with the carrier noted above for which
business is written.
• We assume the experience reflects a standard claims processing time of approximately two
weeks from date of receipt to date paid by the Third Party Administrator. Terms are subject
to change on a retrospective basis if subsequent experience demonstrates a significant,
undisclosed backlog of claims.
• Aggregate Monthly Settlement Option is included.
• Medical coverage options outlined in the proposal are contingent upon network availability.
Excess Loss Insurance Exclusions:
• Transplant Services, except for human to human organ or tissue transplant procedures.
• Expenses eligible for or covered by any worker's compensation, occupational disease law or
similar law.
• Losses due to war or any act of war.
• Penalties, interest, fines or fees imposed under the Policyholder.
• Punitive, exemplary, compensatory or extra-contractual damages paid by the Policyholder.
• Losses resulting from any professional or other liability claims arising from services
rendered by the Policyholder or any employee of affiliated organizations or person.
• Expenses from which the Policyholder is eligible for or receives any payment or reduction in
charges resulting from, but not limited to coordination of benefits or subrogation.
• Sales or use taxes, surcharges, or other such taxes or assessments, unless Lincoln expressly
agrees to make such payments as Lincoln agreed to with New York and Massachusetts
surcharges.
• Cost of claims administration or other administrative expenses and any expense for litigation
involving disputed claims under the plan document.
Swiss Re Lincoln National •
r•� Health&Casualty Insurance Co.
I' 7300 Corporate Center Drive
Suite 205
Miami,Fl 33126-1222 • •
Watts 800-352-0042
Voice 305-715-6145
Fax 305-715-6199
Plan Sponsor Disclosure Statement E-Mail:Eric_Hicks @SwissRe.com
It is the intention of the Plan sponsor to purchase Excess Liability Insurance in connection with the funding of an employee welfare benefit plan. The following
information is provided to the Excess Liability Carrier for use with the Plan Sponsor's application for coverage.
Listed below are:
A. Claims in the last 12 months exceeding 50%of the specific deductible level selected;
B. Any current claims which may be potentially serious regardless of current claim amount;
C. Dependents,retirees, or COBRA beneficiaries who are hospital confined within 30 days of this report; and
D. Employees absent from work due to disability as of the date of this report.
*CLAIMANT# **E/D/R/C DATE OF SEX DATE DIAGNOSIS OR NATURE OF CURRENT STATUS AND TOTAL
BIRTH DISABLED DISABILITY PROGNOSIS BILLS TO
• DATE($)
* For purposes of confidentiality,please identify the claimants as claimant#1,#2, #3, etc.
** E=Employee, D=Dependent, R=Retiree, C=COBRA beneficiary(include date COBRA coverage is expected to terminate)
The Plan Sponsor named below,through its authorized person,hereby represents that the above list is true,complete and accurate to the best of his/her knowledge and belief and
that nothing has been knowingly or intentionally omitted. The Plan Sponsor acknowledges that,as a minimum,its claims administrator,utilization review vendor,and medical
case management vendor participated in the collection of the above data.
PLAN SPONSOR Authorized Person
Address - Signature
Date of Disclosure Title
This information will be treated confidentially by the Excess Liability Carrier. Additional sheets may be attached.
Number of Claims Listed Number of Sheets Attached
www.lincolnre.com
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
PUBLIC RISK MANAGEMENT OF FLORIDA
DENTAL PLAN
The dental program provided through the Public Risk Management of Florida Health Plan is also a
self funded plan. The dental plan is administered by Florida Combined Life, a division of Blue
Cross Blue Shield of Florida, and reinsured by Lincoln Re as part of the overall plan. The dental
program is included as part of the actuarial report submitted to the State of Florida annually pursuant
to Florida Statute 112.08, and each year the State has certified the PRM Health Plan to be actuarially
sound and fully reserved.
Administration/claims services and excess reinsurance are negotiated by the PRM Health Plan on
behalf of dental participants. This allows the Plan to utilize a larger purchasing group and obtain
more competitive rates than could be purchased individually. Any actual purchases must be
approved by the Board of Directors.
The Dental Program provided through the Public Risk Management of Florida I-Iealth Plan is an
indemnity plan without network or provider requirements.
As in the medical plan, all Personnel parameters, ie; employee eligibility for participation in the
Plan, are decided by the individual entity.
Participation in the dental plan is not required for participation in the PRM Health Plan consortium.
12
•
PUBLIC RISK MANAGEMENT OF FLORIDA
DENTAL PLAN
Benefits Maximum
Basic Dental $1,500 per calendar year
Orthodontia $1,500 lifetime
(Available to dependent children
under age 19 only)
Deductible $50 per calendar year, per person
(Waived for Preventive Services 2 per family
and Orthodontia)
Copayment percentage for:
• Preventive Services 100%
• Basic Services 80%
• Major Services 50%
• Orthodontia 50%
Covered Dental Expenses include reasonable and customary necessary expenses incurred for the
services and supplies listed below:
Covered Preventive Services
• Initial oral examination
• Periodontic oral examinations, 2 per calendar year.
• Prophylaxis, including cleaning, routine scaling and polishing, 2 per calendar year.
• Topical Fluoride application once per calendar year for individuals under age 19.
• Palliative (to relieve pain) emergency treatment and emergency oral examinations.
• Sealants for individuals age 6 through 13 years of age, one application per 36 consecutive months.
• Dental X-rays as follows:
One set of full mouth x-rays every 36 months;
2 sets of bitewing x-rays per calendar year;
Other dental x-rays as deemed necessary.
• Space maintainers, except if covered under Orthodontia benefits.
• Pulp vitality tests.
• Caries susceptibility tests.
13
' r
•
PUBLIC RISK MANAGEMENT OF FLORIDA
DENTAL PLAN
(Continued)
Covered Basic Services
• Fillings (amalgam, composite, plastic and acrylic).
• Extractions.
• Endodontics (root canal).
• Recementing of crowns, inlays and/or bridges.
• Biopsies of oral tissue.
• Home visits by a physician or dentist when medically necessary in order to render a Covered dental
service.
• Oral surgery.
• Apicoectomy.
• Hemisection.
• General anesthesia administered in connection with a covered dental service if administered by an
individual licensed to administer general anesthesia, other than the dentist or physician performing
the service for which administered.
• Injection of antibiotic drugs.
• Periodontics:
Occlusal equilibration, when no restoration is involved;
Gingivectomy and gingivoplasty;
Gingival curettage;
Scaling and root planing;
Osseous surgery(osteoplasty and ostectomy), including flap entry and closure;
Surgical Periodontic examination;
Mucogingivoplastic surgery;
Management of acute periodontal infection and oral lesions.
• Denture adjustments, not including relining or rebasing.
• Fixed bridge repair as follows:
Replacement of broken pins;
Replacement of broken pontic;
Replacement of bridgework when the existing bridgework was installed at least 5years prior to its
replacement and the existing bridgework cannot be made serviceable.
• Repairs to existing removable denture (full or partial) as follows:
Repair of broken complete or partial denture and/or replacement of broken teeth;
Replacement or addition of teeth due to the extraction of natural teeth which occurred while
covered under this Plan;
Reattachment of damaged clasp or replacement of broken clasp;
Replacement of denture when the existing denture was installed at least 5 years prior to its
replacement and the existing denture cannot be made serviceable.
14
PUBLIC RISK MANAGEMENT OF FLORIDA
DENTAL PLAN
(Continued)
Covered Major Services
• Inlays (not part of bridge).
• Onlays (not part of bridge).
• Crowns (not part of bridge).
• Inlays, onlays, gold foil restorations, crowns (including precision attachments for dentures).
• Denture adjustments and relining and/or rebasing once each 36 months.
• Dentures, full and partial, and bridges, fixed and removable as follows:
Initial installation of dentures;
Dentures to replace one or more natural teeth extracted while covered under these benefits;
Initial installation of bridges;
Bridgework to replace one or more natural teeth extracted while covered under these benefits
(including inlays and crowns to form abutments);
Six months of post-delivery care.
Covered Orthodontia Services
(available only to dependent children age 19 or less at the date treatment commences.)
• Installations of orthodontic appliances and all orthodontic treatments concerned with the reduction or
elimination of an existing malocclusion and conditions resulting from that malocclusion through
correction of abnormally positioned teeth.
• Diagnostic services, including examination, study models, radiographs and all other diagnostic aids
used to determine orthodontic needs once each 5 years, commencing with the date of the initial visit
to the dentist or physician.
• Active and retentive orthodontic treatment for 24 consecutive months or less. Also, the amount of
orthodontia charges included as covered expenses during the initial calendar year quarter of treatment
will be limited to 30% of the total allowable charges for the cost of the entire orthodontia treatment.
The balance of the covered expenses will be prorated over the remaining calendar year quarters of the
treatment plan or 7 calendar year quarters, whichever is less.
15
City of Okeechobee
Dental Plan Rates
8/01/02 - 9/30/03
Single: =,; _
� . ._.. Family: ,
$31.15 $63.76
4
PUBLIC RISK MANAGEMENT OF FLORIDA
LIFE INSURANCE PLAN
The Life Insurance Plan provided through the Public Risk Management of Florida Health Plan is
fully insured and written by The Standard Insurance Company.
Insured benefit per employee is elected by individual entity and may be based on salary or a flat
amount. The standard PRM Life Plan benefits include Basic Life, Basic Accidental Death &
Dismemberment and Dependent Life. Additional PRM Life Plan benefits include Supplemental
employee and dependent life.
Participation in the life insurance plan is not required for participation in the PRM Medical Plan
Consortium. Gallagher Benefit Services would be happy to assist in alternate plans.
17
City of Okeechobee
Life Insurance Rates
8/01/02 - 9/30/04
Basic Life Rate AD&D Rate
$0.28 per $1,000 $0.03 per $1,000
SECTION V
Blue Cross Blue Shield of Florida
Gallagher Benefit Services
18
PUBLIC RISK MANAGEMENT OF FLORIDA
BLUE CROSS BLUE SHIELD
PROFILE OF SERVICES
Blue Cross Blue Shield provides the following administrative services as part of their contract with the
PRM Health Plan.
• Claims Administration
• Eligibility Maintenance
• PPO/HMO Network
• Customer Service
• Employee Meetings/ Enrollment
• Utilization Review, Pre-Certification, Case Management
• PPO/HMO Claims Filing by Providers
• Prescription Drug Card
• Mail Order Drug Service
• COBRA Administration
• Reports
Entities participating in the PRM Health Plan program will receive all of the above member services.
Employees, entity administrators and providers will deal with Blue Cross representatives assigned
exclusively to PRM for routine issues.
Additionally, Blue Cross PPO providers will be responsible for obtaining pre-certification authorization
and for filing PPO claims.
We anticipate soft dollar savings to PRM Health Plan members in the form of less plan administration, less
time resolving claims issues, less time reporting to various vendors, and less time answering employee
questions and complaints.
19
PUBLIC RISK MANAGEMENT OF FLORIDA
BLUE CROSS BLUE SHIELD ADVANTAGES
• PRM commitment to pooling concept. Fourteen year track record of quality service and plan
implementation.
• Flexibility in plan designs offering two PPO's in addition to an HMO.
• In addition to the Blue Cross Blue Shield service staff, PRM staff, and Gallagher Benefits Services
assist in all areas of plan management.
• Quarterly board meetings include Health Trust status reports, industry updates, and the sharing of
ideas and concepts.
• National recognition and acceptance of I.D. card. The ITS Program offers a reduction in changes and
hold harmless against balance billing when employees incur a claim out-of-state with a participating
Blue Cross/Blue Shield in that state.
• Local presence throughout the state with walk-in service to track all customer inquiries for prompt
resolution or questions.
• Largest PPO network in Florida. Employees have more hospitals and doctors to choose from. The
average reduction of billed charges results in savings of 35-45%.
• Blue Cross/Blue Shield allowances are accepted as payment in full. No balance billing except for copy or
deductible as co-insurance. Providers agree not to require full payment at time of service and providers
will file the claim.
• Network in and out of PPC network. Physicians and hospitals that participate with Blue Cross/Blue
Shield, but not with PPC network agree to accept our allowance at the lower and will not balance. They
will also file claim on behalf of employee.
• Blue Cross/Blue Shield's Cobra Administration(CobraServe)simplifies and holds the account harmless
for errors and omissions in the administration of the Cobra program. No annual fee.
• Personal health advisor available 24 hours a day, 7 days a week. Toll free number to access a medical
nurse confidentially and immediate answer employees health care questions and concerns.
• Virtual Office
20
•
PUBLIC RISK MANAGEMENT OF FLORIDA
GALLAGHER BENEFIT SERVICES
SCOPE OF SERVICES
Gallagher Benefit Services is experienced in all facets of employee benefits. We provide services for our
clients' benefit programs including, but not limited to, medical, dental, life, disability, cafeteria, drug card,
vision, voluntary coverage, and long term care plans.
The Scope of Services below reflects the services available to PRM members and their
consultants/advisors for all lines of coverage contained in their employee benefit plans.
A. Plan Analysis
B. Benefit Analysis
C. Financial Analysis
D. Benefits Marketing
E. Optional Services and Fees
As a full service brokerage and consulting firm, Gallagher has extensive internal resources available,
including but not limited to benefits brokerage and specialty services. All of these services can be
provided or arranged by the Gallagher Benefit Services Boca Raton office.
1. Flexible Benefits/Cafeteria Plan Administration
2. ERISA Audits/Compliance Services
3. COBRA Administration
4. Capital Accumulation/Retirement Planning Services
5. Human Resource Outsourcing Services
The Arthur J. Gallagher organization, and Gallagher Benefit Services, has extensive experience with a
diverse client base utilizing self-funded and/or insured funding arrangements, as well as general plan
administration. We have several specialty divisions allowing us to offer the most comprehensive
employee benefit consulting services. Our first hand experience and variety of services makes us uniquely
qualified to assist our clients in the design and implementation of their benefit plans.
21
CURRENT PRM MEMBERS /REFERENCES
Gallagher Benefit Services -- Consultant
One Boca Place, 2255 Glades Road, Suite 400E
Boca Raton, FL 33430
Phone (561) 995-6706
Fax (561) 995-6708
Jeff Angello, Area President
Richard Schell, Area Assistant Vice President
Glen Volk, Vice President Actuarial Services
Colleen Ramos, Account Coordinator
Tim Reynen, Account Executive
Colleen Ferguson, Technical Support
PRM Administrative Office—7 Employees
2013 Altamont Avenue, Unit 25
Fort Myers, FL 33901
Phone (800) 367-1705
Fax (941) 476-8889
Ross D. Furry, Executive Director
Judy Hearn, Assistant Executive Director/Secretary
Desoto County Board of Commissioners—269 Employees
201 East Oak Street, Suite 202
Arcadia, FL 34266
Phone (863) 993-4808
Fax (863)993-4857
Paul Erickson, Human Resources and Community Services Director
Glades County Board of Commissioners—98 Employees
500 Avenue J
Moore Haven, FL 33471
Phone (863) 946-2140
Fax (863) 946-2860
Mary Ann Dotson, Administrative Secretary
Hendry County Board of Commissioners—226 Employees
18 Hicopochee Avenue
Labelle, FL 33935
Phone (863) 675-5221
Fax (863) 675-5317
Lester Baird, County Administrator
Hendry County Sheriff's Department— 130 Employees
101 S. Bridge Street
Labelle, FL 33935
Phone (941) 674-4630
FX (863) 674-4635
Susie Hicks, Personnel
Town of Longboat Key— 133 Employees
501 Bay Isles Road
Longboat Key, FL 34228-3196
Phone (941) 316-1999
Fax (941) 316-1656
Bonnie Mims, Administrative Services Director
Okeechobee County Board of Commissioners— 179 Employees
304 N.W. 2"d Street, Room 109
Okeechobee, FL 34972
Phone (863) 763-9312
Fax (863) 763-9312
Robbie Chartier, Deputy County Administrator
City of Punta Gorda—273 Employees
326 West Marion Avenue
Punta Gorda, FL 33950-4492
Phone (941) 575-3302
Fax (941) 575-3310
Willard Beck, City Manager
Sarasota-Manatee Airport Authority— 116 Employees
6000 Airport Circle
Sarasota, FL 34243-2105
Phone (941) 359-5200
Fax (941) 359-5054
Martin Lange, Senior Director of Finance and Administration
Levy County Board of Commissioners —222 Employees
355 South Court Street
Bronson, FL 32621
Phone (352) 486-5217
Fax (352) 486-5167
Fred Moody, County Coordinator
Hamilton County Board of Commissioners— 156 Employees
207 Northeast First Street, Room 106
Jasper, FL 32052
Phone (904) 792-1288
Fax (904) 792-3524
Greg Godwin, City Clerk
City of Crystal River—53 Employees
123 North West Highway 9
Crystal River, FL 334428-3930
Phone (352) 795-6994
Fax (352)795-6351
Linda Stilson, Assistant to the Finance Director
South Florida Conservancy District— 14 Employees
2852 US Highway 441
Belle Glade, FL 33430
Phone: (561) 996-2940
Fax: (561) 996-2960
Ron Graydon, General Manager
ARTICLES OF ASSOCIATION
AND BY-LAWS
OF
PUBLIC RISK MANAGEMENT OF FLORIDA
(P RM)
BE IT KNOWN THAT:
The below named public agency or agencies of the State of Florida for the purpose of
forming a risk management and self-insurance association pursuant to the terms of Florida
Statutes Sections 768.28(15)(a), 440.57, and 163.01, Florida Interlocal Cooperation Act of 1969,
do bind themselves contractually to and adopt these Articles of Association and By-Laws.
Article 1 -Name and Duration
1.1 Name. The name of this association shall be Public Risk Management of Florida,
referred to hereinafter as the Pool.
Article 2 - Definitions and Purpose
2.1. Definitions. As used in this agreement, the following terms shall have the
meaning hereinafter set out:
"Annual Payments": The amount each Member must annually pay to fully fund the costs
of the full operation of the Pool.
"Aggregate Excess Insurance": Stop Loss Insurance purchased by the Pool from
insurance companies and/or Lloyd's of London, or other similar entities, approved by the Board
of Directors, or any committee appointed by the Board for such purpose, to protect the Pool from
an accumulation of losses in any policy year should the "Loss Fund" be exhausted. Once the
"Aggregate Excess Insurance" is triggered, any further losses within the "Self Insured Retention"
will be paid by this coverage.
"Fiscal Year": The fiscal year of the Pool shall begin on October IS` and end on
September 30`h
"Joint Self-Insurance" or "Self-Funded": A self-insurance or self-funded program in
which Members agree to annual payments to fully fund the operations of the Risk Management
Pool.
"Loss Fund": The fund established to pay claims occurring within the "Self Insured
Retention." The "Loss Fund" represents the maximum amount for which the Pool is exposed in
a single fiscal period.
1
"Maintenance Deductible": The amount paid by the "Member" before the loss is paid by
the "Self Insured Retention." This is a nominal amount designed to protect the "Loss Fund"
from small claims. The "Maintenance Deductible" applies only to property, automobile physical
damage and crime losses."
"Members": The public agencies of the State of Florida which initially or later enter into
the intergovernmental association established by this Intergovernmental Agreement.
"Multi-Loss Coverage": This multiple loss protection limits a loss involving more than
one line of coverage from one occurrence.(i.e. property, liability, workers' compensation) to one
"Self Insured Retention."
"Pool": Public Risk Management of Florida established pursuant to the Constitution and
the Statutes of the State of Florida by this Intergovernmental Agreement.
"Risk Management": A program attempting to reduce or limit casualty and property
losses to Members and injuries to employees caused by or arising out of the operations of
Members. Where claims arise the Pool will provide processing of claims, investigation, defense
and settlement within the financial limits of the Pool as established in accordance with this
Intergovernmental Agreement and will tabulate such claims, costs and losses.
"Risk Management Pool": A fund of public monies established by the Pool to jointly
self-insure and self-fund property coverages, general liability, automobile liability, professional
liability, public officials' liability and workers' compensation, and any other coverage lines
approved by the Board of Directors.
"Self-Insurance": The decision by a public agency not to purchase insurance coverage for
risks below certain limits; to seek and maintain immunities provided by law for a noninsured
public agency; to rely upon its financial capabilities to pay covered losses which occur in case
third-party claims are held valid and not barred or capped by available immunities: and to
purchase some insurance to protect against catastrophic or aggregate losses. The purchase of
liability insurance by the Pool or any of its Members is not intended to, and does not, waive
sovereign immunity. Purchase of liability insurance shall only be pursuant to Florida Statutes,
which allow for the purchase of insurance by the Pool without the waiver of sovereign immunity
by the Pool or any of the Pool's Members and is not pursuant to any other statute of the State of
Florida.
"Self Insured Retention": A layer of assumed risk where the pool self-insures a pre-
determined amount of loss per occurrence.
"Specific Excess Insurance": Insurance purchased by the Pool from insurance companies
and/or Lloyd's of London, approved by the Board of Directors, or any committee appointed by
the Board for such purpose, that provides catastrophe coverage up to the limit(s) chosen by the
Pool.
2.2. Purpose: The Pool is a cooperative agency voluntarily established by Members as
set forth in Florida Statutes Sections 163.01, 768.28 and 440.57 for the purpose of seeking the
prevention or lessening of casualty and property losses to Members and injuries to persons or
employees which might result in claims being made against Members. The purpose of this Pool
is to carry out and effect the agreed upon functions and purposes of this Intergovernmental
Agreement as stated herein.
It is the intent of the Members of this Pool to create an entity, which will administer a
Risk Management Pool and utilize such funds to defend and protect, in accordance with this
Intergovernmental Agreement, any Member of the Pool against liability for a covered loss. This
Agreement shall constitute the substance of a contract among the Members.
All funds contained within the Risk Management Pool are funds directly derived from its
Members who are public agencies of the State of Florida. It is the intent of the Members in
entering into this Intergovernmental Agreement that, to the fullest extent possible, the scope of
Risk Management undertaken by them through a Joint Self-Insurance or Self-funded program
using governmental funds shall not waive, on behalf of any Member or such Member's
employees as defined in Florida Statutes Section 768.28, any defenses or immunities therein
provided, or provided by the laws of the State of Florida. The Pool and the Members of this Pool
intend to effect no waiver of sovereign immunities through their use of public funds retained
within the Risk Management Pool. Such funds being utilized to protect against risks in
accordance with Florida Statutes Section 768.28 are not intended to constitute the existence,
issuance or purchase of a policy for insurance. This Intergovernmental Agreement is not to be
considered such as would cause this Pool to be treated as an "insurer" within the meaning of any
legislation giving risk to liability or applicability to "insurer", for damages, costs, fees or
expenses, etc., under Florida Statutes Sections 624.155, 626.9541, 626.9561, 627.426, 627.428,
or other statutes applicable to Public Entity Self Insurance in the State of Florida.
2.3 Non- Assessable: Public Risk Management is a non-assessable pool.
Article 3 - Power and Duties
3.1. Powers: The powers of the Pool to perform and accomplish the functions and
purposes set forth herein, within the budgetary limits and procedures set forth in this
Intergovernmental Agreement, shall be as follows:
3.1.1. To establish By-Laws and Amendments to By-Laws, and operational
procedures governing the operations of the Pool which are consistent with this
Intergovernmental Agreement as set forth in Florida Statutes Sections 768.28, 163.01 and
440.57, and to not waive any sovereign immunity not waived statutorily under Florida
Law, and to expressly negate any past, present, or future waiver of sovereign immunity
under Florida Statutes, and to continue to negate any waiver of sovereign immunity for
discretionary and planning functions of government.
3.1.2. To employ agents, employees and independent contractors and approve the
rate of compensation, benefits and/or contracts that apply to Pool employees, Pool
3
officers and service providers, and to ensure all benefits of Florida Statutes Section
163.01(9)(a) and all other applicable Florida Statutes.
3.1.3. To lease real property and to purchase or lease equipment, machinery or
personal property necessary for the carrying out of the purpose of the Pool.
3.1.4. To carry out educational and other programs relating to risk reductions.
3.1.5. To cause the creation of this Pool and see to the collection of funds for the
continued administration of the Risk Management Pool.
3.1.6. To purchase Aggregate Excess Insurance and Specific Excess Insurance to
supplement the Risk Management Pool without such being a waiver of sovereign
immunity under Florida Law.
3.1.7. To establish reasonable and necessary loss reduction and prevention
procedures, which shall be followed by the Members.
3.1.8. To provide Risk Management services including the defense of and
settlement of claims and to have the authority granted by Florida Statutes Section
768.28(14).
3.1.9. To negate, pursuant to Florida Statutes, any implication of a waiver of
sovereign immunity, and to negate any waiver of sovereign immunity other than to the
extent required under Florida Statutes Section 768.28.
3.1.10. To act solely within the budgetary limits established by the Members to
carry out such other activities as are necessarily implied or required to carry out the
purposes of the Pool.
3.1.11. To sue or be sued as a separate legal entity.
Article 4 - Participation and Term
4.1. Term: The initial term of the Pool shall be from 12:01 a.m. on October 1, 1987 to
12:01 a.m. September 30, 1989. After the initial two (2) year term of the Pool, the term shall
automatically be renewed for an additional term of one (1) year each. Provided, however, the
Members may, through the manner provided in Section 6.9.4., terminate the Pool as of the end of
the initial or any additional term during which such action is taken.
