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HomeMy WebLinkAboutCity of Tamarac Resolution R-2001-292Temp. Reso. #9549-September 27, 2001 Page 1 CITY OF TAMARAC, FLORIDA RESOLUTION NO. R-2001-292 A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF TAMARAC, FLORIDA, AUTHORIZING THE APPROPRIATE CITY OFFICIALS TO EXECUTE A CONTRACT FOR THE CITY'S HEALTH INSURANCE PROGRAM WITH AETNA US HEALTHCARE FOR THE PLAN YEAR EFFECTIVE JANUARY 1, 2002; PROVIDING FOR THE CONTINUATION OF THE CURRENT COST ALLOCATION OF THE HEALTH INSURANCE PREMIUM BETWEEN THE CITY AND EMPLOYEES; PROVIDING FOR A WAIVER REIMBURSEMENT MAXIMUM; APPROVING THE APPROPRIATE BUDGETARY TRANSFER OF FUNDS; PROVIDING FOR CONFLICTS; PROVIDING FOR SEVERABILITY; AND PROVIDING FOR AN EFFECTIVE DATE. WHEREAS, the City's three year health insurance contract with HIP is scheduled to expire on December 31, 2001; and WHEREAS, a Request for Proposal (RFP) for the City's health insurance program was issued; and WHEREAS, on June 13, 2001 the City received four proposals: Aetna US Healthcare, Cigna, HIP and Humana; and WHEREAS, the City Manager appointed a proposal evaluation committee consisting of the Director of Personnel, Assistant City Attorney, Assistant Fire Chief, Purchasing and Contracts Manager, Benefits Coordinator, Firefighter Paramedic and the Streets Supervisor; and WHEREAS, presentations were given by all four insurance company proposers, and after careful consideration of all aspects of the proposals, the final ranking by the Temp. Reso. #9549-September 27, 2001 Page 2 Evaluation Committee was: (1) Aetna US Healthcare; (2) HIP; (3) Humana; (4) Cigna; and WHEREAS, after extensive deliberations the committee recommended that the City initiate negotiations with Aetna US Healthcare; and WHEREAS, health insurance rate increases were anticipated and were budgeted accordingly in the FY 2002 Budget; and WHEREAS, the City will continue to pay the premium for HMO single coverage in total, and maintain the current cost allocation on an 80/20 ratio between the City and the employee for all other coverage so that both the City and the employee bear a portion of the premium increase; and WHEREAS, a waiver reimbursement maximum will allow employees who elect to purchase insurance through their spouse's employer or otherwise independently from the City to be reimbursed up to a maximum amount equal to 100% of the single and family HMO rates for the plan year beginning January 1, 2002; and WHEREAS, it is the recommendation of the Director of Personnel and the City Manager that the City of Tamarac execute the employer application and contract documents with Aetna US Healthcare in substantially the same form as attached in Exhibit A, as provided by Aetna US Healthcare for health insurance coverage for City of Tamarac employees effective January 1, 2002. WHEREAS, the City Commission of the City of Tamarac, Florida deems it to be in the best interest of the citizens and residents of the City of Tamarac to execute the employer application and contract documents with Aetna US Healthcare in substantially the same form as attached in Exhibit A, subject to any revisions consistent with the Ll fJ 1 Temp. Reso. #9549-September 27, 2001 Page 3 benefit plan as negotiated by and between City staff and Aetna US Healthcare and approved by the City Manager and the City Attorney as the City's carrier for health insurance coverage for City of Tamarac employees effective January 1, 2002 . NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY OF TAMARAC, FLORIDA: SECTION 1: That the foregoing "WHEREAS" clauses are hereby ratified and confirmed as being true and correct and are hereby made a specific part of this Resolution. SECTION 2: That the appropriate City officials are hereby authorized to execute the employer application and contract documents with Aetna US Healthcare in substantially the same form as attached in Exhibit A, subject to any revisions consistent with the benefit plan as negotiated by and between City staff and Aetna US Healthcare and approved by the City Manager and the City Attorney as the City's carrier for health insurance coverage for City of Tamarac employees effective January 1, 2002. SECTION 3: That the appropriate City officials hereby authorize continued payment of the total cost of the premium for HMO single coverage and maintain the current cost allocation of the health insurance premium on an 80/20 ratio between the City and the employee for all other coverage. 1 1 Temp. Reso. #9549-September 27, 2001 Page 4 SECTION 4: That the appropriate City officials hereby authorize a waiver reimbursement maximum, to allow employees who elect to purchase insurance through their spouse's employer or otherwise independently from the City to be reimbursed up to a maximum amount equal to 100% of the single and family HMO rates for the plan year beginning January 1, 2002. SECTION 5: That the appropriate City officials are authorized to enact any appropriate budget transfers as needed for this purpose. SECTION 6: That all resolutions or parks of resolutions in conflict herewith are hereby repealed to the extent of such conflict. SECTION 7: That if any clause, section, or other part or application of this Resolution is held by any court of competent jurisdiction to be unconstitutional or invalid, in part or application, it shall not affect the validity of the remaining portions or applications of this Resolution. 1 1 1 Temp. Reso. #9549-September 27, 2001 Page 5 This Resolution shall become effective immediately upon adoption. PASSED, ADOPTED, AND APPROVED this 10th day of October, 2001. ATTEST: MARION S NSON, CMC CITY CLERK I HEREBY CERTIFY that I have approved this JOE SCHREIBER MAYOR RECORD OF COMMISSION VOTE: MAYOR SCHREIBER Ayes DIST 1: COMM. PORTNER A ye., DIST 2: COMM. MISHKIN AY& DIST 3: V/M SULTANOF A!e, y DIST 4: COMM. ROBERTS Al el EXHIBIT "A" Temp. Reso. 9549 Health Insurance Policy Contract Between Aetna, Inc. and City of Tamarac Salvador Aleguas II I 8201 Peters Road, Plantation, Florida 33324 Tel 954-382-5651 Fax 954-382-8200 October 5, 2001 Lynda Flurry City of Tamarac Purchasing and Contracts Manager 7525 NW 88"' Avenue Tamarac, Fl. 33321-2401 RE: City of Tamarac Health Benefits Program Dear Lynda: Thank you again for recommending Aetna as your choice for providing health care benefits to your employee's, retirees, and their eligible dependents. Aetna's final contracts with our customers are produced after a group has been set-up, and members enrolled in our system. However, the attached package is intended to document the benefit program that Aetna Inc. will provide to the City of Tamarac upon our final selection as your group health insurance vendor. These provisions will be contained within the contract presented to the City. Enclosed are: 1) Generic group agreement and certificates of coverage for HMO, QPOS and PPO products. 2) A list of changes that will be made to documents 3) Rates (based upon enclosed rates and assumptions) 4) Benefits 5) Employer Application The enclosed are generic group agreements and certificates of coverage documents. In addition to the changes referenced, applicable Florida law may provide certain mandates which may apply to City of Tamarac. Any such mandates will be included in applicable group agreement and certificate of coverage sent to you for signature. Thank you again for the opportunity to provide benefits for the City of Tamarac. The signature below confirms that Aetna, will present for signature a group agreement and certificate of coverage with the terms and conditions set forth above. Sinc rely _ va oo, AZleguas III Manager, Business Services • • 0 HMO This is SAMPLE document. It is provided for illustrative purposes only. AETNA U.S. HEALTHCARE, INC. (FLORIDA) CERTIFICATE OF COVERAGE This Certificate of Coverage ("Certificate") is part of the Group Agreement ("Group Agreement") between Aetna U.S. Healthcare, Inc., hereinafter referred to as HMO, and the Contract Holder. The Group Agreement determines the terms and conditions of coverage. Provisions of this Certificate include the Schedule of Benefits, and any amendments, riders or endorsements. Amendments, riders or endorsements may be delivered with the Certificate or added thereafter. HMO agrees with the Contract Holder to provide coverage for benefits, in accordance with the conditions, rights, and privileges as set forth in this Certificate. Members covered under this Certificate are subject to all the conditions and provisions of the Group Agreement. This Certificate describes covered health care benefits. Coverage for services or supplies is provided only if it is furnished while an individual is a Member. This means that coverage is provided only for health care services furnished while this coverage is in force. Except as shown in the Continuation and Conversion section of this Certificate, coverage is not provided for any services received before coverage starts or after coverage ends. Certain words have specific meanings when used in this Certificate. The defined terms appear in bold type with initial capital letters. The definitions Of those terms are found in the Definitions section of this Certificate. This Certificate is not in lieu of insurance for Worker's Compensation. This Certificate is governed by applicable federal law and the laws of Florida. READ THIS ENTIRE CERTIFICATE CAREFULLY. IT DESCRIBES THE RIGHTS AND OBLIGATIONS OF MEMBERS AND HMO. IT IS THE CONTRACT HOLDER'S AND THE MEMBER'S RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CERTIFICATE. IN SOME CIRCUMSTANCES, CERTAIN MEDICAL SERVICES ARE NOT COVERED OR MAY REQUIRE PREAUTHORIZATION BY HMO. NO SERVICES ARE COVERED UNDER THIS CERTIFICATE IN THE ABSENCE OF PAYMENT OF CURRENT PREMIUMS SUBJECT TO THE PREMIUMS SECTION OF THE GROUP AGREEMENT. GRACE PERIOD: THIS CERTIFICATE HAS A [30-120] DAY GRACE PERIOD. THIS PROVISION MEANS THAT IF ANY REQUIRED PREIMUM IS NOT PAID ON OR BEFORE THE DATE IT IS DUE, IT MAY BE PAID DRING THEFOLLOWING GRACE PERIOD. DURING THE GRACE PERIOD, THE CERTIFICATE WILL STAY IN FORCE. HMO/FL COC-3 12/99 This is SAMPLE document. It is provided for illustrative purposes only. THIS CERTIFICATE APPLIES TO COVERAGE ONLY AND DOES NOT RESTRICT A MEMBER'S ABILITY TO RECEIVE HEALTH CARE SERVICES THAT ARE NOT, OR MIGHT NOT BE, COVERED BENEFITS UNDER THIS CERTIFICATE. NO PARTICIPATING PROVIDER OR OTHER PROVIDER, INSTITUTION, FACILITY OR AGENCY IS AN AGENT OR EMPLOYEE OF HMO. Contract Holder: [ ] Contract Holder Number: [ ] Contract Holder Group Agreement Effective Date [Subscriber Number: [ ] Subscriber Name: [ ] Coverage Type: [ ] Subscriber Effective Date: [ l ] This is SAMPLE document. it is provided for illustrative purposes only. TABLE OF CONTENTS Section p age HMO Procedure [# Eligibility and Enrollment # Covered Benefits # Exclusions and Limitations # Termination of Coverage # Continuation and Conversion # Grievance Procedure # Coordination of Benefits # Third Party Liability and Right of Recovery # Responsibility of Members # General Provisions # Definitions #] HMO/FL COC-3 12/99 2 This is SAMPLE document. it is provided for illustrative purposes only. HMO PROCEDURE A. Selecting a Participating Primary Care Physician. At the time of enrollment, each Member should select a Participating Primary Care Physician (PCP) from HMO's Directory of Participating Providers to access Covered Benefits as described in this Certificate. The choice of a PCP is made solely by the Member. If the Member is a minor or otherwise incapable of selecting a PCP, the Subscriber should select a PCP on the Member's behalf. Until a PCP is selected, benefits will be limited to coverage for care of Emergency Medical Conditions. B. The Primary Care Physician. The PCP coordinates a Member's medical care, as appropriate, either by providing treatment or by issuing Referrals to direct the Member to a Participating Provider. The PCP can also order lab tests and x-rays, prescribe medicines or therapies, and arrange hospitalization. Except in an Emergency Medical Condition or for certain direct access Specialist benefits as described in this Certificate, only those services which are provided by or referred by a Member's PCP will be covered. Covered Benefits are described in the Covered Benefits section of this Certificate. It is a Member's responsibility to consult with the PCP in all matters regarding the Member's medical care. If the Member's PCP performs, suggests, or recommends a Member for a course of treatment that includes services that are not Covered Benefits, the entire cost of any such non -covered services will be the Member's responsibility. C. Availability of Providers. HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, the Member will be notified and given an opportunity to make another PCP selection. The Member must then cooperate with HMO to select another PCP. Until a PCP is selected, benefits are limited to coverage for care of Emergency Medical Conditions. D. Changing a PCP. A Member may change the PCP at any time by calling the Member Services 800 telephone number listed on the Member's identification card or by written or electronic submission of the HMO's change form. A Member may contact HMO to request a change form or for assistance in completing that form. The change will become effective upon HMO's receipt and approval of the request. E. Ongoing Reviews. HMO conducts ongoing reviews of those services and supplies which arc recommended or provided by Health Professionals to determine whether such services and supplies are Covered Benefits under this Certificate. If HMO determines that the recommended services and supplies are not Covered Benefits, the Member will be notified. If a Member wishes to appeal such determination, the Member may then contact HMO to seek a review of the determination. F. Authorization. Certain services and supplies under this Certificate may require authorization by HMO to determine if they are Covered Benefits under this Certificate. Those services and supplies requiring HMO authorization are indicated in this Certificate. HMO/FL COC-3 12/99 This is SAMPLE document. It is provided for illustrative purposes only. ELIGIBILITY AND ENROLLMENT A. Eligibility. 1. To be eligible to enroll as a Subscriber, an individual must: a. meet all applicable eligibility requirements agreed upon by the Contract Holder and HMO; and b. live or work in the Service Area. 2. To be eligible to enroll as a Covered Dependent, the Contract Holder must provide dependent coverage for Subscribers, and the dependent must be: a. the legal spouse of a Subscriber under this Certificate; or b. a dependent unmarried child (including natural, foster, step, legally adopted children, proposed adoptive children, a child under court order,) who meets the eligibility requirements described on the Schedule of Benefits. 3. A Member who resides outside the Service Area is required to choose a PCP and return to the Service Area for Covered Benefits. Members shall be covered for Emergency Services and Urgent Care services only when obtained outside the Service Area. B. Enrollment. Unless otherwise noted, an eligible individual and any eligible dependents may enroll in HMO regardless of health status, age, or requirements for health services within [31-901 days from the eligibility date. Newly Eligible Individuals and Eligible Dependents. An eligible individual and any eligible dependents may enroll within [31-901 days of the eligibility date. 2. Open Enrollment Period. Eligible individuals or dependents who are eligible for enrollment but do not enroll as stated above, may be enrolled during any subsequent Open Enrollment Period upon submission of complete enrollment information and Premium payment to HMO. f1MO/FL COC-3 12/99 4 This is SAMPLE document. It is provided for illustrative purposes only. Enrollment of Newly Eligible Dependents. a. Newborn Children. A newborn child is covered for 31 days from the date of birth. To continue coverage beyond this initial period, the child must be enrolled in HMO within 60 days of the date of birth. If coverage does not require the payment of an additional Premium for a Covered Dependent, the Subscriber must still enroll the child within 60 days of the date of birth. A newborn of a Covered Dependent, other than the spouse of the subscriber or subscriber, is covered for 18 months from the date of birth. At the end of the 18 month period, coverage for the newborn will be terminated and the Member will not be eligible for conversion. The newborn should be enrolled within 60 days from the date of birth, however, failure to enroll the newborn within this time frame will not result in denial of coverage. The coverage for newly born, newly born adopted children, adopted children, and children placed for adoption consists of coverage of injury and sickness, including the necessary care and treatment of congenital defects and birth abnormalities or prematurity, and within the limits of this Certificate. Coverage includes necessary transportation costs from place of birth to the nearest specialized Participating treatment center. b. Adopted Children. A legally adopted child or a child for whom a Subscriber is a court appointed legal guardian, and who meets the definition of a Covered Dependent, will be treated as a dependent from the date of adoption or upon the date the child was placed for adoption with the Subscriber. "Placed for adoption" means the assumption and retention of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The placement must take effect on or after the date a Subscriber's coverage becomes effective. The initial coverage will not he affected by any provision in this Certificate which limits coverage as to a preexisting condition. 4. Special Rules Which Apply to Children. a. Qualified Medical Support Order. Coverage is available for a dependent child not residing with a Subscriber and who resides outside the Service Area, if there is a qualified medical child support order requiring the Subscriber to provide dependent health coverage for a non-resident child, and is issued on or after the date the Subscriber's coverage becomes effective. The child must meet the definition of a Covered Dependent, and the Subscriber must make a written request for coverage within 31 days of the court order. The initial coverage will not be affected by any provision in this Certificate which limits coverage as to a preexisting condition. HMO/FL COC-3 12/99 This is SAMPLE document. It is provided for illustrative purposes only. b. Handicapped Children. Coverage is available for a child who is chiefly dependent upon the Subscriber for support and maintenance, and who is 19 years of age or older but incapable of self- support due to mental or physical incapacity. The incapacity must have commenced prior to the age the dependent lost eligibility. Proof of continued incapacity, including a medical examination, must be submitted to HMO upon denial of a claim for the reason of the child's attainment of the age specified on the Schedule of Benefits. This eligibility provision will no longer apply on the date the dependent's incapacity ends. Notification of Change in Status. It shall be a Member's responsibility to notify HMO of any changes which affect the Member's coverage under this Certificate. Such status changes include, but are not limited to, change of address, change of Covered Dependent status, and enrollment in Medicare or any other group health plan of any Member. Additionally, if requested, a Subscriber must provide to HMO, within 31 days of the date of the request, evidence satisfactory to HMO that a dependent meets the eligibility requirements described in this Certificate. An eligible individual and any eligible dependents may be enrolled if the eligible individual's spouse was covered under another health benefit plan and lost coverage because of termination of coverage, for reasons other than gross misconduct, within 31 days of the loss of coverage even though it is not during the Open Enrollment Period. The eligible individual or the eligible dependent will not be subject to the late enrollment provision described below. HMO's completed change form must be submitted to the Contract Holder within 31 days of the event causing the change in status. An eligible individual and any eligible dependents may be enrolled during a special enrollment period. A special enrollment period occurs when: a. an eligible individual or an eligible dependent is covered under another group health plan or other health insurance coverage when initially eligible for coverage under HMO; b. the eligible individual or eligible dependent declines coverage in writing under HMO; the eligible individual or eligible dependent loses coverage under the other group health plan or other health insurance coverage for one of the following reasons: the other group health coverage is COBRA continuation coverage under another plan, and the COBRA continuation coverage under that other plan has since been exhausted; or the other coverage is a group health plan or other health insurance coverage, and the other coverage has been terminated as a result of loss of eligibility for the coverage or employer contributions towards the other coverage have been terminated. Loss of eligibility includes a loss of coverage as a result of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment, and any loss of eligibility after a period that is measured by reference to any of the foregoing. HMO/FL COC-3 12/99 This is SAMPLE document. it is provided for illustrative purposes only. Loss of eligibility does not include a loss due to failure of the individual or the participant to pay premiums on a timely basis or due to termination of coverage for cause as referenced in the Termination of Coverage section of the HMO Certificate of Coverage; and d. the eligible individual or eligible dependent enrolls within [30-311 days of the loss; e. there is a life event such as: the marriage or divorce of the Member; ii. the birth, proposed adoption or adoption of a child of the Member. The effective date of coverage shall be the date of birth for a newborn; or the date of adoption, or placement for adoption, in the case of an adopted child. The effective date of coverage will be the first day of the first calendar month following the date the completed request for enrollment is received. The eligible individual or the eligible dependent enrolling during a special enrollment period will not be subject to any late enrollment or preexisting condition provision described in this Certificate. C. Effective Date of Coverage. Coverage shall take effect at 12:01 a.m. on the Member's effective date. Coverage shall continue in effect from month to month subject to payment of Premiums made by the Contract Holder and subject to the Contract Holder Termination section of the Group Agreement. Hospital Confinement on Effective Date of Coverage. If a Member is an inpatient in a Hospital on the Effective Date of Coverage, the Member will be covered as of that date. Such services are not covered if the Member is covered by another health plan on that date and the other health plan is responsible for the cost of the services. HMO will not cover any service that is not a Covered Benefit under this Certificate. To be covered, the Member must utilize Participating Providers and is subject to all the terms and conditions of this Certificate. HMO/FL COC-3 12/99 This is SAMPLE document. It is provided for illustrative purposes only. COVERED BENEFITS A Member shall be entitled to the Covered Benefits as specified below, in accordance with the terms and conditions of this Certificate. Unless specifically stated otherwise, in order for benefits to be covered, they must be Medically Necessary. For the purpose of coverage, HMO may determine whether any benefit provided under the Certificate is Medically Necessary, and HMO has the option to only authorize coverage for a Covered Benefit performed by a particular Provider. Preventive care, as described below, will be considered Medically Necessary. To be Medically Necessary, the service or supply must: • be care or treatment as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the Member's overall health condition; • be care or services related to diagnosis or treatment of an existing illness or injury, except for covered periodic health evaluations and preventive and well baby care, as determined by HMO; • be a diagnostic procedure, indicated by the health status of the Member and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the Member's overall health condition; • include only those services and supplies that cannot be safely and satisfactorily provided at home, in a Physician's office, on an outpatient basis, or in any facility other than a Hospital, when used in relation to inpatient Hospital Services; and • as to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any equally effective service or supply in meeting the above tests. In determining if a service or supply is Medically Necessary, HMO's Patient Management Medical Director or its Physician designee will consider: • information provided on the Member's health status; • reports in peer reviewed medical literature; • reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; • professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment; • the opinion of Health Professionals in the generally recognized health specialty involved; • the opinion of the attending Physicians, which have credence but do not overrule contrary opinions; and • any other relevant information brought to HMO's attention. All Covered Benefits will be covered in accordance with the guidelines determined by HMO. HMO/FL COC-3 12/99 8 This is SAMPLE document. It is provided for illustrative purposes only. If a Member has questions regarding coverage under this Certificate, the Member may call the Member Services 800 telephone number listed on the Member's identification card. THE MEMBER IS RESPONSIBLE FOR PAYMENT OF THE APPLICABLE COPAYMENTS LISTED ON THE SCHEDULE OF BENEFITS. EXCEPT FOR DIRECT ACCESS SPECIALIST BENEFITS OR IN AN EMERGENCY MEDICAL CONDITION OR URGENT CARE SITUATION AS DESCRIBED IN THIS CERTIFICATE, THE FOLLOWING BENEFITS MUST BE ACCESSED THROUGH THE PCP'S OFFICE THAT IS SHOWN ON THE MEMBER'S IDENTIFICATION CARD, OR ELSEWHERE UPON PRIOR REFERRAL ISSUED BY THE MEMBER'S PCP. CERTAIN COVERED MEDICAL SERVICES MAY BE PROVIDED, UNDER THE DIRECTION OF A LICENSED PARTICIPATING PHYSICIAN, BY PHYSICIAN ASSISTANTS, NURSE PRACTITIONERS OR OTHER INDIVIDUALS WHO ARE NOT LICENSED PHYSICIANS. MEMBERS HAVE THE RIGHT TO A SECOND MEDICAL OPINION IN ANY INSTANCE IN WHICH THE MEMBER DISPUTES HMO's OR THE TREATING PHYSICIAN'S OPINION OF THE REASONABLENESS OR NECESSITY OF SURGICAL PROCEDURES OR IS SUBJECT TO A SERIOUS INJURY OR ILLNESS. The second opinion, if requested by a Member, is to be provided by a physician chosen by the Member who may select a Participating Physician or a Non -Participating Physician located in the same geographical service are of HMO. If a Member elects a Non -Participating Physician to render a second opinion, any diagnostic tests or further referrals must be coordinated by the Member's Participating Primary Care Physician and/or HMO. A. Primary Care Physician Benefits. office visits during office hours. 