4.2. Notice of Withdrawal: So long as the Pool shall continue in existence, any
current or new Member joining the Pool shall remain a Member for an initial two-year term,
except a new Member coming into the Pool after the first day of the fiscal year shall be obligated
to be a member for not less than eighteen (18) months. A new member's rates will be
guaranteed for their initial term.
4
Any Member may withdraw from the Pool at the end of the fiscal year upon serving on the Pool
by mail, fax or hand delivery at least one year's prior written notice. Such notice shall be
addressed to the Executive Director of the Pool and shall be accompanied by a resolution of the
governing body of the Member electing to withdraw from the Pool.
4.3. Actual Withdrawal/Required Withdrawal. Any Member who has served the
Executive Director with prior written notice of its intent to withdraw at least one (1) year prior to
the beginning of the fiscal year for which the notice to withdraw is applicable, shall serve in
writing to the Executive Director, by mail, fax or hand delivery on or before August 15 prior to
the beginning of such fiscal year, a verification as to whether the Member intends to actually
withdraw from the Pool at the end of the current fiscal year. Failure to serve such verification on
or before August 15 prior to the beginning of the fiscal year for which notice of intent to
withdraw is applied, shall be deemed a revocation of the prior notice of intent to withdraw; thus,
binding the Member to the Pool for the ensuing fiscal year. Provided, however, any Member
who serves written notice of its intent to withdraw from the Pool more than once during any
three (3) year period may be required, at the option of the Board of Directors, to withdraw from
the Pool on the second such notice. An action to expel a Member in this manner shall be taken
by the Board of Directors prior to August 1 of the current fiscal year in the manner described in
Article 16 hereafter.
4.4. Admission of New Members: The Pool's Executive Committee shall establish
and periodically review standards and the approval process for the admission of new Members.
Upon approval of these standards and of the approval process for admission by the Board of
Directors, the Pool's Executive Committee may grant or deny admission to proposed new
Members based upon such criteria. Consideration of new Members will be communicated to all
PRM Board Members by the Executive Director for any information or feedback that a Member
may have regarding the prospective member.
Article 5 - Commencement of the Pool
5.1. Commencement Date: The Pool shall commence operations on October 1, 1987.
Article 6 - Board of Directors of the Pool
6.1. The Board: There is hereby established a Board of Directors (sometimes
hereinafter referred to as the "Board") of the Pool. Each Member shall appoint one (1) person to
represent that body (the "Representative") on the Board of Directors along with another person to
serve as an alternate representative (the "Alternate") when the Representative is unable to carry
out that Representative's duties. The Representative and Alternate shall be appointed in writing
by the governing body of the Member and a copy of the written appointment shall be provided to
the Executive Director of the Pool. Once such appointments are made known to the Pool, the
persons appointed shall remain in office until the Pool receives evidence in writing of the
appointment of other persons by the Member's governing body. The Representative and
Alternate selected must be an employee, an appointed official or elected official of the entity.
5
6.2. The Chairman and Vice Chairman: The Board of Directors shall bi-annually
select a Chairman and Vice Chairman during the final quarter of each two-year term to serve
during the subsequent two-year term. The term of office for the Chairman & Vice Chairman
shall begin on the 1 s` day of a fiscal year and expire on the last day of a fiscal year. No person
may serve as Chairman of the Board of Directors for more than two (2) consecutive full two-year
terms. The Chairman shall preside at all meetings of the Board. The Chairman shall vote on all
matters that come before the Board. The Chairman shall have such other powers as he may be
given from time to time by action of the Board.
The Vice Chairman shall carry out all duties of the Chairman of the Board during the
absence or inability of the Chairman to perform such duties and shall carry out such other
functions as are assigned from time to time by the Chairman or the Board of Directors. The
Board of Directors may from time to time appoint other officers of the Board.
6.3. Board Responsibilities. The Board of Directors shall have the responsibility for: (1)
hiring of Pool officers, agents, non-clerical employees and independent contractors; (2) setting of
compensation for all persons, firms and corporations employed by the Pool; (3) approval of
amendments to the Intergovernmental Agreement; (4) approval of the acceptance of new
Members and expulsion of Members, except that the approval may be delegated to the Executive
Committee under Article 4 above, or by such procedures as are contained in the motion making
delegation; (5) approval and amendment of the annual budget of the Pool; (6) approval of the
operational procedures developed by the Executive Director; (7) approval of educational and
other programs relating to risk reduction; (8) approval of reasonable and necessary loss reduction
and prevention procedures which shall be followed by all Members; (9) approval of Annual
Payments to the Risk Management Pool for each Member; and (10) termination of the Pool in
accordance with this Intergovernmental Agreement.
6.4. Voting: Each Member shall be entitled to one (1) vote on the Board of Directors.
Such vote may be cast only by the Representative of the Member or in the Representative's
absence by the Alternate. No proxy votes or absentee votes shall be permitted. Voting shall be
conducted by show of hands or any method established by the Board that is consistent with
Florida law. A simple majority vote of those Representatives present shall be required to pass on
any motion. On such matters, the Chairman and the Executive Director of the Pool shall cause
each Member's Representative and Alternate to receive the proposed ballot which will include at
a minimum the text of the motion to be voted upon and the purpose of such motion. Only the
Representative or the Alternate may vote on such ballots (not both). If both the Alternate and
Representative submit ballots, only the Representative's ballot will be counted. Favorable votes
by a majority of the Members' Representatives (or Alternates in their absence) entitled to vote
shall pass any action unless an action is taken which is subject to 6.9 below, in which case
passage will be based on the required number of votes as if each Member's Representative or
Alternate was present at a regular or special meeting called to decide such question.
6.5 Representatives: The Representative selected by the Member shall serve until a
successor has been selected. The Representative chosen by the Member may be removed at any
time by the vote of the Member's governing body. In the event that a vacancy occurs in the
position of Representative or Alternate selected by the governing body of a Member, that body
6
shall appoint a successor in writing within 60 days of such vacancy occurring. The failure of a
Member to select a Representative or the failure of that person to participate shall not affect the
responsibilities or duties of a Member under this Intergovernmental Agreement.
6.6. The Executive Committee and other Committees: The Board of Directors shall
have the power to establish both standing and ad hoc committees to further the functions and
purpose of this Pool. Unless the Board of Directors establishes some other procedure, the
authority for selection of Representatives or Alternates serving on the Board of Directors who
shall serve on such committees and chair them shall reside with the Chairman of the Board of
Directors. The Chairman of the Board of Directors may appoint non-voting and non-paid
persons who are not Members of the Board of Directors to serve on committees of the Pool. The
Board of Directors shall dictate to the Executive Director the guidelines for authorizing the
settlement of claims. The Board of Directors shall establish an Executive Committee. That
Executive Committee shall consist of the Chairman of the Board, the Vice Chairman of the
Board, the Treasurer and two Representatives elected by the Board, one from the southern area
and one from the northern area of the Pool, as such areas are designated on the attached map,
Exhibit 6.6. The Board of Directors may grant to the Executive Committee the authority to
approve expenditures, authorize a settlement of claims and suits and take such other action as
shall be specifically delegated to the Executive Committee.
6.7. Operating Rules: The Board of Directors may establish rules governing its own
conduct and procedure not inconsistent with this Intergovernmental Agreement.
6.8. Quorum: A quorum shall consist of a majority of the Representatives (or in their
absence their Alternates) serving on the Board of Directors. Except as provided in Section 6.9
herein, or elsewhere in this Intergovernmental Agreement, a simple majority of a quorum shall
be sufficient to pass upon all matters.
6.9. Super-Majority Voting: A greater vote than a majority of a quorum shall be
required to approve the following matters:
6.9.1. Such matters as the Board of Directors shall establish within its rules as
requiring for passage a vote greater than a majority of a quorum, provided, however, that
such a rule can only be established by a greater than a majority vote at least equal to the
greater than majority vote required by the proposed rule.
6.9.2. The expulsion of a Member shall require two-thirds (2/3) vote of all the
Representatives serving on the Board of Directors.
6.9.3. Any amendment of this Intergovernmental Agreement, except as provided
in Subsection 4 below, shall require two-thirds (2/3) vote of all the Representatives
serving on the Board of Directors.
6.9.4. The amendment of this Intergovernmental Agreement to cause the
termination of this Agreement sooner than two (2) years after its commencement or a
reduction or elimination in the scope of loss protection set out in Article 10 to be
7
furnished by the self-insurance pool derived from payments from the Members, shall
require that specific written notice of the proposed change be sent by registered or
certified mail to the governing body of the Member and to the Representative and
Alternate of the Member serving on the Board of Directors, no less than ten (10) days
prior to a meeting at which this matter is proposed and the amendment as proposed or as
amended at such Board meeting must receive the approval of two-thirds (2/3) vote of all
of the then current Representatives (or in their absence their Alternates) representing the
then Members of the Pool.
6.10. Compensation of Board of Directors: No Representative or Alternate serving on
the Board of Directors shall receive any salary from the Pool.
6.11 Conflict of Interest: Representatives and Alternates shall abide by the guidelines
established by the State Ethics Commission in the performance of their duties, particularly as it
applies to conflicts of interest and financial disclosure.
Article 7 - Board of Directors Meetings
7.1. Meetings: Regular meetings of the Board of Directors shall be held at least four
(4) times a year. The tentative times, dates, and locations of regular meetings of the Board shall
be established at the beginning of each fiscal year. Any item of business may be considered at a
regular meeting, including the scheduling of future regular meetings. The Executive Director
shall attend all Board meetings and Executive Committee meetings to serve as an advisor and to
report as the administrative officer of the Pool.
7.2. Special Meetings: Special meetings of the Board of Directors may be called by
its Chairman, or by any three Representatives (or in their absence their Alternates). The
Chairman or in his absence, the Vice Chairman, shall give ten (10) days written notice of regular
or special meetings to the Representative and Alternate of each Member and an agenda
specifying the subject of any special meeting shall accompany such notice. Business conducted
at special meetings shall be limited to those items specified in the agenda. The time, date and
location of special meetings of the Board of Directors shall be determined by the Chairman of
the Board of Directors, or in his absence, by the Vice Chairman.
7.3. Conduct of Meetings: To the extent not contrary to this Intergovernmental
Agreement and except as modified by the Board of Directors, Robert's Rules of Order, latest
edition, shall govern all meetings of the Board of Directors. Minutes of all regular and special
meetings of the Board of Directors shall be sent to all Representatives (or in their absence their
Alternates) serving on the Board of Directors.
Article 8 - Pool Officers
8.1. Officers: Officers of the Pool shall consist of an Executive Director, a Treasurer,
a Secretary and such other officers as are established from time to time by the Board of
Directors. All Pool officers shall be appointed by the Board of Directors.
8
8.2. Executive Director: The Executive Director shall be the chief administrative
officer of the Pool and shall in general supervise and control the day to day operations of the
Pool and shall carry out the policy and operational procedures of the Pool as established in this
Intergovernmental Agreement and by the Board of Directors. Among the Executive Director's
duties shall be the following:
8.2.1. The Executive Director may sign, with such other person authorized by the
Board of Directors, any instruments which the Board of Directors have authorized to be
executed and, in general, shall perform all duties incident to the office of Executive
Director and such other duties as may be prescribed by the Board of Directors.
8.2.2. The Executive Director shall prepare a proposed annual budget and
proposed Risk Management Pool Annual Payment and shall submit such proposals to the
Board of Directors.
8.2.3. The Executive Director shall, where necessary, make recommendations
regarding policy decisions, the creation of other Pool officers and the employment of
agents and independent contractors. At each regular meeting of the Board of Directors
and at such other times, as he shall be required to do so, he shall present a full report of
his activities and the fiscal condition of the Pool.
8.2.4. The Executive Director shall report quarterly to all Members on all claims
filed and payouts made.
8.2.5. The Executive Director shall, within the constraints of the approved or
amended budget, employ all secretarial, clerical and other similar help and expend funds
for administrative expenses.
8.3. Treasurer: The Treasurer shall:
8.3.1. Have charge and custody of and be responsible for all funds and securities
of the Pool; cause to be received and given all receipts for moneys due and payable to the
Pool from any source whatsoever; cause to be deposited all such moneys in the name of
the Pool in such banks, savings and loan associations or other depositories that are
recognized as "Qualified Public Depositories" by the State Treasurer operating under
Chapter 280 Florida Statutes, as shall be selected by the Board of Directors; cause to be
invested the funds of the Pool as are not immediately required in such securities as the
Board of Directors shall specifically or generally select from time to time; and cause to
be maintained the financial books and records of the Pool.
8.3.2. In general, perform all duties incident to the office of Treasurer and such
other duties as from time to time may be assigned to that individual by the Board of
Directors. Nothing herein shall prevent the Treasurer from delegating, in writing, the
functions of the office to third parties, whether members of the Board of Directors,
employees of the Pool, or third parties, subject to the approval of the Board of Directors.
However, the Treasurer shall maintain the control and responsibility for the execution of
9
•
such functions by such delegates.
8.4 Secretary: The Secretary shall issue notices of all Board meetings, and shall
attend and keep the minutes of same. The Secretary shall have charge of all corporate books,
records and papers; shall be custodian of the corporate seal; and shall keep all written contracts
of the Pool. In general, the Secretary shall perform all duties incident to the office of Secretary
and such other duties as from time to time may be assigned by the Executive Director or the
Board of Directors.
8.5. Third Party Delegations: The Board may select a financial institution or certified
public accountant to carry out some or all of the functions which would otherwise be assigned to
a Treasurer and may select a risk management company or agent to serve as claims administrator
or to carry out some or all of the functions which would otherwise be assigned to the Executive
Director. The Board may also employ persons or companies as independent contractors to carry
out some or all of the functions of officers of the Pool.
8.6. Officer Vacancies: In the absence of the Executive Director, Treasurer or
Secretary, or in the event of the inability or refusal of such officers to act, the Chairman of the
Board of Directors may perform the duties of the Executive Director, Treasurer or Secretary,
and, when so acting, shall have all of the powers of and be subject to all of the restrictions upon
the Executive Director, Treasurer or Secretary.
Article 9 - Finances and Risk Management Pool
9.1. Fiscal Year: The fiscal year of the Pool shall commence on October 1, and end
on September 30, of each year.
9.2. Budget: The Board of Directors or the Executive Committee shall approve a
preliminary budget for the administration of the Pool by June 1 of each year. Copies of all
preliminary and final budgets shall be promptly mailed to each Member of the Board of
Directors. The Board of Directors shall, by August 1 of the year prior to the start of each fiscal
year adopt a final budget and determine the amount of the Annual Payment to be made by each
Member and the date upon which the payment is due. Failure of the Board of Directors or the
Executive Committee to approve a preliminary or final budget within the times set forth within
this Section shall not relieve the Members of the obligation to make any payments to the Pool so
long as such budgets are finally adopted, and the Members are given at least thirty (30) days after
the passage of the final budget in which to make Annual Payments to the Pool.
9.3. Annual Payment Factors: In determining the amount of the Annual Payment due
from each Member, the Board of Directors shall consider some or all of the following factors:
9.3.1. Number of employees;
9.3.2. Property values of the Member;
9.3.3 Number and type of vehicles owned by the Member and the use made of
the vehicles;
10
•
9.3.4. Population of the geographic area represented by the Member;
9.3.5. The payrolls of the Member;
9.3.6. Any unusual exposures presented by the Member;
9.3.7. The operating expenditures of the Member; and
9.3.8 The claims and loss experience of the Member.
The Board of Directors shall establish annually a cost of risk allocation, which is utilized
in making the allocation of the amount of the Annual Payment due from each Member. This
standard may, however, vary from year to year but it must be applied equally to all Members
similarly situated during such period of time as it is utilized.
The Board of Directors may grant debits or credits to Members with above or below
average loss or claims records. The amount of such debits or credits may not vary more than
25% above or below the amount, which the Member would pay if it were not to have been
granted the debit or credit. In establishing the loss and claims record of the Member, the Board
of Directors may utilize the loss and claims experience of the Member during last 3 years of the
Pool.
9.4. Budget Amendments: Budgets may be amended at any time by majority vote of
the Board, provided, however, such amendments may not require payments, when added to
previous payments by a Member for such fiscal year, to exceed such Member's Annual Payment
determined for such year. The forwarding of such payments within a time specified in notices to
the Members giving them not less than forty-five (45) days to make such payments shall be of
the essence of this contract.
9.5. Payments — Timing: In subsequent years, the Board of Directors may permit the
Annual Payments to be made on a monthly or quarterly basis.
9.6. Retirement Fund Obligations: Members shall be both severally and jointly liable
to the State of Florida Department of Administration, Division of Retirement for any Florida
Retirement Systems' contributions, which are owed by the Pool for Pool employees. Each
member shall be responsible for expenses incurred which are attributable to the years of
membership as outlined in the Intergovernmental Agreement, Article 11.
9.7. Distribution of Surplus: If, for any year during which the Pool was in existence,
all claims known or unknown have either been paid or provision has been made for such
payment, the Board of Directors as then constituted shall distribute surplus funds to the Members
who constituted the membership of the Pool in that prior year, after first deducting there from
reasonable administrative and other non-allocated costs incurred by the Pool in the processing of
the claims in years other than the one in which the claim was made. The distribution among the
Members shall be in the same proportion to the total as was their Annual Payment for that year to
the Annual Payments of all Members for such year.
11
9.8. Audit: The Board of Directors shall provide to the Members an annual audit of
the financial affairs of the Pool to be made by a certified public accountant at the end of each
fiscal year in accordance with generally accepted auditing principles. The annual report shall be
delivered to the Chairman of the governing body of each Member.
Article 10 - Excess Insurance
10.1. Specific Excess Insurance: The Pool will purchase Specific Excess Insurance
from underwriters of insurance, insurance companies and/or Lloyd's of London, approved by the
Board of Directors, or any committee appointed by the Board for such purpose, in such amounts
which shall be approved by the Board of Directors and underwriters, based upon but not limited
to the current assets, risk analysis, and loss history of the Pool. The purchase of Specific Excess
Insurance does not, and is not, intended to waive sovereign immunity under Florida law.
10.2. Aggregate Excess Insurance: The Pool will purchase Aggregate Excess Insurance
from underwriters of insurance, insurance companies and/or Lloyd's of London, approved by the
Board of Directors, or any committee appointed by the Board for such purpose, in such amounts
which shall be approved by the Board of Directors and underwriters, based upon but not limited,
to the current assets, risk analysis, and loss history of the Pool. The purchase of Aggregate
Excess Insurance does not, and is not, intended to waive sovereign immunity under Florida law.
10.3. Multiple Loss Coverage: The Pool will purchase Multiple Loss Coverage in the
event a single occurrence involves more than one line of coverage, limiting the occurrence to a
single "Self Insured Retention."
10.4. Losses: The Risk Management Pool (Loss Fund), the Specific Excess Insurance
and Aggregate Excess Insurance shall provide payment for covered losses in any one fiscal year
for members up to the limits approved by the Board of Directors. Should losses in any one fiscal
year extinguish all available funds provided by the Pool then the individual Member or Members
whose judgment or settlement of claim has been perfected by Florida law shall be responsible for
any additional payment. The Pool shall make payments in the order in which the judgments
against the Pool have been entered or settlement of claims have been reached. Membership in
the Pool shall not preclude any Member from purchasing any insurance coverage above those
amounts purchased by the Pool.
Article 11 - Obligations of Members
11:1. Member Obligations: The obligations of Members of the Pool shall be as follows:
11.1.1. To budget for, where necessary, to levy for and to promptly pay all
payments to the Risk Management Pool at such times and in such amounts as shall be
established by the Board of Directors within the scope of this Intergovernmental
Agreement. Any delinquent payments shall be paid with a penalty, which shall be set by
the Board, but such rate shall not exceed the highest interest rate allowed by statute to be
paid by a Florida public agency.
12
*
11.1.2. To select, in writing, a Representative to serve on the Board of Directors
and to select an Alternate Representative.
11.1.3. To allow the Pool reasonable access to all facilities of the Member and all
records including, but not limited to, financial records, which relate to the purpose or
powers of the Pool.
11.1.4. To allow attorneys employed by the Pool to represent the Member in
investigation, settlement discussions and all levels of litigation arising out of any claim
made against the Member within the scope of loss protection furnished by the Pool.
11.1.5. To furnish full cooperation with the Pool attorneys, claims adjusters, the
Executive Director and any agent, employee, officer or independent contractor of the
Pool relating to the purpose or powers of the Pool.
11.1.6. To follow in its operations all loss reduction and prevention procedures
established by the Pool within its purpose or powers.
11.1.7. To report to the Executive Director or his designee within the time limit
specified the following items:
11.1.7.1. To provide on or before May 1 of each fiscal year of the Pool, the
Member's renewal application shall be completed by the member as required by the
Underwriters.
11.1.7.2. To report, within five (5) days of receipt, any and all statutory notices of
claims, as well as summons and complaint or other pleading before a court or agency
involving any claim for which Pool coverage is sought.
11.1.7.3. To report, within ten (10) days of receipt, any oral or written demand
for monetary relief for which coverage is sought to the Pool Executive Director.
11.1.7.4. To report to the Executive Director at the earliest practicable moment
any information of an occurrence, claim or incident received by the Member and from
which the Member could reasonably conclude that coverage will be sought by said
Member for such an occurrence, claim or incident.
In the event that the items set forth above are not submitted to the Executive Director within the
time periods set forth above, the Board of Directors of the Pool, by a vote of a majority of a
quorum of the Board, at a regular or special meeting, may in whole or part decline to provide a
defense to the Member or to extend the funds of the Pool for the payment of losses or damages
incurred. In reaching its decision, the Board shall consider whether and to what extent the Pool
was prejudiced in its ability to investigate and defend the claim due to the failure of the Member
to promptly furnish timely notice of the occurrence, claim or incident to the Executive Director.
The decision of the Board of Directors shall be final. Failure of a Member to abide by these
requirements shall also be grounds for expulsion from the Pool.
13
11.1.8. To make Payment of any "Maintenance" Deductible(s).
Article 12 - Liability of Board of Directors or Officers of the Pool
12.1. Liability of Directors and Officers: The Representatives (or in their absence their
Alternates) serving on the Board of Directors or officers of the Pool should use ordinary care and
reasonable diligence in the exercise of their power and in the performance of their duties
hereunder; they shall not be liable for any mistake of judgment or other action made, taken or
omitted by them in good faith; nor for any action taken or omitted by any agent, employee or
independent contractor selected with reasonable care; nor for loss incurred through investment of
Pool funds, or failure to invest. No Representative shall be liable for any action taken or omitted
by any other Representative. Representatives shall have the immunities provided by law and in
particular Florida Statutes Section 163.01. The Pool may purchase insurance providing liability
coverage for such Representatives or officers.
Article 13 - Additional Insurance
13.1. Member's Option to Purchase Additional Insurance: The Pool, through the
distribution of the minutes of the Board of Directors or through other means shall inform all
Members of the scope and amount of Specific Excess and Aggregate Excess Insurance in force
at all times. Membership in the Pool shall not preclude any Member from purchasing any
insurance coverage above those amounts purchased by the Pool. Such purchase shall not be
construed to waive sovereign immunity of the Members of the Pool or the Pool. The Pool shall
make its facilities available to advise Members of the types of additional or different coverages
available to Pool Members.
Article 14 - Settlements
14.1. Settlement/Advance Notice: Whenever the Pool proposes to settle any pending
claim or suit where the amount of that proposed settlement shall exceed Five Thousand Dollars
($5,000.00), the Member shall be given advance notice of that settlement. Such notice may be
given by the establishment of a reserve amount in excess of Five Thousand Dollars ($5,000.00),
provided that the amount of the settlement does not exceed the amount reserved. The officers
and employees of the Pool shall, however, endeavor to give specific oral or written notice to the
Member's Representative or Alternate of the exact amount of any proposed settlement in excess
of Five Thousand Dollars ($5,000.00) prior to the date at which the Pool proposes to bind itself
to pay such settlement amount. The officers, employees or independent contractors of the Pool
shall attempt to give the Members, as much notice of the settlement negotiations as is possible
under the circumstances of each case.
Article 15 - Contractual Obligation
15.1. Enforcement: This document shall constitute a binding contract under the Florida
Interlocal Cooperation Act of 1969 among those public agencies, which become Members of the
Pool. The obligations and responsibilities of the Members set forth herein, including the
obligation to take no action inconsistent with this Intergovernmental Agreement as originally
14
•
written or validly amended, shall remain a continuing obligation and responsibility of the
Member. The terms of this Intergovernmental Agreement may be enforced in a court of law by
the Pool.
The consideration for the duties herewith imposed upon the Members to take certain
actions and to refrain from certain other actions shall be based upon the mutual promises and
agreements of the Members set forth herein. This Intergovernmental Agreement may be
executed in duplicate originals and its passage by the Member's governing body shall be
evidenced by a certified copy of a resolution passed by the members of the governing body in
accordance with the rules and regulations of such public agency, provided, however, that except
to the extent of the limited financial contributions to the Pool agreed to herein or such additional
obligations as may come about through amendments to this Intergovernmental Agreement no
Member agrees or contracts herein to be held responsible for any claims in tort or contract made
against any other Member. The Members intend in the creation of the Pool to establish an
organization for Risk Management only within the scope herein set out and have not herein
created as between Member and Member any relationship of surety, indemnification or
responsibility for the debts of or claims against any Member.
15.2. Attorneys' Fees: In any legal action between the parties arising out of this
Agreement, any attempts to enforce this Agreement, or any breach of this Agreement, the
prevailing party may recover its expenses of such legal action including, but not limited to, its
costs of litigation (whether taxed by the court or not) and its reasonable attorneys' fees (including
fees generated on appeals) from the other party.
Article 16 - Expulsion or Termination of Members
16.1. Expulsion. By the vote of two-thirds (2/3) of the Directors serving on the Board
of Directors, any Member may be expelled. Such expulsion may be carried out for one or more
of the following reasons:
16.1.1. Failure to make any timely payments due to the Pool.
16.1.2. Failure to undertake or continue loss reduction and prevention procedures
adopted by the Pool.
16.1.3. Failure to allow the Pool reasonable access to all facilities of the Member
and all records which relates to the purpose, powers or functioning of the Pool.
16.1.4. Failure to furnish full cooperation with the Pool's attorneys, claims
adjusters, the Executive Director and any agent, employee, officer or independent
contractor of the Pool relating to the purpose, powers and proper functioning of the Pool.
16.1.5. Failure to carry out any obligation of a Member which impairs the ability
of the Pool to carry out its purpose or powers or functions.
15
16.1.6. The Member has given the one (1) year notice described in Section 4.2
and 4.3 above.
16.2. Notice: No Member may be expelled except after notice from the Pool of the
alleged failure along with a reasonable opportunity of not less than thirty (30) days to cure the
alleged failure. The Member may request a hearing before the Board before any decision is
made as to whether the expulsion shall take place. The Board shall set the date for a hearing
which shall not be less than fifteen (1 5) days after the expiration of the time to cure has passed.
A decision by the Board to expel a Member after notice and hearing and a failure to cure the
alleged defect shall be final. The Board of Directors may establish the date at which the
expulsion of the Member shall be effective at any time not less than sixty (60) days after the vote
expelling the Member has been made by the Board of Directors. If the motion to expel the
Member made by the Board of Directors or a subsequent motion does not state the time at which
the expulsion shall take place, such expulsion shall take place sixty (60) days after the date of the
vote by the Board of Directors expelling the Member.
16.3. Responsibilities of Terminated Member: A former Member shall only continue to
be fully responsible only for its' portion of any obligations incurred but not satisfied during the
period of time they were a Member of the Pool. Such obligations may include, but not be limited
to, premiums, loss fund payments, maintenance deductibles, workers' compensations, final audit
and administrative fees, etc., owed or unpaid by the former Member. The former Member shall
no longer be entitled to participate or vote on the Board of Directors.
Article 17 - Special Provisions for Deferred Funding
During the fiscal years commencing on October 1, 1987 and ending on September 30,
1990, the entire Annual "Loss Fund" Contribution was not required by the Board of Directors to
be paid within the fiscal year to which it was applicable. The difference between the Annual
"Loss Fund" Contribution and the amount required by the Board of Directors to actually be paid
to the Pool during such year by a Member is referred to herein as Deferred Funding. Members
and former Members during any year for which there existed Deferred Funding may be required
by the Board of Directors upon recommendation of the Executive Director to pay their applicable
portion of the Deferred Funding in subsequent years. _Members or former members will be
allowed forty-five (45) days after notification to make any payments of Deferred Funding. The
amount of any payments required for Deferred Funding as to each Member shall be based upon
the same formula as was used in establishing the Annual "Loss Fund" Contribution for that year.
Article 18 - Termination of the Pool
18.1. Termination: If, at the conclusion of any term of the Pool, the Board of Directors
votes to discontinue the existence of the Pool in accordance with Section 6.9.4., then the Pool
shall cease its existence at the close of the then current fiscal year. Under those circumstances,
the Board of Directors shall continue to meet on such a schedule as shall be necessary to carry
out the termination of the affairs of the Pool. It is contemplated that the Board of Directors may
be required to continue to hold meetings for some substantial period of time in order to
accomplish this task, including the settlement of all covered claims incurred during the term of
16
the Pool. The Pool shall continue to be fully responsible and obligated to pay covered claims
and expenses owed by the Pool, which accrued before the Pool's termination. The money used
to pay such covered claims and expenses shall remain with the Pool until such claims are settled
and expenses are paid.
18.2. Post-Termination Responsibilities of Member: After termination of the Pool, the
Member shall continue to hold membership on the Board of Directors but only for the purpose of
voting on matters affecting their limited continuing interest in the Pool for such years as they
were Members of the Pool.
17
•
•
In witness whereof, this agreement has been executed by the Entity:
. The approval of the foregoing agreement was passed by the Entity:
on the day of , 20_, and attached
hereto, I do hereby execute and the does hereby attest to my signature
as evidence that the has approved and hereby
becomes a bound signatory member of the "Intergovernmental Cooperative Agreement" for
Public Risk Management of Florida, a copy of which is attached hereto, and which is pursuant to
Florida Statutes Section 163.01, which commenced its term on October 1, 1987.
Chairperson of Board, or Council
Chairperson, Public Risk
Management of Florida
ATTEST:
This day of , 20!
1
ars t� 1'1 e s Sc.) Mug-./
•UNIMARY OF BENEFITS authorized non authorized
LUE CROSS AND BLUE SHIELD OF FLORIDA yes no yes no alternative
•
'DINT-OF-SERVICE PLAN A16 WITH BLUESCRIPTsnt
iE.NEFITS AUTHORIZED NON-AUTHORIZED
7alendar Year Deductible
Individual SO 5300
Aggregate Family 50 8900
UUhleScript Prescription Drug Rider 55.00 Generic 55.00 Generic
lncludiug Otal Cuntlaceptives) 510.00 N.une llr:uul 510.00 Name flrand
The deductible does not apply to services with a copayment or where indicated.
_,ifetime Maximum No Maximum 51,000,000
:oinsuranee Requirement Limit
Individual 50 52,000
Aggregate Family 50 56,000
Physician Office Services
• Routine Services 55 Copayment 80%Allowed Amount
• Preventive Care 85 Copayment Not Covered
• Well-Child Care 55 Copayment 80%Allowed Amount
No Deductible
• Allergy Injection
(Without Office Visit) 55 Copayment 80%Allowed Amount
• Annual Gynecological Examination
By A 1-101 OB/GYN Physician
Up To S 150 Per Calendar Year
(Does Not Require Authorization
By Primary Care Physician) 55 Copayment Not Covered
• Specialty Care 55 Copayment 80%Allowed Amount
• Maternity Care
First Office Visit S5 Copayment 80%Allowed Amount -
Total Maternity Care No Copayment 80% Allowed Amount
Hospital Services
Hospital Per Admission Deductible SO 5300
(PAD)
• Inpatient
Primary Care Physician No Copayment Not Applicable
Facility No Copayment 80%Allowed Amount
All Other Providers No Copayment 80%Allowed Amount
• Outpatient Hospital/Surgical
Primary Care Physician No Copayment Not Applicable
Facility No Copayment 80%Allowed Amount
All Other Providers No Copayment 80%Allowed Amount
• Non-Routine X-Rays
(Inpatient or Outpatient) No Copayment 80%Allowed Amount
ISCUSV,CAI x•
lilac Cunt:u.l atuc 5h.la.d Flmu1..trc.It+n Indeis W.o, id the ahw COM,...I HI.:SIucW a,.u.wuuo
•
QJRR Nr B Na-rs� ,)
'UMNLA.RY OF BENEFITS
authorized non authorized
ILUE CROSS AND BLUE SHIELD OF FLORIDA yes no yes no alternative
•
'DINT-OF-SERVICE PLAN A16 WITH BLUESCRIPTs"t
iENEFITS AUTHORIZED NON-AUTHORIZED
';alendar Year Deductible
Individual SO 5300
Aggregate Family SO 5900
UhieSeript Prescription Drug Rider 55.00 Generic 55.00 Generic
Including Olal Cuullaceptivcs) SI0.1)0 N:unc ILaud 510.00 Name Dram!
The deductible does—not apply to services with a copayment or where indicated.
Lifetime Maximum No Maximum 51,000,000
Coinsurance Requirement Limit •
Individual 50 52,000
Aggregate Family SO 56,000
Physician Office Services
• Routine Services 55 Copayment 80%Allowed Amount
• Preventive Care 55 Copayment Not Covered
• Well-Child Care 55 Copayment 80%Allowed Amount
No Deductible
• Allergy Injection
(Without Office Visit) 55 Copayment 80%Allowed Amount
• Annual Gynecological Examination
By A 1-101 OB/GYN Physician
Up To 5150 Per Calendar Year
(Does Not Require Authorization
By Primary Care Physician) 55 Copayment Not Covered
• Specialty Care 55 Copayment 80% Allowed Amount
• Maternity Care
First Office Visit 55 Copayment S0%Allowed Amount
Total Maternity Care No Copayment 80%Allowed Amount
Hospital Services
Hospital Per Admission Deductible SO 5300
(PAD)
• Inpatient
Primary Care Physician No Copayment Not Applicable
Facility No Copayment 80%Allowed Amount
All Other Providers No Copayment 80%Allowed Amount
• Outpatient Hospital/Surgical
Primary Care Physician No Copayment Not Applicable
Facility No Copayment 80%Allowed Amount
All Other Providers No Copayment 80/Allowed Amount
• Non-Routine X-Rays
(Inpatient or Outpatient) No Copayment 80%Allowed Amount
BC tt5Ylchl st.
Illu.C...,3141 Olu.Sh..IJ 111 f,..L,.Inc.a.,lidcrcn,.m Lucn..cc of ill.Oluc Cn..a wul Ill...SIucld Aaa.1:111.M1
'CLUSIONS _t
Services and supplies which are, in our opinion, experimental, investigational,
Jr not medically necessary;
?rivate duty nursing services;
Dental care(except accident-related);
:osmetic surgery (surgery performed solely to improve appearance of an
ndividual);
Eye refractions, eye glasses and hearing aids or examinations for their
-prescription or fitting, except as specified in the Preventive Health Services Section;
toutine health examinations, except as covered under the Well-Child Care Section and the
r'reventive Health Services Section;
Rehabilitative services except as provided in the cardiac rehabilitation and pulmonary
ehabilitation sections;
Care obtained without cost;
Services rendered by an individual who is related by blood or marriage;
'reatment in a VA hospital or government facility (due to service-related
lisability);
Treatment of any condition arising out of a felony, riot, rebellion, or war;
Treatment of any condition or an intentionally self-inflicted condition, suicide, or
ttempted suicide;
speech therapy, except as provided under Home Health Care Services and Therapeutic
Services sections;
)iagnostic admissions;
)ccupational therapy,except as provided under Home Health Care Services and
Therapeutic Services sections;
-ervices or supplies related to sexual reassignment;
'ravel expenses, even if prescribed by a physician (this exclusion does not
apply to medically necessary transportation of a newborn child);
custodial care;
xercise programs of any kind;
'on-prescription drugs, vitamins, mineral supplements, or fluoride drugs;
Work-related injuries;
!rvices associated with autopsy or postmortem examination;
°rvices and supplies not specifically covered under the BCBSF Care Manager
Point Of Service Plan;
''ontraceptive devices, appliances or other supplies when used for contraception.
I services rendered in the Emergency Room which are not Emergency Care Services will be subject to calendar year deductible and
nsurancc amount listed above unless authorized by the Primary Care Physician.
it a contract. The above Summary of Benefits is only a partial description of the many benefits and services covered by Blue Cross
Shield of Florida,Inc. These benefits apply only to groups of 51 or more employees, For a complete description of benefits and
s.please see Blue Cross and Blue Shield of Florida's Care Manager Point Of Service Contract#15483-1096 SR and Schedule of
is#15499-1096 SR;its terms prevail. Blue Cross and Blue Shield of Florida,Inc.is an Independent Licensee of the Blue Cross and Blue
Association.
BCBSF/CM sl+
c Mark of Bine Cross said Blue Shield of Florida.Inc.
Blue Cue,dud Blue Shield lit Honda.Itx; i'do ludepe wkm Licentic lit the Blue CS AN alit Blue Shield A.actduun.
PUBLIC RISK MANAGEMENT
SCHEDULE OF BENEFIT SUMMARIES
BLUE CROSS/ BLUE SHIELD
HIGH OPTION PPO
Effective 10/1/2002
Pta ::.
902::. :,,; ;;� :: Platt 9Q2 _ `..._:r.
•In hetworkx-: .,
, N
• uthoirzed ` 's: y;
:' (NOn=Authorized) ",
Maximum Lifetime Benefit $2,000,000 $2,000,000
Annual Deductible $200 $200
Family Deductible $600 $600
Annual Maximum Copayments N/A N/A
Family Maximum Copayments N/A N/A
Maximum Annual Out of Pocket $1,500 $1,500
Maximum Family Out of Pocket $4,500 $4,500
Coinsurance 90%of allowance 70%of allowance
4th Quarter Carryover Deductible Carryover applies Carryover applies
Physician Office Visit $15 Copay Ded,then 70%of allowance
Wellcare Visits-Annual exam
Adult $15 copay.Covered up to$250- 70%of allowance,Ded waived.
combined OB/GYN and Adult Covered up to$250-combined
OB/GYN Wellness OB/GYN and Adult Wellness
• -Child health $15 Copay.(Birth to age 16) 70%of allowance,Ded waived
Mammograms 100%of allowance(Ded waived) 100%of allowance, Ded waived
(may be balance billed)
Specialist Office Visit $15 copay Ded,then 70%of allowance
Second Opinion Surgical Ded,then 70%of allowance
P g $15 Copay(Not Required) (Not Required)
Infertility Services/Treatment Plans $15 Copay(diagnosis) /$20,000
Ded,then 70%of allowance
(Treatment covers artificial insemination, (diagnosis)/$20,000 lifetime max for
IVF,GIFT,&ZIFT lifetime max for treatment
treatment
$15 Copay(physician's office)Ded, Ded,then 70%of allowance
Ph sical Thera then 90%of allowance
y Py (inpatient/outpatient)up to$10,000 (inpatient/outpatient)up to$10,000
lifetime max(combined therapy) lifetime max(combined therapy)
$15 Copay(physician's office)Ded, Ded,then 70%of allowance
Speech then 90%of allowance
p (inpatient/outpatient)up to$10,000 (inpatient/outpatient)up to$10,000
lifetime max(combined therapy) lifetime max(combined therapy)
• $15 Copay(physician's office)Ded, Ded,then 70%of allowance
Occupational then 90%of allowance
P (inpatient/outpatient)up to$10,000 (inpatient/outpatient)up to$10,000
lifetime max(combined therapy) lifetime max(combined therapy)
Acupuncture Not Covered Not Covered
Injections/Immunizations(child health) $15 Copay 70%of allowance,Ded waived
Allergy Testing $15 Copay Ded,then 70%of allowance
Allergy Injections(not including serum) $5 copay Ded,then 70%of allowance
Office Surgery $15 Copay Ded,then 70%of allowance
Outpatient Surgery(hospital or surgery Ded,then 90%of allowance Ded,then 70%of allowance
center)
X-ray and Lab Outpatient-Physician's Ded,then 90%of allowance Ded,then 70%of allowance
Office
Outpatient Radiation Ded,then 90%of allowance Ded,then 70%of allowance
PUBLIC RISK MANAGEMENT
SCHEDULE OF BENEFIT SUMMARIES
BLUE CROSS/ BLUE SHIELD
HIGH OPTION PPO
Effective 10/1/2002
Proposed
.•:. '2. ' Plan 902
. •-": (ifon'-AiithOriied)
RAP Providers
Ded,then 70%of allowance
(Non-PPO Radiologist,Anesthesiologist,
Ded,then 90')/0 of allowance (If participating hospital,Ded,then
pathologist,and ER phys.services at PPO
90%of allowance)
hosp.)
Emergency Room/Hospital
-Illness Ded,then 90%of allowance Ded,then 70%of allowance
-Accidents 90%of allowance,Ded waived — 70%of allowance,Ded waived
Ambulance Ded,then 90%of allowance Ded,then 90%of allowance
Ded,then 90%of allowance(Covers Ded,then 70%of allowance(Covers
removal of impacted teeth,including removal of impacted teeth,including
Dental Oral Surgery
impacted wisdom teeth,related x- impacted wisdom teeth,related x-rays
rays&anasthesia) &anasthesia)
Ded,then 70%of allowance.$100
Inpatient Hospital Ded,then 90%of allowance
per admission deductible
X-ray and Lab Inpatient Ded,then 90%of allowance Ded,then 70%of allowance
Ded,then 90%of allowance (no Ded,then 70%of allowance (no
Blood and Blood Plasma
limit) limit)
Ded,then 90%of allowance. Ded,then 70%of allowance.$12,000
Home Health Care
$12,000 Calendar year max. Calendar year max.
Ded,then 90%of allowance Ded,then 70%of allowance.$7,500
Hospice
$7,500 lifetime max lifetime max.
Ded,then 90%of allowance.60 Ded,then 70%of allowance.60 days
Skilled Nursing Facility
days per calendar year. per calendar year.
Durable Medical Equip. Ded,then 90%of allowance Ded,then 70%of allowance
Maternity
-Physician $15 copay initial visit Ded,then 70%of allowance
-Hospital Ded,then 90%of allowance Ded,then 70%of allowance
Covered as maternity benefit up to Covered as maternity benefit up to 18
Dependant Daughter Maternity
18 months (or longer) months (or longer)
Birthing Centers Ded,then 70%of allowance Ded,then 70%of allowance
Abortions Not Covered Not Covered
Ded,then 90%of allowance.30 Ded,then 70%of allowance.30
In-Patient Mental/Nervous
days per calendar year. days per calendar year
$15 Copay.20 visits per calendar Ded,then 70%of allowance.20 visits
Out-Patient Mental/Nervous
year per calender year
Attempted Suicide Ded,then 90%of allowance Ded,then 70%of allowance
Ded,then 90%of allowance. Ded,then 70%of allowance.$2,500
In-Patient Substance Abuse
$2,500 lifetime max lifetime max
Ded,then 90%of allowance. Ded,then 70%of allowance. $2,500
Out-Patient Substance Abuse
$2,500 lifetime max. lifetime max.
Prescription Drugs - Includes coverage for
oral contraceptives&diaphragms
Ded,then 70%of allowance.
-Generic $7 Copay-30 day supply
30 day supply
Ded,then 70%of allowance.
-Brand $14 Copay-30 day supply
30 day supply
Prescription Card Yes No
Prescription Mail Order Yes No
Generic $14 Copay-90 day supply Not Applicable
Brand $28 Copay-90 day supply Not Applicable
•
•
• PUBLIC RISK MANAGEMENT
SCHEDULE OF BENEFIT SUMMARIES
BLUE CROSS/ BLUE SHIELD - LOW OPTION PPO
Effective 10/1/2002
PrtiPo •�.'. + :�', a.�� ... =,f:.:.�.Proposed` ..... ... .. .
J.,.b :!:3=�d �La i�d?':aY ,.{, .etr
Plan 719::;,: y y£,4JXa•r _.ria,, ..r9., pa., _t'S,i
In Netw ,,.
ark, ��„ ;v.�:. ,..: £.�:;;::Outof.Network'•s .�`
^
.
Attthorizedj•�, ..,,{�e;: ' ` t�` Non=tiutfioized ,.., . .
Maximum Lifetime Benefit $2,000,000 $2,000,000
Annual Ded $500 $500
Family Ded $1,500 $1,500
Annual Maximum Copayments N/A N/A
Family Maximum Copayments N/A N/A
Maximum Annual Out of Pocket $1,500 $1,500
Maximum Family Out of Pocket $4,500 $4,500
Coinsurance 80%of allowance 60%of allowance
4th Quarter Carryover Ded Carry Over applies Carry Over applies
Physician Office Visit $15 Copay Ded,then 60%of allowance
Wellcare Visits-Annual exam
$15 copay,$250 calendar year max 60%of allowance,Ded waived,$250
(combined OBGYN/adult wellness) calendar year max(combined
Adult/OB/GYN OBGYN/adult wellness)
-Child health $15 Copay.(Birth to age 16) 60%of allowance,Ded waived(Birth to
age 16)
Mammograms 80%of allowance,Ded waived 60%of allowance,Ded waived(may be
balance billed)
Specialist Office Visit $15 Copay Ded,then 60%of allowance
Second Opinion Surgical $15 Copay(Not Required) Ded,then 60%of allowance
Infertility Services/Treatment Plans
(Treatment covers artificial insemination, No Coverage No Coverage
IVF,GIFT,&ZIFT
Ded,then 80%of allowance
Physical Therapy u to$5,000 Ded,then 60%(inpatient/outpatient)up
y py p to$5,000 lifetime max
lifetime max
Ded,then 80%of allowance Ded,then 60%of allowance
Speech (inpatient/outpatient)up to$5,000 (inpatient/outpatient)up to$5,000
lifetime max lifetime max
Ded,then 80%of allowance Ded,then 60%of allowance
Occupational (inpatient/outpatient)up to$5,000 (inpatient/outpatient)up to$5,000
lifetime max lifetime max
Acupuncture Not Covered Not Covered
$15 Copay 60%of allowance,Ded waived(Birth to
Injections/Immunizations(child health) age 16)
Allergy Testing $15 Copay Ded,then 60%of allowance
Allergy Injections(not including serum) $10 copay Ded,then 60%of allowance
PUBLIC RISK MANAGEMENT
SCHEDULE OF BENEFIT SUMMARIES
BLUE CROSS/ BLUE SHIELD - LOW OPTION PPO
Effective 10/1/2002
‘; , -.;3:•Plan
In Net*Yor-K,,:';4::!alOut of-NOOYPrY"?,
tAiitthorilid) Athorized
Office Surgery $15 Copay Ded,then 60%of allowance
Outpatient Surgery(hospital or surgery
Ded,then 80%of allowance Ded,then 60%of allowance
center)
X-ray and Lab Outpatient-Physician's
Ded,then 80%of allowance Ded,then 60%of allowance
Office
Outpatient Radiation Ded,then 80%of allowance Ded,then 60%of allowance
Ded,then 70%of allowance
RAP Providers (Non-PPO
Ded,then 80%of allowance (If participating hospital,Ded,then 80%
Radiologist,anaesthesiologist,pathologist,
of allowance)
and ER phys.services at PPO hosp.)
Emergency Room/Hospital
-Illness Ded,then 80%of allowance Ded,then 60%of allowance
-Accidents 80%of allowance,Ded waived 60%of allowance,Ded waived
Ambulance Ded,then 80%of allowance Ded,then 80%of allowance
Ded,then 80%of allowance Ded,then 60%of allowance
Dental Oral Surgery (Injury due to external force of sound and (Injury due to external force of sound and
natural teeth) natural teeth)
$300 per admission Ded,then 60%of
Inpatient Hospital Ded,then 80%of allowance
allowance
X-ray and Lab Inpatient Ded,then 80%of allowance Ded,then 60%of allowance
Ded,then 80%of allowance (No Ded,then 60%of allowance (No
Blood and Blood Plasma
Limit) Limit)
Ded,then 80%of allowance. $2,500 per Ded,then 60%of allowance. $2,500 per
Home Health Care
calendar year calendar year
Ded,then 80%of allowance. $7,500 Ded,then 60%of allowance. $7,500
Hospice
lifetime max. lifetime max.
Ded,then 80%of allowance. 60 days per Ded,then 60%of allowance. 60 days/
Skilled Nursing Facility
calendar yr. calendar year
Ded,then 80%of allowance Ded,then 60%of allowance
Durable Medical Equip.
Maternity
-Physician Ded,then 80%of allowance Ded,then 60%of allowance
-Hospital Ded,then 80%of allowance Ded,then 60%of allowance
Dependent Daughter Maternity Ded,then 80%of allowance Ded,then 60%of allowance
Birthing Centers Ded,then 60%of allowance Ded,then 60%of allowance
Abortions Not Covered Not Covered
PUBLIC RISK MANAGEMENT
SCHEDULE OF BENEFIT SUMMARIES
BLUE CROSS/ BLUE SHIELD - LOW OPTION PPO
Effective 10/1/2002
Proposed .. :Proposed.;
Plan 719 " 'Plan 719°�
In:Network':• • Out of Network=
(Authorized):; tii (Non.Authorized)_.
In-Patient Mental/Nervous Ded,then 80%of allowance.30 days;30 Ded,then 60%of allowance.30 days;30
visits per calendar yr. visits per calendar yr.
Out-Patient Mental/Nervous Ded,then 80%of allowance.20 visits per Ded,then 60%of allowance.20 visits per
calendar yr(partial hopitalization). calendar yr(partial hopitalization).