2. Home visits. After-hours PCP services. PCPs are required to provide or arrange for on -call coverage 24 hours a day, 7 days a week. If a Member becomes sick or is injured after the PCP's regular office hours, the Member should: a. call the PCP's office; and identify himself or herself as a Member; and C. follow the PCP's or covering Physician's instructions. If the Member's injury or illness is an Emergency Medical Condition, the Member should follow the procedures outlined under the Emergency Care/Urgent Care Benefits section of this Certificate. Hospital visits. HMO/FL COC-3 12/99 This is SAMPLE document. it is provided for illustrative purposes only. 5. Periodic health evaluations to include: a. well child care from birth including immunizations and booster doses of all immunizing agents used in child immunizations which conform to the standards of the Advisory Committee on Immunization Practices of the Centers for Disease Control, U.S. Department of Health and Human Services. b. routine physical examinations. C. routine gynecological examinations, including pap smears, for routine care, administered by the PCP. Or the Member may also go directly to a Participating gynecologist without a Referral for routine GYN examinations and pap smears. See the Direct Access Specialist Benefits section of this Certificate for a description of these benefits. d. routine hearing screenings. C. immunizations (but not if solely for the purpose of travel or employment). f. routine vision screenings. 6. Injections, including allergy desensitization injections. 7. Casts and dressings. 8. Health Education Counseling and Information. 9. Child Health Supervision Services for children from birth through age 16, including a physical examination, developmental assessment; anticipatory guidance, appropriate immunizations and laboratory tests as Medically Necessary. Such services and periodic visits shall be provided in accordance with prevailing medical standards consistent with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics. B. Diagnostic Services. Services include, but are not limited to, the following: 1. diagnostic, laboratory, and x-ray services. 2. mammograms, by a Participating Provider, The Member is required to obtain a Referral from her PCP or gynecologist, or obtain prior authorization from HMO to a Participating Provider, prior to receiving this benefit. Screening mammogram benefits for female Members are provided as follows: age 35 to 39, one baseline mammography • age 40 and older, one routine mammography every year; or one or more mammograms a year, based upon a Physician's recommendation for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy -proven benign breast disease, because of having a mother, sister, or daughter who has had breast cancer, or because a woman has not given birth before the age of 30. HMO/FL COC-3 12/99 10 This is SAMPLE document. It is provided for illustrative purposes only. C. Specialist Physician Benefits. Covered Benefits include outpatient and inpatient services. D. Direct Access Specialist Benefits. The following services are covered without a Referral when rendered by a Participating Provider. Routine Gynecological Examination(s). Routine gynecological visit(s) and pap smear(s). The number of visits, if any, is listed on the Schedule of Benefits. • Direct Access to Dermatologists. Benefits are provided for Members for dermatological services performed by a Participating Dermatologist limited to office visits, minor procedures and testing. The number of visits, if any, is listed on the Schedule of Benefits. • Open Access to Gynecologists. Benefits are provided to female Members for services performed by a Participating gynecologist for diagnosis and treatment of gynecological problems. See the Infertility Services section of this Certificate for a description of Infertility benefits. [ • Routine Eye Examinations, including refraction, as follows: 1. if Member is age 1 through 18 and wears eyeglasses or contact lenses, one exam every 12-month period. 2. if Member is age 19 and over and wears eyeglasses or contact lenses, one exam every 24- month period. 3. if Member is age 1 through 45 and does not wear eyeglasses or contact lenses, one exam every 36-month period. 4. if Member is age 46 and over and does not wear eyeglasses or contact lenses, one exam every 24-month period.] [ • Preventive Dental Care for Members under the age of 12. Benefits are limited to: Oral prophylaxis (cleaning) as necessary; Topical application of fluorides and the prescription of fluorides for systematic use when not available in the community water supply; and Oral examination and hygiene instruction.] E. Maternity Care and Related Newborn Care. Outpatient and inpatient pre -natal and postpartum care and obstetrical services provided by Participating Providers are a Covered Benefit. Services may be provided by Participating nurse -midwives, midwives and/or birth centers if available in HMO's Service Area. To be covered for these benefits, the Member must choose a Participating obstetrician from HMO's list of Participating Providers and inform HMO by calling the Member Services 800 telephone number listed on the Member's identification card, prior to receiving services. The Participating Provider is responsible for obtaining prior authorization for all obstetrical care from HMO after the first prenatal visit. HMO/FL COC-3 12/99 11 This is SAMPLE document. It is provided for illustrative purposes only. Coverage is provided for postdelivery care for the Member and her newborn infant. Coverage will include a postpartum assessment and newborn assessment to be provided at the hospital, the attending Physician's office, an outpatient maternity center or in the Member's home by a qualified licensed health care professional trained in mother and baby care. The services will include physical assessment o the newborn and mother, and the performance of any Medically Necessary clinical tests and immunizations in keeping with prevailing medical standards which are Covered Benefits under this Certificate. Coverage does not include routine maternity care (including delivery) received while outside the Service Area unless the Member receives prior authorization from HMO. As with any other medical condition, Emergency Services are covered when Medically Necessary. F. Inpatient Hospital & Skilled Nursing Facility Benefits. A Member is covered for services only at Participating Hospitals and Participating Skilled Nursing Facilities. All services are subject to preauthorization by HMO. In the event that the Member elects to remain in the Hospital or Skilled Nursing Facility after the date that the Participating Provider and/or the HMO Medical Director has determined and advised the Member that the Member no longer meets the criteria for continued inpatient confinement, the Member shall be fully responsible for direct payment to the Hospital or Skilled Nursing Facility for such additional Hospital, Skilled Nursing Facility, Physician and other Provider services, and HMO shall not be financially responsible for such additional services. As an exception to the Medically Necessary requirements of this Certificate, the following coverage is provided for a mother and newly born child: a minimum of 48 hours of inpatient care in a Participating Hospital following a vaginal delivery; 2. a minimum of 96 hours of inpatient care in a Participating Hospital following a cesarean section; or a shorter Hospital stay, if requested by a mother, and if determined to be medically appropriate by the Participating Providers in consultation with the mother. If a Member requests a shorter Hospital stay, the Member will be covered for one home health care visit scheduled to occur within 24 hours of discharge. An additional visit will be covered when prescribed by the Participating Provider. This benefit is in addition to the home health maximum number of visits, if any, shown on the Schedule of Benefits. A Copayment will not apply for home health care visits. Coverage for Skilled Nursing Facility benefits is subject to the maximum number of days, if any, shown on the Schedule of Benefits. G. Transplants. Transplants, including bone marrow transplants approved by the Florida Agency for Health Care Administration, which are non -experimental or non -investigational are a Covered Benefit. Covered transplants must be ordered by the Member's PCP and Participating Specialist Physician and approved by HMO's Medical Director in advance of the surgery. The transplant must be performed at Hospitals specifically approved and designated by HMO to perform these procedures. A transplant is non - experimental and non -investigational hereunder when HMO has determined, in its sole discretion, that the Medical Community has generally accepted the procedure as appropriate treatment for the specific condition of the Member. Coverage for a transplant where a Member is the recipient includes coverage for the medical and surgical expenses of a live donor, HMO/FL COC-3 12/99 12 This is SAMPLE document. It is provided for illustrative purposes only. H. Outpatient Surgery Benefits. Coverage is provided for outpatient surgical services and supplies in connection with a covered surgical procedure when furnished by a Participating outpatient surgery center. All services and supplies are subject to preauthorization by HMO. [I. Substance Abuse Benefits. A Member is covered for the following services as authorized and provided by Participating Behavioral Health Providers. Outpatient care benefits are covered for Detoxification. Benefits include diagnosis, medical treatment and medical referral services (including referral services for appropriate ancillary services) by the Member's PCP for the abuse of or addiction to alcohol or drugs. [Rehabilitation services are not covered.] [Member is entitled to outpatient visits to a Participating Behavioral Health Provider upon Referral by the PCP for diagnostic, medical or therapeutic Rehabilitation services for Substance Abuse. Coverage is subject to the limits, if any, shown on the Schedule of Benefits.] Inpatient care benefits are covered for Detoxification. Benefits include medical treatment and referral services for Substance Abuse or addiction. The following services shall be covered under inpatient treatment: lodging and dietary services; Physicians, psychologist, nurse, certified addictions counselor and trained staff services; diagnostic x-ray; psychiatric, psychological and medical laboratory testing; and drugs, medicines, equipment use and supplies. [Rehabilitation services are not covered.] [Member is entitled to medical, nursing, counseling or therapeutic Rehabilitation services in an inpatient, non -hospital residential facility, appropriately licensed by the Department of Health, upon referral by the Member's Participating Behavioral Health Provider for alcohol or drug abuse or dependency. Coverage is subject to the limits, if any, shown on the Schedule of Benefits.] ] [7. Mental Health Benefits. A Member is covered for services for the treatment of the following Mental or Behavioral Conditions through Participating Behavioral Health Providers. Outpatient benefits are covered for short-term, outpatient evaluative and crisis intervention or home health mental health services, and is subject to the maximum number of visits, if any, shown on the Schedule of Benefits. [2. Inpatient benefits may be covered for medical, nursing, counseling or therapeutic services in an inpatient, non -hospital residential facility, appropriately licensed by the Department of Health or its equivalent. Coverage, if applicable, is subject to the maximum number of days, if any, shown on the Schedule of Benefits. Inpatient benefit exchanges are a Covered Benefit. When authorized by HMO, 1 mental health inpatient day, if any, may be exchanged for up to 4 outpatient or home health visits. This is limited to an exchange of up to a maximum of 10 inpatient days for a maximum of 40 additional outpatient visits. One (1) inpatient day, if any, may be exchanged for 2 days of treatment in a Partial Hospitalization and/or outpatient electroshock therapy (ECT) program in lieu of hospitalization up to the maximum benefit limitation upon approval by HMO. HMO/FL COC-3 12/99 13 This is SAMPLE document. It is provided for illustrative purposes only. Requests for a benefit exchange must be initiated by the Member's Participating Behavioral Health Provider under the guidelines set forth by the HMO. Member must utilize all outpatient mental health benefits, if any, available under the Certificate and pay all applicable Copayments before an inpatient and outpatient visit exchange will be considered. The Member's Participating Behavioral Health Provider must demonstrate Medical Necessity for extended visits and be able to support the need for hospitalization if additional visits were not offered. Request for exchange must be approved in writing by HMO prior to utilization.] K. Emergency Care/Urgent Care Benefits. A Member is covered for Emergency Services and Care, provided the service is a Covered Benefit The determination as to whether an Emergency Medical Condition exists shall be made by a Physician of the hospital or, as permitted by Florida law, by other appropriate licensed hospital personnel under the supervision of the hospital Physician. Coverage shall be provided for screening, evaluation and examination reasonably necessary to determine whether an Emergency Medical Condition exists. The Copayment for an emergency room visit as described on the Schedule of Benefits will not apply either in the event that the Member was referred for such visit by the Member's PCP for services that should have been rendered in the PCP's office or if the Member is admitted into the Hospital. The Member will be reimbursed for the cost for Emergency Services and Care rendered by a non -participating Provider located either within or outside the HMO Service Area, for those expenses, less Copayments, which are incurred up to the time the Member is determined by HMO and the attending Physician to be medically able to travel or to be transported to a Participating Provider. In the event that transportation is Medically Necessary, the Member will be reimbursed for the cost as determined by HMO, minus any applicable Copayments. Reimbursement may be subject to payment by the Member of all Copayments which would have been required had similar benefits been provided during office hours and upon prior Referral to a Participating Provider. Medical transportation is covered during an Emergency Medical Condition. The Member will be covered for Urgent Care services obtained from a licensed Physician or facility outside of the Service Area if: a. the service is a Covered Benefit; b. a Member could not reasonably have anticipated the need for such care prior to leaving the Service Area; and C. a delay in receiving services and supplies until a Member could reasonably return and receive care from a Participating Provider would have caused serious deterioration of the Member's health. 3. A Member is covered for any follow-up care. Follow-up care is any care directly related to the need for emergency care which is provided to a Member after the Emergency Medical Condition or Urgent Care situation has terminated. All follow-up and continuing care must be provided or arranged by a Member's PCP. The Member must follow this procedure, or the Member will be responsible for payment for all services received. HMO/FL COC-3 12/99 14 This is SAMPLE document. It is provided for illustrative purposes only. M. Rehabilitation Benefits. 1. Inpatient and Outpatient Rehabilitation Benefits. The following benefits are covered by Participating Providers upon Referral issued by the Member's PCP and approved by HMO in advance of treatment. a. Cardiac rehabilitation benefits are available as part of a Member's inpatient Hospital stay. A limited course of outpatient cardiac rehabilitation is covered when Medically Necessary following angioplasty, cardiovascular surgery, congestive heart failure or myocardial infarction. b. Pulmonary rehabilitation benefits are available as part of a Member's inpatient Hospital stay. A limited course of outpatient pulmonary rehabilitation is covered when Medically Necessary for the treatment of reversible pulmonary disease states. 2. Outpatient Rehabilitation Benefits. The following benefits are covered by Participating Providers upon Referral issued by the Member's PCP and approved by HMO in advance of treatment. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. a. Cognitive therapy associated with physical rehabilitation is covered for non -chronic conditions and acute illnesses and injuries as part of a treatment plan coordinated with HMO. b. Physical therapy is covered for non -chronic conditions and acute illnesses and injuries. C. Occupational therapy (except for vocational rehabilitation or employment counseling) is covered for non -chronic conditions and acute illnesses. d. Speech therapy is covered for non -chronic conditions and acute illnesses and injuries. Services rendered for the treatment of delays in speech development, unless resulting from disease, injury, or congenital defects, are not covered. N. Horne Health Benefits. The following services are covered when rendered by a Participating home health care agency. Preauthorization must be obtained from the Member's attending Participating Physician. HMO shall not be required to provide home health benefits when HMO determines the treatment setting is not appropriate, or when there is a more cost effective setting in which to provide appropriate care. Coverage is subject to the maximum number of visits, if any, shown on the Schedule of Benefits. 1. Skilled nursing services for a Homebound Member. Treatment must be provided by or supervised by a registered nurse. 2. Services of a home health aide. These services are covered only when the purpose of the treatment is Skilled Care. 3. Medical social services. Treatment must be provided by or supervised by a qualified medical Physician or social worker, along with other Home Health Services. The PCP must certify that such services are necessary for the treatment of the Member's medical condition. HMO/FL COC-3 12/99 is This is SAMPLE document. It is provided for illustrative purposes only. 4. Short-term physical, speech, or occupational therapy is covered. Services are subject to the limitations listed in the Rehabilitation Benefits section of this Certificate. Q. Hospice Benefits. Hospice Care services for a terminally ill Member are covered when preauthorized by HMO. Services may include home and Hospital visits by nurses and social workers; pain management and symptom control; instruction and supervision of a family Member; inpatient care; counseling and emotional support; and other home health benefits listed above. Coverage is not provided for bereavement counseling, funeral arrangements, pastoral counseling, financial or legal counseling. Homemaker or caretaker services, and any service not solely related to the care of the Member, including but not limited to, sitter or companion services for the Member or other Members of the family, transportation, house cleaning, and maintenance of the house are not covered. [Coverage is not provided for Respite Care.] P. Prosthetic Appliances. The Member's initial provision of a prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease or injury or congenital defects is covered, when such device is prescribed by a Participating Provider and authorized in advance by HMO. Coverage includes repair and replacement when due to congenital growth. Instruction and appropriate services required for the Member to properly use the item (such as attachment or insertion) are covered. Coverage is provided for prosthetic devices incidental to a covered Mastectomy. [Replacement prosthetic devices that temporarily or permanently replace all or part of an external body part lost or impaired as a result of disease or injury or congenital defects arc covered, when such devices are prescribed by a Participating Provider and authorized in advance by HMO. Coverage includes repair and replacement when due to congenital growth. Instruction and appropriate services required for the Member to properly use the item (such as attachment or insertion) are covered. ] Q. Injectable Medications. Injectable medications, including those medications intended to be self administered, are a Covered Benefit when an oral alternative drug is not available, unless specifically excluded as described in the Exclusions and Limitations section of this Certificate. Medications must be prescribed by a Provider licensed to prescribe federal legend prescription drugs or medicines, and approved in advance of treatment by HMO. If the drug therapy treatment is approved for self -administration, the Member is required to obtain covered medications at an HMO Participating pharmacy designated to fill injectable prescriptions. Injectable drugs or medication used for the treatment of cancer or HIV are covered when the off -label use of the drug has not been approved by the FDA for that indication, provided that such drug is recognized for treatment of such indication in one of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) and the safety and effectiveness of use for this indication has been adequately demonstrated by at least one study published in a nationally recognized peer reviewed journal. R. Infertility Services. Infertility services are covered upon prior authorization by HMO when provided by a Participating Provider. Benefits include, but are not limited to, services to diagnose and treat the underlying medical cause of Infertility which are furnished to a Member. HMO/FL COC-3 12/99 16 This is SAMPLE document. it is provided for illustrative purposes only. S. Diabetic Supplies and Equipment. Subject to the applicable Copayment, coverage is provided for equipment, supplies and education services for the treatment of diabetic conditions are covered when ordered or prescribed by a Participating Physician and obtained through a Participating Provider. Coverage also includes diabetes outpatient self -management training and educational services used to treat diabetes as Medically Necessary. Such education must be provided under the direct supervision of a Participating certified diabetes educator or a Participating board -certified endocrinologists. T. Osteoporosis. Coverage is provided for the Medically Necessary diagnosis and treatment of osteoporosis for high -risk Members, including but not limited to Members who: are estrogen -deficient and are at clinical risk for osteoporosis; have vertebral abnormalities, are receiving long-term glucocorticoid (steroid) therapy, have primary hyperparathyroidism, and have a family history of osteoporosis. U. Reconstructive Breast Surgery resulting from a Mastectomy is covered. Coverage includes reconstruction of the breast on which the Mastectomy is performed including aereolar reconstruction and the insertion of a breast implant; surgery and reconstruction performed on the non -diseased breast to establish symmetry when reconstructive breast surgery on the diseased breast has been performed; and Medically Necessary physical therapy to treat the complications of Mastectomy, including lymphedema. Coverage is provided for inpatient care following a Mastectomy until the completion of the appropriate period of stay for such inpatient care, as determined by the attending Physician in consultation with the Member. Coverage will also be provided for the number of outpatient follow-up visits as determined to be appropriate by the attending Physician after consultation with the Member. The outpatient follow-up visit(s) must be conducted by a Physician, a physician's assistant or a registered professional nurse with experience in post- surgical care. In consultation with the Member, the attending Physician, physician's assistant or registered professional nurse will determine whether any outpatient follow-up visit(s) will be conducted at home or at the office. V. Cleft Lip and Palate Benefits. Orthodontics, oral surgery, otologic, nutrition services, audiological and speech/language treatment involved in the management of birth defects known as cleft lip or cleft palate or both. This includes both inpatient and outpatient treatment. W. Additional Benefits. General Anesthesia for Dental Care. Coverage is provided for general anesthesia and associated hospital or ambulatory facility charges in conjunction with dental care provided to a Member if the Member is: under 8 years of age and determined by a licensed dentist and the child's Physician to require necessary dental treatment in a hospital or ambulatory surgical enter due to a significantly complex dental condition or a developmental disability in which patient management in the dental office has proved to be ineffective; or — an individual who has one or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental treatment or surgery if not rendered in a hospital or ambulatory surgical center. Coverage is NOT provided for dental services associated with general anesthesia and associated hospital or ambulatory facility charges except as otherwise provided in this Certificate or a rider to this Certificate. HMO/FL COC-3 12/99 17 This is SAMPLE document. It is provided for illustrative purposes only. ` Subluxation Benefits. Services by a Participating Provider when Medically Necessary are covered. Services must be consistent with HMO guidelines for spinal manipulation to correct a muscular skeletal problem or Subluxation which could be documented by diagnostic x-rays performed by an HMO Participating radiologist. Coverage is subject to the maximum number of visits, if any, shown on the Schedule of Benefits. A Copayment, a maximum annual out-of-pocket payment, and a maximum annual benefit may apply to this service. Refer to the Schedule of Benefits attached to this Certificate. [ • Durable Medical Equipment Benefits. Durable Medical Equipment will be provided when preauthorized by HMO. The wide variety of Durable Medical Equipment and continuing development of patient care equipment makes it impractical to provide a complete listing, therefore, the HMO Medical Director has the authority to approve requests on a case -by -case basis. Covered Durable Medical Equipment includes those items covered by Medicare unless excluded in the Exclusions and Limitations section of this Certificate. HMO reserves the right to provide the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of HMO. Instruction and appropriate services required for the Member to properly use the item, such as attachment or insertion, is also covered upon preauthorization by HMO. Replacement, repairs and maintenance are covered only if it is demonstrated to the HMO that: it is needed due to a change in the Member's physical condition; or it is likely to cost less to buy a replacement than to repair the existing equipment or to rent like equipment. All maintenance and repairs that result from a misuse or abuse are a Member's responsibility. A Copayment, a maximum annual out-of-pocket payment, and a maximum annual benefit may apply to this service. Refer to the Schedule of Benefits attached to this Certificate.] EXCLUSIONS AND LIMITATIONS A. Exclusions. The following are not Covered Benefits except as described in the Covered Benefits section of this Certificate or by a rider attached to this Certificate: • Ambulance services, for routine transportation to receive outpatient or inpatient services. Beam neurologic testing. • Biofeedback, except as specifically approved by HMO. • Care for conditions that state or local law require to be treated in a public facility, including but not limited to, mental illness commitments. • Care furnished to provide a safe surrounding, including the charges for providing a surrounding