Attempted Suicide Ded,then 80%of allowance Ded,then 60%of allowance
In-Patient Substance Abuse Ded,then 80%of allowance.$2,500 Ded,then 60%of allowance.$2,500
lifetime max. lifetime max.
Out-Patient Substance Abuse Ded,then 80%of allowance.$35 max per Ded,then 60%of allowance.$35 max per
visit;44 visits max;$2,500 lifetime max. visit;44 visits max;$2,500 lifetime max.
Prescription Drugs (Includes coverage for
oral contraceptives and Diaphragms)
-Generic $10 Copay,30 day supply Ded,then 60%of allowance
-Brand $25 Copay,30 day supply Ded,then 60%of allowance
Prescription Card Yes No
Prescription Mail Order Yes No
Generic $20 Copay,90 day supply Not Applicable
$50 Copay,90 day supply Not Applicable
Brand
' Florida
inHealth Care
Plans
A Proud Partner of Halifax•Fish Community Health
P.O.Box 9910,Daytona Beach,FL 32120
www.floridahealthcares.com
May 28, 2002
Ms. Lola Parker
Account Supervisor
CITY OF OKEECHOBEE
55 S.E. Third Avenue
Okeechobee,Florida 34974-2932
Dear Ms. Parker:
On behalf of Florida Health Care Plan, Inc. (FHCP), I thank you for the opportunity to
participate in the current RFP process for the City of Okeechobee. FHCP is licensed to
operate in the counties of Volusia,Flagler, and Seminole, Florida. After review of the
City of Okeechobee employee census supplied with the RFP, it appears not to contain
residents of any of those three(3) counties; therefore we must decline to submit a
proposal at this time.
Again,we thank you for the invitation, and wish you success in your search for
affordable, quality health coverage for the employees of the City of Okeechobee.
Since I , i /
Kitty Whitmar
Membership Growth and
Retention Coordinator
Holly Hill -Administrative Offices-386/676-7100- 1-800-352-9824
Daytona Beach -386/238-3200- 1-800-321-1227 • DeLand -386/736-1948
Edgewater-386/427-4868 • Orange City-386/774-2550- 1-800-390-3427
Ormond Beach -386/671-4337 • Palm Coast-386/445-7073
Port Orange East-386/763-1000 • Port Orange West-386/756-6658
An Equal Opportunity-Affirmative Action Employer
Marybeth O'Connor
National Account Executive
South Florida Sales
CIGNA HealthCare
April 16, 2003 Routing 362
1580 Sawgrass Corporate Parkway
Suite 200
Sunrise,FL 33323
Telephone 954.693.7591
Facsimile 954.693.7540
marybeth.o'connor@cigna.com
City of Okeechobee
55 S.E. Third Avenue
Okeechobee, FL 34974-2932
Re: Invitation to Bid - City of Okeechobee - Bid Number: FIN 03-00-04-03
To Whom It May Concern,
Thank you for your request for proposal for The City of Okeechobee. Your interest in CIGNA
HealthCare is greatly appreciated.
At this time, I must respectfully decline to quote on medical on this opportunity. We find
that we are unable to provide a financially attractive alternative to the existing plan.
Thank you again for considering CIGNA HealthCare. Hopefully the next opportunity will
have more positive results.
Cor•ially,
(t0
Marybeth O'Connor
MOC/mgb
Proud National Sponsor of the March of Dimes®WalkAmerica...the Walk that Saves Babies
"CIGNA HealthCare"or"CIGNA"refer to various operating subsidiaries of CIGNA Corporation.Products and services are provided by these subsidiaries and not by
CIGNA Corporation.These subsidiaries include Connecticut General Life Insurance Company,Tel-Drug,Inc.and its affiliates,CIGNA Behavioral Health,Inc.,Intracorp,
and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health,Inc.
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4152 WEST BLUE HERON
RIVIE BLVD, SUITE 226
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FLHE300 334842030 1401 02 05/22/02
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:FLORIDA HEALTH CHOICE PLAN
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3t' ORIGINAL
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PUBLIC RISK MANAGEMENT OF FLORIDA
(PRM) HEALTH PLAN
Proposal for Group Health Insurance
For:
City of Okeechobee
Bid Number: FIN 01-00-05-02
July 5, 2002
�. Presented By:
RICHARD G.SCHELL
Area Assistant Vice President
Timothy R.Reynen
Account Executive
Arthur J. Gallagher&Co.
Gallagher Benefit Services
One Boca Place
2255 Glades Road,Suite 400E
Boca Raton,FL 33431
(561)995-6706
..
PUBLIC RISK MANAGEMENT
.. OF FLORIDA (PRM) HEALTH PLAN
TABLE OF CONTENTS
Section I Introduction
Section II Medical Plan
Section III Dental Plan
.. Section IV Life Insurance Plan
Section V Blue Cross Blue Shield of Florida
Gallagher Benefit Services
Section VI Current PRM Members
..
Section VII Agreement to Participate
PRM Bi-Laws
Section VIII Benefit Summary Comparison
. AM Best Ratings
1
Gallagher Benefit Services, Inc.
A Subsidiary of Arthur J. Gallagher& Co.
July 3, 2002
•• Lola Parker, Account Supervisor
City of Okeechobee
55 S.E. Third Avenue
Okeechobee, FL 34974
Re: Public Risk Management Medical, Dental and Life Proposal
Dear Lola,
We appreciate the opportunity to present the enclosed Public Risk Management Health Trust
proposal. The proposal contains quotes for the High Option PPO, Low Option PPO, Blue Care
HMO as well as the PRM Dental and Life Insurance program.
The medical rates illustrated would be for the period August 1, 2002 through September 30,
2003, to coincide with the PRM plan year (a fourteen month contract). The Dental rates are
effective August 1, 2002 through September 30, 2002. The Life Insurance rates illustrated would
be from August 1, 2002 through September 30, 2004.
The PRM Health Trust, like the P&C Pool, will offer the City of Okeechobee increased value
and the opportunity to provide a more stable renewal process as health trends continue to
escalate. Groups with good claims experience receive additional credit at renewal.
The Trust requires a two-year commitment from the City of Okeechobee in order to participate.
The advantages of self-funding and the pooling concept are the results of long term commitment
as demonstrated by the continued success of the PRM program.
Should you have any questions, please contact me or Tim Reynen at 561-995-6706. Again,
thank you for the opportunity to provide the City of Okeechobee a proposal from the Public Risk
Management Health Trust.
Sincerely,
.0441 RTr�
�• Richard G. Schell
Area Assistant Vice President
encl.
One Boca Place
2255 Glades Road, Suite 400 E
Boca Raton, FL 33431
561.995.6706
Fax 561.995.6708
a www.ajg.com
INTRODUCTION
Gallagher Benefit Services, a division of Arthur J. Gallagher & Co., is pleased to provide the enclosed
information on behalf of Public Risk Management of Florida concerning the benefit programs available
through the PRM Health Plan.
PRM is a purchasing cooperative of governmental agencies founded in 1988 for the purpose of banding
together to obtain the most competitive contracts for provision of Property& Casualty and Employee
Benefit insurances.
Arthur J. Gallagher & Co. acts as insurance consultant and broker to the PRM risk pools, working with
the membership and their individual consultants to provide quality programs to participating entities.
Members of the Property& Casualty risk pool have first hand knowledge of the expertise and
experience Arthur J. Gallagher & Co. brings to the membership. Gallagher Benefit Services brings the
same talents to the Employee Benefits arena,providing the PRM membership with expertise and
guidance through the quickly changing and heavily mandated employee benefits areas.
The PRM Health Plan is governed by a Board of Directors which meets quarterly to review plan
operation, financials, legislative issues and any other pertinent information. Each participating entity
delegates its' own Board Member, and each entity receives one vote. Each member has input regarding
the plan, future enhancements, funding levels, etc.
The plan year begins on October 1 of each year. Due to budgetary requirements, renewal discussions
begin in April and are finalized at the end of June each year. All contracts and funding levels are based
on an October 1 through September 30 plan year, although multi year rate guarantees are obtained from
the carriers whenever possible.
Medical coverage is required for participation in the PRM Health Plan. Other coverages offered as part
of the PRM Health Plan to participating entities are dental, life, AD&D and Dependent Life insurances.
These are offered for the convenience of the membership and are not required for participation.
Gallagher Benefit Services is also available for and happy to work with individual entities and their
advisors in the development of other additional employee benefits.
3
SECTION II
Medical Plan
die
r
ale
rr
4
PRM MEDICAL PLAN
The Medical program provided through the Public Risk Management of Florida Health Plan is a self
funded plan using the Blue Cross Blue Shield of Florida network, administered by Blue Cross Blue
Shield of Florida and reinsured by Lincoln Re. At the close of each fiscal year an actuarial report is
submitted to the State of Florida pursuant to Florida Statute 112.08, and each year the State has
�. certified the Plan to be actuarially sound and fully reserved.
Administration/claims services, network access and excess reinsurance are negotiated by the PRM
Health Plan on behalf of its' members. This allows the Plan to utilize a larger purchasing group and
obtain more competitive rates than could be purchased individually. Any actual purchases must be
approved by the Board of Directors.
A choice of three medical plans is offered: A High Option PPO, a Low Option PPO, and an HMO.
Participating entities may select whichever plan, or combination of plans, best suit their needs. Plan
designs can be found on the following pages.
As PRM members are first and foremost individual entities, all Personnel parameters, i.e.; employee
�. eligibility for participation in the Plan, are decided by the individual entity. This allows the entities to
retain the personnel practices in place.
.r Prospective participants are initially underwritten based on individual group demographics and
experience.
5
.. PUBLIC RISK MANAGEMENT OF FLORIDA
SUMMARY OF BENEFITS
HIGH OPTION PPO
Lifetime Maximum $2,000,000
Copay $15 Per Office Visit at PPC
Physician's Office(Deductible and Coinsurance
Waived)
Deductibles
Calendar Year $200 (3 Per Family-Aggregate)
+- Per Admission(Non PPC Hospital Only) $100
Coinsurance 90%of PPC Schedule For Utilization of PPC
Providers; 70%Of Allowance For Utilization of Non-
i` PPC Providers
Prescription Drugs Rx Card(See Attached)
Maternity Delivery,Pre-and Postpartum Care Subject to
Deductible and Coinsurance
Adult Well Care $15 Copay per visit up to$250 combined adult
wellness and OB/GYN
Well Child Care $15 Copay Per Well Child Care Visit at PPC
Birth to Age 16 (18 Visits) Physician's Office; Out of Network,Deductible
Waived
Accident Care 90%of allowance(Deductible and Coinsurance
waived)
Mental Nervous
Inpatient -30 Days; 30 Visits $15 Copay Per Office Visit at PPC Physician's Office;
Per Calendar Year
Outpatient- Up to 20 Visits Per Out of Network, Subject to Deductible and
Calendar Year Coinsurance
.. Partial Hospitalization
Alcohol and Drug
$2,500 Lifetime Maximum $15 Copay Per Office Visit at PPC Physician's Office;
(Inpatient,Outpatient of any Combination) Out of network,Subject to Deductible and Coinsurance
Skilled Nursing Facility 60 Days Per Calendar Year
Home Health Care $12,000 Per Calendar Year
Hospice $7,500 Lifetime Maximum
Maximum Out-Of-Pocket
Coinsurance Expense $1,500 Per Person
Amount Per Calendar Year (Maximum 3 Per Family-Aggregate)
6
AWN PUBLIC RISK MANAGEMENT OF FLORIDA
HIGH OPTION PPO
$7 GENERIC/$14 BRAND NAME PRESCRIPTION DRUG COVERAGE
..�
BlueScript Pharmacy Program
The cost of prescription drugs accounts for a significant share of your total health care expense. Blue Cross and Blue Shield
of Florida has developed the BlueScript Pharmacy Program in an effort to help control the increasing cost of prescription
drugs. BlueScript covers most medications,which,by law,may only be dispensed by a written prescription.
®• No claims to file. When your employees select a BlueScript participating pharmacy, they simply present their Blue Cross
and Blue Shield of Florida identification card and pay the applicable copayment amount for each covered prescription drug.
The participating pharmacy will file the claim for your employees.
Participating Pharmacies. More than 2,400 pharmacies participate in BlueScript statewide. Selection of a pharmacy for
participating in BlueScript is based on quality,service,competitive pricing,convenience to our customers, and ability to
provide all necessary information for claims filing. The pharmacy also must have on-line capability to provide timely
via verification of eligibility,coverage and pricing information at the point-of-sale.
Non-Participating Pharmacies. Covered prescription drugs purchased at non-participating pharmacies are subject to the
copayment amount and reimbursed at a lower percentage. At the point-of-sale, your employees will pay the full cost of the
prescription drug and obtain an itemized receipt. It will be the employee's responsibility to complete a prescription drug
claim form,attach the itemized paid receipt, and submit both to Blue Cross and Blue Shield of Florida for payment. After
processing,payment will be made directly to the employee.
BlueScript Key Features:
�., • Broad accessibility with more than 2,400 participating pharmacies statewide,giving your employees more
choices with convenient locations.
• Participating pharmacies file claims for you,so you and your employees receive hassle-free service.
• Program flexibility with coverage designed to meet your needs at the point-of-sale.
• On-line claims information,providing quick answers on eligibility,pricing and coverage.
BlueScript provides hassle-fee service with no claims to file when using a participating pharmacy. It's another way Blue
Cross and Blue Shield of Florida is helping to control the high cost of health care.
sMService mark of Blue Cross and Blue Shield of Florida,Inc.
.r.
all
a.
7
PUBLIC RISK MANAGEMENT OF FLORIDA
SUMMARY OF BENEFITS
LOW OPTION PPO
Lifetime Maximum $2,000,000
Copay $15 Per Office Visit at PPC
Physician's Office(Deductible and Coinsurance
Waived)
�. Deductibles
Calendar Year $500 (3 Per Family-Aggregate)
Per Admission(Non PPC Hospital Only) $500
Coinsurance 80%of PPC Schedule For Utilization of PPC
Providers; 60%Of Allowance For Utilization of Non-
PPC Providers
Prescription Drugs Rx Card(See Attached)
Maternity Delivery,Pre-and Postpartum Care Subject to
Deductible and Coinsurance
Adult Well Care $15 Copay per visit up to$250 combined adult
wellness and OB/GYN
Well Child Care $15 Copay Per Well Child Care Visit at PPC
Birth to Age 16(18 Visits) Physician's Office; Out of Network,Deductible
Waived
Accident Care 80%of allowance(Deductible and Coinsurance
waived)
Mental Nervous
Inpatient -30 Days; 30 Visits $15 Copay Per Office Visit at PPC Physician's Office;
Per Calendar Year
"• Outpatient-Up to 20 Visits Per Out of Network, Subject to Deductible and
Calendar Year Coinsurance
Partial Hospitalization
Alcohol and Drug
$2,500 Lifetime Maximum $15 Copay Per Office Visit at PPC Physician's Office;
(Inpatient, Outpatient of any Combination) Out of network,Subject to Deductible and Coinsurance
Skilled Nursing Facility 60 Days Per Calendar Year
Home Health Care $2,500 Per Calendar Year
Hospice $7,500 Lifetime Maximum
Maximum Out-Of-Pocket
Coinsurance Expense $1,500 Per Person
Amount Per Calendar Year (Maximum 3 Per Family-Aggregate)
Aem
8
�... PUBLIC RISK MANAGEMENT OF FLORIDA
LOW OPTION PPO
$10 GENERIC/$25 BRAND NAME PRESCRIPTION DRUG COVERAGE
BlueScripts m Pharmacy Program
The cost of prescription drugs accounts for a significant share of your total health care expense. Blue Cross and Blue Shield
of Florida has developed the BlueScript Pharmacy Program in an effort to help control the increasing cost of prescription
drugs. BlueScript covers most medications which,by law,may only be dispensed by a written prescription.
No claims to file. When your employees select a BlueScript participating pharmacy, they simply present their Blue Cross
and Blue Shield of Florida identification card and pay the applicable copayment amount for each covered prescription drug.
The participating pharmacy will file the claim for your employees.
Participating Pharmacies. More than 2,400 pharmacies participate in BlueScript statewide. Selection of a pharmacy for
participating in BlueScript is based on quality, service, competitive pricing,convenience to our customers,and ability to
provide all necessary information for claims filing. The pharmacy also must have on-line capability to provide timely
verification of eligibility,coverage and pricing information at the point-of-sale.
Non-Participating Pharmacies. Covered prescription drugs purchased at non-participating pharmacies are subject to the
.,, copayment amount and reimbursed at a lower percentage. At the point-of-sale,your employees will pay the full cost of the
prescription drug and obtain an itemized receipt. It will be the employee's responsibility to complete a prescription drug
claim form, attach the itemized paid receipt,and submit both to Blue Cross and Blue Shield of Florida for payment. After
processing,payment will be made directly to the employee.
BlueScript Key Features:
• Broad accessibility with more than 2,400 participating pharmacies statewide,giving your employees more
choices with convenient locations.
• Participating pharmacies file claims for you, so you and your employees receive hassle-free service.
• Program flexibility with coverage designed to meet your needs at the point-of-sale.
• On-line claims information,providing quick answers on eligibility,pricing and coverage.
BlueScript provides hassle-fee service with no claims to file when using a participating pharmacy. It's another way Blue
Cross and Blue Shield of Florida is helping to control the high cost of health care.
sMService mark of Blue Cross and Blue Shield of Florida, Inc.
AO
AO
9
. PUBLIC RISK MANAGEMENT OF FLORIDA
SUMMARY OF BENEFITS
HMO PLAN
Benefit Authorized
m. Out of Pocket Maximum
Individual $1,500
Family $3,000
' Hospital per Admission Copay $250
Physician Office Services
me
Primary Care Physician $10 Copay
Specialist $10 Copay
Office Surgery $10 Copay
""' Routine Services $10 Copay
Preventive Care $10 Copay
Well Child Care $10 Copay
,l, Allergy Testing $0 Copay
Allergy Immunization $10 Copay
Annual GYN exam $10 Copay
X-Ray&Lab $0 Copay
'" Infertility Services $10 Copay
Hospital Services:
.. Inpatient $250 per Admission Copay
Outpatient Hospital/Surgical $100 Copay
Emergency Room $50 Copay
a. Hospice Care $0 Copay
Home Health Care $0 Copay
$0 Copay
Skilled Nursing Facility 90 days/yr. max
Mental& Nervous
"' Inpatient $250 Copay/admission; 30 days/yr.
Outpatient $25 Copay/visit; 20 visits/yr.
are Substance Abuse Inpatient/Outpatient
Inpatient $250 Copay/admission;Detox only
Outpatient $15 Copay/visit; 20 visits/yr.
on Other Healthcare Providers(Ambulance,DME) $0 Copay
Prescription Drug Program
Drug Card: Generic $7.00 Copay
Brand $14.00 Copay
Mail Order: Generic $14.00 Copay
AN Brand $28.00 Copay
10
...
City of Okeechobee
PRM Health Trust Rate Breakdown - Medical
Effective: 8/1/02 - 9/30/02
'Plr.0* .r.re4:Prt,AMP: *- ElnP!Plfe644*' Employee,;Employee
gigholitioi;" ',1..::„--;: i.,,: .:::::.::'5-,;'RI:::',:lt:- iiiieA.;:3:::1,:,,§ii0UseO:!;'7,,=ii:Ciiiid i,:.:::*Family
Attachment Factor $450.90 $1,014.19 $941.26 $1,504.72
Specific Excess @ $80,000 $42.79 $96.25 $89.33 $142.81
..
Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $42.89 $42.89 $42.89 $42.89
.. PRM Administration $5.11 $5.11 $5.11 $5.11
Conversion $0.50 $0.50 $0.50 $0.50
. Monthly Funding Rate $545.55 $1,162.301 $1,082.451 $1,699.39
Prcferi0:100ilai:.11,Q :,4?-: .:1',..h,' ';:::,;:,.',i:::-,,: ,:,::,::;: ;jiq).,Y*o-* ,'.E*pi*:*•ftEtoii!(i*,
Lovr'00*Ii',,, i'i'f ::- ',''t;;;:!‘:::; ,',1',:.:7:74.61144,t ::: '' 1.:'-(Siiiiii;:',,:k : ,!'ktiiiii(:':.4*i'fii*-
Attachment Factor $392.28 $882.34 $818.90 $1,309.10
Specific Excess @ $80,000 $42.79 $96.25 $89.33 $142.81
. Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $42.89 $42.89 $42.89 $42.89
PRM Administration $5.11 $5.11 $5.11 $5.11
Conversion $0.50 $0.50 $0.50 $0.50
Monthly Funding Rate I $486.931 $1,030.451 $960.091 $1,503.77
Health Maintenance '--:-41:--:. :Z:LIA'r;i'll'1 ‘4::',:', :',**Wi'''' '4,-'',k-Y:5-V4 ';:ji;.:.-;-:'''•=!''Y' '
,oriiiiiti4;0:0an;;7::411 *Ps:P?i'''::,:401":iliniiigii4 ;I:iiiii;4i4.:6*Zii.
: ,,„ ,s , : -:,, ,-,,;,:,1;,,;:, : ,, ,,_,, , -
Blue Cara, ,,'\: =::---: 1'''' ,':' ,:';',r';!1::r ' ';''kiiiPloYe :. .,:!:$1Siiiert:;" 840/14 :A TO/11/1Y"
a■
Attachment Factor $378.75 $851.92 $790.66 $1,263.96
Specific Excess @ $80,000 $36.08 $81.15 $75.32 $120.40
. Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $62.00 $62.00 $62.00 $62.00
PRM Administration $5.11 $5.11 $5.11 $5.11
Conversion $0.50 $0.50 $0.50 $0.50
Monthly Funding Rate I $485.80 $1,004.04[ $936.951 $1,455.33
"` City of Okeechobee
PRM Health Trust Rate Breakdown - Medical
Effective: 10/1/02 - 9/30/03
Pr eferred ProVi, e tT PO: ;:V4,;4, ,. := � k4 ,Employ + :
ms 10 • : �g...�
,i i •
in � :"i+rS.= <x" :fqqt-n=Jyg;a="'ak ' �\ � &t �«@:p 4 - >,♦ i :' , t p $ ' a
Attachment Factor $450.90 $1,014.19 $941.26 $1,504.72
,,, Specific Excess @ $80,000 $42.79 $96.25 $89.33 $142.81
Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $48.90 $48.90 $48.90 $48.90
PRM Administration $5.32 $5.32 $5.32 $5.32
Conversion $0.50 $0.50 $0.50 $0.50
.., Monthly Funding Rate $551.77 $1,168.521 $1,088.671 $1,705.61
P neferi ed:,:'rovi_deir PPO' != .,,: ,
..�:...,.w ° �r�: `Em Io .. ;aEi� lo° a „E`�n likyee_.
i•:.J�•�r- z -'Y^dv`,:= �Z..v� �?Aa\'•••� '".Cx:r ..1.:. •.� i�ri..,,y .�..�a w •�y n N.4-�.
.a:,. --, ;a°'M ,:q'',w,.i fi' tom.�i. .�°-�=r<e= �• , &•:•�'ss.:• ,-
P. $4.:1;:,!::1; wEmplayee:_. ,Sgous�. � ';.&��"Ch�1 :;,..f,:',74� -
'' Attachment Factor $392.28 $882.34 $818.90 $1,309.10
Specific Excess @ $80,000 $42.79 $96.25 $89.33 $142.81
. Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $48.90 $48.90 $48.90 $48.90
PRM Administration $5.32 $5.32 $5.32 $5.32
Conversion $0.50 $0.50 $0.50 $0.50
Monthly Funding Rate $493.15 $1,036.67 $966.311 $1,509.99
.. ealtl%t, •ainitenance = :> ,, r:.,;..,.
Oanp 4 : E..
r g. i tiak tonr;.:_..:, p x? ��-. i'l' � �. . m�to �,. lo o e' � •, �gl
' e
"y- Cd,- , '. ..� w.. n ." +3 SL � Z P N � ;;ye:
.
Bu aro l „ emploe . ; t�p0 WZ �Ch��2 . mmy
Attachment Factor $378.75 $851.92 $790.66 $1,263.96
Specific Excess @ $80,000 $36.08 $81.15 $75.32 $120.40
.. Aggregate Excess $3.36 $3.36 $3.36 $3.36
BC/BS Administration $62.00 $62.00 $62.00 $62.00
PRM Administration $5.32 $5.32 $5.32 $5.32
Conversion $0.50 $0.50 $0.50 $0.50
Monthly Funding Rate $486.01 $1,004.25 $937.161 $1,455.54
..
Conditions and Limitations:
• Completion of Plan Sponsor Disclosure Form. Disclosure pertains to: 1) any claim relating
to a serious medical condition, 2) each claim in the last 12 months that has exceeded or
expected to exceed 50% of the specific deductible, 3) employees absent from work due to
disability and dependents, retirees or COBRA beneficiaries who are hospital confined.
• A Plan Document. The Excess Loss Policy cannot be issued until the Plan Document has
been received and approved by Lincoln Re Risk Management Services.
• Paid Claims experience from 4/1/02 — 9/30/02.
• A census of final enrollment. Terms are subject to change if final enrollment varies by more
than 15% from proposal assumptions.
• Capitation is included as an eligible expense under the aggregate.
"r • Minimum participation requirement is 75% of eligible employees. Employees who waive
coverage on this plan due to coverage elsewhere will be considered non participating.
• We assume implementation of the proposed PRM schedule of benefits with Blue Cross &
Blue Shield.
• The proposed program complies with State and Federal Statutes currently and in the future.
HIPAA compliance is included.
• Specific applies to all claims for all conditions for each individual.
• Specific applies to the mother and each child separately.
• The agent/broker is properly licensed and appointed with the carrier noted above for which
business is written.
• We assume the experience reflects a standard claims processing time of approximately two
weeks from date of receipt to date paid by the Third Party Administrator. Terms are subject
to change on a retrospective basis if subsequent experience demonstrates a significant,
,, undisclosed backlog of claims.
• Aggregate Monthly Settlement Option is included.
• Medical coverage options outlined in the proposal are contingent upon network availability.
.ti.
Excess Loss Insurance Exclusions:
• Transplant Services, except for human to human organ or tissue transplant procedures.
• Expenses eligible for or covered by any worker's compensation, occupational disease law or
similar law.
• Losses due to war or any act of war.
• Penalties, interest, fines or fees imposed under the Policyholder.
• Punitive, exemplary, compensatory or extra-contractual damages paid by the Policyholder.
• Losses resulting from any professional or other liability claims arising from services
rendered by the Policyholder or any employee of affiliated organizations or person.
• Expenses from which the Policyholder is eligible for or receives any payment or reduction in
charges resulting from, but not limited to coordination of benefits or subrogation.
• Sales or use taxes, surcharges, or other such taxes or assessments, unless Lincoln expressly
agrees to make such payments as Lincoln agreed to with New York and Massachusetts
surcharges.
• Cost of claims administration or other administrative expenses and any expense for litigation
involving disputed claims under the plan document.
1
Swiss Re
Lincoln National
Health&Casualty Insurance Co.
I' 7300 Corporate Center Drive
Suite 205
Miami,Fl 33126-1222
Watts 800-352-0042
Voice 305-715-6145
Fax 305-715-6199
Plan Sponsor Disclosure Statement E-Mail:Eric_Hicks @SwissRe.com
It is the intention of the Plan sponsor to purchase Excess Liability Insurance in connection with the funding of an employee welfare benefit plan. The following
information is provided to the Excess Liability Carrier for use with the Plan Sponsor's application for coverage.
Listed below are:
A. Claims in the last 12 months exceeding 50%of the specific deductible level selected;
B. Any current claims which may be potentially serious regardless of current claim amount;
C. Dependents,retirees, or COBRA beneficiaries who are hospital confined within 30 days of this report; and
D. Employees absent from work due to disability as of the date of this report.
*CLAIMANT# **E/D/R/C DATE OF SEX DATE DIAGNOSIS OR NATURE OF CURRENT STATUS AND TOTAL
BIRTH DISABLED DISABILITY PROGNOSIS BILLS TO
DATE($)
* For purposes of confidentiality,please identify the claimants as claimant#1,#2,#3,etc.
**E=Employee, D=Dependent, R=Retiree,C=COBRA beneficiary(include date COBRA coverage is expected to terminate)
The Plan Sponsor named below,through its authorized person,hereby represents that the above list is true,complete and accurate to the best of his/her knowledge and belief and
that nothing has been knowingly or intentionally omitted. The Plan Sponsor acknowledges that,as a minimum,its claims administrator,utilization review vendor,and medical
case management vendor participated in the collection of the above data.
PLAN SPONSOR Authorized Person
Address - Signature
Date of Disclosure Title
This information will be treated confidentially by the Excess Liability Carrier. Additional sheets may be attached.
Number of Claims Listed Number of Sheets Attached
eww.lincolnre.com
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
..r
SECTION III
AMP
Dental Program
all
NO
r
11
PUBLIC RISK MANAGEMENT OF FLORIDA
DENTAL PLAN
The dental program provided through the Public Risk Management of Florida Health Plan is also a
self funded plan. The dental plan is administered by Florida Combined Life, a division of Blue
,,r Cross Blue Shield of Florida, and reinsured by Lincoln Re as part of the overall plan. The dental
program is included as part of the actuarial report submitted to the State of Florida annually pursuant
to Florida Statute 112.08, and each year the State has certified the PRM Health Plan to be actuarially
sound and fully reserved.
Administration/claims services and excess reinsurance are negotiated by the PRM Health Plan on
behalf of dental participants. This allows the Plan to utilize a larger purchasing group and obtain
more competitive rates than could be purchased individually. Any actual purchases must be
approved by the Board of Directors.
The Dental Program provided through the Public Risk Management of Florida Health Plan is an
indemnity plan without network or provider requirements.
As in the medical plan, all Personnel parameters, ie; employee eligibility for participation in the
Plan, are decided by the individual entity.
0.
Participation in the dental plan is not required for participation in the PRM Health Plan consortium.
PUBLIC RISK MANAGEMENT OF FLORIDA
•"' DENTAL PLAN
Benefits Maximum
Basic Dental $1,500 per calendar year
Orthodontia $1,500 lifetime
(Available to dependent children
under age 19 only)
Deductible $50 per calendar year, per person
(Waived for Preventive Services 2 per family
and Orthodontia)
Copayment percentage for:
• Preventive Services 100%
• Basic Services 80%
• Major Services 50%
• Orthodontia 50%
Covered Dental Expenses include reasonable and customary necessary expenses incurred for the
services and supplies listed below:
Covered Preventive Services
• Initial oral examination
• Periodontic oral examinations, 2 per calendar year.
• Prophylaxis, including cleaning, routine scaling and polishing, 2 per calendar year.
• Topical Fluoride application once per calendar year for individuals under age 19.
• Palliative (to relieve pain) emergency treatment and emergency oral examinations.
• Sealants for individuals age 6 through 13 years of age, one application per 36 consecutive months.
• Dental X-rays as follows:
One set of full mouth x-rays every 36 months;
2 sets of bitewing x-rays per calendar year;
Other dental x-rays as deemed necessary.
• Space maintainers, except if covered under Orthodontia benefits.
• Pulp vitality tests.
• Caries susceptibility tests.
13
PUBLIC RISK MANAGEMENT OF FLORIDA
DENTAL PLAN
(Continued)
Covered Basic Services
• Fillings (amalgam, composite, plastic and acrylic).
• Extractions.
• Endodontics (root canal).
• Recementing of crowns, inlays and/or bridges.
• Biopsies of oral tissue.
• Home visits by a physician or dentist when medically necessary in order to render a Covered dental
service.
• Oral surgery.
• Apicoectomy.
• Hemisection.
• General anesthesia administered in connection with a covered dental service if administered by an
individual licensed to administer general anesthesia, other than the dentist or physician performing
the service for which administered.
• Injection of antibiotic drugs.
• Periodontics:
Occlusal equilibration, when no restoration is involved;
Gingivectomy and gingivoplasty;
Gingival curettage;
Scaling and root planing;
Osseous surgery(osteoplasty and ostectomy), including flap entry and closure;
Surgical Periodontic examination;
"" Mucogingivoplastic surgery;
Management of acute periodontal infection and oral lesions.
• Denture adjustments, not including relining or rebasing.
• Fixed bridge repair as follows:
Replacement of broken pins;
Replacement of broken pontic;
Replacement of bridgework when the existing bridgework was installed at least 5years prior to its
replacement and the existing bridgework cannot be made serviceable.
• Repairs to existing removable denture (full or partial) as follows:
Repair of broken complete or partial denture and/or replacement of broken teeth;
Replacement or addition of teeth due to the extraction of natural teeth which occurred while
covered under this Plan;
Reattachment of damaged clasp or replacement of broken clasp;
Replacement of denture when the existing denture was installed at least 5 years prior to its
replacement and the existing denture cannot be made serviceable.
14
PUBLIC RISK MANAGEMENT OF FLORIDA
DENTAL PLAN
(Continued)
Covered Major Services
• Inlays (not part of bridge).
• Onlays (not part of bridge).
• Crowns (not part of bridge).
• Inlays, onlays, gold foil restorations, crowns (including precision attachments for dentures).
• Denture adjustments and relining and/or rebasing once each 36 months.
• Dentures, full and partial, and bridges, fixed and removable as follows:
Initial installation of dentures;
Dentures to replace one or more natural teeth extracted while covered under these benefits;
Initial installation of bridges;
Bridgework to replace one or more natural teeth extracted while covered under these benefits
(including inlays and crowns to form abutments);
Six months of post-delivery care.
,.. Covered Orthodontia Services
(available only to dependent children age 19 or less at the date treatment commences.)
• Installations of orthodontic appliances and all orthodontic treatments concerned with the reduction or
elimination of an existing malocclusion and conditions resulting from that malocclusion through
correction of abnormally positioned teeth.
• Diagnostic services, including examination, study models, radiographs and all other diagnostic aids
used to determine orthodontic needs once each 5 years, commencing with the date of the initial visit
to the dentist or physician.
• Active and retentive orthodontic treatment for 24 consecutive months or less. Also, the amount of
orthodontia charges included as covered expenses during the initial calendar year quarter of treatment
will be limited to 30% of the total allowable charges for the cost of the entire orthodontia treatment.
The balance of the covered expenses will be prorated over the remaining calendar year quarters of the
treatment plan or 7 calendar year quarters, whichever is less.
15
City of Okeechobee
Dental Plan Rates
8/01/02 - 9/30/03
S�.ngle� � .
$31.15 $63.76
al.
SECTION IV
Life Insurance Plan
MIN
Ala
efts
1 F
PUBLIC RISK MANAGEMENT OF FLORIDA
LIFE INSURANCE PLAN
The Life Insurance Plan provided through the Public Risk Management of Florida Health Plan is
fully insured and written by The Standard Insurance Company.
Insured benefit per employee is elected by individual entity and may be based on salary or a flat
amount. The standard PRM Life Plan benefits include Basic Life, Basic Accidental Death &
Dismemberment and Dependent Life. Additional PRM Life Plan benefits include Supplemental
employee and dependent life.
.. Participation in the life insurance plan is not required for participation in the PRM Medical Plan
Consortium. Gallagher Benefit Services would be happy to assist in alternate plans.
17
City of Okeechobee
Life Insurance Rates
8/01/02 - 9/30/04
Basic Life Rate: - .=
k _.
$0.28 per $1,000 $0.03 per $1,000
.• SECTION V
Blue Cross Blue Shield of Florida
Gallagher Benefit Services
�- 18
PUBLIC RISK MANAGEMENT OF FLORIDA
BLUE CROSS BLUE SHIELD
PROFILE OF SERVICES
Blue Cross Blue Shield provides the following administrative services as part of their contract with the
PRM Health Plan.
• Claims Administration
•• • Eligibility Maintenance
• PPO/HMO Network
• Customer Service
• Employee Meetings/ Enrollment
• Utilization Review, Pre-Certification, Case Management
• PPO/HMO Claims Filing by Providers
• Prescription Drug Card
• Mail Order Drug Service
• COBRA Administration
• Reports
�.. Entities participating in the PRM Health Plan program will receive all of the above member services.
Employees, entity administrators and providers will deal with Blue Cross representatives assigned
exclusively to PRM for routine issues.
Additionally, Blue Cross PPO providers will be responsible for obtaining pre-certification authorization
and for filing PPO claims.
We anticipate soft dollar savings to PRM Health Plan members in the form of less plan administration, less
time resolving claims issues, less time reporting to various vendors, and less time answering employee
questions and complaints.
19
PUBLIC RISK MANAGEMENT OF FLORIDA
BLUE CROSS BLUE SHIELD ADVANTAGES
• PRM commitment to pooling concept. Fourteen year track record of quality service and plan
implementation.
• Flexibility in plan designs offering two PPO's in addition to an HMO.
• In addition to the Blue Cross Blue Shield service staff, PRM staff, and Gallagher Benefits Services
assist in all areas of plan management.
• Quarterly board meetings include Health Trust status reports, industry updates, and the sharing of
ideas and concepts.
••• • National recognition and acceptance of I.D. card. The ITS Program offers a reduction in changes and
hold harmless against balance billing when employees incur a claim out-of-state with a participating
Blue Cross/Blue Shield in that state.
• Local presence throughout the state with walk-in service to track all customer inquiries for prompt
resolution or questions.
• Largest PPO network in Florida. Employees have more hospitals and doctors to choose from. The
average reduction of billed charges results in savings of 35-45%.
• Blue Cross/Blue Shield allowances are accepted as payment in full. No balance billing except for copy or
deductible as co-insurance. Providers agree not to require full payment at time of service and providers
will file the claim.
• Network in and out of PPC network. Physicians and hospitals that participate with Blue Cross/Blue
Shield,but not with PPC network agree to accept our allowance at the lower and will not balance. They
will also file claim on behalf of employee.
• Blue Cross/Blue Shield's Cobra Administration(CobraServe)simplifies and holds the account harmless
for errors and omissions in the administration of the Cobra program. No annual fee.
• Personal health advisor available 24 hours a day, 7 days a week. Toll free number to access a medical
nurse confidentially and immediate answer employees health care questions and concerns.
• Virtual Office
20
PUBLIC RISK MANAGEMENT OF FLORIDA
GALLAGHER BENEFIT SERVICES
SCOPE OF SERVICES
Gallagher Benefit Services is experienced in all facets of employee benefits. We provide services for our
clients'benefit programs including, but not limited to, medical, dental, life, disability, cafeteria, drug card,
vision, voluntary coverage, and long term care plans.
.. The Scope of Services below reflects the services available to PRM members and their
consultants/advisors for all lines of coverage contained in their employee benefit plans.
A. Plan Analysis
B. Benefit Analysis
C. Financial Analysis
D. Benefits Marketing
E. Optional Services and Fees
As a full service brokerage and consulting firm, Gallagher has extensive internal resources available,
including but not limited to benefits brokerage and specialty services. All of these services can be
provided or arranged by the Gallagher Benefit Services Boca Raton office.
1. Flexible Benefits/Cafeteria Plan Administration
2. ERISA Audits/Compliance Services
.. 3. COBRA Administration
4. Capital Accumulation/Retirement Planning Services
5. Human Resource Outsourcing Services
The Arthur J. Gallagher organization, and Gallagher Benefit Services, has extensive experience with a
diverse client base utilizing self-funded and/or insured funding arrangements, as well as general plan
administration. We have several specialty divisions allowing us to offer the most comprehensive
employee benefit consulting services. Our first hand experience and variety of services makes us uniquely
qualified to assist our clients in the design and implementation of their benefit plans.
21
SECTION VI
A• Current PRM Members
ION
MEI
ANN
22
CURRENT PRM MEMBERS/REFERENCES
Gallagher Benefit Services -- Consultant
One Boca Place, 2255 Glades Road, Suite 400E
Boca Raton, FL 33430
Phone (561) 995-6706
Fax (561) 995-6708
•• Jeff Angello, Area President
Richard Schell, Area Assistant Vice President
Glen Volk, Vice President Actuarial Services
Colleen Ramos, Account Coordinator
Tim Reynen, Account Executive
Colleen Ferguson, Technical Support
PRM Administrative Office—7 Employees
2013 Altamont Avenue, Unit 25
Fort Myers, FL 33901
Phone (800) 367-1705
Fax (941) 476-8889
Ross D. Furry, Executive Director
Judy Hearn, Assistant Executive Director/Secretary
Desoto County Board of Commissioners—269 Employees
�.. 201 East Oak Street, Suite 202
Arcadia, FL 34266
Phone (863) 993-4808
Fax (863)993-4857
Paul Erickson, Human Resources and Community Services Director
Glades County Board of Commissioners—98 Employees
500 Avenue J
Moore Haven, FL 33471
Phone (863) 946-2140
Fax (863) 946-2860
Mary Aim Dotson, Administrative Secretary
Hendry County Board of Commissioners—226 Employees
18 Hicopochee Avenue
Labelle, FL 33935
Phone (863) 675-5221
Fax (863) 675-5317
a
Lester Baird, County Administrator
a
Hendry County Sheriff's Department— 130 Employees
a 101 S. Bridge Street
Labelle, FL 33935
Phone (941) 674-4630
FX (863) 674-4635
.® Susie Hicks, Personnel
Town of Longboat Key— 133 Employees
a 501 Bay Isles Road
Longboat Key, FL 34228-3196
Phone (941) 316-1999
. Fax (941) 316-1656
Bonnie Mims, Administrative Services Director
a..
Okeechobee County Board of Commissioners— 179 Employees
304 N.W. 2"d Street, Room 109
Okeechobee, FL 34972
Phone (863) 763-9312
Fax (863) 763-9312
Robbie Chartier, Deputy County Administrator
City of Punta Gorda—273 Employees
326 West Marion Avenue
a Punta Gorda, FL 33950-4492
Phone (941) 575-3302
Fax (941) 575-3310
a
Willard Beck, City Manager
a Sarasota-Manatee Airport Authority— 116 Employees
6000 Airport Circle
Sarasota, FL 34243-2105
a
Phone (941) 359-5200
Fax (941) 359-5054
r
Martin Lange, Senior Director of Finance and Administration
a Levy County Board of Commissioners —222 Employees
355 South Court Street
Bronson, FL 32621
a Phone (352) 486-5217
Fax (352) 486-5167
a Fred Moody, County Coordinator
Hamilton County Board of Commissioners— 156 Employees
..
207 Northeast First Street, Room 106
Jasper, FL 32052
.. Phone (904) 792-1288
Fax (904) 792-3524
.. Greg Godwin, City Clerk
City of Crystal River—53 Employees
-• 123 North West Highway 9
Crystal River, FL 334428-3930
Phone (352) 795-6994
Fax (352)795-6351
Linda Stilson, Assistant to the Finance Director
South Florida Conservancy District— 14 Employees
2852 US Highway 441
..
Belle Glade, FL 33430
Phone: (561) 996-2940
,. Fax: (561) 996-2960
Ron Graydon, General Manager
AGREEMENT TO PARTICIPATE IN THE
PRM GROUP HEALTH
BENEFITS PROGRAM
WHEREAS, Public Risk Management of Florida (PRM) has established a Group Health Benefits
�• Program to provide group health benefits coverage for Members desiring to participate in the program
(the "Group Health Benefits Program").
WHEREAS, ("Participant"), desires to participate in the aforementioned
Group Health Benefits Program; and
WHEREAS, PRM and Participant are desirous of setting forth the obligations and responsibilities of
each party hereto; •
WHEREAS, the finances of the Group Health Benefits Program (the "Trust") and Property and
Casualty Fund are considered separate funds. The Trust shall not be responsible for financial
obligations of the Property and Casualty Fund. The Property and Casualty Fund shall not be
responsible for the financial obligations of the Group Health Benefits Program.
NOW, THEREFORE, IN CONSIDERATION OF the mutual covenants herein contained, the parties
hereto, intending to be legally bound hereby, agree as follows:
I. PRM's GROUP HEALTH BENEFITS PROGRAM (the "PROGRAM") AGREES THAT:
a. It will make available to Participants group health benefits through one or more group
health benefit plans offered by or through insurance, including self-insurance, as may be
from time to time approved and endorsed by the Program.
b. It will provide for the administration of the Trust and its operations and any attendant
and related costs of the Program.
c. It may, from time to time, deposit a portion of funds received from the Participant's
contributions or premiums into a designated reserve fund. Funds so designated shall
become and remain the sole and exclusive property of the Program, provided, however,
that should the Program cease to operate, all reserve funds remaining after settlement of
all obligations of the Program shall be returned to the Participants.
d. It will supply periodic reports to each Member in a format and upon such frequency as
determined by the Program's Board of Directors.
e. It will provide for an annual, audited financial statement.
f. The Program Participants shall establish a separate Board of Directors to govern
matters of the Program.
II. THE PARTICIPANT AGREES THAT:
a. It will abide by the Intergovernmental Cooperative Agreement of PRM. All rules
and regulations adopted by the Program's Board of Directors, now in existence
and as may be from time to time amended, abridged, modified or repealed.
1
b. It will enroll in the Program, for an initial period at a contribution or premium rate
established by the Program's Board of Directors and as agreed to by the Member.
c. It will continue to participate in the Program for the same period as it is obligated
to participate in PRM as outlined in Article IV of PRM's Intergovernmental
Cooperative Agreement.
�• d. It will, upon termination of this Agreement, not be allowed to participate in the
Program for a period of not less than 24 months.
e. Upon termination of this Agreement, all contributions made to any designated
�• reserve fund by the terminating Participant shall remain in reserve and held by
Program and shall be utilized to pay the Participant's share of excess claim
obligations and expenses for the time period in which the terminating Participant
was a Participant in the Program.
f. It will undertake and implement any cost containment programs approved by the
Program.
g. During the term of this Agreement, it will furnish in a timely manner the Program,
insurers or other service entities ("Providers") when and as requested, all
employment, dependency and identification information necessary for the proper
operation of the Program and its programs.
h. It will be solely responsible for payment of all premium or contributions for group
health benefits. Failure to remit contributions or premiums due or to provide
required information shall be grounds for immediate termination of coverage and
benefits by the Program or Providers.
i. It shall notify its employees of group health benefits being provided by the
Program or Providers. Participants shall be solely responsible for furnishing all
data and information to employees, dependents, or other beneficiaries required by
applicable state or federal law.
III. The operative date initiating obligations and rights of the parties under the Agreement
shall commence on , 2000.
IV. This Agreement shall be approved by the Participant's governing body and executed on
,.. behalf of the Participant by its duly authorized officer and shall be forwarded to the
Program. A copy of the Minutes of the Participant's governing body adopting this
Agreement shall be attached to this Agreement.
•- MEMBER:
BY: DATE:
(It's Duly Authorized Officer)
PRM's GROUP HEALTH BENEFITS PROGRAM
BY: DATE:
(It's Duly Authorized Officer)
9
AMENDMENT
AGREEMENT TO PARTICIPATE IN THE
PRM GROUP HEALTH
BENEFITS PROGRAM
V. Subject to the Intergovernmental Cooperative Agreement of PRM, which agreement shall
�• control in the event of any inconsistencies, this Agreement may be modified by approval
from two-thirds (2/3) of the Program's Board of Directors present at a meeting where a
quorum of the Directors are present (a quorum shall consist of Directors representing a
majority of the Members of the Program, one Director being appointed by each Member)
at a meeting called for such purpose.
Adopted 4-18-91
3
AMENDMENT
AGREEMENT TO PARTICIPATE IN THE
PRM GROUP HEALTH
BENEFITS PROGRAM
VI. All former Members of the Program, whether termination of membership occurs
voluntarily or involuntarily or by termination of the Program, shall continue to be
responsible fully and obligated to pay, their portion of covered claims payable by the
Program, which covered claims occurred or were incurred during the period the Member
was a participant in the Program, along with, its portion of all other obligations of the
Program which relate to the period during which the terminated Member was a
participant in the Program.
Adopted 4-18-91
4
AMENDMENT
AGREEMENT TO PARTICIPATE IN THE
PRM GROUP HEALTH
BENEFITS PROGRAM
VII. In the event a Member intends to include the employees of a Constitutional Officer of the
State of Florida, located within the jurisdiction of such Member (the "Sponsoring
Member"), in the number of persons to be covered under the health insurance program
established by the PRM Group Health Benefits Program (the "Health Trust"), then such
•.+ Constitutional Officer must irrevocably agree to be bound by the rules and regulations, as
such may be amended from time to time, of the Health Trust, in a writing approved by
PRM's Executive Director upon advice of counsel, or become a Member of the Health
Trust. This amendment shall be prospective in nature, and no covered employee
presently included in the PRM Health Trust shall be denied coverage merely because of
the Amendment. With respect to such presently covered employees, the Executive
Vie Director and the Members will use their best faith efforts to obtain the membership of
such Constitutional Officers in the Health Trust, or their agreement to be bound by the
rules and regulations of the PRM Group Health Trust for so long as the Sponsoring
Member is a Member of the Health Trust.
Adopted 12-12-91
5
THE INTERGOVERNMENTAL COOPERATIVE AGREEMENT
(A CONTRACT AND BY-LAWS FOR
PUBLIC RISK MANAGEMENT OF FLORIDA)
(PRM)
AS AMENDED AND RESTATED THROUGH AUGUST 13, 1999
a
THE INTERGOVERNMENTAL COOPERATIVE AGREEMENT
(A CONTRACT AND BY-LAWS FOR PUBLIC RISK MANAGEMENT OF FLORIDA)
(PRM)
a
INDEX
a
PAGE
1 Article 1 Name and Duration
1 Article 2 Definitions and Purpose
4 Article 3 Power and Duties
5 Article 4 Participation and Term
6 Article 5 Commencement of the Pool
6 Article 6 Board of Directors of the Pool
9 Article 7 Board of Directors Meetings
9 Article 8 Pool Officers
11 Article 9 Finances and Risk Management Pool
13 Article 10 Excess Insurance
14 Article 11 Obligations of Members
15 Article 12 Liability of Board of Directors or Officers of the Pool
15 Article 13 Additional Insurance
16 Article 14 Settlements
16 Article 15 Contractual Obligation
17 Article 16 Expulsion or Termination of Members
18 Article 17 Special Provisions for Deferred Funding
a 18 Article 18 Termination of Pool
ARTICLES OF ASSOCIATION
AND BY-LAWS
OF
PUBLIC RISK MANAGEMENT OF FLORIDA
(PRM)
BE IT KNOWN THAT:
The below named public agency or agencies of the State of Florida for the purpose of
forming a risk management and self-insurance association pursuant to the terms of Florida
Statutes Sections 768.28(15)(a), 440.57, and 163.01, Florida Interlocal Cooperation Act of 1969,
do bind themselves contractually to and adopt these Articles of Association and By-Laws.