free from exposure that can worsen the disease or injury. HMO/FL COC-3 12/99 18 This is SAMPLE document. It is provided for illustrative purposes only. Cosmetic Surgery, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery, other than Medically Necessary Services. This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. Reduction mammoplasty, except when determined to be Medically Necessary by an HMO Medical Director, is not covered. This exclusion does not apply to surgery to correct the results of injuries when performed within 2 years of the event causing the impairment, or as a continuation of a staged reconstruction procedure, or congenital defects necessary to restore normal bodily functions, including but not limited to, cleft lip and cleft palate. • Costs for services resulting from the commission or attempt to commit a felony by the Member. • Court ordered services, or those required by court order as a condition of parole or probation. • Custodial Care. • Dental services, including but not limited to, services related to the care, filling, removal or replacement of teeth and treatment of injuries to or diseases of the teeth. dental services related to the gums, including but not limited to, apicoectomy (dental root resection), orthodontics, root canal treatment, soft tissue impactions, alveolectomy, augmentation and vestibuloplasty treatment of periodontal disease, prosthetic restoration of dental implants, and dental implants. This exclusion does not include bone fractures, removal of tumors, and orthodontogenic cysts. Educational services and treatment of behavioral disorders, together with services for remedial education including evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental and learning disorders, behavioral training, and cognitive rehabilitation. This includes services, treatment or educational testing and training related to behavioral (conduct) problems, learning disabilities, or developmental delays. Special education, including lessons in sign language to instruct a Member, whose ability to speak has been lost or impaired, to function without that ability, are not covered. Experimental or Investigational Procedures, or ineffective surgical, medical, psychiatric, or dental treatments or procedures, research studies, or other experimental or investigational health care procedures or pharmacological regimes as determined by HMO, unless approved by HMO prior to the treatment being rendered. This exclusion will not apply with respect to drugs; that have been granted treatment investigational new drug (IND) or Group c/treatment IND status; that are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute; or HMO has determined that available scientific evidence demonstrates that the drug is effective or the drug shows promise of being effective for the disease. False teeth. Hair analysis. Health services, including those related to pregnancy, rendered before the effective date or after the termination of the Member's coverage, unless coverage is continued under the Continuation and Conversion section of this Certificate. HMQ/FL COC-3 12/99 19 This is SAMPLE document. It is provided for illustrative purposes only. • Hearing aids. • Household equipment, including but not limited to, the purchase or rental of exercise cycles, water purifiers, hypo -allergenic pillows, mattresses or waterbeds, whirlpool or swimming pools, exercise and massage equipment, central or unit air conditioners, air purifiers, humidifiers, dehumidifiers, escalators, elevators, ramps, stair glides, emergency alert equipment, handrails, heat appliances, improvements made to a Member's house or place of business, and adjustments made to vehicles. • Hypnotherapy, except when specifically approved by HMO. • Implantable drugs. • Infertility services, including the treatment of male and female Infertility, injectable Infertility drugs, charges for the freezing and storage of cryopreserved embryos, charges for storage of sperm, and donor costs, including but not limited to, the cost of donor eggs and donor sperm, the costs for ovulation predictor kits, and the costs for donor egg program or gestational carriers. • Military service related diseases, disabilities or injuries for which the Member is legally entitled to receive treatment at government facilities and which facilities are reasonably available to the Member. • Missed appointment charges, including any charge incurred for a missed appointment with a Participating Provider. • Non -medically necessary services, including but not limited to, those services and supplies: 1. which are not Medically Necessary, as determined by HMO, for the diagnosis and treatment of illness, injury, restoration of physiological functions, or covered preventive services; 2. that do not require the technical skills of a medical, mental health or a dental professional; 3. furnished mainly for the personal comfort or convenience of the Member, or any person who cares for the Member, or any person who is part of the Member's family, or any Provider; 4. furnished solely because the Member is an inpatient on any day in which the Member's disease or injury could safely and adequately be diagnosed or treated while not confined; 5. furnished solely because of the setting if the service or supply could safely and adequately be furnished in a Physician's or a dentist's office or other less costly setting. • Orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision). + Orthotics. • Outpatient prescription or non-prescription drugs and medicines. • Outpatient supplies, including but not limited to, outpatient medical consumable or disposable supplies such as syringes, incontinence pads, elastic stockings, and reagent strips. HMO/FL COC-3 12/99 20 This is SAMPLE document. It is provided for illustrative purposes only. • Payment for benefits for which Medicare or a third party payer is the primary payer. • Personal comfort or convenience items, including those services and supplies not directly related to medical care, such as guest meals and accommodations, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, take-home supplies, and other like items and services. • Private duty or special nursing care, unless pre -authorized by HMO. • Radial keratotomy, including related procedures designed to surgically correct refractive errors. • Recreational, educational, and sleep therapy, including any related diagnostic testing. • Rehabilitation services, for Substance Abuse, including treatment of chronic alcoholism or drug addiction. • Religious, marital and sex counseling, including services and treatment related to religious counseling, marital/relationship counseling, and sex therapy. • Reversal of voluntary sterilizations, including related follow-up care and treatment of complications of such procedures. • Routine foot/hand care, including routine reduction of nails, calluses and corns. • Services for which a Member is not legally obligated to pay in the absence of this coverage. • Services for the treatment of sexual dysfunctions or inadequacies, including therapy, supplies, or counseling for sexual dysfunctions or inadequacies that do not have a physiological or organic basis. • Services performed by a relative of a Member for which, in the absence of any health benefits coverage, no charge would be made. • Services required by third parties, including but not limited to, physical examinations, diagnostic services and immunizations in connection with obtaining or continuing employment, obtaining or maintaining any license issued by a municipality, state, or federal government, securing insurance coverage, travel, school admissions or attendance, including examinations required to participate in athletics, except when such examinations are considered to be part of an appropriate schedule of wellness services. • Services which are not a Covered Benefit under this Certificate, even when a prior Referral has been issued by a PCP. * Specific non-standard allergy services and supplies, including but not limited to, skin titration (wrinkle method), cytotoxicity testing (Bryan's Test), treatment of non-specific candida sensitivity, and urine autoinjections. • Specific injectable drugs, including: experimental drugs or medications, or drugs or medications that have not been proven safe and effective for a specific disease or approved for a mode of treatment by the Food and Drug Administration (FDA) and the National Institutes of Health (NIH); HMO/FL COC-3 12/99 21 This is SAMPLE document. It is provided for illustrative purposes only. 2, needles, syringes and other injectable aids; 3. drugs related to the treatment of non -covered services; and drugs related to the treatment of Infertility, contraception, and performance enhancing steroids. • Special medical reports, including those not directly related to treatment of the Member, e.g., employment or insurance physicals, and reports prepared in connection with litigation. + Surgical operations, procedures or treatment of obesity, except when specifically approved by HMO. • Therapy or rehabilitation, including but not limited to, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetic therapy, vision perception training, and carbon dioxide. • Thermograms and thermography. • Transsexual surgery, sex change or transformation, including any procedure or treatment or related service designed to alter a Member's physical characteristics from the Member's biologically determined sex to those of another sex, regardless of any diagnosis of gender role or psychosexual orientation problems. • 'Treatment in a federal, state, or governmental entity, including care and treatment provided in a non -participating Hospital owned or operated by any federal, state or other governmental entity, except to the extent required by applicable laws. • Treatment of mental retardation, defects, and deficiencies. This exclusion does not apply to mental health services or to medical treatment of mentally retarded Members in accordance with the benefits provided in the Covered Benefits section of this Certificate. • Treatment of occupational injuries and occupational diseases eligible for coverage under a worker's compensation plan, including those injuries that arise out of (or in the course of) any work for pay or profit, or in any way results from a disease or injury which does. However, if proof is furnished to HMO that the Member is covered under a workers' compensation law or similar law, but is not covered for a particular disease or injury under such law, that disease or injury will be considered "non -occupational" regardless of cause. + Unauthorized services, including any service obtained by or on behalf of a Member without prior Referral issued by the Member's PCP or certified by HMO. This exclusion does not apply in an Emergency Medical Condition, in an Urgent Care situation, or when it is a direct access benefit. • Vision care services and supplies. • Weight reduction programs, or dietary supplements. Acupuncture and acupuncture therapy, except when performed by a Participating Physician as a form of anesthesia in connection with covered surgery. [ • Durable Medical Equipment.] HMO/FL COC-3 12/99 22 This is SAMPLE document. It is provided for illustrative purposes only. Family planning services. Services related to the care, filling, removal or replacement of impacted teeth. Temporomandibular joint disorder treatment (TMJ)], including treatment performed by prosthesis placed directly on the teeth. Coverage will be provided for diagnostic or surgical procedures involving the bones or joints of the jaw and facial region if such procedure is Medically Necessary to treat conditions caused by congenital or developmental deformity, disease or injury. Coverage will not be provided for care or treatment of the teeth or gums, for intraoral prosthetic devices, or for surgical procedures for cosmetic purposes. B. Limitations. In the event there are two or more alternative Medical Services which in the sole judgment of HMO are equivalent in quality of care, HMO reserves the right to provide coverage only for the least costly Medical Service, as determined by HMO, provided that HMO approves coverage for the Medical Service or treatment in advance. Determinations regarding eligibility for benefits, coverage for services, benefit denials and all other terms of this Certificate are at the sole discretion of HMO, subject to the terms of this Certificate. DETERMINATIONS REGARDING DENIAL OF BENEFITS DUE TO INAPPROPRITE USE OF THE HMO NETWORK ARE AT THE SOLE DISCRETION OF THE HMO. TERMINATION OF COVERAGE A Member's coverage under this Certificate will terminate upon the earliest of any of the conditions listed below, and termination will be effective on the date indicated on the Schedule of Benefits. A. Termination of Subscriber Coverage. A Subscriber's coverage will terminate for any of the following reasons: 1. employment terminates; 2. the Group Agreement terminates; 3. the Subscriber is no longer eligible as outlined on the Schedule of Benefits; or 4. the Subscriber becomes covered under an alternative health benefit plan or under any other plan which is offered by, through, or in connection with, the Contract Holder in lieu of coverage under this Certificate. B. Termination of Dependent Coverage. A Covered Dependent's coverage will terminate for any of the following reasons: a Covered Dependent is no longer eligible, as outlined on the Schedule of Benefits; the Group Agreement terminates; or HMO/FL COC-3 12/99 23 This is SAMPLE document. It is provided for illustrative purposes only. the Subscriber's coverage terminates. C. Termination For Cause. HMO may terminate coverage for cause: 1. subject to the Grievance Procedure described in this Certificate, upon 45 days advance written notice, if the Member is unable to establish or maintain, after repeated attempts, a satisfactory physician -patient relationship with a Participating Provider. Notice shall be given by certified mail and return receipt requested. At the effective date of such termination, prepayments received by HMO on account of such terminated Member or Members for periods after the effective date of termination shall be refunded to the Contract Holder. 2. upon 45 days advance written notice, for misuse of the HMO identification membership card. 3. upon 45 days advance written notice, if the Member refuses to cooperate with HMO as required by the Group Agreement. 4. immediately, upon discovering a material misrepresentation by the Member in applying for or obtaining coverage or benefits under this Certificate or discovering that the Member has committed fraud against HMO. This may include, but is not limited to, furnishing incorrect or misleading information to HMO, or allowing or assisting a person other than the Member named on the identification card to obtain HMO benefits. HMO may, at its discretion, rescind a Member's coverage on and after the date that such misrepresentation or fraud occurred. It may also recover from the Member the reasonable and recognized charges for Covered Benefits, plus HMO's cost of recovering those charges, including reasonable attorneys' fees. In the absence of fraud or material misrepresentation, all statements made by any Member or any person applying for coverage under this Certificate will be deemed representations and not warranties. No statement made for the purpose of obtaining coverage will result in the termination of coverage or reduction of benefits unless the statement is contained in writing and signed by the Member, and a copy of same has been furnished to the Member prior to termination. immediately, if a Member acts in such a disruptive manner as to prevent or adversely affect the ordinary operations of HMO or a Participating Provider. The advance written notice provided by HMO upon termination shall contain the reason(s) for termination of the coverage. HMO shall have no further liability or responsibility under this Certificate except for coverage for Covered Benefits provided prior to the date of termination of coverage. The fact that Members are not notified by the Contract Holder of the termination of their coverage due to the termination of the Group Agreement shall not deem the continuation of a Members' coverage beyond the date coverage terminates. A Member may request that HMO conduct a grievance hearing, as described in the Grievance Procedure section of this Certificate, within 15 working days after receiving notice that HMO has or will terminate the Member's coverage as described in the Termination For Cause subsection of this Certificate. HMO will continue the Member's coverage in force until a final decision on the grievance is rendered, provided the Premium is paid throughout the period prior to the issuance of that final decision. HMO may rescind coverage, to the date coverage would have terminated had the Member not requested a grievance hearing, if the final decision is in favor of HMO. HMO/FL COC-3 12/99 24 This is SAMPLE document. It is provided for illustrative purposes only. If coverage is rescinded, HMO will refund any Premiums paid for that period after the termination date, minus the cost of Covered Benefits provided to a Member during this period. Coverage will not be terminated on the basis of a Member's health status or health care needs, nor if a Member has exercised the Member's rights under the Certificate's Grievance Procedure to register a complaint against HMO. The grievance process described in the preceding paragraph applies only to those terminations affected pursuant to the Termination for Cause subsection of this Certificate. CONTINUATION AND CONVERSION A. COBRA Continuation Coverage. COBRA is the Consolidated Omnibus Budget Reconciliation Act of 1985 and the Tax Reform Act of 1986. This Act permits Members or Covered Dependents to elect to continue group coverage as follows: Employees and their Covered Dependents will not be eligible for the continuation of coverage provided by this section if the Contract Holder is exempt from the provisions of COBRA. Minimum Size of Group: The Contract Holder must have normally employed more than 20 employees on a typical business day during the preceding calendar year. This refers to the number of employees employed, not the number of employees covered by a health plan, and includes full-time and part-time employees. 2. Loss of coverage due to termination (other than for gross misconduct) or reduction of hours of employment: Member may elect to continue coverage for 18 months after eligibility for coverage under this Certificate would otherwise cease. 3. Loss of coverage due to: a, divorce or legal separation, or b. Subscriber's death, or C. Subscriber's entitlement to Medicare benefits, or, d. cessation of Covered Dependent child status under the Eligibility and Enrollment section of this Certificate: The Member may elect to continue coverage for 36 months after eligibility for coverage under this Certificate would otherwise cease. HMO/FL COC-3 12/99 25 This is SAMPLE document. It is provided for illustrative purposes only. Continuation coverage ends at the earliest of the following events: a. the last day of the 18-month period. b. the last day of the 36-month period. C. the first day on which timely payment of Premium is not made subject to the Premiums section of the Group Agreement. d. the first day on which the Contract Holder ceases to maintain any group health plan. e. the first day on which a Member is actually covered by any other group health plan. In the event the Member has a preexisting condition, and the Member would be denied coverage under the new plan for a preexisting condition, continuation coverage will not be terminated until the last day of the continuation period, or the date upon which the Member's preexisting condition becomes covered under the new plan, whichever occurs first, f. the date the Member is entitled to Medicare. 5. Extensions of Coverage Periods: a. The 18-month coverage period may be extended if an event which would otherwise qualify the Member for the 36-month coverage period occurs during the 18-month period, but in no event may coverage be longer than 36 months from the event which qualified the Member for continuation coverage initially. In the event that a Member is determined, within the meaning of the Social Security Act, to be disabled and notifies the Contract Holder before the end of the initial 18-month period, continuation coverage may be extended up to an additional 11 months for a total of 29 months. This provision is limited to Members who are disabled at any time during the first 60 days of continuation coverage under this subsection (A) and only when the qualifying event is the Members reduction in hours or termination. The Member may be charged a higher rate for the extended period. Responsibility to provide Member with notice of Continuation Rights: The Contract Holder is responsible for providing the necessary notification to Members, within the defined time period (sixty (60) days), as required by the Consolidated Omnibus Budget Reconciliation Act of 1985 and the Tax Reform Act of 1986. 7. Responsibility to pay Premiums to HMO: Coverage for the sixty (60) day period as described above to initially enroll, will be extended only where the Subscriber or Member pays the applicable Premium charges due within forty-five (45) days of submitting the application to the Contract Holder and Contract Holder in turn remitting same to HMO. 8. Premiums due HMO for the continuation of coverage under this section shall be due in accordance with the procedures of the Premiums section of the Group Agreement and shall be calculated in accordance with applicable federal law and regulations. HMO/FL COC-3 12/99 26 This is SAMPLE document. It is provided for illustrative purposes only. B. Continuation of Coverage by HMO. In the event a Subscriber's employment with Contract Holder is terminated involuntarily and without cause, Subscriber shall be entitled to continue coverage, including coverage of Covered Dependents, immediately thereafter, without payment of additional Premium, for a period equal to one month (i.e., the corresponding day of the following month, for example from February 15th to March 15th) for each year that Subscriber has continuously (i.e., no lapse of more than thirty (30) days) maintained coverage with HMO under an eligible Group Agreement, commencing with the date that Subscriber is effective under this section, to a maximum of three months of such coverage. All continued coverage utilized by Subscriber pursuant to this section shall be deducted from Subscriber's accumulated eligibility for continued coverage under this subsection (i.e., if Subscriber has used one (1) month of a three (3) month accumulated continued coverage period, two (2) months will remain until such time as Subscriber again becomes eligible for three (3) months of continued coverage.) To be eligible for and obtain such continued coverage an application must be received by HMO within thirty (30) days after Subscriber's termination of employment and shall include (x) a signed representation from the Subscriber that the Subscriber is not eligible for other comprehensive group health coverage (such as through a spouse or other employer) or Medicare, and (y) a signed written certification from the Contract Holder that the Subscriber's employment was terminated involuntarily and without cause. In the event Subscriber exercises Subscriber's COBRA or other continuation rights under this Certificate, continuation of coverage hereunder shall be in the form of the waiver of the applicable COBRA Premium or other continuation Premium. C. Continuation under Florida Law Florida Statute 627.6692, known as the FLORIDA HEALTH INSURANCE COVERAGE CONTINUATION ACT, which became effective January 1, 1997, requires that employers with fewer than 20 eligible employees offer eligible employees and their families the opportunity for a temporary extension of health coverage (called "continuation coverage") in certain instances where coverage under the plan would otherwise end. This notice is intended to inform the Member, in a summary fashion, of the Member's rights and obligations under the continuation coverage provisions of the law. This summary of rights should be reviewed by the Subscriber, the Subscriber's spouse and Covered Dependents (if applicable), retained with other benefits documents, and referred to in the event that any action is required on the Member's part. If the Subscriber is an employee of an employer with fewer than 20 employees and covered by its group health plan, the Subscriber has a right to choose this continuation coverage in the event of: 1. loss of group health coverage because of a reduction in hours of employment, or; 2. the termination of employment (for reasons other than gross misconduct). If the Member is the covered spouse of an employee, the Member has the right to choose continuation coverage due to loss of group health coverage for any of the following four reasons: Types of Qualifying Events (1) The death of the employee; (2) the termination of the employee's employment (for reasons other than gross misconduct) or a reduction in the employee's hours of employment; (3) divorce or legal separation from the employee; or (4) the employee becomes entitled to Medicare. If the case of a Covered Dependent child of an employee, or covered spouse, he or she has the right to continuation coverage if group health coverage is lost for any of the following six reasons: (1) The death of the employee; HMOTL COC-3 12/99 27 This is SAMPLE document. It is provided for illustrative purposes only. (2) the termination of the employee's employment (for reasons other than gross misconduct) or a reduction in the employee's hours of employment; (3) parent's divorce or legal separation; (4) the employee becomes entitled to Medicare; or (5) the dependent ceases to be a "dependent child" under the terms of the group health plan. (6) The Member also has a right to elect continuation coverage if the Member is covered under the plan as a retiree or spouse or child of a retiree, and loses coverage within one year before or after the commencement of proceedings under Title 11 (bankruptcy) United States Code by the employer from whose employment the covered employee retired. Under the law, qualified beneficiary has the responsibility to inform HMO of a qualified event. This notification must be made within 30 days of the date of the qualifying event which would cause a loss of coverage. The notice must be in writing, and include: (a) the name of the qualified beneficiary; (b) the date of the qualifying event; (c) one of the types of qualifying events as listed above; (d) the name of the employer; (c) the group health plan number; and (f) the name and address of all qualified beneficiaries. When HMO is notified that one of these events has happened, it will in turn notify the Member of the right to choose continuation coverage. Under the law, the Member has 30 days from the date of receipt of the Election and Premium Notice form, to elect continuation coverage. If and when this election is made, return the Election and Premium Notice form with applicable premium to the carrier. Coverage will become effective on the day after coverage would otherwise be terminated. If the Member does not elect coverage and pays the premium, group health insurance coverage will terminate in accordance with the provisions outlined in the benefits handbook or other applicable plan documents. If' the Member chooses continuation coverage, such coverage will be identical to the