Article 1 -Name and Duration
1.1 Name. The name of this association shall be Public Risk Management of Florida,
referred to hereinafter as the Pool.
Article 2 - Definitions and Purpose
2.1. Definitions. As used in this agreement, the following terms shall have the
meaning hereinafter set out:
"Annual Payments": The amount each Member must annually pay to fully fund the costs
of the full operation of the Pool.
"Aggregate Excess Insurance": Stop Loss Insurance purchased by the Pool from
insurance companies and/or Lloyd's of London, or other similar entities, approved by the Board
of Directors, or any committee appointed by the Board for such purpose, to protect the Pool from
an accumulation of losses in any policy year should the "Loss Fund" be exhausted. Once the
"Aggregate Excess Insurance" is triggered, any further losses within the "Self Insured Retention"
will be paid by this coverage.
"Fiscal Year": The fiscal year of the Pool shall begin on October 1st and end on
September 30th
"Joint Self-Insurance" or "Self-Funded": A self-insurance or self-funded program in
which Members agree to annual payments to fully fund the operations of the Risk Management
Pool.
"Loss Fund": The fund established to pay claims occurring within the "Self Insured
Retention." The "Loss Fund" represents the maximum amount for which the Pool is exposed in
a single fiscal period.
1
"Maintenance Deductible": The amount paid by the "Member" before the loss is paid by
the "Self Insured Retention." This is a nominal amount designed to protect the "Loss Fund"
from small claims. The "Maintenance Deductible" applies only to property, automobile physical
damage and crime losses."
"Members": The public agencies of the State of Florida which initially or later enter into
the intergovernmental association established by this Intergovernmental Agreement.
"Multi-Loss Coverage": This multiple loss protection limits a loss involving more than
one line of coverage from one occurrence (i.e. property, liability, workers' compensation) to one
"Self Insured Retention."
"Pool": Public Risk Management of Florida established pursuant to the Constitution and
the Statutes of the State of Florida by this Intergovernmental Agreement.
"Risk Management": A program attempting to reduce or limit casualty and property
losses to Members and injuries to employees caused by or arising out of the operations of
Members. Where claims arise the Pool will provide processing of claims, investigation, defense
and settlement within the financial limits of the Pool as established in accordance with this
Intergovernmental Agreement and will tabulate such claims, costs and losses.
"Risk Management Pool": A fund of public monies established by the Pool to jointly
,.. self-insure and self-fund property coverages, general liability, automobile liability, professional
liability, public officials' liability and workers' compensation, and any other coverage lines
approved by the Board of Directors.
"Self-Insurance": The decision by a public agency not to purchase insurance coverage for
risks below certain limits; to seek and maintain immunities provided by law for a noninsured
... public agency; to rely upon its financial capabilities to pay covered losses which occur in case
third-party claims are held valid and not barred or capped by available immunities: and to
purchase some insurance to protect against catastrophic or aggregate losses. The purchase of
liability insurance by the Pool or any of its Members is not intended to, and does not, waive
sovereign immunity. Purchase of liability insurance shall only be pursuant to Florida Statutes,
which allow for the purchase of insurance by the Pool without the waiver of sovereign immunity
by the Pool or any of the Pool's Members and is not pursuant to any other statute of the State of
Florida.
"Self Insured Retention": A layer of assumed risk where the pool self-insures a pre-
determined amount of loss per occurrence.
"Specific Excess Insurance": Insurance purchased by the Pool from insurance companies
and/or Lloyd's of London, approved by the Board of Directors, or any committee appointed by
the Board for such purpose, that provides catastrophe coverage up to the limit(s) chosen by the
Pool.
2.2. Purpose: The Pool is a cooperative agency voluntarily established by Members as
set forth in Florida Statutes Sections 163.01, 768.28 and 440.57 for the purpose of seeking the
prevention or lessening of casualty and property losses to Members and injuries to persons or
employees which might result in claims being made against Members. The purpose of this Pool
is to carry out and effect the agreed upon functions and purposes of this Intergovernmental
Agreement as stated herein.
It is the intent of the Members of this Pool to create an entity, which will administer a
Risk Management Pool and utilize such funds to defend and protect, in accordance with this
Intergovernmental Agreement, any Member of the Pool against liability for a covered loss. This
Agreement shall constitute the substance of a contract among the Members.
All funds contained within the Risk Management Pool are funds directly derived from its
Members who are public agencies of the State of Florida. It is the intent of the Members in
entering into this Intergovernmental Agreement that, to the fullest extent possible, the scope of
Risk Management undertaken by them through a Joint Self-Insurance or Self-funded program
using governmental funds shall not waive, on behalf of any Member or such Member's
employees as defined in Florida Statutes Section 768.28, any defenses or immunities therein
provided, or provided by the laws of the State of Florida. The Pool and the Members of this Pool
intend to effect no waiver of sovereign immunities through their use of public funds retained
within the Risk Management Pool. Such funds being utilized to protect against risks in
accordance with Florida Statutes Section 768.28 are not intended to constitute the existence,
issuance or purchase of a policy for insurance. This Intergovernmental Agreement is not to be
considered such as would cause this Pool to be treated as an "insurer" within the meaning of any
legislation giving risk to liability or applicability to "insurer", for damages, costs, fees or
expenses, etc., under Florida Statutes Sections 624.155, 626.9541, 626.9561, 627.426, 627.428,
or other statutes applicable to Public Entity Self Insurance in the State of Florida.
2.3 Non- Assessable: Public Risk Management is a non-assessable pool.
Article 3 - Power and Duties
3.1. Powers: The powers of the Pool to perform and accomplish the functions and
purposes set forth herein, within the budgetary limits and procedures set forth in this
®• Intergovernmental Agreement, shall be as follows:
3.1.1. To establish By-Laws and Amendments to By-Laws, and operational
procedures governing the operations of the Pool which are consistent with this
Intergovernmental Agreement as set forth in Florida Statutes Sections 768.28, 163.01 and
440.57, and to not waive any sovereign immunity not waived statutorily under Florida
Law, and to expressly negate any past, present, or future waiver of sovereign immunity
under Florida Statutes, and to continue to negate any waiver of sovereign immunity for
discretionary and planning functions of government.
3.1.2. To employ agents, employees and independent contractors and approve the
rate of compensation, benefits and/or contracts that apply to Pool employees, Pool
3
officers and service providers, and to ensure all benefits of Florida Statutes Section
163.01(9)(a) and all other applicable Florida Statutes.
3.1.3. To lease real property and to purchase or lease equipment, machinery or
personal property necessary for the carrying out of the purpose of the Pool.
3.1.4. To carry out educational and other programs relating to risk reductions.
3.1.5. To cause the creation of this Pool and see to the collection of funds for the
continued administration of the Risk Management Pool.
3.1.6. To purchase Aggregate Excess Insurance and Specific Excess Insurance to
supplement the Risk Management Pool without such being a waiver of sovereign
immunity under Florida Law.
3.1.7. To establish reasonable and necessary loss reduction and prevention
procedures, which shall be followed by the Members.
3.1.8. To provide Risk Management services including the defense of and
settlement of claims and to have the authority granted by Florida Statutes Section
768.28(14).
3.1.9. To negate, pursuant to Florida Statutes, any implication of a waiver of
sovereign immunity, and to negate any waiver of sovereign immunity other than to the
extent required under Florida Statutes Section 768.28.
3.1.10. To act solely within the budgetary limits established by the Members to
carry out such other activities as are necessarily implied or required to carry out the
purposes of the Pool.
3.1.11. To sue or be sued as a separate legal entity.
Article 4 - Participation and Term
4.1. Term: The initial term of the Pool shall be from 12:01 a.m. on October 1, 1987 to
12:01 a.m. September 30, 1989. After the initial two (2) year term of the Pool, the term shall
automatically be renewed for an additional term of one (1) year each. Provided, however, the
Members may, through the manner provided in Section 6.9.4., terminate the Pool as of the end of
the initial or any additional term during which such action is taken.
4.2. Notice of Withdrawal: So long as the Pool shall continue in existence, any
current or new Member joining the Pool shall remain a Member for an initial two-year term,
except a new Member coming into the Pool after the first day of the fiscal year shall be obligated
to be a member for not less than eighteen (18) months. A new member's rates will be
guaranteed for their initial term.
4
Any Member may withdraw from the Pool at the end of the fiscal year upon serving on the Pool
by mail, fax or hand delivery at least one year's prior written notice. Such notice shall be
addressed to the Executive Director of the Pool and shall be accompanied by a resolution of the
governing body of the Member electing to withdraw from the Pool.
4.3. Actual Withdrawal/Required Withdrawal. Any Member who has served the
Executive Director with prior written notice of its intent to withdraw at least one (1) year prior to
the beginning of the fiscal year for which the notice to withdraw is applicable, shall serve in
writing to the Executive Director, by mail, fax or hand delivery on or before August 15 prior to
the beginning of such fiscal year, a verification as to whether the Member intends to actually
withdraw from the Pool at the end of the current fiscal year. Failure to serve such verification on
or before August 15 prior to the beginning of the fiscal year for which notice of intent to
withdraw is applied, shall be deemed a revocation of the prior notice of intent to withdraw; thus,
binding the Member to the Pool for the ensuing fiscal year. Provided, however, any Member
who serves written notice of its intent to withdraw from the Pool more than once during any
three (3) year period may be required, at the option of the Board of Directors, to withdraw from
the Pool on the second such notice. An action to expel a Member in this manner shall be taken
by the Board of Directors prior to August 1 of the current fiscal year in the manner described in
Article 16 hereafter.
4.4. Admission of New Members: The Pool's Executive Committee shall establish
and periodically review standards and the approval process for the admission of new Members.
Upon approval of these standards and of the approval process for admission by the Board of
Directors, the Pool's Executive Committee may grant or deny admission to proposed new
Members based upon such criteria. Consideration of new Members will be communicated to all
PRM Board Members by the Executive Director for any information or feedback that a Member
may have regarding the prospective member.
Article 5 - Commencement of the Pool
5.1. Commencement Date: The Pool shall commence operations on October 1, 1987.
Article 6 - Board of Directors of the Pool
6.1. The Board: There is hereby established a Board of Directors (sometimes
hereinafter referred to as the "Board") of the Pool. Each Member shall appoint one (1) person to
represent that body (the "Representative") on the Board of Directors along with another person to
serve as an alternate representative (the "Alternate") when the Representative is unable to carry
out that Representative's duties. The Representative and Alternate shall be appointed in writing
by the governing body of the Member and a copy of the written appointment shall be provided to
the Executive Director of the Pool. Once such appointments are made known to the Pool, the
persons appointed shall remain in office until the Pool receives evidence in writing of the
appointment of other persons by the Member's governing body. The Representative and
,., Alternate selected must be an employee, an appointed official or elected official of the entity.
5
6.2. The Chairman and Vice Chairman: The Board of Directors shall bi-annually
select a Chairman and Vice Chairman during the final quarter of each two-year term to serve
during the subsequent two-year term. The term of office for the Chairman & Vice Chairman
shall begin on the 1st day of a fiscal year and expire on the last day of a fiscal year. No person
may serve as Chairman of the Board of Directors for more than two (2) consecutive full two-year
terms. The Chairman shall preside at all meetings of the Board. The Chairman shall vote on all
matters that come before the Board. The Chairman shall have such other powers as he may be
given from time to time by action of the Board.
The Vice Chairman shall carry out all duties of the Chairman of the Board during the
absence or inability of the Chairman to perform such duties and shall carry out such other
functions as are assigned from time to time by the Chairman or the Board of Directors. The
Board of Directors may from time to time appoint other officers of the Board.
6.3. Board Responsibilities. The Board of Directors shall have the responsibility for: (1)
hiring of Pool officers, agents, non-clerical employees and independent contractors; (2) setting of
compensation for all persons, firms and corporations employed by the Pool; (3) approval of
amendments to the Intergovernmental Agreement; (4) approval of the acceptance of new
Members and expulsion of Members, except that the approval may be delegated to the Executive
Committee under Article 4 above, or by such procedures as are contained in the motion making
delegation; (5) approval and amendment of the annual budget of the Pool; (6) approval of the
operational procedures developed by the Executive Director; (7) approval of educational and
�., other programs relating to risk reduction; (8) approval of reasonable and necessary loss reduction
and prevention procedures which shall be followed by all Members; (9) approval of Annual
Payments to the Risk Management Pool for each Member; and (10) termination of the Pool in
accordance with this Intergovernmental Agreement.
6.4. Voting: Each Member shall be entitled to one (1) vote on the Board of Directors.
Such vote may be cast only by the Representative of the Member or in the Representative's
absence by the Alternate. No proxy votes or absentee votes shall be permitted. Voting shall be
conducted by show of hands or any method established by the Board that is consistent with
�• Florida law. A simple majority vote of those Representatives present shall be required to pass on
any motion. On such matters, the Chairman and the Executive Director of the Pool shall cause
each Member's Representative and Alternate to receive the proposed ballot which will include at
a minimum the text of the motion to be voted upon and the purpose of such motion. Only the
Representative or the Alternate may vote on such ballots (not both). If both the Alternate and
Representative submit ballots, only the Representative's ballot will be counted. Favorable votes
by a majority of the Members' Representatives (or Alternates in their absence) entitled to vote
shall pass any action unless an action is taken which is subject to 6.9 below, in which case
passage will be based on the required number of votes as if each Member's Representative or
Alternate was present at a regular or special meeting called to decide such question.
6.5 Representatives: The Representative selected by the Member shall serve until a
successor has been selected. The Representative chosen by the Member may be removed at any
time by the vote of the Member's governing body. In the event that a vacancy occurs in the
position of Representative or Alternate selected by the governing body of a Member, that body
6
shall appoint a successor in writing within 60 days of such vacancy occurring. The failure of a
Member to select a Representative or the failure of that person to participate shall not affect the
responsibilities or duties of a Member under this Intergovernmental Agreement.
6.6. The Executive Committee and other Committees: The Board of Directors shall
have the power to establish both standing and ad hoc committees to further the functions and
purpose of this Pool. Unless the Board of Directors establishes some other procedure, the
authority for selection of Representatives or Alternates serving on the Board of Directors who
shall serve on such committees and chair them shall reside with the Chairman of the Board of
Directors. The Chairman of the Board of Directors may appoint non-voting and non-paid
persons who are not Members of the Board of Directors to serve on committees of the Pool. The
Board of Directors shall dictate to the Executive Director the guidelines for authorizing the
settlement of claims. The Board of Directors shall establish an Executive Committee. That
Executive Committee shall consist of the Chairman of the Board, the Vice Chairman of the
Board, the Treasurer and two Representatives elected by the Board, one from the southern area
and one from the northern area of the Pool, as such areas are designated on the attached map,
Exhibit 6.6. The Board of Directors may grant to the Executive Committee the authority to
approve expenditures, authorize a settlement of claims and suits and take such other action as
shall be specifically delegated to the Executive Committee.
6.7. Operating Rules: The Board of Directors may establish rules governing its own
conduct and procedure not inconsistent with this Intergovernmental Agreement.
6.8. Quorum: A quorum shall consist of a majority of the Representatives (or in their
absence their Alternates) serving on the Board of Directors. Except as provided in Section 6.9
herein, or elsewhere in this Intergovernmental Agreement, a simple majority of a quorum shall
be sufficient to pass upon all matters.
6.9. Super-Majority Voting: A greater vote than a majority of a quorum shall be
required to approve the following matters:
6.9.1. Such matters as the Board of Directors shall establish within its rules as
requiring for passage a vote greater than a majority of a quorum, provided, however, that
such a rule can only be established by a greater than a majority vote at least equal to the
greater than majority vote required by the proposed rule.
6.9.2. The expulsion of a Member shall require two-thirds (2/3) vote of all the
Representatives serving on the Board of Directors.
6.9.3. Any amendment of this Intergovernmental Agreement, except as provided
,., in Subsection 4 below, shall require two-thirds (2/3) vote of all the Representatives
serving on the Board of Directors.
6.9.4. The amendment of this Intergovernmental Agreement to cause the
termination of this Agreement sooner than two (2) years after its commencement or a
reduction or elimination in the scope of loss protection set out in Article 10 to be
7
furnished by the self-insurance pool derived from payments from the Members, shall
require that specific written notice of the proposed change be sent by registered or
certified mail to the governing body of the Member and to the Representative and
Alternate of the Member serving on the Board of Directors, no less than ten (10) days
prior to a meeting at which this matter is proposed and the amendment as proposed or as
amended at such Board meeting must receive the approval of two-thirds (2/3) vote of all
of the then current Representatives (or in their absence their Alternates) representing the
then Members of the Pool.
6.10. Compensation of Board of Directors: No Representative or Alternate serving on
the Board of Directors shall receive any salary from the Pool.
6.11 Conflict of Interest: Representatives and Alternates shall abide by the guidelines
established by the State Ethics Commission in the performance of their duties, particularly as it
applies to conflicts of interest and financial disclosure.
Article 7 - Board of Directors Meetings
7.1. Meetings: Regular meetings of the Board of Directors shall be held at least four
(4) times a year. The tentative times, dates, and locations of regular meetings of the Board shall
be established at the beginning of each fiscal year. Any item of business may be considered at a
regular meeting, including the scheduling of future regular meetings. The Executive Director
shall attend all Board meetings and Executive Committee meetings to serve as an advisor and to
report as the administrative officer of the Pool.
7.2. Special Meetings: Special meetings of the Board of Directors may be called by
its Chairman, or by any three Representatives (or in their absence their Alternates). The
Chairman or in his absence, the Vice Chairman, shall give ten (10) days written notice of regular
or special meetings to the Representative and Alternate of each Member and an agenda
specifying the subject of any special meeting shall accompany such notice. Business conducted
at special meetings shall be limited to those items specified in the agenda. The time, date and
location of special meetings of the Board of Directors shall be determined by the Chairman of
the Board of Directors, or in his absence, by the Vice Chairman.
7.3. Conduct of Meetings: To the extent not contrary to this Intergovernmental
Agreement and except as modified by the Board of Directors, Robert's Rules of Order, latest
edition, shall govern all meetings of the Board of Directors. Minutes of all regular and special
meetings of the Board of Directors shall be sent to all Representatives (or in their absence their
Alternates) serving on the Board of Directors.
Article 8 - Pool Officers
8.1. Officers: Officers of the Pool shall consist of an Executive Director, a Treasurer,
a Secretary and such other officers as are established from time to time by the Board of
Directors. All Pool officers shall be appointed by the Board of Directors.
8
AMP
8.2. Executive Director: The Executive Director shall be the chief administrative
officer of the Pool and shall in general supervise and control the day to day operations of the
d• Pool and shall carry out the policy and operational procedures of the Pool as established in this
Intergovernmental Agreement and by the Board of Directors. Among the Executive Director's
duties shall be the following:
8.2.1. The Executive Director may sign, with such other person authorized by the
Board of Directors, any instruments which the Board of Directors have authorized to be
executed and, in general, shall perform all duties incident to the office of Executive
Director and such other duties as may be prescribed by the Board of Directors.
8.2.2. The Executive Director shall prepare a proposed annual budget and
proposed Risk Management Pool Annual Payment and shall submit such proposals to the
Board of Directors.
8.2.3. The Executive Director shall, where necessary, make recommendations
regarding policy decisions, the creation of other Pool officers and the employment of
agents and independent contractors. At each regular meeting of the Board of Directors
and at such other times, as he shall be required to do so, he shall present a full report of
his activities and the fiscal condition of the Pool.
8.2.4. The Executive Director shall report quarterly to all Members on all claims
filed and payouts made.
8.2.5. The Executive Director shall, within the constraints of the approved or
amended budget, employ all secretarial, clerical and other similar help and expend funds
for administrative expenses.
8.3. Treasurer: The Treasurer shall:
WIN
8.3.1. Have charge and custody of and be responsible for all funds and securities
of the Pool; cause to be received and given all receipts for moneys due and payable to the
Pool from any source whatsoever; cause to be deposited all such moneys in the name of
the Pool in such banks, savings and loan associations or other depositories that are
recognized as "Qualified Public Depositories" by the State Treasurer operating under
Chapter 280 Florida Statutes, as shall be selected by the Board of Directors; cause to be
invested the funds of the Pool as are not immediately required in such securities as the
Board of Directors shall specifically or generally select from time to time; and cause to
be maintained the financial books and records of the Pool.
8.3.2. In general, perform all duties incident to the office of Treasurer and such
other duties as from time to time may be assigned to that individual by the Board of
Directors. Nothing herein shall prevent the Treasurer from delegating, in writing, the
functions of the office to third parties, whether members of the Board of Directors,
employees of the Pool, or third parties, subject to the approval of the Board of Directors.
However, the Treasurer shall maintain the control and responsibility for the execution of
9
such functions by such delegates.
�- 8.4 Secretary: The Secretary shall issue notices of all Board meetings, and shall
attend and keep the minutes of same. The Secretary shall have charge of all corporate books,
records and papers; shall be custodian of the corporate seal; and shall keep all written contracts
of the Pool. In general, the Secretary shall perform all duties incident to the office of Secretary
and such other duties as from time to time may be assigned by the Executive Director or the
Board of Directors.
8.5. Third Party Delegations: The Board may select a financial institution or certified
public accountant to carry out some or all of the functions which would otherwise be assigned to
a Treasurer and may select a risk management company or agent to serve as claims administrator
or to carry out some or all of the functions which would otherwise be assigned to the Executive
Director. The Board may also employ persons or companies as independent contractors to carry
out some or all of the functions of officers of the Pool.
8.6. Officer Vacancies: In the absence of the Executive Director, Treasurer or
Secretary, or in the event of the inability or refusal of such officers to act, the Chairman of the
Board of Directors may perform the duties of the Executive Director, Treasurer or Secretary,
and, when so acting, shall have all of the powers of and be subject to all of the restrictions upon
the Executive Director, Treasurer or Secretary.
Article 9 - Finances and Risk Management Pool
9.1. Fiscal Year: The fiscal year of the Pool shall commence on October 1, and end
on September 30, of each year.
9.2. Budget: The Board of Directors or the Executive Committee shall approve a
preliminary budget for the administration of the Pool by June 1 of each year. Copies of all
preliminary and final budgets shall be promptly mailed to each Member of the Board of
Directors. The Board of Directors shall, by August 1 of the year prior to the start of each fiscal
year adopt a final budget and determine the amount of the Annual Payment to be made by each
Member and the date upon which the payment is due. Failure of the Board of Directors or the
Executive Committee to approve a preliminary or final budget within the times set forth within
this Section shall not relieve the Members of the obligation to make any payments to the Pool so
WIN
long as such budgets are finally adopted, and the Members are given at least thirty (30) days after
the passage of the final budget in which to make Annual Payments to the Pool.
9.3. Annual Payment Factors: In determining the amount of the Annual Payment due
from each Member, the Board of Directors shall consider some or all of the following factors:
9.3.1. Number of employees;
9.3.2. Property values of the Member;
.., 9.3.3 Number and type of vehicles owned by the Member and the use made of
the vehicles;
10
9.3.4. Population of the geographic area represented by the Member;
9.3.5. The payrolls of the Member;
9.3.6. Any unusual exposures presented by the Member;
9.3.7. The operating expenditures of the Member; and
9.3.8 The claims and loss experience of the Member.
The Board of Directors shall establish annually a cost of risk allocation, which is utilized
in making the allocation of the amount of the Annual Payment due from each Member. This
standard may, however, vary from year to year but it must be applied equally to all Members
similarly situated during such period of time as it is utilized.
The Board of Directors may grant debits or credits to Members with above or below
average loss or claims records. The amount of such debits or credits may not vary more than
25% above or below the amount, which the Member would pay if it were not to have been
granted the debit or credit. In establishing the loss and claims record of the Member, the Board
of Directors may utilize the loss and claims experience of the Member during last 3 years of the
Pool.
9.4. Budget Amendments: Budgets may be amended at any time by majority vote of
the Board, provided, however, such amendments may not require payments, when added to
previous payments by a Member for such fiscal year, to exceed such Member's Annual Payment
determined for such year. The forwarding of such payments within a time specified in notices to
the Members giving them not less than forty-five (45) days to make such payments shall be of
the essence of this contract.
9.5. Payments — Timing: In subsequent years, the Board of Directors may permit the
Annual Payments to be made on a monthly or quarterly basis.
9.6. Retirement Fund Obligations: Members shall be both severally and jointly liable
to the State of Florida Department of Administration, Division of Retirement for any Florida
Retirement Systems' contributions, which are owed by the Pool for Pool employees. Each
member shall be responsible for expenses incurred which are attributable to the years of
membership as outlined in the Intergovernmental Agreement, Article 11.
9.7. Distribution of Surplus: If, for any year during which the Pool was in existence,
all claims known or unknown have either been paid or provision has been made for such
payment, the Board of Directors as then constituted shall distribute surplus funds to the Members
who constituted the membership of the Pool in that prior year, after first deducting there from
reasonable administrative and other non-allocated costs incurred by the Pool in the processing of
the claims in years other than the one in which the claim was made. The distribution among the
Members shall be in the same proportion to the total as was their Annual Payment for that year to
the Annual Payments of all Members for such year.
11
9.8. Audit: The Board of Directors shall provide to the Members an annual audit of
the financial affairs of the Pool to be made by a certified public accountant at the end of each
fiscal year in accordance with generally accepted auditing principles. The annual report shall be
delivered to the Chairman of the governing body of each Member.
Article 10 - Excess Insurance
10.1. Specific Excess Insurance: The Pool will purchase Specific Excess Insurance
from underwriters of insurance, insurance companies and/or Lloyd's of London, approved by the
Board of Directors, or any committee appointed by the Board for such purpose, in such amounts
which shall be approved by the Board of Directors and underwriters, based upon but not limited
to the current assets, risk analysis, and loss history of the Pool. The purchase of Specific Excess
Insurance does not, and is not, intended to waive sovereign immunity under Florida law.
10.2. Aggregate Excess Insurance: The Pool will purchase Aggregate Excess Insurance
from underwriters of insurance, insurance companies and/or Lloyd's of London, approved by the
Board of Directors, or any committee appointed by the Board for such purpose, in such amounts
which shall be approved by the Board of Directors and underwriters, based upon but not limited,
to the current assets, risk analysis, and loss history of the Pool. The purchase of Aggregate
Excess Insurance does not, and is not, intended to waive sovereign immunity under Florida law.
10.3. Multiple Loss Coverage: The Pool will purchase Multiple Loss Coverage in the
event a single occurrence involves more than one line of coverage, limiting the occurrence to a
single "Self Insured Retention."
10.4. Losses: The Risk Management Pool (Loss Fund), the Specific Excess Insurance
and Aggregate Excess Insurance shall provide payment for covered losses in any one fiscal year
for members up to the limits approved by the Board of Directors. Should losses in any one fiscal
year extinguish all available funds provided by the Pool then the individual Member or Members
whose judgment or settlement of claim has been perfected by Florida law shall be responsible for
any additional payment. The Pool shall make payments in the order in which the judgments
against the Pool have been entered or settlement of claims have been reached. Membership in
the Pool shall not preclude any Member from purchasing any insurance coverage above those
amounts purchased by the Pool.
Article 11 - Obligations of Members
11.1. Member Obligations: The obligations of Members of the Pool shall be as follows:
11.1.1. To budget for, where necessary, to levy for and to promptly pay all
payments to the Risk Management Pool at such times and in such amounts as shall be
established by the Board of Directors within the scope of this Intergovernmental
Agreement. Any delinquent payments shall be paid with a penalty, which shall be set by
the Board, but such rate shall not exceed the highest interest rate allowed by statute to be
paid by a Florida public agency.
12
11.1.2. To select, in writing, a Representative to serve on the Board of Directors
and to select an Alternate Representative.
11.1.3. To allow the Pool reasonable access to all facilities of the Member and all
records including, but not limited to, financial records, which relate to the purpose or
powers of the Pool.
11.1.4. To allow attorneys employed by the Pool to represent the Member in
investigation, settlement discussions and all levels of litigation arising out of any claim
made against the Member within the scope of loss protection furnished by the Pool.
11.1.5. To furnish full cooperation with the Pool attorneys, claims adjusters, the
Executive Director and any agent, employee, officer or independent contractor of the
Pool relating to the purpose or powers of the Pool.
11.1.6. To follow in its operations all loss reduction and prevention procedures
established by the Pool within its purpose or powers.
11.1.7. To report to the Executive Director or his designee within the time limit
specified the following items:
11.1.7.1. To provide on or before May 1 of each fiscal year of the Pool, the
Member's renewal application shall be completed by the member as required by the
Underwriters.
11.1.7.2. To report, within five (5) days of receipt, any and all statutory notices of
claims, as well as summons and complaint or other pleading before a court or agency
involving any claim for which Pool coverage is sought.
11.1.7.3. To report, within ten (10) days of receipt, any oral or written demand
for monetary relief for which coverage is sought to the Pool Executive Director.
11.1.7.4. To report to the Executive Director at the earliest practicable moment
any information of an occurrence, claim or incident received by the Member and from
which the Member could reasonably conclude that coverage will be sought by said
Member for such an occurrence, claim or incident.
In the event that the items set forth above are not submitted to the Executive Director within the
time periods set forth above, the Board of Directors of the Pool, by a vote of a majority of a
quorum of the Board, at a regular or special meeting, may in whole or part decline to provide a
defense to the Member or to extend the funds of the Pool for the payment of losses or damages
incurred. In reaching its decision, the Board shall consider whether and to what extent the Pool
was prejudiced in its ability to investigate and defend the claim due to the failure of the Member
to promptly furnish timely notice of the occurrence, claim or incident to the Executive Director.
The decision of the Board of Directors shall be final. Failure of a Member to abide by these
requirements shall also be grounds for expulsion from the Pool.
13
11.1.8. To make Payment of any "Maintenance" Deductible(s).
Article 12 - Liability of Board of Directors or Officers of the Pool
12.1. Liability of Directors and Officers: The Representatives (or in their absence their
Alternates) serving on the Board of Directors or officers of the Pool should use ordinary care and
reasonable diligence in the exercise of their power and in the performance of their duties
hereunder; they shall not be liable for any mistake of judgment or other action made, taken or
omitted by them in good faith; nor for any action taken or omitted by any agent, employee or
independent contractor selected with reasonable care; nor for loss incurred through investment of
Pool funds, or failure to invest. No Representative shall be liable for any action taken or omitted
by any other Representative. Representatives shall have the immunities provided by law and in
particular Florida Statutes Section 163.01. The Pool may purchase insurance providing liability
coverage for such Representatives or officers.
Article 13 - Additional Insurance
13.1. Member's Option to Purchase Additional Insurance: The Pool, through the
distribution of the minutes of the Board of Directors or through other means shall inform all
Members of the scope and amount of Specific Excess and Aggregate Excess Insurance in force
at all times. Membership in the Pool shall not preclude any Member from purchasing any
insurance coverage above those amounts purchased by the Pool. Such purchase shall not be
construed to waive sovereign immunity of the Members of the Pool or the Pool. The Pool shall
make its facilities available to advise Members of the types of additional or different coverages
available to Pool Members.
Article 14 - Settlements
14.1. Settlement/Advance Notice: Whenever the Pool proposes to settle any pending
claim or suit where the amount of that proposed settlement shall exceed Five Thousand Dollars
($5,000.00), the Member shall be given advance notice of that settlement. Such notice may be
given by the establishment of a reserve amount in excess of Five Thousand Dollars ($5,000.00),
provided that the amount of the settlement does not exceed the amount reserved. The officers
and employees of the Pool shall, however, endeavor to give specific oral or written notice to the
Member's Representative or Alternate of the exact amount of any proposed settlement in excess
of Five Thousand Dollars ($5,000.00) prior to the date at which the Pool proposes to bind itself
to pay such settlement amount. The officers, employees or independent contractors of the Pool
shall attempt to give the Members, as much notice of the settlement negotiations as is possible
under the circumstances of each case.
Article 15 - Contractual Obligation
15.1. Enforcement: This document shall constitute a binding contract under the Florida
Interlocal Cooperation Act of 1969 among those public agencies, which become Members of the
Pool. The obligations and responsibilities of the Members set forth herein, including the
obligation to take no action inconsistent with this Intergovernmental Agreement as originally
14
written or validly amended, shall remain a continuing obligation and responsibility of the
Member. The terms of this Intergovernmental Agreement may be enforced in a court of law by
the Pool.
The consideration for the duties herewith imposed upon the Members to take certain
actions and to refrain from certain other actions shall be based upon the mutual promises and
agreements of the Members set forth herein. This Intergovernmental Agreement may be
executed in duplicate originals and its passage by the Member's governing body shall be
evidenced by a certified copy of a resolution passed by the members of the governing body in
accordance with the rules and regulations of such public agency, provided, however, that except
to the extent of the limited financial contributions to the Pool agreed to herein or such additional
of, obligations as may come about through amendments to this Intergovernmental Agreement no
Member agrees or contracts herein to be held responsible for any claims in tort or contract made
against any other Member. The Members intend in the creation of the Pool to establish an
• organization for Risk Management only within the scope herein set out and have not herein
created as between Member and Member any relationship of surety, indemnification or
responsibility for the debts of or claims against any Member.
15.2. Attorneys' Fees: In any legal action between the parties arising out of this
Agreement, any attempts to enforce this Agreement, or any breach of this Agreement, the
prevailing party may recover its expenses of such legal action including, but not limited to, its
costs of litigation (whether taxed by the court or not) and its reasonable attorneys' fees (including
fees generated on appeals) from the other party.
Article 16 - Expulsion or Termination of Members
16.1. Expulsion. By the vote of two-thirds (2/3) of the Directors serving on the Board
of Directors, any Member may be expelled. Such expulsion may be carried out for one or more
of the following reasons:
16.1.1. Failure to make any timely payments due to the Pool.
16.1.2. Failure to undertake or continue loss reduction and prevention procedures
adopted by the Pool.
16.1.3. Failure to allow the Pool reasonable access to all facilities of the Member
and all records which relates to the purpose, powers or functioning of the Pool.
16.1.4. Failure to furnish full cooperation with the Pool's attorneys, claims
adjusters, the Executive Director and any agent, employee, officer or independent
contractor of the Pool relating to the purpose, powers and proper functioning of the Pool.
16.1.5. Failure to carry out any obligation of a Member which impairs the ability
of the Pool to carry out its purpose or powers or functions.
15
16.1.6. The Member has given the one (1) year notice described in Section 4.2
and 4.3 above.
16.2. Notice: No Member may be expelled except after notice from the Pool of the
alleged failure along with a reasonable opportunity of not less than thirty (30) days to cure the
alleged failure. The Member may request a hearing before the Board before any decision is
made as to whether the expulsion shall take place. The Board shall set the date for a hearing
which shall not be less than fifteen (15) days after the expiration of the time to cure has passed.
A decision by the Board to expel a Member after notice and hearing and a failure to cure the
alleged defect shall be final. The Board of Directors may establish the date at which the
expulsion of the Member shall be effective at any time not less than sixty (60) days after the vote
•• expelling the Member has been made by the Board of Directors. If the motion to expel the
Member made by the Board of Directors or a subsequent motion does not state the time at which
the expulsion shall take place, such expulsion shall take place sixty (60) days after the date of the
vote by the Board of Directors expelling the Member.
16.3. Responsibilities of Terminated Member: A former Member shall only continue to
be fully responsible only for its' portion of any obligations incurred but not satisfied during the
period of time they were a Member of the Pool. Such obligations may include, but not be limited
to, premiums, loss fund payments, maintenance deductibles, workers' compensations, final audit
and administrative fees, etc., owed or unpaid by the former Member. The former Member shall
no longer be entitled to participate or vote on the Board of Directors.
Article 17 - Special Provisions for Deferred Funding
During the fiscal years commencing on October 1, 1987 and ending on September 30,
1990, the entire Annual "Loss Fund" Contribution was not required by the Board of Directors to
be paid within the fiscal year to which it was applicable. The difference between the Annual
"Loss Fund" Contribution and the amount required by the Board of Directors to actually be paid
to the Pool during such year by a Member is referred to herein as Deferred Funding. Members
and former Members during any year for which there existed Deferred Funding may be required
by the Board of Directors upon recommendation of the Executive Director to pay their applicable
*" portion of the Deferred Funding in subsequent years. .Members or former members will be
allowed forty-five (45) days after notification to make any payments of Deferred Funding. The
amount of any payments required for Deferred Funding as to each Member shall be based upon
the same formula as was used in establishing the Annual "Loss Fund" Contribution for that year.
Article 18 - Termination of the Pool
18.1. Termination: If, at the conclusion of any term of the Pool, the Board of Directors
votes to discontinue the existence of the Pool in accordance with Section 6.9.4., then the Pool
shall cease its existence at the close of the then current fiscal year. Under those circumstances,
the Board of Directors shall continue to meet on such a schedule as shall be necessary to carry
out the termination of the affairs of the Pool. It is contemplated that the Board of Directors may
be required to continue to hold meetings for some substantial period of time in order to
accomplish this task, including the settlement of all covered claims incurred during the term of
16
the Pool. The Pool shall continue to be fully responsible and obligated to pay covered claims
and expenses owed by the Pool, which accrued before the Pool's termination. The money used
to pay such covered claims and expenses shall remain with the Pool until such claims are settled
and expenses are paid.
18.2. Post-Termination Responsibilities of Member: After termination of the Pool, the
Member shall continue to hold membership on the Board of Directors but only for the purpose of
voting on matters affecting their limited continuing interest in the Pool for such years as they
were Members of the Pool.
17
In witness whereof, this agreement has been executed by the Entity:
. The approval of the foregoing agreement was passed by the Entity:
on the day of , 20_, and attached
hereto, I do hereby execute and the does hereby attest to my signature
as evidence that the has approved and hereby
becomes a bound signatory member of the "Intergovernmental Cooperative Agreement" for
Public Risk Management of Florida, a copy of which is attached hereto, and which is pursuant to
Florida Statutes Section 163.01, which commenced its term on October 1, 1987.
Chairperson of Board, or Council
Chairperson, Public Risk
Management of Florida
ATTEST:
This day of , 20,
1
..
CURREff BENEETI5 se_c_ Y3 ; t S v"fel Gs
'UNINLARY OF BENEFITS /
authorized non authorized
n,„„iLUE CROSS AND BLUE SHIELD OF FLORIDA yes no yes no alternative
•
'OINT-OF-SERVICE PLAN Alb WITH BLUESCRIPTSNt
ENEFITS AUTHORIZED NON-AUTHORIZED
"'alendar Year Deductible
-
Individual $0 1300
'"" Aggregate Family SO $900
tlloeScript Prescription Drug Rider 55.00 Generic 15.00 Generic
Including Oral Cuultaccptives) 1 0.110 N.uuc Hrand $10.00 Name ftrand _
The deductible does-not apply to services with a copayment or where indicated.
_ifetime Maximum No Maximum $1,000,000
ANCoinsurance Requirement Limit
Individual 10 12,000
Aggregate Family SO $6,000
Ave hysician Office Services
• Routine Services 15 Copayment 80%Allowed Amount •
• Preventive Care 55 Copayment Not Covered
• Well-Child Care $5 Copayment 80%Allowed Amount
'" No Deductible
• Allergy Injection
(Without Office Visit) 55 Copayment 80%Allowed Amount
• Annual Gynecological Examination
MIS
By A FI01 OB/GYN Physician
Up To$150 Per Calendar Year
(Does Not Require Authorization
at" By Primary Care Physician) 15 Copayment Not Covered
• Specialty Care $5 Copayment 80%Allowed Amount
• Maternity Care
First Office Visit 55 Copayment S0%Allowed Amount
"" Total Maternity Care No Copayment 80%Allowed Amount
Hospital Services
Hospital Per Admission Deductible SO $300
(PAD)
• Inpatient
r Primary Care Physician No Copayment Not Applicable
Facility No Copayment 80%Allowed Amount -
All Other Providers No Copayment 80%Allowed Amount
• Outpatient Hospital/Surgical
Primary Care Physician No Copayment Not Applicable
Facility No Copayment 80%Allowed Amount
All Other Providers No Copayment 80%Allowed Amount
• Non-Routine X-Rays
"" (Inpatient or Outpatient) No Copayment 80%Allowed Amount
.r
• SCUSPICSt St•
Illu.CU.{anti Uluc Sl u:W ul Runt,I .a an IiWcpaukm l�tcmccc.J ilk Ulue Guar mul It$SIucW A W wu.•1
+WO
•
CURIUM' BENEFITS r
',UNIIYLARY OF BENEFITS
authorized non authorized
,,.IILUE CROSS AND BLUE SHIELD OF FLORIDA yes no yes no alternative
•
'DINT-OF-SERVICE PLAN A16 WITH BLUESCRUPTsnt
,®3ENEFITS AUTHORIZED NON-AUTHORIZED
Talendar Year Deductible
Individual 10 1300
.I. Aggregate Family 50 1900
Bluescript Prescription Drug Rider 55.00 Generic 55.00 Generic
Including Oral Cunt,accptivcs) 510.00 Name Brand SI0.00 Name Brand
The deductible does-not apply to services with a copayment or where indicated.
Lifetime Maximum No Maximum 11,000,000
•Coinsurance Requirement Limit •
Individual 50 12,000
Aggregate Family 50 16,000
•
.+.Physician Office Services
• Routine Services 15 Copayment 80%Allowed Amount •
• Preventive Care 15 Copayment Not Covered
• Well-Child Care 55 Copayment 80%Allowed Amount
No Deductible
• Allergy Injection
(Without Office Visit) 15 Copayment 80%Allowed Amount
• Annual Gynecological Examination
By A F101 OB/GY• Physician
Up To 1150 Per Calendar Year
(Does Not Require Authorization
r By Primary Care Physician) 15 Copayment Not Covered
• Specialty Care 15 Copayment 80%Allowed Amount
• Maternity Care
First Office Visit 55 Copayment 80%Allowed Amount
"' Total Maternity Care No Copayment 80%Allowed Amount
Hospital Services
Hospital Per Admission Deductible 10 1300
(PAD)
• Inpatient
®r Primary Care Physician No Copayment Not Applicable
Facility No Copayment 80%Allowed Amount
All Other Providers No Copayment 80%Allowed Amount
• Outpatient Hospital/Surgical
. • Primary Care Physician No Copayment Not Applicable
Facility No Copayment 80%Allowed Amount
All Other Providers No Copayment 80%Allowed Amount
• Non-Routine X-Rays
(Inpatient or Outpatient) No Copayment 80% Allowed Amount
eCUSV/CAI]l.
I INC Cr■...u.l Ulw Si,I4 ul Fl.m u.Inc.a r..Luklniukni Lacnncc of■bc UL.c Cn.....I Ulu.Siueld 1m.+nuuc,.
VON
AMP
_ t
1410
'CLUSIONS
1414
Services and supplies which are, in our opinion, experimental, investigational,
Jr not medically necessary;
+aPrivate duty nursing services;
Dental care(except accident-related);
2osmetic surgery (surgery performed solely to improve appearance of an
ndividual);
Eye refractions,eye glasses and hearing aids or examinations for their
-)rescription or fitting,except as specified in the Preventive Health Services Section;
toutine health examinations, except as covered under the Well-Child Care Section and the
""Preventive Health Services Section;
Rehabilitative services except as provided in the cardiac rehabilitation and pulmonary
ehabilitation sections;
are obtained without cost;
Services rendered by an individual who is related by blood or marriage;
-reatment in a VA hospital or government facility (due to service-related
disability);
Treatment of any condition arising out of a felony,riot,rebellion,or war;
Treatment of any condition or an intentionally self-inflicted condition, suicide,or
rtempted suicide;
"Speech therapy, except as provided under Home Health Care Services and Therapeutic
Services sections;
)iagnostic admissions;
,a.)ccupational therapy, except as provided under Home Health Care Services and
Therapeutic Services sections;
-ervices or supplies related to sexual reassignment;
ravel expenses,even if prescribed by a physician(this exclusion does not
apply to medically necessary transportation of a newborn child);
custodial care;
xercise programs of any kind;
'}Mon-prescription drugs, vitamins, mineral supplements, or fluoride drugs;
Work-related injuries;
srvices associated with autopsy or postmortem examination;
,,.ervices and supplies not specifically covered tinder the BCBSF Care Manager
Point Of Service Plan;
ontraceptive devices, appliances or other supplies when used for contraception.
.taa
d services rendered in the Emergency Room which are not Emergency Care Services will be subject to calendar year deductible and
insurance amount listed above unless authorized by the Primary Care Physician.
it a contract. The above Summary of Benefits is only a partial description of the many benefits and services covered by Blue Cross
Shield of Florida,Inc. These benefits apply only to groups of 51 or more employees. For a complete description of benefits and
dos,please see Blue Cross and Blue Shield of Florida's Care Manager Point Of Service Contract#15483-1096 SR and Schedule of
is#15499-1096 SR.:its terms prevail. Blue Cross and Blue Shield of Florida.Inc.is an Independent Licensee of the Blue Cross and Blue
Association.
s BCBSF/CM 51.
e Mark of Blue Cross and Blue Shield of Florida.lie.
Blue Crux,and Blue Shield it Honda.Inc.is:a,InJcjxnJcm Licenox if the Blue Cross and Blue Shield Awlecwim.
PUBLIC RISK MANAGEMENT
SCHEDULE OF BENEFIT SUMMARIES
BLUE CROSS/ BLUE SHIELD
HIGH OPTION PPO
Effective 10/1/2002
- °;Froosed : : °; w, ;<Proposed :
;,.<
,
>.�-: x- .;:E,,,,.• ..-- :.." '��cL rsH"�° �-i�:a�.�.i��i E .:
-In,Network -,C3ut a
(iYuithoized) ° : '_ '(Non-Authorized)
Maximum Lifetime Benefit $2,000,000 $2,000,000
Annual Deductible $200 $200
Family Deductible $600 $600
Annual Maximum Copayments N/A N/A
Family Maximum Copayments N/A N/A
Maximum Annual Out of Pocket $1,500 $1,500
Maximum Family Out of Pocket $4,500 $4,500
Coinsurance 90%of allowance 70%of allowance
4th Quarter Carryover Deductible Carryover applies Carryover applies
Physician Office Visit $15 Copay Ded,then 70%of allowance
Wellcare Visits-Annual exam
Adult $15 copay.Covered up to$250- 70%of allowance,Ded waived.
combined OB/GYN and Adult Covered up to$250-combined
r OB/GYN Wellness OB/GYN and Adult Wellness
-Child health $15 Copay.(Birth to age 16) 70%of allowance,Ded waived
Mammograms 100%of allowance, Ded waived
g 100%of allowance(Ded waived)
(may be balance billed)
Specialist Office Visit $15 copay Ded,then 70%of allowance
Second Opinion Surgical Ded,then 70%of allowance
P g $15 Copay(Not Required) (Not Required)
++ Infertility Services/Treatment Plans Ded,then 70%of allowance
(Treatment covers artificial insemination, $15 Copay(diagnosis) /$20,000
lifetime max for treatment (diagnosis)/$20,000 lifetime max for
IVF,GIFT,&ZIFT treatment
$15 Copay(physician's office)Ded, Ded,then 70%of allowance
Physical Therapy then 90%of allowance
(inpatient/outpatient)up to$10,000 in
up to$10,000
lifetime max(combined therapy) lifetime max(combined therapy)
$15 Copay(physician's office)Ded,
then 90%of allowance Ded,then 70%of allowance
Speech (inpatient/outpatient)up to$10,000 (inpatient/outpatient)up to$10,000
..r lifetime max(combined therapy) lifetime max(combined therapy)
$15 Copay(physician's office)Ded, Ded,then 70%of allowance
Occupational then 90%of allowance (inpatient/outpatient)up to$10,000
(inpatient/outpatient)up to$10,000 lifetime max(combined therapy)
lifetime max(combined therapy)
Acupuncture Not Covered Not Covered
Injections/Immunizations(child health) $15 Copay 70%of allowance,Ded waived
Allergy Testing $15 Copay Ded,then 70%of allowance
Allergy Injections(not including serum) $5 copay Ded,then 70%of allowance
,rr Office Surgery $15 Copay Ded,then 70%of allowance
Outpatient Surgery(hospital or surgery
Ded,then 90%of allowance Ded,then 70%of allowance
center)
X-ray and Lab Outpatient-Physician's Ded,then 90%of allowance Ded,then 70%of allowance
""' Office
Outpatient Radiation Ded,then 90%of allowance Ded,then 70%of allowance
PUBLIC RISK MANAGEMENT
SCHEDULE OF BENEFIT SUMMARIES
4.. BLUE CROSS/ BLUE SHIELD
HIGH OPTION PPO
Effective 10/1/2002
Proposed Proposed
an: .` •
I Network
� ut�o Network
,
(Authorized) _(Non-Authorze
d)
RAP Providers
(Non-PPO Radiologist,Anesthesiologist, Ded,then 70%of allowance
pathologist,and ER phys.services at PPO Ded,then 90%of allowance (If participating hospital,Ded,then
hosp.) 90%of allowance)
Emergency Room/Hospital
-Illness Ded,then 90%of allowance Ded,then 70%of allowance
"" -Accidents 90%of allowance,Ded waived 70%of allowance,Ded waived
Ambulance Ded,then 90%of allowance Ded,then 90%of allowance
Ded,then 90%of allowance(Covers Ded,then 70%of allowance(Covers
Dental Oral Surgery removal of impacted teeth,including removal of impacted teeth,including
impacted wisdom teeth,related x- impacted wisdom teeth,related x-rays
rays&anasthesia) &anasthesia)
Inpatient Hospital Ded,then 70%of allowance.$100
P P Ded,then 90%of allowance
AND
per admission deductible
X-ray and Lab Inpatient Ded,then 90%of allowance Ded,then 70%of allowance
Blood and Blood Plasma Ded,then 90%of allowance (no Ded,then 70%of allowance (no
limit) limit)
..r Home Health Care Ded,then 90%of allowance. Ded,then 70%of allowance.$12,000
$12,000 Calendar year max. Calendar year max.