coverage provided under the plan to similarly situated employees or family members. The law requires that the Member be afforded the opportunity to maintain continuation coverage for 18 months. However, the law also provides that continuation coverage may be terminated for any of the following reasons: (1) The employer/former employer no longer provides group health coverage to any of its employees; (2) the premium for continuation coverage is not paid by the expiration grace period expiration date, which is 30 days; (3) the Member first becomes, after electing continuation coverage, covered under any other group health plan (as an employee or otherwise) which does not contain any exclusion or limitation with respect to any pre-existing condition; or (4) the Member is approved, after electing continuation coverage, for Medicare. HMO/FL COC-3 12/99 28 This is SAMPLE document. It is provided for illustrative purposes only. *Note: A Qualified Beneficiary who is determined under Title II or XVI of the Social Security Act, to have been disabled as of the date of termination of employment or reduction in hours may be eligible to continue coverage for an additional 11 months (29 months total). The Member must notify the HMO within 60 days of receipt of the determination of disability by the Social Security Administration and prior to the end of the 18-month continuation period. The HMO can charge up to 150% of the group rate during the 11- month extension. The qualified beneficiary must notify the HMO within 30 days upon the determination that the qualified beneficiary is no longer disabled under Title I1 or XVI of the Social Security Act. The Member does not have to show that he or she is insurable to choose continuation coverage. However, the Member may have to pay up to 115% of the applicable Premium for continuation coverage. The law also requires that, at the end of the 18-month or 29-month continuation coverage period, the Member must be allowed to enroll in an individual conversion health plan provided under the current group health plan. If the Member has any questions about this, please contact the person or office shown below. Also if the Subscriber has changed marital status or the Subscriber, the Subscriber's spouse, or any eligible Covered Dependent have changed address, please notify in writing this person or office shown below: Aetna U.S. Healthcare, Inc. P.O. Box 30167 Tampa FL 33630-3167 Attn: Tom Striano If any covered child is at a different address, please notify HMO in writing so that a separate notice may be sent by the carrier to the separate household. D. Conversion Privilege. This subsection does not continue coverage under the Group Agreement. It permits the issuance of an individual health care coverage agreement (conversion coverage) under certain conditions. Conversion is not initiated by HMO. The conversion privilege set forth in this subsection must be initiated by the eligible Member. The Contract Holder is responsible for giving notice of the conversion privilege in accordance with its normal procedures; however, in the event continuation coverage ceases pursuant to expiration of COBRA benefits as described in the COBRA Continuation Coverage section of this Certificate or the "Continuation under Florida law" section of the Certificate, the Contract Holder shall notify the Member at some time during the 180-day period prior to the expiration of coverage. Upon notification by the Member to HMO of a request for conversion, HMO shall mail an election and premium notice form, including an outline of coverage for each conversion plan to be offered, within 14 days of receipt of the request. This notice form will provide the Member with information regarding the two conversion plans from which the Member may choose to elect their conversion coverage. Eligibil . In the event a Member ceases to be eligible for coverage under this Certificate and has been continuously enrolled for 3 months under HMO, such person may, within 63 days after termination of coverage under this Certificate, or if termination is a result of failure to pay any required premium, 63 days from the date notice of such termination is mailed to the Contract Holder, convert to individual coverage with HMO, effective as of the date of such termination, without evidence of insurability provided that Member's coverage under this Certificate termi- nated for one of the following reasons: a. Coverage under this Certificate was terminated, and was not replaced with continuous and similar coverage by the Contract Holder within 31 days after termination; or HMO/FL COC-3 12/99 29 This is SAMPLE document. It is provided for illustrative purposes only. The Subscriber ceased to meet the eligibility requirements as described in the Eligibility and Enrollment section of this Certificate, in which case the Subscriber and Subscriber's dependents who are Members pursuant to this Certificate, if any, are eligible to convert; or C. A Covered Dependent ceased to meet the eligibility requirements as described in the Eligibility and Enrollment section of this Certificate because of the Member's age or the death or divorce of Subscriber; or d. Continuation coverage ceased under the COBRA Continuation Coverage section of this Certificate or the "Continuation under Florida law" section of the Certificate. Any Member who is eligible to convert to individual coverage, may do so in accordance with the rules and regulations governing items such as initial payment, the form of the agreement and all terms and conditions thereunder as HMO may have in effect at the time of Member's application for conversion, without furnishing evidence of insurability. The conversion coverage will provide benefits no less than what is then required by, and no benefits contrary to, any applicable law or regulation. However, the conversion coverage may not provide the same coverage, and may be less than what is provided under the Group Agreement. Upon request, HMO or the Contract Holder will furnish details about conversion coverage. 2. A spouse has the right to convert upon the death of or divorce from the Subscriber and a Covered Dependent child has the right to convert upon reaching the age limit or upon death of the Subscriber (subject to the ability of minors to be bound by contract). E. Extension of Benefits While Member is Receiving Inpatient Care. Any Member who is receiving inpatient care in a Hospital or Skilled Nursing Facility on the date coverage under this Certificate terminates is covered in accordance with the Certificate only for the specific medical condition causing that confinement or for complications arising from the condition causing that confinement, until the earlier of: 1. the date of discharge from such inpatient stay; or 2. determination by the HMO Medical Director in consultation with the attending Physician, that care in the Hospital or Skilled Nursing Facility is no longer Medically Necessary; or 3. the date the contractual benefit limit has been reached; or 4. the date the Member becomes covered for similar coverage from another health benefits plan; or 5. 12 months from the termination date of the Group Agreement. The extension of benefits shall not extend the time periods during which a Member may enroll for continuation or conversion coverage, expand the benefits for such coverage, nor waive the requirements concerning the payment of Premium for such coverage. HMO/FL COC-3 12/99 30 This is SAMPLE document. It is provided for illustrative purposes only. F. Continuation of Coverage for a Member Receiving Maternity Benefits HMO will continue to provide covered services if the Contract is terminated while a Member is pregnant, provided that the pregnancy commenced while the Contract was in effect. This Extension of Benefits shall only: (1) provide covered services that are Medically Necessary to treat medical conditions directly related to the pregnancy; and (2) remain in effect until the earlier to occur of the date that: (a) the Member is no longer pregnant; or (b) the Member has exhausted the covered services available for treatment of pregnancy; or (c) the Member becomes eligible for coverage from another health benefit plan which does not exclude coverage for a preexisting maternity condition. G. Extension of Benefits Upon Total Disability. Any Member who is Totally Disabled on the date coverage under this Certificate terminates is covered in accordance with the Certificate, however, no Member is eligible for this extension if termination of the Certificate by HMO was for the one or more of the following reasons: • fraud or material misrepresentation; • termination for cause; or • the Member has relocated outside the HMO Service Area. This extension of benefits shall only: provide Covered Benefits that are necessary to treat medical conditions causing or directly related to the disability as determined by HMO; and 2. remain in effect until the earlier of the date that: a. the Member is no longer Totally Disabled; or b. the Member has exhausted the Covered Benefits available for treatment of that condition; or C. the Member has become eligible for coverage from another health benefit plan which does not exclude coverage for the disabling condition; or d. after a period of twelve (12) months in which benefits under such coverage are provided to the Member. The extension of benefits shall not extend the time periods during which a Member may enroll for continuation or conversion coverage, expand the benefits for such coverage, nor waive the requirements concerning the payment of Premium for such coverage. GRIEVANCE PROCEDURE The following procedures govern complaints, grievances, and grievance appeals made or submitted by Members. A. Definitions. An "inquiry" or "complaint" is a Member's verbal request for administrative service, information, or to express an opinion, including but not limited to, claims regarding scope of coverage for health services, denials, cancellations, terminations or renewals, and the quality of services provided. HMO/FL COC-3 12/99 31 This is SAMPLE document, It is provided for illustrative purposes only. 2. A "grievance" is a written complaint to HMO from a Member or Member's representative on behalf of the Member. B. Grievance Review. Summary of the Procedure Informal In uir A Member should call HMO to discuss any questions or concerns . An HMO representative can be reached at 813-775-0000 or toll -free at 800-323-9930. Representatives can immediately respond to most inquiries. If they cannot respond immediately, they will investigate and either respond to the inquiry or advise Member that they need more time to respond, within 15 working days after the date of that inquiry. Formal Grievance If a Member is not satisfied with the response to their inquiry or chooses to file a written complaint, the Member may file a written grievance with HMO. The grievance must be addressed to Aetna U.S. Healthcare, Inc., Regional Grievance Unit, 11675 Great Oaks Way, Alpharetta, GA 30022. Telephone: 800-323-9930 toll -free. Member must submit a grievance within one (1) year after the occurrence of the action that initiated the grievance. 2. A written notice shall be sent by HMO to the Member: i. acknowledging each grievance; and ii, inviting the Member to provide any additional information to assist HMO in handling and deciding the grievance; and iii, informing the Member of the Member's grievance rights and the grievance process; and iv. informing the Member as to when a response should be forthcoming. 3. The Grievance Review Panel deciding the grievance shall be a majority of providers who have appropriate expertise and not include any person whose decision is being appealed, any person who made the initial decision regarding the claim, or any person with previous involvement with the grievance. The Grievance Review Panel shall review and decide the grievance within 30 days of receipt unless additional information from outside the service area is necessary to resolve the grievance and by the mutual written agreement of HMO and the Member there is a 15 day extension. However, any mutually agreed time frame modification will not preclude the Member from appealing to the Statewide Provider and Subscriber Assistance Panel.. 4. A written notice stating the result of the review by the Grievance Committee shall be forwarded by HMO to the Member. Such notice shall include: a. The decision, in clear terms with contractual (benefits) or clinical (medical appropriateness) rationale; and b. Notification that a list of individuals participating in the review of the grievance, along with titles and credentialing is available upon request; and c. A statement of the reviewers understanding of the pertinent facts of the grievance; and d. Reference to the evidence or documentation used as the basis for the decision; and in cases involving a denial of services, instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used; and HMO/FL COC-3 12/99 32 This is SAMPLE document. It is provided for illustrative purposes only. e. Member/provider notification that the next level of appeal is the Appeal Hearing Panel and must be requested within 10 days of the date of the letter notifying them of an adverse determination; and f. Member notification that they have a right to appear before the Appeal Hearing Panel or the opportunity to communicate with the Panel by conference call or other appropriate technology if unable to appear in person. C. Appeal Hearing. 1. Upon receipt of an appeal hearing request by HMO an acknowledgement letter shall be sent to the Member filing the appeal explaining the procedures governing appeals before the Appeal Hearing Panel. The Member shall be notified of the Member's right to have an uninvolved HMO representative available to assist the Member in understanding the appeal process. 2. The Appeal Hearing Panel shall be established and shall be comprised of at least three jndividuals. The Network Medical Director facilitates the Appeal Hearing. When the appeal involves clinical issues the hearing Panel shall include at least one practitioner in the same or similar specialty that typically manages the medical condition, procedure or treatment. The Appeal Hearing Panel shall not include any person previously involved with the grievance. 3. When possible the Appeal Hearing should be held at times and locations that are reasonably accessible to the Member. The Member has the right to submit additional materials and to have a representative of the Member's choice present including legal representation upon advance written notice to the Plan. HMO will be represented by legal counsel. The Member has the right to have a timely review, within 20 days of the receipt of the request for the hearing. 4. The appeal hearing shall be informal. The Appeal Hearing Panel shall not apply formal rules of evidence in reviewing documentation or accepting testimony at the hearing. 5. A written record of the appeal hearing shall be made by stenographic transcription. 6. Once all evidence and arguments have been received, the record of the appeal hearing shall be closed. The deliberations of the Appeal Hearing Panel shall be confidential and shall not be transcribed. 7. The Appeal Hearing Panel shall render a written decision within 5 working days of the conclusion of the appeal hearing. The decision shall contain: a. a statement of the Appeal Hearing Panel's understanding of the nature of the grievance and the material facts related thereto; and b. the Appeal Hearing Panel's decision and specific rationale; and C. documentation used in making the decision; and HMO/FL COC-3 12/99 33 This is SAMPLE document. It is provided for illustrative purposes only. a statement of the Member's right to request a review of the organization's decision concerning the grievance by Statewide Provider and Subscriber Assistance Program within 365 days after receipt o the final decision letter, and explanation of how to initiate such a review, and the addresses and toll -free numbers of the agency and the Statewide Provider and Subscriber Assistance Program. Agency for Health Care Administration Fort Knox Building One # 306 2727 Mahan Drive Tallahassee, F132308-5403 850-921-5458 or Toll -Free Number: 1-800-226-1062 Statewide Provider and Subscriber Assistance Program Fort Knox Building One Room # 343 2727 Mahan Drive Tallahassee, Fl 32308 850-921-5458 or Toll -Free Number: 1-800-226-1062 D. Emergency or Urgently Needed Care. In the event the issue is of an emergent/urgent nature, an HMO Medical Director that was not involved in the initial adverse decision shall review the matter as soon as possible or within 72 hours, and communicate a decision to the Member and/or provider acting on behalf of the Member by telephone or facsimile, followed by written notification within 2 working days after providing notification of that decision. In any case, when the expedited review process does not resolve the difference of opinion between the organization and the Member or provider acting on behalf of the Member, the Member or provider acting on behalf of the Member may submit a written grievance to the Statewide Provider and Subscriber Assistance Program. An expedited review shall not be provided for a retrospective review of an adverse determination. E. Record Retention. HMO shall retain the records of all grievances for a period of at least 7 years. F. Fees and Costs. Nothing herein shall be construed to required HMO to pay counsel fees or any other fees or costs incurred by a Member in pursuing a grievance or appeal. COORDINATION OF BENEFITS Some Members have health coverage in addition to the coverage provided under this Certificate. When this is the case, the benefits paid by other plans will be taken into account. This may mean a reduction in benefits payable under this Certificate. When coverage under this Certificate and coverage under another plan applies, the order in which the various plans will pay benefits must be figured. This will be done as follows using the first rule that applies: HMO/FL COC-3 12/99 34 This is SAMPLE document. It is provided for illustrative purposes only. A. A plan with no rules for coordination with other benefits will be deemed to pay its benefits before a plan which contains such rules. B. A plan which covers a person other than as a dependent will be deemed to pay its benefits before a plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary and as a result of the Social Security Act of 1965, as amended, Medicare is: 1. secondary to the plan covering the person as a dependent; and primary to the plan covering the person as other than a dependent; the benefits of a plan which covers the person as a dependent will be determined before the benefits of a plan which: covers the person as other than a dependent; and 2. is secondary to Medicare. C. Except in the case of a dependent child whose parents are divorced or separated, the plan which covers the person as a dependent of a person whose birthday comes first in a calendar year will be primary to the plan which covers the person as a dependent of a person whose birthday comes later in that calendar year. If both parents have the same birthday, the benefits of a plan which covered one parent longer are determined before those of a plan which covered the other parent for a shorter period of time. If the other plan does not have the rule described in this provision (C) but instead has a rule based on the gender of the parent and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits. D. In the case of a dependent child whose parents are divorced or separated: If there is a court decree which states that the parents shall share joint custody of a dependent child, without stating that one of the parents is responsible for the health care expenses of the child, the order of benefit determination rules specified in (C) above will apply. 2. If there is a court decree which makes one parent financially responsible for the medical, dental or other health care expenses of such child, the benefits of a plan which covers the child as a dependent of such parent will be determined before the benefits of any other plan which covers the child as a dependent child. If there is not such a court decree: If the parent with custody of the child has not remarried, the benefits of a plan which covers the child as a dependent of the parent with custody of the child will be determined before the benefits of a plan which covers the child as a dependent of the parent without custody. If the parent with custody of the child has remarried, the benefits of a plan which covers the child as a dependent of the parent with custody shall be determined before the benefits of a plan which covers that child as a dependent of the stepparent. The benefits of a plan which covers that child as a dependent of the stepparent will be determined before the benefits of a plan which covers that child as a dependent of the parent without custody. HMO/FL COC-3 12/99 35 This is SAMPLE document. It is provided for illustrative purposes only. E. If A, B, C and D above do not establish an order of payment, the plan under which the person has been covered for the longest will be deemed to pay its benefits first; except that: The benefits of a plan which covers the person as a: l . laid -off or retired employee; or 2. the dependent of such person; shall be determined after the benefits of any other plan which covers such person as: 1. an employee who is not laid -off or retired; or 2. a dependent of such person. If the other plan does not have a provision: 1. regarding laid -off or retired employees; and 2. as a result, each plan determines its benefits after the other, then the above paragraph will not apply. The benefits of a plan which covers the person on whose expenses claim is based under a right of continuation pursuant to federal or state law shall be determined after the benefits of any other plan which covers the person other than under such right of continuation. If the other plan does not have a provision: 1. regarding right of continuation pursuant to federal or state law; and 2. as a result, each plan determines its benefits after the other, then the above paragraph will not apply. HMO has the right to release or obtain any information and make or recover any payment it considers necessary in order to administer this provision. Other plan means any other plan of health expense coverage under: 1. Group insurance. 2. Any other type of coverage for persons in a group. This includes plans that are insured and those that are not. 3. No-fault and traditional "fault" auto insurance required by law and provided on other than a group basis. Only the level of benefits required by the law will be counted. HMO/FL COC-3 12/99 36 This is SAMPLE document. It is provided for illustrative purposes only. Payment of Benefits. Under the Coordination of Benefits provision of this Certificate, the amount normally reimbursed for Covered Benefits under this Certificate is reduced to take into account payments made by other plans. The general rule is that the benefits otherwise payable under this Certificate for all Covered Benefits incurred in a calendar year will be reduced by all other plan benefits payable for those expenses. When the Coordination of Benefits rules of this Certificate and an other plan both agree that this Certificate determines its benefits before such other plan, the benefits of the other plan will be ignored in applying the general rule above to the claim involved Such reduced amount will be charged against any applicable benefit limit of this coverage. Facility of Payment. A payment made by another plan may include an amount which should have been paid under this Certificate. If it does, HMO may pay that amount to the plan that made that payment. That amount will then be treated as though it were a benefit paid by HMO. HMO will not have to pay that amount again. The term "payment made" means reasonable cash value of the benefits provided in the form of services. Recovery of Overpayments. If the benefits paid under this Certificate, plus the benefits paid by other plans, exceeds the total amount of Allowable Expenses expenses, HMO has the right to recover the amount of that excess payment if it is the Secondary Plan, from among one or more of the following: (1) any person to or for whom such payments were made; (2) other plans; or (3) any other entity to which such payments were made. This right of recovery shall be exercised at HMO's discretion. A Member shall execute any documents and cooperate with HMO to secure its right to recover such overpayments, upon request from HMO. Medicare And Other Federal Or State Government Programs. The provisions of this section will apply to the maximum extent permitted by federal or state law. HMO will not reduce the benefits due any Member due to that Member's eligibility for Medicare where federal law requires that HMO determines its benefits for that Member without regard to the benefits available under Medicare. The coverage under this Certificate is not intended to duplicate any benefits for which Members are, or could be, eligible for under Medicare or any other federal or state government programs (such as Workers' Compensation). All sums payable under such programs for services provided pursuant to this Certificate shall be payable to and retained by HMO. Each Member shall complete and submit to HMO such consents, releases, assignments and other documents as may be requested by HMO in order to obtain or assure reimbursement under Medicare or any other government programs for which Members are eligible. Active Employees and Their Dependents Who Are Eligible For Medicare. Certain rules apply to active employees and their Dependents who are eligible for Medicare. When a active Subscriber, or the Dependent of a active Subscriber, is eligible for Medicare and the Subscriber or Dependent belongs to a group covered by this Certificate with twenty (20) or more employees, that Member must make a written election to the Contract Holder indicating whom that Member wants to be his primary carrier. If the Member elects the Contract Holder's group plan as the primary plan, this Certificate will be the primary payer. If the Member elects Medicare as the primary plan, all benefits otherwise payable to that Member under this Certificate shall terminate. If the Member belongs to a covered group of less than twenty (20) employees, this Certificate will be secondary payer and all benefits otherwise payable with respect to the Member will be paid in accordance with the Provision for Coordination with Medicare section below. HMO/FL COC-3 12/99 37 This is SAMPLE document. It is provided for illustrative purposes only. Covered Persons Who Are Disabled or Who Have End Stage Renal Disease (ESRD). Special rules apply to Members who are disabled or who have End Stage Renal Disease. This Certificate will make primary and secondary payer determination in accordance with the Omnibus Budget Reconciliation Act (OBRA), as amended. Provision for Coordination with Medicare Benefits under this Certificate will cease for any Member eligible for Medicare. If coverage would cease because a Subscriber is, or could be, eligible for Medicare or any other Federal or State government programs (such as Worker's Compensation) any benefits in force for the Subscriber's Covered Dependents may be continued. Coverage will then continue until it terminates for some other reason under the rules of this Certificate. A conversion privilege may be available in the event that a Dependent's coverage under this Certificate ends because the Subscriber becomes eligible for Medicare. This does not apply if the Member is eligible for any Medicare related benefits under this Certificate. THIRD PARTY LIABILITYAND RIGHT OF RECOVERY If HMO provides health care benefits under this Certificate to a Member for injuries or illness for which a third party is or may be responsible, then HMO retains the right to repayment of the full cost of all benefits provided by HMO on behalf of the Member that are associated with the injury or illness for which the third party is or may be responsible. HMO's rights of recovery apply to any recoveries made by or on behalf of the Member from the following third -party sources, as allowed by law, including but not limited to: payments made by a third -party tortfeasor or any insurance company on behalf of the third -party tortfeasor; any payments or awards under an uninsured or underinsured motorist coverage policy; any worker's compensation or disability award or settlement; medical payments coverage under any automobile policy, premises or homeowners medical payments coverage or premises or homeowners insurance coverage; any other payments from a source intended to compensate a Member for injuries resulting from alleged negligence of a third party. The Member specifically acknowledges HMO's right of subrogation. When HMO provides health care benefits for injuries or illnesses for which a third party is or may be responsible, HMO shall be subrogated to the Member's rights of recovery against any third party to the extent of the full cost of all benefits provided by HMO, to the fullest extent permitted by law. HMO may proceed against any third party with or without the Member's consent. The Member also specifically acknowledges HMO's right of reimbursement. This right of reimbursement attaches, to the fullest extent permitted by law, when HMO has provided health care benefits for injuries or illness for which a third party is or may be responsible and the Member and/or the Member's representative has recovered any amounts from the third party or any party making payments on the third party's behalf. By providing any benefit under this Certificate, HMO is granted an assignment of the proceeds of any settlement, judgment or other payment received by the Member to the extent of the full cost of all benefits provided by HMO. HMO's right of reimbursement is cumulative with and not exclusive of HMO's subrogation right and HMO may choose to exercise either or both rights of recovery. The Member and the Member's representatives further agree to: A. Notify HMO promptly and in writing when notice is given to any third party of the intention to investigate or pursue a claim to recover damages or obtain compensation due to injuries or illness sustained by the Member that may be the legal responsibility of a third party; and B. Cooperate with HMO and do whatever is necessary to secure HMO's rights of subrogation and/or reimbursement under this Certificate; and HMO/FL COC-3 12/99 38 This is SAMPLE document. It is provided for illustrative purposes only. C. Give HMO a first -priority lien on any recovery, settlement or judgment or other source of compensation which may be had from a third party to the extent of the full cost of all benefits associated with injuries or illness provided by HMO for which a third party is or may be responsible (regardless of whether specifically set forth in the recovery, settlement, judgment or compensation agreement); and D. Pay, as the first priority, from any recovery, settlement or judgment or other source of compensation, any and all amounts due HMO as reimbursement for the full cost of all benefits associated with injuries or illness provided by HMO for which a third party is or may be responsible (regardless of whether specifically set forth in the recovery, settlement, judgment, or compensation agreement), unless otherwise agreed to by HMO in writing; and E. Do nothing to prejudice HMO's rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of all benefits provided by HMO. HMO may recover the full cost of all benefits provided by HMO under this Certificate without regard to any claim of fault on the part of the Member, whether by comparative negligence or otherwise. No court costs or attorney fees may be deducted from HMO's recovery without the prior express written consent of HMO. In the event the Member or the Member's representative fails to cooperate with HMO, the Member shall be responsible for all benefits paid by HMO in addition to costs and attorney's fees incurred by HMO in obtaining repayment. Any such Right of Recovery provided to HMO under this Certificate shall not apply or shall be limited to the extent that Florida Statutes or the courts of Florida eliminate or restrict such rights. RESPONSIBILITY OF MEMBERS A. Members or applicants shall complete and submit to HMO such application or other forms or statements as HMO may reasonably request. Members represent that all information contained in such applications, forms and statements submitted to HMO incident to enrollment under this Certificate or the administration herein shall be true, correct, and complete to the best of the Member's knowledge and belief. B. The Member shall notify HMO immediately of any change of address for the Member or any of the Member's Covered Dependents. C. The Member understands that HMO is acting in reliance upon all information provided to it by the Member at time of enrollment and afterwards and represents that information so provided is true and accurate, D. By electing coverage pursuant to this Certificate, or accepting benefits hereunder, all Members who are legally capable of contracting, and the legal representatives of all Members who are incapable of contracting, at time of enrollment and afterwards, represent that all information so provided is true and accurate and agree to all terms, conditions and provisions hereof. E. Members are subject to and shall abide by the rules and regulations of each Provider from which benefits are provided. HMO/FL COC-3 12/99 39 This is SAMPLE document. It is provided for illustrative purposes only. GENERAL PROVISIONS A. Identification Card. The identification card issued by HMO to Members pursuant to this Certificate is for identification purposes only. Possession of an HMO identification card confers no right to services or benefits under this Certificate, and misuse of such identification card may be grounds for termination of Member's coverage pursuant to the Termination of Coverage section of this Certificate. If the Member who misuses the card is the Subscriber, coverage may be terminated for the Subscriber as well as any of the Covered Dependents. To be eligible for services or benefits under this Certificate, the holder of the card must be a Member on whose behalf all applicable Premium charges under this Certificate have been paid. Any person receiving services or benefits which such person is not entitled to receive pursuant to the provisions of this Certificate shall be charged for such services or benefits at billed charges. If any Member permits the use of the Member's HMO identification card by any other person, such card may be retained by HMO, and all rights of such Member and their Covered Dependents, if any, pursuant to this Certificate shall be terminated immediately, subject to the Grievance Procedure set forth in the Grievance Procedure section of this Certificate. B. Reports and Records. HMO is entitled to receive from any Provider of services to Members, information reasonably necessary to administer this Certificate subject to all applicable confidentiality requirements as defined in the General Provisions section of this Certificate. By accepting coverage under this Certificate, the Subscriber, for himself or herself, and for all Covered Dependents covered here- under, authorizes each and every Provider who renders services to a Member hereunder to: disclose all facts pertaining to the care, treatment and physical condition of the Member to HMO, or a medical, dental, or mental health professional that HMO may engage to assist it in reviewing a treatment or claim; render reports pertaining to the care, treatment and physical condition of the Member to HMO, or a medical, dental, or mental health professional that HMO may engage to assist it in reviewing a treatment or claim; and 3. permit copying of the Member's records by HMO. C. Refusal of Treatment. A Member may, for personal reasons, refuse to accept procedures, medicines, or courses of treatment recommended by a Participating Provider. If the Participating Provider (after a second Participating Provider's opinion, if requested by Member) believes that no professionally accep- table alternative exists, and if after being so advised, Member still refuses to follow the recommended treatment or procedure, neither the Participating Provider, nor HMO, will have further responsibility to provide any of the benefits available under this Certificate for treatment of such condition or its consequences or related conditions. HMO will provide written notice to Member of a decision not to provide further benefits for a particular condition. This decision is subject to the Grievance Procedure set forth in the Grievance Procedure section of this Certificate. Coverage for treatment of the condition involved will be resumed in the event Member agrees to follow the recommended treatment or procedure. D. Assignment of Benefits. All rights of the Member to receive benefits hereunder are personal to the Member and may not be assigned. E. Legal Action. No action at law or in equity may be maintained against HMO for any expense or bill unless and until the appeal process has been exhausted, and in no even prior to the expiration of 60 days after written submission of claim has been furnished in accordance with requirements set forth in this Group Agreement. No action shall be brought after the expiration of (5) five years after the time written submission of claim is required to be furnished. HMO/FL COC-3 12/99 40 This is SAMPLE document. It is provided for illustrative purposes only. F. Independent Contractor Relationship. 1. No Participating Provider or other Provider, institution, facility or agency is an agent or employee of HMO. Neither HMO nor any Member of HMO is an agent or employee of any Participating Provider or other Provider, institution, facility or agency. 2. Neither the Contract Holder nor a Member is the agent or representative of HMO, its agents or employees, or an agent or representative of any Participating Provider or other person or organization with which HMO has made or hereafter shall make arrangements for services under this Certificate. 3. Participating Physicians maintain the physician -patient relationship with Members and are solely responsible to Member for all Medical Services which are rendered by Participating Physicians. 4. HMO cannot guarantee the continued participation of any Provider or facility with HMO. In the event a PCP terminates its contract or is terminated by HMO, HMO shall provide notification to Members in the following manner: a. within thirty days of the termination of a PCP contract to each affected Subscriber, if the Subscriber or any Dependent of the Subscriber is currently enrolled in the PCP's office; and b. services rendered by a PCP or Hospital to an enrollee between the date of termination of the Provider Agreement and five business days after notification of the contract termination is mailed to the Member at the Member's last known address shall continue to be Covered Benefits. 5. Restriction on Choice of Providers: Unless otherwise approved by HMO, Members must utilize Participating Providers and facilities who have contracted with HMO to provide services. G. Inability to Provide Service. In the event that due to circumstances not within the reasonable control of HMO, including but not limited to, major disaster, epidemic, complete or partial destruction of facilities, riot, civil insurrection, disability of a significant part of the Participating Provider Network, the rendition of medical or Hospital benefits or other services provided under this Certificate is delayed or rendered impractical, HMO shall not have any liability or obligation on account of such delay or failure to provide services, except to refund the amount of the unearned prepaid Premiums held by HMO on the date such event occurs. HMO is required only to make a good -faith effort to provide or arrange for the provision of services, taking into account the impact of the event. H. Confidentiality. Information contained in the medical records of Members and information received from Physicians, surgeons, Hospitals or other Health Professionals incident to the physician -patient relationship or hospital -patient relationship shall be kept confidential in accordance with applicable law. Information may not be disclosed without the consent of the Member except for use incident to bona fide medical research and education as may be permitted by law, or reasonably necessary by HMO in connection with the administration of this Certificate, or in the compiling of aggregate statistical data. I. Limitation on Services. Except in cases of an Emergency Medical Condition, as provided under the Covered Benefits section of this Certificate, services are available only from Participating Providers. HMO shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a Member from any Physician, Hospital, Spilled Nursing Facility, home health care agency, or other person, entity, institution or organization unless prior arrangements are made by HMO. HMO/FL COC-3 12/99 41 This is SAMPLE document. It is provided for illustrative purposes only. Incontestability. In the absence of fraud, all statements made by a Member shall be considered representations and not warranties, and no statement shall be the basis for voiding coverage or denying a claim after the Group Agreement has been in force for 2 years from its effective date, unless the statement was material to the risk and was contained in a written application. K. This Certificate applies to coverage only, and does not restrict a Member's ability to receive health care benefits that are not, or might not be, Covered Benefits. L. Contract Holder hereby makes HMO coverage available to persons who are eligible under the Eligibility and Enrollment section of this Certificate. However, this Certificate shall be subject to amendment, modification or termination in accordance with any provision hereof, by operation of law, by filing with and approval by the state Department of Insurance. This can also be done by mutual written agreement between HMO and Contract Holder without the consent of Members. M. HMO may adopt policies, procedures, rules and interpretations to promote orderly and efficient administration of this Certificate. N. No agent or other person, except an authorized representative of HMO, has authority to waive any condition or restriction of this Certificate, to extend the time for making a payment, or to bind HMO by making any promise or representation or by giving or receiving any information. No change in this Certificate shall be valid unless evidenced by an endorsement to it signed by an authorized representative. O. This Certificate, including the Schedule of Benefits, any Riders, and any amendments, endorsements, inserts, or attachments, constitutes the entire Certificate between the parties hereto pertaining to the subject matter hereof and supersedes all prior and contemporaneous arrangements, understandings, negotiations and discussions of the parties with respect to the subject matter hereof, whether written or oral; and there are no warranties, representations, or other agreements between the parties in connection with the subject matter hereof, except as specifically set forth herein. No supplement, modification or waiver of this Certificate shall be binding unless executed in writing by authorized representatives of the parties. P. This Certificate has been entered into and shall be construed according to applicable state and federal law. Q. Notice of Claim: Written notice of claim must be furnished to HMO within 20 days after the occurrence or commencement of any loss covered by this Certificate, or as soon thereafter as is reasonable possible. Notice given by or on behalf of the Member or the beneficiary to HMO at the address indicated on the Member's Identification Card, or to any authorized agent of HMO with information sufficient to identify the Member, shall be deemed notice to HMO. R. Proof of Loss: Written proof of loss must be furnished to HMO within 90 days after the Member incurs Allowable Expenses. Failure to furnish the proof of loss within the time required will not invalidate nor reduce any claim if it is not reasonably possible to give the proof of loss within 90 days, provided the proof of loss is furnished as soon as reasonably possible. However, except in the absence of legal capacity of the claimant, the proof of loss may not be furnished later than one year from the date when the proof of loss was originally required. Time of Payment of Claim: Benefits payable under this Certificate will be paid as soon as possible upon receipt by HMO of satisfactory proof of loss, unless this Certificate provides for periodic payment. If any portion of a claim is contested by HMO, the uncontested portion of the claim will be paid promptly after the receipt of proof of loss by HMO. HMO/FL COC-3 12/99 42 This is SAMPLE document. It is provided for illustrative purposes only. The following words and phrases when used in this Certificate shall have, unless the context clearly indicates otherwise, the meaning given to them below: • Actively at Work. The condition where an employee is performing all of the Subscriber's regular duties for the Contract Holder (the Subscriber's employer) on a regularly scheduled work day, at the location where such duties are normally performed, and on a full-time basis. An employee will be considered to be actively at work on a non-scheduled work day only if such person is actively at work on the last regularly scheduled work day immediately preceding such non-scheduled work day. • Allowable Expense. Any necessary and reasonable health expense, part or all of which is covered under any of the plans covering the Member for whom claim is made. • Behavioral Health Provider. A licensed organization or professional providing diagnostic, therapeutic or psychological services for behavioral health conditions. • Breast Reconstructive Surgery - Surgery performed as a result of a Mastectomy to reestablish symmetry between the two breasts. • Certificate. This Certificate of Coverage, including the Schedule of Benefits, and any riders, amendments, or endorsements, which outlines coverage for a Subscriber and Covered Dependents according to the Group Agreement. • Contract Holder. An employer or organization who agrees to remit the Premiums for coverage under the Group Agreement payable to HMO. The Contract Holder shall act only as an agent of HMO Members in the Contract Holder's group, and shall not be the agent of HMO for any purpose. • Contract Year. A period of one year commencing on the Contract Holder's Effective Date of Coverage and ends at 12:00 midnight on the last day of the one year period. • Coordination of Benefits. A provision that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more plans providing benefits or services for medical, dental or other care or treatment. It avoids claims payment delays by establishing an order in which plans pay their claims and providing the authority for the orderly transfer of information needed to pay claims promptly. It may avoid duplication of benefits by permitting a reduction of the benefits of a plan when, by the rules established by this provision, it does not have to pay its benefits first. Refer to the Coordination of Benefits section of this Certificate for a description of the Coordination of Benefits provision. • Copayment. A specified dollar amount or percentage required to be paid by or on behalf of a Member in connection with benefits, if any, as set forth in the Schedule of Benefits. Copayments may be changed by HMO upon 30 days written notice to the Contract Holder. • Copayment Maximum. The maximum annual out-of-pocket amount for payment of Copayments, if any, to be paid by a Subscriber and any Covered Dependents, if any. HMO/FL COC-3 12/99 43 This is SAMPLE document. It is provided for illustrative purposes only. Cosmetic Surgery. Any non -medically necessary surgery or procedure whose primary purpose is to improve or change the appearance of any portion of the body to improve self-esteem, but which does not restore bodily function, correct a diseased state, physical appearance, or disfigurement caused by an accident, birth defect, or correct or naturally improve a physiological function. Cosmetic Surgery includes, but is not limited to, ear piercing, rhinoplasty, lipectomy, surgery for sagging or extra skin, any augmentation or reduction procedures (e.g., mammoplasty, liposuction, keloids, rhinoplasty and associated surgery) or treatment relating to the consequences or as a result of Cosmetic Surgery. Covered Dependent. Any person in a Subscriber's family who meets all the eligibility requirements of the Eligibility and Enrollment section of this Certificate and the Dependent Eligibility section of the Schedule of Benefits, has enrolled in HMO, and is subject to Premium requirements set forth in the Premiums section of the Group Agreement. Covered Benefits. Those Medically Necessary Services and supplies set forth in this Certificate, which are covered subject to all of the terms and conditions of the Group Agreement and Certificate. Creditable Coverage. Coverage of the Member under a group health plan (including a governmental or church plan), a health insurance coverage (either group or individual insurance), Medicare, Medicaid, a military -sponsored health care (CHAMPUS), a program of the Indian Health Service, a State health benefits risk pool, the Federal Employees Health Benefits Program (FEHBP), a public health plan, and any health benefit plan under section 5(e) of the Peace Corps Act. Creditable Coverage does not include coverage only for accident; workers' compensation or similar insurance; automobile medical payment insurance; coverage for on -site medical clinics; or limited -scope dental benefits, limited -scope vision benefits, or long- term care benefits that is provided in a separate policy. Custodial Care. Any type of care provided in accordance with Medicare guidelines, including room and board, that a) does not require the skills of technical or professional personnel; b) is not furnished by or under the supervision of such personnel or does not otherwise meet the requirements of post -hospital Skilled Nursing Facility care; or c) is a level such that the Member has reached the maximum level of physical or mental function and such person is not likely to make further significant improvement. Custodial Care includes, but is not limited to, any type of care where the primary purpose of the type of care provided is to attend to the Member's daily living activities which do not entail or require the continuing attention of trained medical or paramedical personnel. Examples of this include, but are not limited to, assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, changes of dressings of non infected, post operative or chronic conditions, preparation of special diets, supervision of medication which can be self' -administered by the Member, general maintenance care of colostomy or ieostomy, routine services to maintain other service which, in the sole determination of HMO, based on medically accepted standards, can be safely and adequately self-administered or performed by the average non -medical person without the direct supervision of trained medical or paramedical personnel, regardless of who actually provides the service, residential care and adult day care, protective and supportive care including educational services, rest cures, convalescent care Detoxification. The process whereby an alcohol or drug intoxicated or alcohol or drug dependent person is assisted, in a facility licensed by the appropriate regulatory authority, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors or alcohol in combination with drugs as determined by a licensed Physician, while keeping the physiological risk to the patient at a minimum. Durable Medical Equipment. Equipment, as determined by HMO, which is a) made to withstand prolonged use; b) made for and mainly used in the treatment of a disease or injury; c) suited for use while not confined as an inpatient in the Hospital; d) not normally of use to persons who do not have a disease or injury; e) not for use in altering air quality or temperature; and f) not for exercise or training. HMO/FL COC-3 12/99 44 This is SAMPLE document. It is provided for illustrative purposes only. Effective Date of Coverage. The commencement date of coverage under this Certificate as shown on the records of HMO. Emergency Medical Condition. 