Hospice Ded,then 90%of allowance Ded,then 70%of allowance.$7,500
$7,500 lifetime max lifetime max.
Skilled Nursing Facility Ded,then 90%of allowance.60 Ded,then 70%of allowance.60 days
days per calendar year. per calendar year.
Durable Medical Equip. Ded,then 90%of allowance Ded,then 70%of allowance
ar Maternity
-Physician $15 copay initial visit Ded,then 70%of allowance
-Hospital Ded,then 90%of allowance Ded,then 70%of allowance
Dependant Daughter Maternity Covered as maternity benefit up to Covered as maternity benefit up to 18
18 months (or longer) months (or longer)
Birthing Centers Ded,then 70%of allowance Ded,then 70%of allowance
Abortions Not Covered Not Covered
In-Patient Mental/Nervous Ded,then 90%of allowance.30 Ded,then 70%of allowance.30
days per calendar year. days per calendar year
Out-Patient Mental/Nervous $15 Copay.20 visits per calendar Ded,then 70%of allowance.20 visits
year per calender year
Attempted Suicide Ded,then 90%of allowance Ded,then 70%of allowance
In-Patient Substance Abuse Ded,then 90%of allowance. Ded,then 70%of allowance.$2,500
$2,500 lifetime max lifetime max
Out-Patient Substance Abuse Ded,then 90%of allowance. Ded,then 70%of allowance. $2,500
$2,500 lifetime max. lifetime max.
Prescription Drugs - Includes coverage for
oral contraceptives&diaphragms
Generic Ded,then 70%of allowance.
INS $7 Copay-30 day supply 30 day supply
-Brand $14 Copay-30 day supply Ded,then 70%of allowance.
30 day supply
s
Prescription Card Yes No
Prescription Mail Order Yes No
Generic $14 Copay-90 day supply Not Applicable
Brand $28 Copay-90 day supply Not Applicable
PUBLIC RISK MANAGEMENT
SCHEDULE OF BENEFIT SUMMARIES
BLUE CROSS/ BLUE SHIELD - LOW OPTION PPO
Effective 10/1/2002
Prropo s ,:'
? �`" �Proposed: .:
•
in'Netwark. '.::.<•' Out of
;._He
( )...,r t�.y'� - ` Nain=Aattiorized)��' .. . -
Maximum Lifetime Benefit $2,000,000 $2,000,000
Annual Ded $500 $500
r _
Family Ded $1,500 $1,500
Annual Maximum Copayments N/A N/A
Family Maximum Copayments N/A N/A
Maximum Annual Out of Pocket $1,500 $1,500
Maximum Family Out of Pocket $4,500 $4,500
01111 Coinsurance 80%of allowance 60%of allowance
4th Quarter Carryover Ded Carry Over applies Carry Over applies
Physician Office Visit $15 Copay Ded,then 60%of allowance
Wellcare Visits-Annual exam
$15 copay,$250 calendar year max 60%of allowance,Ded waived,$250
(combined OBGYN/adult wellness) calendar year max(combined
+r Adult/OB/GYN OBGYN/adult wellness)
Child health $15 Copay.(Birth to age 16) 60%of allowance,Ded waived(Birth to
age 16)
Mammograms 60%of allowance,Ded waived(may be
AID
g 80%of allowance,Ded waived
balance billed)
Specialist Office Visit $15 Copay Ded,then 60%of allowance
Second Opinion Surgical $15 Copay(Not Required) Ded,then 60%of allowance
Infertility Services/Treatment Plans
(Treatment covers artificial insemination, No Coverage No Coverage
IVF,GIFT,&ZIFT
Ded,then 80%of allowance
aim
Physical Therapy Ded,then 60%(inpatient/outpatient)up
Ph
Y py (inpatient/outpatient)up to$5,000 to$5,000 lifetime max
lifetime max
Ded,then 80%of allowance Ded,then 60%of allowance
Speech (inpatient/outpatient)up to$5,000 (inpatient/outpatient)up to$5,000
lifetime max lifetime max
Ded,then 80%of allowance Ded,then 60%of allowance
Occupational (inpatient/outpatient)up to$5,000 (inpatient/outpatient)up to$5,000
411• lifetime max lifetime max
Acupuncture Not Covered Not Covered
$15 Copay 60%of allowance,Ded waived(Birth to
Injections/Immunizations(child health) age 16)
Allergy Testing $15 Copay Ded,then 60%of allowance
Allergy Injections(not including serum) $10 copay Ded,then 60%of allowance
PUBLIC RISK MANAGEMENT
SCHEDULE OF BENEFIT SUMMARIES
BLUE CROSS/ BLUE SHIELD - LOW OPTION PPO
Effective 10/1/2002
Propose Proposed`,:
• +:Phut 4i9:';:e .s Pfarr7l
In Network Out of Network
(Authorized) (Non-A u tho rize
d).:
41110 ..
Office Surgery $15 Copay Ded,then 60%of allowance
Outpatient Surgery(hospital or surgery
center) Ded,then 80%of allowance Ded,then 60%of allowance
,,r X-ray and Lab Outpatient-Physician's Ded,then 80%of allowance Ded,then 60%of allowance
Office
Outpatient Radiation Ded,then 80%of allowance Ded,then 60%of allowance
a RAP Providers (Non-PPO Ded,then 70%of allowance
Radiologist,anaesthesiologist,pathologist, Ded,then 80%of allowance (If participating hospital,Ded,then 80%
and ER phys.services at PPO hosp.) of allowance)
Emergency Room/Hospital
-Illness Ded,then 80%of allowance Ded,then 60%of allowance
-Accidents 80%of allowance,Ded waived 60%of allowance,Ded waived
Ambulance Ded,then 80%of allowance Ded,then 80%of allowance
Ded,then 80%of allowance Ded,then 60%of allowance
Dental Oral Surgery (Injury due to external force of sound and (Injury due to external force of sound and
natural teeth) natural teeth)
Inpatient Hospital Ded,then 80%of allowance $300 per admission Ded,then 60%of
N allowance
AN
X-ray and Lab Inpatient Ded,then 80%of allowance Ded,then 60%of allowance
Blood and Blood Plasma Ded,then 80%of allowance (No Ded,then 60%of allowance (No
Limit) Limit)
Home Health Care Ded,then 80%of allowance. $2,500 per Ded,then 60%of allowance. $2,500 per
calendar year calendar year
Hospice Ded,then 80%of allowance. $7,500 Ded,then 60%of allowance. $7,500
lifetime max. lifetime max.
Ded,then 80%of allowance. 60 days per Ded,then 60%of allowance. 60 days/
Skilled Nursing Facility
calendar yr. calendar year
Durable Medical Equip. Ded,then 80%of allowance Ded,then 60%of allowance
Maternity
-Physician Ded,then 80%of allowance Ded,then 60%of allowance
-Hospital Ded,then 80%of allowance Ded,then 60%of allowance
Dependent Daughter Maternity Ded,then 80%of allowance Ded,then 60%of allowance
Birthing Centers Ded,then 60%of allowance Ded,then 60%of allowance
.r1
Abortions Not Covered Not Covered
arr
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PUBLIC RISK MANAGEMENT
SCHEDULE OF BENEFIT SUMMARIES
BLUE CROSS/ BLUE SHIELD - LOW OPTION PPO
Effective 10/1/2002
• .. - ` Pro�osed
Plan 7]9 PIe rp 719:.. •.; ';
n Network -. _ put ofNetwork. _ _
.r
• (Authorized). (Non-Authorized)
In-Patient Mental/Nervous Ded,then 80%of allowance.30 days;30 Ded,then 60%of allowance.30 days;30
visits per calendar yr. visits per calendar yr.
.r Out-Patient Mental/Nervous Ded,then 80%of allowance.20 visits per Ded,then 60%of allowance.20 visits per
calendar yr(partial hopitalization). calendar yr(partial hopitalization).
Attempted Suicide Ded,then 80%of allowance Ded,then 60%of allowance
„10 In-Patient Substance Abuse Ded,then 80%of allowance.$2,500 Ded,then 60%of allowance.$2,500
lifetime max. lifetime max.
Out-Patient Substance Abuse Ded,then 80%of allowance.$35 max per Ded,then 60%of allowance.$35 max per
visit;44 visits max;$2,500 lifetime max. visit;44 visits max;$2,500 lifetime max.
sw
Prescription Drugs (Includes coverage for
oral contraceptives and Diaphragms)
..r -Generic $10 Copay,30 day supply Ded,then 60%of allowance
-Brand $25 Copay,30 day supply Ded,then 60%of allowance
ar Prescription Card Yes No
Prescription Mail Order Yes No
Generic $20 Copay,90 day supply Not Applicable
$50 Copay,90 day supply Not Applicable
Brand
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P.O.Brix 7Ha8
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(219) 455.3896
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Treasurer and Insurance Commissioner
• . • -•.
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'�� Articles of Amendment, filed on October 27, 1987, to Articles of OPc
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Introduction
Blue Cross and Blue Shield of Florida, Inc. (BCBSF) is a leader in the health care
benefits industry, committed to the effective financing, delivery and administration of
health care benefits. We bring our clients the benefit of over 57 years of health care
experience, combined with the strength of the state's largest health insurer. BCBSF and
.xrFT:
our subsidiaries serve more than 5 million Floridians.
Eighteen years ago, the first generation of Blue Cross and Blue Shield of Florida's
managed care programs began successfully controlling quality, price and use of hospital
inpatient and physician services. Our HMO subsidiary, Health Options, Inc., began
operations in 1983. Our PPO program was introduced in 1984. Today, Health Options
has the largest commercial HMO market share in Florida. Our PPO has the largest
PPO membership in Florida. Through extensive data analysis and satisfaction surveys
' y ; of our members and providers, we continually monitor the effectiveness of our products
and programs to ensure BCBSF remains at the forefront of the industry in meeting the
needs of our customers.
c : Over the years, we have established a reputation for solid financial stability. Like all
commercial carriers, BCBSF is regulated by the Florida Department of Insurance. We
maintain a reserve level well within established standards. Our earnings, enrollment
and policyholders' equity show a pattern of steady growth.
This strong financial performance has resulted in BCBSF receiving an "A" rating from
Standard & Poor's, an "A" rating from A.M. Best, and an "A3" rating from Moody's, the
17;4 highly respected insurance rating services, in their most recent rating reports. They
noted our strong core market presence, our established managed care capabilities, our
k.' consistent revenue growth, adequate capital level, diverse product portfolio, and
extensive provider networks.
Florida Combined Life Insurance Company (FCL), a BCBSF subsidiary, has an A.M.
Best rating of"A" and has been writing group life insurance since it was established in
1988. BCBSF formed FCL in order to provide its customers with a broader array of
products, including life, accidental death and dismemberment, disability income and a
variety of pretax programs. Today, FCL also offers voluntary group insurance, as well
as dental insurance.
Why should all of this matter to you? Because the stronger we are as a company, the
better we can serve you in researching and developing new and better ways to deliver
health care benefits.
Our stability has allowed us to invest in managed care programs that help control health
care costs. That is only part of what you get as a Blue Cross and Blue Shield of Florida
r 2 member.
.1:
'A.
•
Here is what Blue Cross and Blue Shield of Florida can mean to you.Introduction
• Blue Cross and Blue Shield Recognition
The Blue Cross and Blue Shield identification card is recognized and accepted as a
symbol of quality health care benefits around the world.
t#.
• A Managed Care Company
All of our products and services are designed to provide cost-effective health care
coverage that meets or exceeds the needs of employers and employees.
• HMO Accredited by NCQA
The National Committee for Quality Assurance (NCQA) has awarded our Southern
Geographical Business Unit an Excellent rating. Our Northern Geographical
Business Unit has earned a Commendable rating.
;; • Local Presence
Through local offices located across the state, BCBSF offers a personalized touch to
customer service and managed care programs.
• Medical Management Teams
Each of Florida's five major metropolitan areas has a local medical management
team that regularly reviews and monitors physician and hospital services to ensure
appropriate cost-effective quality health care.
2f.4'
• Customer Service Units •
We offer toll-free customer service telephone lines, as well as walk-in service at 11
of our 14 local offices throughout the state. We track all customer inquiries to
ensure you receive prompt, efficient resolution of any questions or problems.
• Personal Service
A Field Service Representative (FSR) and Account Representative will be available
" to handle and address any questions your group administrator may have. Also, a
Personal Service Representative (PSR) will be assigned to handle your group's
eligibility and billing.
• Employee Benefit Programs
We offer a full range of integrated health, life, disability, dental and flexible benefit
programs.
• Reduced Paperwork
When using our networks, you eliminate claim filing and balance billing of members.
• Combined Billing
Coverages included in the benefit programs can be conveniently and efficiently
administered through combined billing arrangements.
w•
Introduction
s
Flexibility in Plan, Benefit and Funding Design
BCBSF provides customized plan, benefit and funding designs that adhere to sound
practices of underwriting and risk management.
• Our HMO benefit plans provide a comprehensive level of benefits, including •
preventive health care, with care managed via a Primary Care Physician;
• We offer PPO benefit plans for those employees who want more freedom of choice.
Our PPO product includes the added value of access to our traditional provider
network;
• Our Traditional indemnity plans provide broad access medical care through a wide
variety of providers; and
• Specific benefit levels are designed to meet your needs.
Local and National Support
The BCBSF corporate office is located in Jacksonville, Florida. Blue Cross and Blue
Shield of Florida has divided the Florida marketplace into two Geographical Business
Units (GBUs), the Northern GBU and the Southern GBU. The Northern GBU consists of
a main office in Jacksonville, Florida and additional offices in Tampa, Gainesville,
Sarasota, Tallahassee, Panama City, Ft. Myers and Pensacola. The Southern GBU
consists of a main office in Miami, Florida and additional offices in Orlando, Lakeland,
Ft. Lauderdale, West Palm Beach, and Port St. Lucie.
BCBSF is able to operate effectively on the national, state and local level. Each local
Blue Cross and Blue Shield plan participates in the national Blue Cross and Blue Shield
Association. The Association is empowered to develop and enforce national standards,
business policies, customer service arrangements and benefits administration. Each
local plan has access to the resources and experience of the national organization.
BlueCard PPO Program
Under the PPO plan, for employees living outside of Florida and Florida employees
••� receiving covered services outside of Florida, BCBSF participates in the BlueCard PPO
program through the Blue Cross and Blue Shield Association. Under the BlueCard PPO
program, employees receive the benefit of the local Blue Cross and Blue Shield plan's
provider network, including the following:
• Accept prenegotiated allowances;
• File all claims directly with the local Blue Cross and Blue Shield plan; and
• Not balance bill for the difference in the prenegotiated allowance and the provider's
charge. The provider will bill only for any deductibles, copays, coinsurance and non-
,,, covered services.
Aim
Introduction
A.
BlueCard HMO Program
AS Under the HMO plan, for members traveling outside the Health Options service area,
BCBSF participates in the BlueCard program through the Blue Cross and Blue Shield
Association. Under the BlueCard Program, members seeking medical care receive the
. benefit of the local Blue Cross and Blue Shield plan's traditional provider network,
including the following:
• Accept prenegotiated allowances;
a..
• File all claims directly with the local Blue Cross and Blue Shield Plan; and
• Not balance bill for the difference in the prenegotiated allowance and the provider's
,,, charge. The provider will bill only for any applicable copays, any non-covered
services and expenses for services where an Authorization from the Primary Care
Physician was required and not obtained. (Authorizations are the member's
,,, responsibility.)
Away From Home Care® HMO Program
Also, Health Options is part of the Blue Cross and Blue Shield Association's HMO
l network, Away From Home Care®, which is designed to provide benefit coverage
outside the State of Florida via a network of participating Blue Cross and Blue Shield
HMOs.
The Away From Home Care® Guest Membership program enables an individual who is
away from home for at least 90 days to enroll in another participating, operational HMO ,
plan service area and receive medical services as a guest member. Subscribers are
eligible to be out of the service area up to six months; dependents do not have a time
limit out-of-area. An example of someone who meets the eligible criteria would be a
tstudent attending college in another state or in a "families apart" situation.
The member will work with an Away From Home Care® Coordinator who will assist in
identifying the availability of a participating, operational HMO in the area in which the
member is residing.
FCompatibility with Current and Future Systems 1
BCBSF is continually improving operations to meet customer needs and expectations.
Our present operational capacity allows us to provide you with:
f
• The administration of both in and out-of-network claims;
• Combined billing for health and life products; and
I • Our commitment to accommodating future needs. .
BCBSF's systems capture detailed claims and benefit information. Our systems provide
1 a major base of data, which is used to analyze and monitor claims performance and
medical costs. This database is able to satisfy the management information needs of
even our largest accounts.
1,
Introduction
Virtual Office
In order to meet future needs of our customers, BCBSF is developing Virtual Office
(VO). VO is a new business process using new technology to support online interaction
below is an
and information exchange with providers serving our customers. Provided be
overview of VO.
• Technology Components:
- VO streamlines most transactions between physicians, hospitals and BCBSF on
behalf of our customers; and
VO dramatically reduces the time required to complete a transaction and
enhances relationships with physicians and customers.
• Organizational Components:
VO will literally transform the way we do business to ensure more effective
physician relationships as well as improve the experiences of our customers; and
A single point of accountability, through a Provider Focus Team (PFT), will help
r to strengthen and better manage relationships with providers.
• BCBSF information will be available "virtually" in the physician's office.
- VO will improve the total health care experience for customers, physicians and
hospitals;
`L. - In the rapidly-expanding age of electronic commerce, VO offers a new way of
7`4: using technology to support online interaction and information exchange with
•i participating physicians and hospitals;
- Customers will know their financial responsibility up front and have abetter
overall medical encounter; and
- VO will build relationships with providers by eliminating the need to contact
BCBSF for routine tasks like eligibility, benefits and copay status.
• To maintain our leadership position in Florida, BCBSF must continue to
sign, differentiate itself.
s<> - VO improves access to quality health care;
- VO provides online settlement and patient's responsibility for deductibles, copays
. .. and other payments at the time of service;
- VO instantly verifies eligibility at the physician's office;
- VO immediately issues referrals to other providers or specialists; and
- VO reduces administrative hassle by eliminating paperwork.
• VO capabilities offer providers the following benefits:
,N f - Physicians can collect payment from the member/patient at the time of service;
- Reduced administrative expenses and improved cashflow/profitability;
- Reduced/eliminated phone calls for referrals, authorizations and eligibility;
- Improved patient satisfaction due to reduced "wait time" for referrals; and
- Potential to electronically reconcile patient accounts and reduce administrative
overhead.
j it;
Introduction
Other Employee Benefit Programs
Although we are best known for providing state-of-the-art health care benefits, BCBSF is
also dedicated to providing other types of employee benefits. We employ professional
staff and maintain affiliate relationships, which enable us to provide you with the latest,
first-rate cost sharing and employee choice benefit programs.
We offer a variety of ancillary group benefits and Section 125 pretax programs through
Florida Combined Life which include:
• Group term life, supplemental life, dependent life and accidental death and
dismemberment plans;
• Short term and long term disability plans;
• Voluntary plans: group term life, accidental death and dismemberment, short term
— disability and long term disability;
• Group Dental plans: BlueDental Care (HMO-type), BlueDental Choice (PPO) and
BlueDental Freedom (Indemnity) -- on both an employer sponsored and voluntary
basis; and
• Pretax programs, including premium conversion plans, flexible spending accounts,
flexible benefit plans and 401(k) salary deferral and retirement plans.
Group, Member and Provider Satisfaction
BCBSF provides high levels of quality service to the employer, the employee members
and the medical providers.
• Customer and member services are available at both centralized and regional levels
depending on the benefit plans selected;
• Centralized and regional medical management and provider relations departments
are staffed by MDs, RNs, LPNs and other managed care professionals;
• "Transparent" claims processing. Participating providers bill BCBSF directly.
Members need not deal with claim forms or bills beyond deductibles, coinsurance or
copayments when receiving services from network participating providers; and
• Periodic surveys of providers and general membership are carried out by both
BCBSF and independent outside survey organizations to monitor the customer's
level of satisfaction with our programs and performance.
1
•
i.
: .
CUSTOMER SERVICE
Brand Recce n§bno BCBSF
T| e! Blue Cross Blue Shield ide%ƒc tioncard is recognized and accepted a a symbo l of quality health
care benefits around the world.
Local Customer Service
We service member inquiries within each of the Geographic Busilelss Units (GBUs) within the state. The
main service centers are located in Tampa, Miami and Jacksonville and handle walk-in inq uiries, as well as
telephone or written inquiries. Our customer service representatives are experienced in resolving all levels
of customer inquiries regarding the part icipant's questions, including, but not limited to eligible covered
services, pmGder partb\26nandpayment amounts
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We offer toll-free customer service telephone lines, as well as walk-in service at II our 14 local offices
throughout the state. We track all customer inquiries to ensure you receive prompt, efficient resolution of
any questions or probl ems.
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AM Best A A 07/10/2000 07/10/2000
Standard & A A 11/2/2001 11/2/2001
Poor
Standard & Poor's and A.1Y1. Best
' The independent financial rating firms of Standard & Poor's and A.M. Best have given BCBSF high marks,
underscoring the fact that the company is financially strong. Standard & Poor's gave a rating of"A" for
claims paying ability. A.M. Best awarded BCBSF its "A" rating with a size category of"X." Standard &
•r" ' Poor's rating was based on BCBSF's strong market position, diverse product portfolio, and extensive
•y; 4, provider networks. Insurers rated "A" offer good financial security. BCBSF is the largest writer of health
: < insurance in Florida, which has allowed us to develop important local market expertise. Heavy investments
in and commitment to managed care have also contributed to strong growth in earnings and capital.
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HIP AA
Ya; We support the protection of patient identifiable information. We are also sensitive to the information
needs of the health plans and plan sponsors. We are currently assessing the recent regulations on privacy
and are developing plans to comply with the regulations while satisfying our customers needs.
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In 1996, Congress approved the Health Insurance Portability and Accountability Act- Administrative
Simplification title (H[PAA-AS). This law is intended to "improve the efficiency and effectiveness of the
health care system through the establishment of standards and requirements for electronic transmission of
certain health information" and "to protect the security and privacy of health care information by setting
standards regarding its use and disclosure".
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Preparing for the business implications and legal requirements imposed by HIPAA-AS will be a challenge
t.'., for the entire health care industry. At Blue Cross Blue Shield of Florida we are responding to the law with
a continued commitment of servicing our customers and providing affordable, quality health plans.
• `.; Blue Cross Blue Shield of Florida established the HIPAA-AS Project Team to facilitate and coordinate
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enterprise H[PAA-AS compliance activities. The HIPAA-AS team is comprised of a cross section of
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management and experienced representatives from within our organization and is chartered with
interpreting regulations, providing staff education and awareness programs, analyzing risk factors to our
••i y business, facilitating g the design and implementation of the necessary changes to achieve compliance, and
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} , tracking enterprise progress toward HIPAA-AS compliance.
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``o We recently completed an assessment of our applications and business processes to identify the systems and
procedures that are impacted by HIPAA-AS law. We are actively working on the changes necessary to
bring our claims, membership and other systems and associated business processes into compliance with the
"' transactions, codes and privacy rules. Design and planning activities are in progress for security and
I identifiers based on the proposed rules. Testing of the new transactions and codes is scheduled to begin in
the first quarter 2002. We plan to complete all of the necessary changes for compliance within the
yo mandated timeframes. We will make every effort to ensure customer service is maintained through the
i transition of our activities.
You can expect the same level of service and programs that you've come to know from Blue Cross Blue
7 Shield health plans. We anticipate that implemented changes resulting form HIPAA-AS law will improve
our capabilities and the delivery of health care administration functions. It will also provide a more secure,
retention of health records for all our members.
COBRA .
Blue Cross and Blue Shield of Florida has contracted with COBRAServ, a third party COBRA
administrator to provide COBRA compliance services for all of our eligible groups. COBRASery will
provide these services:
1 • Generation of monthly invoices to all continuants with a remittance stub requesting certification that
there is no other coverage invalidating COBRA;
• Collection of monthly premiums from continuants;
• Remittance of the monthly premium received along with detailed accounting statements for ease of
reconciliation;
• Generation of grace letters for continuants who have not paid their COBRA premiums approximately
fifteen days prior to the end of the grace period;
• Concise weekly and monthly eligibility reports broken down by coverage and division;
• Telephone support for continuants and employers; and
r • Updates on legislative and judicial changes that impact COBRA administration.
• COBRASery is included in our proposed funding.
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