1. A medical condition manifesting itself by acute symptoms of sufficient severity, which may include sever pain or acute symptoms, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: a) Serious jeopardy to the health of a patient, including a pregnant woman or a fetus. b) Serious impairment to bodily functions. c) Serious dysfunction of any bodily organ or part. 2. With respect to a pregnant woman: a) That there is inadequate time to effect safe transfer to another hospital prior to delivery; b) That a transfer may pose a threat to the health and safety of the patient or fetus; or c) That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. Emergency Services and Care. Medical screening, examination and evaluation by a Physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a Physician, to determine if an Emergency Medical Condition exists and, if it does, the care, treatment, or surgery for a Covered Benefit by a Physician necessary to relieve or eliminate the Emergency Medical Condition, within the service capability of a Hospital. Experimental or Investigational Procedures. Services or supplies that are, as determined by HMO, experimental. A drug, device, procedure or treatment will be determined to be experimental if: 1. there is not sufficient outcome data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved; or 2. required FDA approval has not been granted for marketing; or 3. a recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental or for research purposes; or 4. the written protocol or protocol(s) used by the treating facility or the protocol or protocol(s) of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental or for research purposes; or 5. it is not of proven benefit for the specific diagnosis or treatment of a Member's particular condition; or 6. it is not generally recognized by the Medical Community as effective or appropriate for the specific diagnosis or treatment of a Member's particular condition; or 7. it is provided or performed in special settings for research purposes. Group Agreement. The Group Agreement between HMO and the Contract Holder, including the Group Application, Cover Sheet, this Certificate, the Schedule of Benefits, any Riders, any amendments, any endorsements, and any attachments, as subsequently amended by operation of law and as filed with and approved by the applicable public authority. HMO/FL COC-3 12/99 45 This is SAMPLE document. It is provided for illustrative purposes only. • Health Professionals. A Physician or other professional who is properly licensed or certified to provide medical care under the laws of the state where the individual practices, and who provides Medical Services which are within the scope of the individual's license or certificate. • HMO. Aetna U.S. Healthcare, Inc., a state corporation licensed by the Florida Department of Insurance as a Health Maintenance Organization. • Homebound Member. A Member who is confined to the home due to an illness or injury which makes leaving the home medically contraindicated or which restricts the Member's ability to leave the Member's place of residence except with the aid of supportive devices, the use of special transportation, or the assistance of another person. • Home Health Services. Those items and services provided by Participating Providers as an alternative to hospitalization, and approved and coordinated in advance by HMO. + Hospice Care. A program of care that is provided by a Hospital, Skilled Nursing Facility, hospice, or a duly licensed Hospice Care agency, and is approved by HMO, and is focused on a palliative rather than curative treatment for Members who have a medical condition and a prognosis of less than 6 months to live. • Hospital. An institution rendering inpatient and outpatient services, accredited as a Hospital by the Joint Commission on Accreditation of Health Care Organizations, the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by HMO as meeting reasonable standards. A Hospital may be a general, acute care, rehabilitation or specialty institution. • Infertile or Infertility. The condition of a presumably healthy Member who is unable to conceive or produce conception after a period of one year of frequent, unprotected heterosexual sexual intercourse. This does not include conditions for male Members when the cause is a vasectomy or orchiectomy or for female Members when the cause is a tubal ligation or hysterectomy. • Mastectomy - The removal of all or part of a breast for Medically Necessary reasons as determined by a licensed Physician. • Medical Community. A majority of Physicians who are Board Certified in the appropriate specialty. • Medical Services. The professional services of Health Professionals, including medical, surgical, diagnostic, therapeutic, preventive care and birthing facility services. • Medically Necessary, Medically Necessary Services, or Medical Necessity. Services that are appropriate and consistent with the diagnosis in accordance with accepted medical standards as described in the Covered Benefits section of this Certificate. Medical Necessity, when used in relation to services, shall have the same meaning as Medically Necessary Services. This definition applies only to the determination by HMO of whether health care services are Covered Benefits under this Certificate. • Member. A Subscriber or Covered Dependent as defined in this Certificate. HMO/FL COC-3 12/99 46 This is SAMPLE document. It is provided for illustrative purposes only. Mental or Behavioral Condition. A condition which manifests signs and/or symptoms which are primarily mental or behavioral, for which the primary treatment is psychotherapy, psychotherapeutic methods or procedures, and/or the administration of psychotropic medication, regardless of any underlying physical or medical cause. Mental or behavioral disorders and conditions include, but are not limited to, psychosis, affective disorders, anxiety disorders, personality disorders, obsessive -compulsive disorders, attention disorders with or without hyperactivity, and other psychological, emotional, nervous, behavioral, or stress -related abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems, whether or not caused or in any way resulting from chemical imbalance, physical trauma, or a physical or medical condition. • Non -Hospital Facility. A facility, licensed by the appropriate regulatory authority, for the care or treatment of alcohol or drug dependent persons, except for transitional living facilities. • Open Enrollment Period. A period of not less than thirty (30) consecutive working days, at least every 18 months, when eligible enrollees of the Contract Holder may enroll in HMO without a waiting period or exclusion or limitation based on health status or, if already enrolled in HMO, may transfer to an alternative health plan offered by the Contract Holder. • Partial Hospitalization. The provision of medical, nursing, counseling or therapeutic services on a planned and regularly scheduled basis in a Hospital or Non -Hospital Facility which is licensed as an alcohol or drug abuse or mental illness treatment program by the appropriate regulatory authority, and which is designed for a patient or client who would benefit from more intensive services than are offered in outpatient treatment but who does not require inpatient care. + Participating. A description of a Provider that has entered into a contractual agreement with HMO for the provision of services to Members. • Physician. A duly licensed member of a medical profession, who has an M.D. or D.O. degree, who is properly licensed or certified to provide medical care under the laws of the state where the individual practices, and who provides Medical Services which are within the scope of the individual's license or certificate. This definition includes podiatrists, osteopaths, chiropractors, nurse midwives, midwives and nurse anesthetists. • Premium. The amount the Contract Holder or Member is required to pay to HMO to continue coverage. • Primary Care Physician. A Participating Physician who supervises, coordinates and provides initial care and basic Medical Services as a general or family care practitioner, or in some cases, as an internist or a pediatrician to Members, initiates their Referral for Specialist care, and maintains continuity of patient care. • Provider. A Physician, Health Professional, Hospital, Skilled Nursing Facility, home health agency or other recognized entity or person licensed to provide Hospital or Medical Services to Members. • Reasonable Charge. The charge for a Covered Benefit which is determined by the HMO to be the prevailing charge level made for the service or supply in the geographic area where it is furnished. HMO may take into account factors such as the complexity, degree of skill needed, type or specialty of the Provider, range of services provided by a facility, and the prevailing charge in other areas in determining the Reasonable Charge for a service or supply that is unusual or is not often provided in the area or is provided by only a small number of providers in the area. Referral. Specific directions or instructions from a Member's PCP, in conformance with HMO's policies and procedures, that direct a Member to a Participating Provider for Medically Necessary care. HMO/FL COC-3 12/99 47 This is SAMPLE document. It is provided for illustrative purposes only. • Respite Care. Care furnished during a period of' time when the Member's family or usual caretaker cannot, or will not, attend to the Member's needs. • Service Area. The geographic area, established by HMO and approved by the appropriate regulatory authority. • Skilled Care. Medical care that requires the skills of technical or professional personnel. • Skilled Nursing Facility. An institution or a distinct part of an institution that is licensed or approved under state or local law, and which is primarily engaged in providing skilled nursing care and related services as a Skilled Nursing Facility, extended care facility, or nursing care facility approved by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by HMO to meet the reasonable standards applied by any of the aforesaid authorities. • Specialist. A Physician who provides medical care in any generally accepted medical or surgical specialty or subspecialty. • Subscriber. A person who meets all applicable eligibility requirements as described in this Certificate and on the Schedule of Benefits, has enrolled in HMO, and is subject to Premium requirements as set forth in the Premiums section of the Group Agreement. • Substance Abuse. Any use of alcohol and/or drugs which produces a pattern of pathological use causing impairment in social or occupational functioning or which produces physiological dependency evidenced by physical tolerance or withdrawal. • Substance Abuse Rehabilitation. Services, procedures and interventions to eliminate dependence on or abuse of legal and/or illegal chemical substances, according to individualized treatment plans. • Totally Disabled or Total Disability. A Member shall be considered Totally Disabled if. 1. the Member is a Subscriber and is prevented, because of injury or disease, from performing any occupation for which the Member is reasonably fitted by training, experience, and accomplishments; or 2. the Member is a Covered Dependent and is prevented because of injury or disease, from engaging in substantially all of the normal activities of a person of like age and sex in good health. • Urgent Care. Covered Benefits required in order to prevent serious deterioration of a Member's health that results from an unforeseen illness or injury if the Member is temporarily absent from the HMO Service Area and receipt of the health care service cannot be delayed until the Member's return to the Service Area. HMO/FL COC-3 12/99 48 This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. Contract Holder: Contract Holder Number: HMO Benefit Level: Group Agreement Effective Date: Term of Group Agreement: AETNA U.B. HEALTHCARE, INC. (FLORIDA) GROUP AGREEMENT COVER SHEET [Group Name] [Group No.] [Locations/Eligibility Class] [Service Areas] [Plan Name] Benefits Package [Effective Date] The initial term shall be: From to Thereafter, subsequent terms shall be: From to Initial HMO Premium Rates: Single $ Parent & Child $ Parent & Children $ Couple $ Family $ Term of Rates: From to [These rates are subject to adjustments based upon final regulatory determinations.] Premium Due Dates: The Group Agreement Effective Date and the [ ] day of each succeeding calendar month. HMO/FL GA-2 08/97 This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. NOTICE: Written notice shall be given by U.S. Mail, postage prepaid, to HMO at: Aetna U.S. Healthcare, Inc. Post Office Box 30167 Tampa, FL 33631-3167 Attention: Employer Services/Contracts and to Contract Holder at: Signed this HMO(s): B, ABCD Contract Holder: By: Title: day of , 199 Robert A. Williams (Vice President) Contract Holder Name: Contract Holder Number: Contract Holder Locations: Contract Holder Service Areas: Contract Holder Group Agreement Effective Date: HMO/FL GA-2 08/97 This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. AETNA U.S. HEALTHCARE, INC. (FLORIDA) GROUP AGREEMENT This is a Group Agreement between Aetna U.S. Healthcare, Inc. (hereinafter referred to as "HMO") and [Contract Holder Name] (hereinafter referred to as "Contract Holder"). HMO agrees with the Contract Holder to provide coverage for benefits, in accordance with the terms, conditions, rights, and privileges as set forth in this Group Agreement and the Certificate of Coverage. Members covered under this Group Agreement are subject to all the conditions and provisions contained herein. This Group Agreement is governed by applicable federal law and the laws of Florida. If any provision of this Group Agreement is deemed to be invalid or illegal, such provision shall be fully severable and the remaining provisions of this Group Agreement shall continue in full force and effect. In consideration of the Premium payments made by or on behalf of the Contract Holder, HMO shall provide coverage for those services described in the Certificate of Coverage subject to the terms and conditions set forth in this Group Agreement and the Certificate of Coverage (herein after referred to as "Certificate") which is attached to this Group Agreement, and fully incorporated herein by reference. The terms and conditions used in this Group Agreement have the same meaning given those terms in the Certificate unless otherwise specifically defined in this Group Agreement. Group Agreement Effective Date: Contract Holder Number: HMO/FL GA-2 08/97 This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. PRFMITIMS A. Premiums for the Covered Benefits under this Group Agreement are set forth in the Cover Sheet attached hereto, which is fully incorporated herein by reference. B. The Premiums set forth in the Cover Sheet shall be effective for the initial term of this Group Agreement. Thereafter, if HMO gives a minimum of 30 days prior written notice to the Contract Holder, HMO may change the Premiums: upon the renewal date of this Group Agreement; or upon the effective date of any applicable law or regulation having a direct and material impact on the cost of providing coverage to Members. Payment of the applicable Premium on and after that date shall constitute acceptance of those changes by the Contract Holder, individually and on behalf of all Members enrolled under this Group Agreement. C. Premiums are payable to HMO on or in advance of each Premium due date at the corporate offices of HMO unless otherwise specified by HMO in writing. The payment of any Premium shall not maintain coverage under this Group Agreement in force beyond the date when the next payment becomes due; however, a ### day grace period, during which time this Group Agreement will remain in force, shall be granted for payment of each amount due after the first. The Contract Holder shall remain liable for the payment of the Premium for the time coverage was in effect during the grace period and the Member shall remain liable for Copayments owed. A check is not a payment until it is honored by a bank. HMO reserves the right to return a check issued against insufficient funds without resorting to a second deposit attempt. D. Retroactive adjustments to the Contract Holder's billings may be made by HMO for the termination of Members not posted to previous Contract Holder billings. However, the Contract Holder may only receive a maximum of 2 month's credit for Member terminations which occurred more than 31 days prior to the date HMO was notified of such termination by the Contract Holder. Retroactive additions will be made at the discretion of HMO based upon eligibility guidelines, as detailed in the Certificate and on the Schedule of Benefits, and are subject to the payment of all applicable Premiums. As between HMO and the Contract Holder, the Contract Holder shall be responsible for any claims paid by HMO with respect to a Member, to the extent HMO relied on the Contract Holder's submitted enrollment to confirm coverage where coverage was not valid. E. [Premiums shall be paid in full for Members whose coverage is effective on the Premium due date or whose coverage terminates on the last day of the Premium period.] [Premiums for Members whose coverage is effective on a day other than the first day of a month or whose coverage terminates on a day other than the last day of a month shall be adjusted as indicated below. [[1.J If membership is effective between the [1st through the 15th of the month,J[I6th through the 31st of the month,J inclusive, the Premium for the whole month is due. If membership is effective between the [ 16th through the 31 st of the month, J [ 1 st through the 15th of the month, J inclusive, no Premium is due for the first month of membership. HMO/FL GA-2 08/97 This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. [If membership terminates between the [ I st through the 15th of the month,] [ 16th through the 31 st of the month,] inclusive, no Premium is due for that month. If membership terminates between the [16th through the 31 st of the month,] [ 1st through the 15th of the month,] inclusive, the Premium for the whole month is due.]] [[2.] For all newly eligible individuals whose coverage does not begin on the Premium due date, one- half the monthly Premium is due. For all newly eligible Members whose coverage begins on a Premium due date, a full month's Premium is due. [For all Members whose coverage terminates on the Premium due date, no monthly Premium is due. For all Members whose coverage terminates on a date other than the Premium due date, one-half month's Premium is due.]] [[3.1 If membership is effective on the first of the month, the Premium for the whole month is due. If membership is effective after the first of the month, no Premium is due for the first month of membership. [If membership terminates on the first of the month, no Premium is due for that month. If membership terminates after the first of the month, the Premium for the whole month is due.]] [[4.] Billing will begin the day of eligibility on a pro-rata basis. The formula for pro-rata billing is: one month's full Premium multiplied by 12 (months in a year), then divided by 365 (days in a year) to achieve a daily rate which is then multiplied by the number of days the Member is actually enrolled during the first month. [Member termination is effective on the actual date of termination and Premium is due on a pro- rata basis for each day the Member is active in the final month of membership. The formula for pro-rata computation is: one month's full Premium multiplied by 12 (months in a year), then divided by 365 (days in a year) to achieve a daily rate which is then multiplied by the number of days the Member was eligible during the month.]]] [F.] If the Premiums are not paid by the Premium due date, HMO will require the Contract Holder to pay interest on the overdue amount at 1 1/2% for each month overdue, commencing on the 31st day after the Premium due date. In the event of non-payment of any amount due, HMO shall be entitled to all remedies provided for in law or in equity, including but not limited to, reasonable attorney's fees (which the parties acknowledge may constitute at least 33 1/3% of the sum sued upon), costs of suit (including but not limited to filing fees and deposition transcript costs), and pre- and post -judgment interest at the rate of 1 1/2% per month. ENROLLMENT Enrollment for eligible individuals, as described in the Certificate, will be permitted during the Open Enrollment Period, or within 31 days from the date the individual and any dependent becomes eligible for coverage. Completed enrollment information must be submitted to the Contract Holder for transmittal to HMO. Eligible individuals and any eligible dependents who are not enrolled within the Open Enrollment Period or 31 days of becoming eligible, may be enrolled during any subsequent Open Enrollment. Coverage shall not become effective until confirmed by HMO. The Open Enrollment Period shall be consistent with the Open Enrollment Period applicable to any other group health benefit plan being offered by the Contract Holder and in compliance with applicable law. The IV* IuC47/a1LtfVI1rfm This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. Contract Holder shall permit representatives of HMO to meet with eligible individuals during the Open Enrollment Period unless the parties agree upon an alternate enrollment procedure. There may be a waiting period before individuals are eligible for coverage under this Group Agreement. The waiting period, if any, is specified on the Schedule of Benefits. The eligibility of the group, the composition of the group and the eligibility requirements used to determine membership in the group which exist at the effective date of this Group Agreement are material to the execution of this Group Agreement by HMO. The Contract Holder shall not during the term of this Group Agreement modify the Open Enrollment Period, the waiting period as described on the Schedule of Benefits, or any other eligibility requirements as described in the Certificate and on the Schedule of Benefits, for the purposes of enrolling the Contract Holder's eligible individuals and dependents under this Group Agreement, unless agreed to in writing by HMO. CONTRACT HOLDER TERMINATION A. This Group Agreement may be terminated by the Contract Holder on any Premium due date by giving 30 days' prior written notice. B. The Contract Holder may terminate this Group Agreement as of its renewal date, by providing HMO written notice of non -renewal not less than 45 days prior to the renewal date. C. The Contract Holder may terminate this Group Agreement as of the date any Premium change would become effective, by providing HMO with written notice of termination not less than 30 days prior to such effective date. D. Immediately upon written notice, HMO may terminate or non -renew the Group Agreement if: I . HMO does not receive payment from the Contract Holder for the entire Premium due under this Group Agreement within the grace period, HMO may, terminate this Group Agreement as of the last day for which Premiums were received, subject to the grace period. The termination of this Group Agreement following the expiration of the grace period shall not relieve the Contract Holder of its obligation to pay the Premium for coverage provided during the grace period; 2. The Contract Holder, has performed an act or practice that constitutes fraud or material misstatement by the Contract Holder, in obtaining coverage under this Group Agreement; 3. the Contract Holder has failed to comply with a material plan provision relating to any employer contribution or group participation rules, under applicable state or federal law; 4. HMO ceases to offer coverage in the market in accordance with state law; 5. HMO ceases to offer coverage of a specific product in the market in accordance with state law; 6. the Contract Holder no longer has any enrollee under the plan who lives, resides, or works in the Service Area [; or 7. the Contract Holder's membership in the association ceases]. HMO/FL GA-2 08/97 This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. No termination shall relieve the Contract Holder from any obligation incurred prior to the date of termination of this Group Agreement. No change in the eligibility or participation requirements of the Contract Holder shall be permitted to affect eligibility or enrollment under this Group Agreement unless such change is agreed to by HMO and the Contract Holder, and is not otherwise contrary to applicable state or federal laws, rules or regulations. Breach of this provision is considered a material breach of this Group Agreement and may be the basis for termination by giving 45 days' prior written notice. It is the responsibility of the Contract Holder to notify the Subscribers of the termination of the Group Agreement in compliance with all applicable laws. However, HMO reserves the right to notify Subscribers of termination of the Group Agreement for any reason, including non-payment of Premium. In accordance with the Certificate, the Contract Holder shall provide written notice to Members of their rights upon termination of coverage. INDEPENDENT CONTRACTOR RELATIONSHIPS A. Between Participating Providers and HMO. The relationship between HMO and Participating Providers is a contractual relationship among independent contractors. Participating Providers are not agents or employees of HMO nor is HMO an agent or employee of any Participating Provider. Participating Providers are solely responsible for any health services rendered to their Member patients. HMO makes no express or implied warranties or representations concerning the qualifications, continued participation, or quality of services of any Physician, Hospital or other Participating Provider, A Provider's participation may be terminated at any time without advance notice to the Contract Holder or Members. B. Between the Contract Holder and HMO. The relationship between HMO and the Contract Holder is limited to a contractual relationship between independent contractors. Neither party is an agent nor employee of the other in performing its obligations pursuant to this Group Agreement. ADMINISTRATION OF THE AGREEMENT HMO may adopt policies, procedures, rules and interpretations to promote orderly and efficient administration of this Group Agreement. A. Entire Agreement. This Group Agreement, including the Group Application, Cover Sheet, Certificate of Coverage, Schedule of Benefits, any Riders, and any amendments, endorsements, inserts or attachments, constitutes the entire Group Agreement between the Contract Holder and HMO, and on the Effective Date of Coverage, supersedes all other prior and contemporaneous arrangements, understandings, agreements, negotiations, and discussions between the parties, whether written or oral, previously issued by HMO for Covered Benefits provided by this Group Agreement. HMO/FL GA-2 08/97 This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. All statements made by the Contract Holder or a Member shall be deemed representations and not warranties. No written statement made by a Member shall be used by HMO in a contest unless a copy of the statement is or has been furnished to the Member or his or her beneficiary, or the person making the claim. B. Amendments. This Group Agreement is subject to all rules and regulations promulgated at any time by any state or federal regulatory agency or authority having supervisory authority over HMO, and this Group Agreement shall be deemed to be amended to conform therewith at all times. This Group Agreement may be changed at any time for any other reason by agreement between HMO and the Contract Holder, without the consent of any employee, Member, or other person, Except as detailed below, any amendments to this Group Agreement shall be in writing and must be approved and executed by authorized representatives of both the Contract Holder and HMO. No other individual has the authority to modify this Group Agreement; waive any of its provisions, conditions, or restrictions; extend the time for making a payment; or bind HMO by making any other commitment or representation or by giving or receiving any information. No change in this Group Agreement shall be valid unless evidenced by an endorsement, signed by an authorized representative of HMO. Formal acceptance of an amendment to this Group Agreement by the Contract Holder shall not be required if: the change was requested by either the Contract Holder or HMO and is agreed to in writing by the other; or 2. the change is required to bring the Group Agreement into conformance with any applicable federal or state law or regulation, or ruling of the jurisdiction in which the Group Agreement is delivered; or the Contract Holder makes payment of any applicable Premium on and after the effective date of such amendment. C. Forms. HMO shall supply the Contract Holder with a reasonable supply of its forms and descriptive literature. The Contract Holder shall distribute HMO's forms and descriptive literature to any eligible individual who becomes eligible for coverage. The Contract Holder shall, within 31 days of receipt from an eligible individual, forward all applicable forms and other required information to HMO. D. Records. HMO shall maintain Member records. The records will contain key facts about the Member's coverage. Each month during the period of this Group Agreement, on forms approved by HMO, the Contract Holder shall furnish to HMO such information as may reasonably be required to administer the Group Agreement. This includes, but is not limited to, information needed to enroll Members of the Contract Holder, process terminations, and effect changes in family status and transfer of employment of Members. HMO shall not be liable to Members for the fulfillment of any obligation prior to information being received in a form satisfactory to HMO. HMO/FL GA-2 08/97 This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. The Contract Holder shall make payroll and other records directly related to Member's coverage under this Group Agreement available to HMO for inspection, at HMO's expense, at the Contract Holder's office, during regular business hours, upon reasonable advance request from HMO. This provision shall survive the termination of this Group Agreement as necessary to resolve outstanding financial or administrative issues pursuant to this Group Agreement. E. Clerical Errors. Incorrect information furnished to HMO may be corrected, provided that HMO has not acted to its prejudice in reliance thereon. Clerical errors or delays in keeping or reporting data relative to coverage will neither invalidate coverage which would otherwise be in force, continue coverage which would otherwise be validly terminated if HMO, in its sole discretion, determines that a clerical error has been made, nor grant additional benefits to Members. Upon discovery of such errors or delay, an adjustment of Premiums shall be made. In no case will adjustments in coverage or Premiums be made effective more than two (2) Premium due dates prior to the date HMO is notified in writing, on a form satisfactory to HMO, of the requested addition, deletion, or change in coverage. F. Claim Determinations. HMO has complete authority to review all claims for Covered Benefits under this Group Agreement. In exercising such responsibility, HMO shall have discretionary authority to determine whether and to what extent eligible individuals and beneficiaries are entitled to coverage and construe any disputed or doubtful terms under this Group Agreement. HMO shall be deemed to have properly exercised such authority unless HMO abuses its discretion by acting arbitrarily and capriciously. G. Fraudulent or Material Misstatements. If any relevant fact as to a Member is found to have been misstated, an equitable adjustment of Premiums may be made. If the misstatement affects the existence or amount of coverage, the true facts will be used in determining whether coverage is to remain in force. H. Incontestability. Except as to a fraudulent misstatement, or issues concerning Premiums due: No statement made by the Contract Holder or any Member shall be the basis for voiding coverage or denying coverage or be used in defense of a claim unless it is in writing. No statement made by the Contract Holder shall be the basis for voiding this Group Agreement after it has been in force for 2 years from its effective date. No statement made by a Member shall be used in defense of a claim for loss incurred or commencing after coverage has been in effect for 2 years. I. Assignability. No rights or benefits under this Group Agreement are assignable by the Contract Holder to any other party unless approved by HMO. Waiver. HMO/FL GA-2 08/97 This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. HMO's failure to implement, or insist upon compliance with, any provision of this Group Agreement or the terms of the Certificate incorporated hereunder, at any given time or times, shall not constitute a waiver of HMO's right to implement or insist upon compliance with that provision at any other time or times. This includes, but is not limited to, the payment of Premiums or benefits. This applies whether or not the circumstances are the same. K. Notices. Any notice required or permitted under this Group Agreement shall be in writing and shall be deemed to have been given on the date when delivered in person; or, if delivered by first-class United States mail, on the date mailed, proper postage prepaid, and properly addressed to the address set forth in the Group Application, or Cover Sheet, or to any more recent address of which the sending party has received written notice. L. Third Parties. This Group Agreement shall not confer any rights or obligations on third parties except as specifically provided herein. M. Non -Discrimination. The Contract Holder agrees to offer participation in HMO to all persons as described in the Subscriber Eligibility section of the Schedule of Benefits under terms and conditions no less favorable than those for any alternate health benefit plans. The Contract Holder agrees to make no attempt, whether through differential Contract Holder Premium contributions or otherwise to encourage or discourage enrollment in HMO of eligible individuals and eligible Dependents based on health status or health risk. N. Execution of this Agreement. This Group Agreement shall be executed by HMO and the Contract Holder once the Group Application, which is attached hereto and fully incorporated herein by reference, is completed and signed. However, payment of the applicable Premium on and after the effective date of this Group Agreement shall constitute execution of this Group Agreement by the Contract Holder. O. Inability to Arrange Services. In the event that due to circumstances not within the reasonable control of HMO, including but not limited to major disaster, epidemic, complete or partial destruction of facilities, riot, civil insurrection, disability of a significant part of HMO's Participating Providers or entities with whom HMO has arranged for services under this Group Agreement, or similar causes, the rendition of medical or Hospital benefits or other services provided under this Group Agreement is delayed or rendered impractical, HMO shall not have any liability or obligation on account of such delay or failure to provide services, except to refund the amount of the unearned prepaid Premiums held by HMO on the date such event occurs. HMO is required only to make a good -faith effort to provide or arrange for the provision of services, taking into account the impact of the event. P. Use of the HMO Name and all Symbols, Trademarks, and Service Marks. HMO reserves the right to control the use of its name and all symbols, trademarks, and service marks presently existing or hereinafter established with respect to it. The Contract Holder agrees that it will not use such name, symbols, trademarks, or service marks in advertising or promotional materials or otherwise HMO/FL GA-2 08/97 This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. without prior written consent of HMO and will cease any and all usage immediately upon request of HMO or upon termination of this Group Agreement. HMO/FL GA-2 08/97 This is only a SAMPLE document. It is provided for illustrative purposes only. Certain benefits are only provided by purchase of a Rider to the Agreement. Q. Worker's Compensation. The Contract Holder is responsible for protecting HMO's interests in any worker's compensation claims or settlements with any eligible individual. HMO shall be reimbursed for all paid medical expenses which have occurred as a result of any work related injury that is compensable or settled in any manner. At the signing of this Group Agreement and upon renewal, the Contract Holder shall submit proof of their worker's compensation coverage or an exclusion form which has been accepted by the applicable regulatory authority governing Worker's Compensation. The Contract Holder is also required to submit a monthly report to HMO listing all worker's compensation cases. Such list will contain the name, social security number, date of loss and diagnosis of all applicable eligible individual. HMO/FL GA-2 08/97 10 T.73:�vS:^r+�wrt�e:. u.. QPOS This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) AETNA U.S. HEALTHCARE, INC. (FLORIDA) QUALITY POINT -OF -SERVICE PROGRAM RIDER This Rider is to be used in conjunction with the HMO Certificate of Coverage, which is made up of the HMO Certificate of Coverage, Schedule of Benefits, and any amendments, riders, or endorsements. Together, this Rider and the HMO Group Agreement is referred to as the Quality Point -of -Service Program. The Quality Point -of -Service Program provides coverage for Referred and Non -Referred Benefits received from Participating Providers and Non -Participating Providers. This Rider details Non -Referred Benefits accessed through Non -Participating Providers, or through Participating Providers upon Self -Referral, and the HMO Certificate of Coverage details Referred Benefits accessed through Participating Providers. Members must be covered by the HMO Certificate of Coverage to be eligible for benefits under this Rider. .A� Certain words have specific meanings when used in this Rider. The defined terms appear in bold initial capital letters. The definitions of those terms are found in the Definitions section of this RrradHMO Certificate. IN SOME CIRCUMSTANCES, CERTAIN MEDICAL OR MAY REQUIRE PRECERTIFICATION. IT IS, THEREFORE, IMPORTANT THAT AND IGATiS OF M AND I ER'S ON ITY T STAND I ATIV PROVIDER, ARE W IT IS TH CT TERMS i N� ON, FACILITY OR HMO/FL QPOSRII7ER-1 02/00 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) NO SERVICES OR SUPPLIES ARE COVERED UNDER THIS RIDER IN THE ABSENCE OF PAYMENT OF CURRENT PREMIUMS SUBJECT TO THE 31DAY GRACE PERIOD AND THE PREMIUMS SECTION OF THE HMO GROUP POLICY. THIS RIDER APPLIES TO COVERAGE ONLY AND DOES NOT RESTRICT A MEMBER'S ABILITY TO RECEIVE HEALTH CARE SERVICES OR SUPPLIES THAT ARE NOT, OR MIGHT NOT BE, COVERED BENEFITS UNDER THIS CERTIFICATE. Important Unless otherwise specifically provided, no Member has the right to receive the benefits of this plan for health care services or supplies furnished following termination of coverage. Benefits of this plan are available only for services or supplies furnished during the term the coverage is in effect and while the individual claiming the benefits is actually covered by the Group Insurance Policy. Benefits may be modified durin wr m of this plan as specifically provided under the terms of the Group Insurance Policy or upon ren nefits are modified, the revised benefits (including any reduction in benefits or elimination of be ) apply for services or supplies furnished on or after the effective date of the modificati There is no, ested right to receive the benefits of the Group Insurance Policy. NOTE: THIS PO HMO/FL QPOSRIDER-1 02/00 Cy ', �� RT )E CTI TE CONTAINS A This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) TABLE OF CONTENTS Section P_a,e Non -Referred Procedure [#] Eligibility [#] Method of Payment: Deductibles, Coinsurance and Copayments [#] Covered Benefits [#] Termination of Coverage [#] Exclusions and Limitations [#] Continuation and Conversion [#] Grievance Procedure Coordination of Benefits HMO/FL QPOSRIDER- 102/00 3 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) NON -REFERRED PROCEDURE A. You Must Have Coverage with HMO. A Member must be covered by HMO for the health benefits listed in the HMO Certificate of Coverage in order to be eligible to be covered by this Rider. If a Member is not covered under the HMO Certificate of Coverage or fails to remain covered under the HMO Certificate of Coverage, the Member cannot be covered under this Rider. B. Benefits Available Through this Program. This Rider provides coverage in the event the Member seeks Non -Referred Benefits. HMO must be contacted for Precertification prior to receiving certain services or su t are identified in this Rider as requiring Precertification in order to avoid a reduction in benefi C. The HMO Certificate of Coverage. The Member's eligibility to receive HMO Benefits P"Bejn MO ificate of Cov es the Member eligible to receive coverage under this Ridererred vered Benefi se of any discrepancy in meaning, this Rider shall c of Covefor -Referred Be fits under this Rider. �. D. HMO and HMO/FL QPOSRIDER- 102/00 4 E. F This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) Precertification. Prior to being hospitalized or receiving certain other Medical Services or supplies specified in the Covered Benefits section of this Rider, there are certain procedures that must be followed. _ p' em a or a member of the Member s family, a Hospital staff member, or the attending Phvsician, must notify HMO to precertify the admission or treatment as the case may be, prior to receiving any of the services or supplies that require Precertification pursuant to this Rider. To obtain Precertification, call HMO at the telephone number listed on the Member's identification card, This call must be made: 1. prior to any planned admission into a Hospital and prior to receiving such other services that require Precertification under this Rider; and 2. failure to notify the HMO in the case of a maternity related admission will not to the Member. The Member may request a review of the Precertification decision pur'' nt to the Gi section of this Rider. Precertification Penalty. ;ed by t "' , perce. ' ge or d r amount set for Pre t , ,,, n set fo in this Rider aid bal�ie benefit s.iki penalty on the non- T IN REDUCTION ' «' EFITS UNDER THIS tEFEED SCHEDU OF BENEFITS FOR THE the usual, customary, and reasonable charge (UCR) which a )btain Precertification under this section is not a Covered Ale amount or the Maximum Out -of -Pocket limit, if any. ELIGIBILITY In ordik'16"be eligible to receive benefits and to be covered under this Rider, a Member first must be eligible to receive benefits as a Subscriber or as a dependent of a Subscriber under the HMO Certificate of Coverage, and be covered under it. HMO/FL QPOSRII]ER-1 02/00 5 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) METHOD OF PAYMENT: DEDUCTIBLES COINSURANCE AND COPAYMENT A Member first must satisfy the Deductible amount, if any, listed on the non -referred Schedule of Benefits before Non -Referred Benefits are reimbursed. Thereafter, the Member must pay a Coinsurance portion of the Covered Expenses for Non -Referred Benefits that the Member received. When the Member obtains Self -Referred care from a Participating Provider, the Member must pay the applicable Copayment or Coinsurance listed on the non -referred Schedule of Benefits. 01 13 C. FI The Deductible. A Member will be eligible for reimbursement of Covered Benefits after the Member has satisfied the Deductible amount specified on the non -referred Schedule of Benefits. The Deductible applies to each Member, subject to any family Deductible listed on the non -referred Schedule of Benefits. For purposes of the Deductible, "family" means the Subscriber ered Dependents. The Deductible must be satisfied once each calendar year, except for: • the Common Accident Provision: if the Deductible applies to . c'dent expens and if two or more members of one family incur Covered Expenses be of disabilitie' esulf from injuries sustained in any one accident, the Dedu 11 be ap d only once to all 3.� and]' Covered Expenses incurred as a result of the �' in E*ksm6L i1CR. nbJril.l be r`' onsibl or charges in excess of the HMO's contractual liability under this Rider. byovider execofUCR will not be covered by HMO and will not be counted toward the sutible mount or Maximum Out -of -Pocket limit, if any. Out -of -Pocket Limit. [If a Member's Coinsurance payments reach the Maximum Out -of -Pocket limit set forth on the Schedule of Benefits, HMO will pay 100% of the UCR charges for Covered Benefits during that calendar year, up to the Maximum Benefit listed on the Schedule of Benefits. Covered Benefits must be rendered to the Member during that calendar year. Charges in excess of UCR charges and the additional percentage or dollar amount of UCR charges which a Member may pay as a penalty for failure to obtain Precertification will not be applied to the Maximum Out -of -Pocket limit and not eligible for 100% reimbursement. The Member's Coinsurance payments for outpatient mental health treatment will not be applied to the Maximum Out -of -Pocket limit and not eligible for 100% reimbursement. ] [The Member's Out -of -Pocket amount is unlimited. All Covered Expenses in excess of the Deductible amount will be paid by HMO and the Member in accordance with the Copayment and Coinsurance provisions listed on the non -referred Schedule of Benefits.] HMO/FL QPOSRIDER- 102/00 E. F This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) Benefit Limitations. A Member is covered under this Rider up to the Maximum Benefit for all Services and Supplies set forth on the non -referred Schedule of Benefits. Calculations; Determination of UCR; Determination of Benefits. A Member's financial responsibility for the costs of care will be calculated on the basis of when the service or supply is provided, not when payment is made. Charges will be pro -rated to account for treatment or portions of stays that occur in more than one calendar year. HMO reserves the right and sole discretion to determine the UCR rate. It is solely within the discretion of HMO to determine when expenses are covered under this Rider. V NEWNWEBWA HMO/FL QPOS1t1DER-1 02/00 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) COVERED BENEFITS A Member shall be entitled to the Covered Benefits as specified below for treatment of an illness or injury, in accordance with the terms and conditions of this Rider and the non -referred Schedule of Benefits. Unless specifically stated otherwise, in order for expenses to be covered, they must be Medically Necessary and the Covered Benefit must be performed by a Provider that is licensed to perform such services. Preventive care, as described below, will be considered Medically Necessary. To be Medically Necessary, the service or supply must: • be care or treatment as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the Member's overall health condition; • be care or services related to diagnosis or treatment of an existing illness or injury, exce vered periodic health evaluations and preventive and well baby care, as determined by HMO;'; • be a diagnostic procedure, indicated by the health status of the Mem and be as li y to result in information that could affect the course of treatment as, and no more like °to produce a ative tcome than, any alternative service or supply, both as to the d' , jury in ved and the verall health condition; • include only those services and pplies cannot safely, d saris Aorily provid ; alN at home, in a Physician's office, on an outpa basis,, n any fa' "ty of than a pital, when u in re on to inpatient Hospital rvices; and N� � • as to diagnosis, and trea e n"' e costly king into accou nth expenses incurred in ction with ervice or ) tn; ny equal effective servic ''"" e' "yin meeting the above es In d ' rmining if a sery or ply is ''Fdi N ssary, O's Patient Management Medical Director or its Ph designee wil • "in ation p ided q he Me er''s'health status; • rep in pe reviewe medical literature; • its and guidelines published by nationally recognized health care organizations that include supporting ie'ntific data; + professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment; • the opinion of Health Professionals in the generally recognized health specialty involved; • the opinion of' the attending Physicians, which have credence but do not overrule contrary opinions; and • any other relevant information brought to HMO's attention. All Covered Benefits will be covered in accordance with the guidelines determined by HMO. HMQ/FL QPOSRU)ER-1 02/00 8 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) If an Member has questions regarding coverage under this Rider, the Member may call the Member Services 800 telephone number listed on the Member's identification card. THE MEMBER IS RESPONSIBLE FOR PAYMENT OF THE APPLICABLE DEDUCTIBLE AND COINSURANCE OR COPAYMENTS, IF ANY, LISTED ON THE SCHEDULE OF BENEFITS. BENEFITS ARE SUBJECT TO THE LIMITS, IF ANY, SHOWN ON THE SCHEDULE OF BENEFITS. Physician Benefits. 1. Office visits during office hours. 2. Home visits. 3. After-hours PCP services. 4. Hospital visits. 5. Outpatient postsurgical follow-up care following mastectomy to provided at appropriate setting, as determined by the treating Physician, Diagnostic Services. S^ 35 to, on`annual mammography — ale 40 and older, one routine mammography every year; or ically le of — one or more mammograms a year, based upon a Physician's recommendation for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy -proven benign breast disease, because of having a mother, sister, or daughter who has had breast cancer, or because a woman has not given birth before the age of 30. Routine Pap exam.] Routine prostate specific antigen test for males ages 50 or older.] Child Health Supervision Services for children from birth through age 16, including a physical examination, developmental assessment; anticipatory guidance, appropriate immunizations and laboratory tests as Medically Necessary. Such services and periodic visits shall be provided in accordance with prevailing medical standards consistent with HMO/FL QPOSRH)ER-1 02/00 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics. No deductible applies. Specialist Physician Benefits. Covered Benefits include outpatient and inpatient services. + Maternity Care and Related Newborn Care. Outpatient and inpatient pre -natal and postpartum care and obstetrical services are Covered Benefits. Services may be provided by nurse -midwives, midwives and/or birth centers. Coverage for maternity care and related newborn care benefits is provided to the extent covered by this Rider for Specialist Physician benefits and inpatient Hospital benefits, and is subject to the limits 'f any, shown for these benefits on the Schedule of Benefits. ry " exceptiR� to they edicallNec°ssary requirements of this Rider, the following coverage is provided for other d newly rn child: 1. a imum of 48 hours of inpatient care in a Hospital following a vaginal delivery; a minimum of 96 hours of inpatient care in a Hospital following a cesarean section; or HMO/FL QPOSRIDER- 102/00 10 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) a shorter Hospital stay, if requested by a mother, and if determined to be medically appropriate by the Providers in consultation with the mother. If an Member requests a shorter Hospital stay, the Member will be covered for one home health care visit scheduled to occur within 24 hours of discharge. An additional visit will be covered when prescribed by the Provider. This benefit is in addition to the home health maximum number of visits, if any, shown on the Schedule of Benefits. A Copayment or Coinsurance will not apply for these home health care visits. All services and supplies are subject to Precertification by HMO. Skilled Nursing Facility Benefits. A Member is covered for Skilled Care in a Skilled Nursing Facility. Coverage for Skilled Facility benefits is subject to the limits, if any, shown on the Schedule of Benefits. x All services and supplies are subject to Precertification by HMO. Transplants. Transplants, including bone marrow transplants ap r"nsple Administration are a Covered Benefit. Ca ge fora coverage for the medical and sur 'cal expe'tl'""'s of a li dono the transplant is Medically Nec ry, an Memb must limits, if any, listedpn the Sche ,,,, of Bed'",'�. Outpatient care benefits are covered for Detoxification. Benefits include diagnosis, medical treatment and medical referral services (including referral services for appropriate ancillary services) for the abuse of or addiction to alcohol or drugs. The Member is entitled to outpatient visits to a Behavioral Health Provider upon for diagnostic, medical or therapeutic Substance Abuse Rehabilitation services for Substance Abuse. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. All services and supplies are subject to Precertification by HMO. 2. Inpatient care benefits are covered for Detoxification. Benefits include medical treatment and referral services for Substance Abuse or addiction. The following services shall be covered under HMO/FL QPOSRII)ER-1 02/00 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) inpatient treatment: lodging and dietary services; Physicians, psychologist, nurse, certified addictions counselor and trained staff services; diagnostic x-ray; psychiatric, psychological and medical laboratory testing; and drugs, medicines, equipment use and supplies. The Member is entitled to medical, nursing, counseling or therapeutic Substance Abuse Rehabilitation services in an inpatient, non -hospital residential facility, appropriately licensed by the Department of Health, for alcohol or drug abuse or dependency. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. All services and supplies are subject to Precertiiycation by HMO. [ • Mental Health Benefits. A Member is covered for services for the treatment of the following Mental or Behavioral through Behavioral Health Providers. . [l. Outpatient benefits are covered for short-term, outpatient evaluative and crisi tervention or home health mental health services, and is subject to the limits, ny, shown on e Schedule of Benefits.`t All services and supplies are subject to [2, Partial Hospitalization Batmen overed en ren ed in a4ensed facility. "overage is subject to the limits, if is shod,„' n the Sc dule o enefits. , All serv' `''"'"' and suppliow subjWflo Precer,o#w In by HMO/FL QPOSRIDER-1 02/00 12 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) 2, Outpatient Rehabilitation Benefits. Coverage is provided for the following benefits, and is subject to the limits, if any, shown on the Schedule of Benefits. a. Physical therapy is covered for non -chronic conditions and acute illnesses and injuries. b. Occupational therapy (except for vocational rehabilitation or employment counseling) is covered for non -chronic conditions and acute illnesses. C. Speech therapy is covered for non -chronic conditions and acute illnesses and injuries. Services rendered for the treatment of delays in speech development, unless resulting from disease, injury, or congenital defects, are not covered. All services and supplies are subject to Precertification by HMO. Home Health Care Benefits. The following services and supplies are covered when rendered by a approved and coordinated in advance by HMO. H1V, of be benefits when HMO determines the treatment settin ropri effective setting in which to provide appro to care. , , ;' Duero s sub, the Schedule of Benefits. Skilled a supervis y a regisie urse ter, oviaea 4Tegtsterea gra nurse. AServic o ome hea„ e. h service we covered only is Skil ' e. ,3 Medi service w� T me must be provided by or supervised by a qualified medical Phy 0. cial ker'�' long with other Home Health Services. The services must be nece y for' trea t o the Member's medical condition. 4. Sh term physical, speech, or occupational therapy is covered. Services are subject to the li dons, if any, listed in the Rehabilitation Benefits section of this Rider. I services and supplies are subject to Precertification by HMO. HMO/FL QPOSRIDER-1 02/00 13 A This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) Hospice Benefits. Hospice Care services and supplies for a terminally ill Member are covered. Services and supplies may include home and Hospital visits by nurses and social workers; pain management and symptom control; instruction and supervision of a family Member; inpatient care; counseling and emotional support; and other home health benefits listed above. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. Coverage is not provided for bereavement counseling, funeral arrangements, pastoral counseling, financial or legal counseling. Homemaker or caretaker services, and any service not solely related to the care of the Member, including but not limited to, sitter or companion services for the Member or other Members of the family, transportation, house cleaning, and maintenance of the house are not covered. Coverage is not provided for Respite Care. All services and supplies are subject to Precertification by HMO. Prosthetic Appliances. The Member's initial provision of a prosthetic device that tc of an external body part lost or impaired as a result o when such device is prescribed by a Provider and at i repair due to normal wear and tear, and „ lacemen hen appropriate services required forthe Mem to prope use covered. Coverage is provided , rosthe "' " vices in enta Infertility part injury congenital der vered, advance by HMO. Ccludes toco '° nital growth.n and em (suW as attachment insertion) are cover M„MMastectomy. tility servi s " d suppli t dia the un lying medical n ility treat n °not cove All services an uppJ s are su ' ct ec , catioq t5y HMO, are covered. e is ovided tests which are ordered by a Physician and given to an Member prior to the is mission to a Hospital as a registered bed inpatient. The tests must be necessary and nt the diagnosis and treatment of the condition for which Hospital care is required. Also, the 1 admission must take place within 14 days after the tests are given, unless such tests or other condition indicate otherwise. Private Duty Nursing. Coverage is provided for the charges for private duty professional nursing services from a L.P.N. or R.N. for an Member's non -hospitalized acute -illness or injury. Private duty nursing care furnished for Custodial Care is not covered. Benefits are subject to the limits, if any, shown for these benefits on the Schedule of Benefits. All services and supplies are subject to Precertification by HMO. Reconstructive Breast Surgery resulting from a Mastectomy and prosthetic devices are covered. Coverage includes reconstruction of the breast on which the Mastectomy is performed including aereolar HMO/FL QPOSRTI)ER-1 02/00 14 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) reconstruction and the insertion of a breast implant; surgery and reconstruction performed on the non - diseased breast to establish symmetry when Reconstructive Breast Surgery on the diseased breast has been performed; and Medically Necessary physical therapy to treat the complications of Mastectomy, including lymphedema. Reconstructive Breast Surgery will be in a manner chosen by the treating Physician, consistent with prevailing medical standards, and in consultation with the patient. All services and supplies are subject to Precertification by HMO. Cleft Lip and Palate Benefits for Children. For Covered Dependents under the age of 18, coverage is provided for medical, dental, speech therapy, audiology and nutrition services if such services are prescribed by the treating Physician or surgeon and such Physician or surgeon certifies that such services are Medically Necessary and consequent to treatment of the cleft liD and/or cleft palate. Eli MIR treat of a ,rosis re at roil) come �s of from vases t not All services and supplies are subject to Precertification by HMO. HMO/FL QPOSR rDER-1 02/00 15 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) • General Anesthesia for Dental Care. Coverage is provided for general anesthesia and associated hospital or ambulatory facility charges in conjunction with dental care provided to a Member if the Member is: -- under 8 years of age and determined by a licensed dentist and the child's Physician to require necessary dental treatment in a hospital or ambulatory surgical enter due to a significantly complex dental condition or a developmental disability in which patient management in the dental office has proved to be ineffective; or — an individual who has one or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental treatment or surgery if not rendered in a hospital or ambulatory surgical center. All services ire HMO/FL. QPOSRIT)ER-1 02/00 16 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) Durable Medical Equipment Benefits. Coverage is provided for Durable Medical Equipment. The wide variety of Durable Medical Equipment and continuing development of patient care equipment makes it impractical to provide a complete listing of covered items, therefore, the HMO Medical Director has the authority to approve requests on a case -by -case basis. Coverage for Durable Medical Equipment includes those items covered by Medicare unless excluded in the Exclusions and Limitations section of this Rider. HMO reserves the right to cover only the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of HMO. Instruction and appropriate services required for the Member to properly use the item, such as attachment or insertion, is also covered upon preauthorization by HMO. Replacement, repairs and maintenance are covered only if it is demonstrated to HMO that: it is needed due to a 2. it is likely to cost 1, equipment. All maintenance and repairs i Coverage is subject to the lin All services and supplies are HMO/FL QPOSRIDER-1 02/00 17 t like This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) EXCLUSIONS AND LIMITATIONS A. Exclusions. The following are not Covered Benefits except as described in the Covered Benefits section of this Rider: • Ambulance services for routine transportation to receive outpatient or inpatient services. • Any service beyond the Maximum Benefit listed on the Schedule of Benefits. • Beam neurologic testing. • Biofeedback, except as specifically approved by HMO. • Blood and blood plasma, including but not limited to, provision of blood, bloorno blood derivatives, synthetic blood or blood products other than blood derived clot, and immunoglobulins, the collection or storage of blood plasma, the co t of receivines of professional blood donors, apheresis or plasmapheresis. Only ad istration, prolood, processing fees, and fees related to autologous blood &nations a fees related & bo arrow transplants are covered. • Care for conditions that state or local limited to, mental illness commitments • Care furnish to provide . from exoosu at can wo be tr d in a Iblic facility, i luding but not ling, inc charges r providing a or injur " • Wharges i rr " ` outside thl, i t eW, States Medical is drugs, u 'ias, such s the Unite t ,, • arges, penses costs, excess of UCR. with completicW51WElaim form. free Member traveled to such location to obtain drugs or supplies are unavailable or illegal in • arge u' xpenses, or costs applied toward satisfaction of any applicable Deductible, Coinsurance, or onavritent amounts. 4 Cosmetic Surgery, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery, other than Medically Necessary Services. This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. Reduction mammoplasty, except when determined to be Medically Necessary by a HMO Medical Director, is not covered. This exclusion does not apply to surgery as a continuation of a staged reconstruction procedure, or congenital defects necessary to restore normal bodily functions, including but not limited to, cleft lip and cleft palate. • Court ordered services, or those required by court order as a condition of parole or probation. • Custodial Care. HMO/FL QYOSRIDER-1 02/00 18 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) Dental services, including but not limited to, services related to the care, filling, removal or replacement of teeth and treatment of injuries to or diseases of the teeth, dental services related to the gums, apicoectomy (dental root resection), orthodontics, root canal treatment, soft tissue impactions, alveolectomy, augmentation and vestibuloplasty treatment of periodontal disease, prosthetic restoration of dental implants, and dental implants. This exclusion does not include bone fractures, removal of tumors, and orthodontogenic cysts. Educational services and treatment of behavioral disorders, together with services for remedial education including evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental and learning disorders, behavioral training, and cognitive rehabilitation. This includes services, treatment or educational testing and training related to behavioral (conduct) problems, learning disabilities, or developmental delays. Special education, including lessons in sign language to instruct an Member, whose ability to speak has been lost or impaired, to function without that ability, are not covered. • False • Nealth ices, i ding those related to pregnancy, rendered before the effective date or after the ''rmina of the Member's coverage, unless coverage is continued under the Continuation and ;eonver n section of this Rider. Hearing aids, including charges for examinations or adjustments. • Home Births • Household equipment, including but not limited to, the purchase or rental of exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypo -allergenic pillows, mattresses or waterbeds, • Household fixtures, including but not limited to, the purchase or rental of escalators, elevators, and swimming pools, • Hypnotherapy, except when specifically approved by HMO. HMO/FL QPOSRIDER-1 02/00 19 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) • Implantable drugs. • Immunizations obtained for the purpose of travel. • Infertility services, including the treatment of male and female Infertility, injectable Infertility drugs, charges for the freezing and storage of cryopreserved embryos, charges for storage of sperm, and donor costs, including but not limited to, the cost of donor eggs and donor sperm, the costs for ovulation predictor kits, the costs for donor egg program or gestational carriers, in vitro fertilization procedures, gamete intra fallopian transfer (GIFT), zygote intra fallopian transfer (ZIFr), Infertility supplies. • Military service related diseases, disabilities or injuries for which the Member is legally entitled to receive treatment at government facilities and which facilities are reasonably available to the Member. 4. furnishe lely becau I the f§ng if th " 'ce or supply ould , fely a equately be Furnish a Physici a tit's office other less costl to correct the visual axes of eyes not properly • ,u'''' tpatie supplie ""'ncludi but not limited to, outpatient medical consumable or disposable supplies 9ch asAV,""iabetic inges, i ntinence pads, elastic stockings, and reagent strips, except as otherwise provided rein supplies.. Payment for benefits for which Medicare or a third party payer is the primary payer. • Personal comfort or convenience items, including those services and supplies not directly related to medical care, such as guest meals and accommodations, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, take-home supplies, and other like items and services. • Private duty or special nursing care, unless precertified by HMO. • Radial keratotomy, including related procedures designed to surgically correct refractive errors. • Recreational, educational, and sleep therapy, including any related diagnostic testing. HMO/FL QPOSRIDER- 102100 20 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) • Religious, marital and sex counseling, including services and treatment related to religious counseling, marital/relationship counseling, and sex therapy. • Reversal of voluntary sterilizations, including related follow-up care and treatment of complications of such procedures. • Routine foot/hand care, including routine reduction of nails, calluses and corns. • Services for which an Member is not legally obligated to pay in the absence of this coverage. • Services for the treatment of sexual dysfunctions or inadequacies, including therapy, supplies, or counseling for sexual dysfunctions or inadequacies that do not have a physiological or organic basis. • Services performed by a relative of an Member for which, in the absence of any health nefits coverage, no charge would be made. '' • Services required by third parties, including but not limited to, ph sical examina ns, diagnostic services and immunizations in connection with obtaining or conti ing employm obtaining or maintainingan license issued b a municipality �" y y p y, stat r federal overnment, se" in ranee coverage, travel, school admissions or attendane exami ions required ate in athletics, except when such examinations are co' 110cre be pa f an appropr schedule of wellness services. • Services which are not a under aaro aver vicUs supplie " i''fding but not ited , skin on (wrinkle icity testi yat), trea nt of non-speci a sensitivity, and urine drugs, or " ons r drugs or medications that have not been proven safe and :ifi[di is orapproved for a mode of treatment by the Food and Drug the National Institutes of Health (NIH); syringes and other injectable aids, except as otherwise provided herein as diabetic 'WKIKI— 3. drugs related to the treatment of non -covered services; and 4. drugs related to contraception, and performance enhancing steroids. • Special medical reports, including those not directly related to treatment of the Member, e.g., employment or insurance physicals, and reports prepared in connection with litigation. • Surgical operations, procedures or treatment of obesity, except when specifically approved by HMO. • Therapy or rehabilitation, including but not limited to, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetic therapy, vision perception training, and carbon dioxide. HMO/FL QPOSRit7ER-1 02/00 21 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) • Thermograms and thermography. • Transsexual surgery, sex change or transformation, including any procedure or treatment or related service designed to alter an Member's physical characteristics from the Member's biologically determined sex to those of another sex, regardless of any diagnosis of gender role or psychosexual orientation problems. • Treatment in a federal, state, or governmental entity, including care and treatment provided in a Hospital owned or operated by any federal, state or other governmental entity, except to the extent required by applicable laws. • Treatment of mental retardation, defects, and deficiencies. This exclusion does not apply to mental health services or to medical treatment of mentally retarded Members in accordance with the benefits provided in the Covered Benefits section of this Rider. _1 • Treatment of occupational injuries and occupational diseases eligible for coverageL nder a worker's compensation plan, including those injuries that arise out of (or in the coursork for pay or profit, or in any way results from a disease or injury which do „P However, ifnished to HMO that the Member is covered under a workers' mpensati ' law or similis not covered for a particular disease or injury under � hat dise or injury widered "non -occupational" regardless of cause. • Weight reduction programs dietary care,1011ing, removal or replacement of impacted teeth. • rmporectly andibular joint disorder treatment (TMJ), including treatment performed by prosthesis laced on the teeth. Coverage will be provided for diagnostic or surgical procedures involving the bones or joints of the jaw and facial region if such procedure is Medically Necessary to treat conditions caused by congenital or developmental deformity, disease or injury. Coverage will not be provided for care or treatment of the teeth or gums, for intraoral prosthetic devices, or for surgical procedures for cosmetic purposes. • Coverage of a non -Member donor in a transplant procedure unless the recipient of the transplant is an Member. In the event a HMO Member is the recipient, coverage will be provided under this Rider for a non -Member donor to the extent benefits are unavailable from any other source. • Birth control devices, including but not limited to, IUDs, diaphragms, condoms, Norplant and other implanted birth control devices. • Orthotics. HMO/FL QPOSRIDER- 102/00 22 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) • Outpatient prescription or non-prescription drugs and medicines. [' Inpatient and Outpatient Mental Health Treatment.] [ • Preventive care, subject to the services and limits, if any, listed on the Schedule of Benefits.] Family planning services. B. Limitations. • Determinations regarding eligibility for benefits, coverage for services, and all other terms of this Rider are at the sole discretion of HMO, subject to the terms of this Rider. TERMINATION OF COVERAGE A Member's coverage will be terminated in accordance with the Termination Provisions of the Coverage. Id A Member is entitled to the Continuation and Coverage. The procedures described is section #to HMPXertificateWlCoverage go in the under this Rider. of of es descriZ in a HM eUateoVbf Cover a govern complaints, grievances, and grievance or submi tubers arc ` 'gage under this Rider. thisVider will be subject to Coordination of Benefits as described in the HMO RESPONSIBILITY OF MEMBERS Refer to the Responsibility of Members section of the HMO Certificate of Coverage. GENERAL PROVISIONS A. Proof of Loss and Claims Payment. 1. Proof of Loss: Written proof of loss must be furnished to HMO within 90 days after a Member incurs Covered Benefits. Failure to furnish the proof of loss within the time required will not invalidate nor reduce any claim if it is not reasonably possible to give the proof of loss within 90 days, provided the proof of loss is furnished as soon as reasonably possible. However, except in HMO/FL QPOSRIDER-1 02/00 23 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) the absence of legal capacity of the claimant, the proof of loss may not be furnished later than one year from the date when the proof of loss was originally required. A proof of loss form may be obtained from HMO or the Contract Holder. If the Member does not receive such form before the expiration of 15 days after HMO receives the request, the Member shall be deemed to have complied with the requirements of this Rider upon submitting within the time fixed in this Rider written proof covering the occurrence, character and extent of the loss for which claim is made. 2. Time for Payment of Claim: Benefits payable under this Rider will be paid within 30 days of filing satisfactory proof of loss. If any portion of a claim is contested by HMO, the uncontested portion of the claim will be paid within 30 days after the receipt of proof of loss by HMO. Payment of Claims: All or any portion of any indemnities provided by the Rider on account of Hospital, nursing, medical or surgical services shall be paid to the Provider rendering such services; but it is not required that the service be rendered by a particular Hospital or persq, Any payment made by HMO in good faith pursuant to this provision will fully discp O's obligation to the extent of the payment. The Member may request that payme''' a made pursuant to this provision. The request must be made in writing and must be gi to HMO not later than the time of filing proof of loss. Payment made prior tlavirient ceipt of the ber's written request at HMO's principal executive office will be deemed to b made i"' ood faith. D. Legal Action. No legal action may be brought to recover on this Rider within 60 days after written proof of loss has been given as required by this Rider. No such action may be brought after the expiration of the applicable statute of limitations from the time written proof of loss is required to be given. HMO/FL QPOSRIDER-1 02/00 24 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) DEFINITIONS The following wards and phrases when used in this Rider shall have, unless the context clearly indicates otherwise, the meaning given to them below: • Behavioral Health Provider. A licensed organization or professional providing diagnostic, therapeutic or psychological services for behavioral health conditions. This includes duly certified substance abuse professionals, who are certified by the North Carolina Substance Abuse Professional Certification Board, and Pastoral Counselors. • Continuous Period of Disability. Any and all successive Hospital stays unless HMO receives satisfactory evidence that a successive Hospital stay: is due to causes not related to those of the earlier stay; occurs after full recovery from the causes of the earlier Hospital stay; or the later Hospital stay occurs after the Member has complete6 period of 9 ays without a • Effective Date of Coverage. The commencement date of coverage under the HMO Certificate of Coverage and this Rider as shown on the records of HMO and HMO. • Experimental or Investigational Procedures. Services or supplies that are, as determined by HMO, experimental. A drug, device, procedure or treatment will be determined to be experimental if: there is not sufficient outcome data available from controlled clinical trials published in the pecr reviewed literature to substantiate its safety and effectiveness for the disease or injury involved; or 2. required FDA approval has not been granted for marketing; or HMO/FL QPOSRIDER-1 02/00 25 • • This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) 3. a recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental or for research purposes; or 4. the written protocol or protocol(s) used by the treating facility or the protocol or protocol(s) of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental or for research purposes; or 5. it is not of proven benefit for the specific diagnosis or treatment of a Member's particular condition; or 6, it is not generally recognized by the Medical Community as effective or appropriate for the specific diagnosis or treatment of a Member's particular condition; or 7. it is provided or performed in special settings for research purposes. HMO Benetfts. Coverage. The referred benefits covered under the HMO Group Agreement a HMO Primary Care Physician. An HMO Particip ysician "" o supervises, provides initial care and basic Medical Services as a mily c practitioner, as an internist or a pediatrician to Memb , initiate eir R rral f Specialist cai continuity of patient care under th HMO ificate o overa 4! �awwb, q , a; HMO/FL QPOSRIDER-1 02/00 26 Certificate of and mpsume cases, and maintains This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) • Hospice Care Agency. An agency or organization which: 1. has Hospice Care available 24 hours a day; 2. meets all licensing or certification standards set forth by the jurisdiction where it is located; 3. provides skilled nursing services; medical social services; psychological and dietary counseling; and bereavement counseling for the immediate family; • H Heal Servi. T e items and services provided by Providers as an alternative to hos lizati and ap ed and coordinated in advance by HMO. • H " ice Ca4r�e. A program of care that is provided by a Hospital, Skilled Nursing Facility, Hospice lity, or a duly licensed Hospice Care agency, and is approved by HMO, and is focused on a palliative other than curative treatment for Members who have a medical condition and a prognosis of less than 6 months to live. • Hospice Facility. A facility, or distinct part of one, which; 1. mainly provides inpatient Hospice Care to terminally ill individuals; 2. charges its patients; 3. meets all licensing or certification standards set forth by the jurisdiction where it is located; 4, keeps a medical record on each patient; HMO/FL QPOSRIDER-1 02/00 27 This is SAMPLE document. It is provided for illustrative purposes only. (Quality Point -of -Service) 5. provides an ongoing quality assurance program; this includes reviews by Physicians other than those who own or direct the facility; 6. is run by a staff of Physicians; at least one such Physician must be on call at all times; 7. provides, 24 hours a day, nursing services under the direction of a R.N; and 8. has a full-time administrator. • Non -Participating Provider. A Provider not designated as an HMO Participating Provider or such other Provider not part of the HMO network or a Participating Provider that is seen upon a Member's Self -Referral. • Non -Referred Benefits. Covered Benefits under this Rider received from Participating o Non - Participating Providers without a prior Referral issued by the Member's HMO Care Physician. • Participating Provider. A Provider designated as an HMO Partic ting Provid or such other Providers as HMO determines to be part of its network. t _A • Precertification. A certification from HMO that a ,a a ust obt prior to rece any of the services that are identified by this Rider as ding Pr rtifica I' n in or rW' ` to receive un " uced benefits. • TCR. The usual, customary, and reasonable charge for a Covered Benefit which is determined by HMO to be the prevailing charge level made for the service or supply in the geographic area where it is furnished. HMO may take into account factors such as the complexity, degree of skill needed, type or specialty of the Provider, range of services provided by a facility, and the prevailing charge in other areas in determining the UCR for a service or supply that is unusual or is not often provided in the area or is provided by only a small number of Providers in the area. HMO/FL QPOSRIDER-1 02/00 28 This is SAMPLE document. It is provided for illustrative purposes only. AETNA U.S. HEALTHCARE, INC. (FLORIDA) USUAL, CUSTOMARY AND REASONABLE CHARGES AMENDMENT Contract Holder Group Insurance Policy Effective Date: The definition of "UCR", appearing in the Definitions section of the Certificate is hereby deleted and replaced with the following: UCR. The usual, customary, and reasonable charge for a Covered Benefit. Only that part of a charge which is usual, customary and reasonable is covered. The usual, customary, and reasonable charge for a service or supply is the lowest of: 1. the Provider's usual charge for furnishing it; and 2. the charge HMO determines to be appropriate, based on factors such as the cost of providing the same or a similar service or supply and the manner in which charges for the service or supply are made; and 3. the charge HMO determines to be the prevailing charge level made for it in the geographic area where it is furnished. In some circumstances, HMO may have an agreement, either directly or indirectly through a third party, with a Provider which sets the rate that HMO will pay for a service or supply. In these instances, in spite of the methodology described above, the usual, customary and reasonable charge is the rate established in such agreement. In determining the usual, customary, and reasonable charge for a service or supply that is unusual; or not often provided in the area; or provided by only a small number of Providers in the area; HMO may take into account factors, such as: L the complexity; 2. the degree of skill needed; 3. the type of specialty of the Provider; 4. the range of services or supplies provided by a facility; and 5. the prevailing charge in other areas. HMO/FL UCR-AMEND-1 05101 .y;ufi.H;.., n:<�.,..z,^::� , zu,..q:�u.,,�,�':•�,� _.,�'t,�ur:�`.�':'�$"+'.�". z�,•r1�n;r,!}1T "','`�.rc-^'.`��•�.`".�at�'. - . ,p': .. Table of Contents Summary of Coverage .................................................... Issued With Your Booklet Health Expense Coverage.....................................................................................3 Prescription Drug Expense Coverage................................................................3 Comprehensive Medical Expense Coverage.....................................................6 General Exclusions.........................................................................................25 Effect of Benefits Under Other Plans.................................................................29 Other Plans Not Including Medicare...............................................................29 Effect of A Health Maintenance Organization Plan On Coverage ..................32 Effectof Medicare..........................................................................................33 Effect of Prior Coverage - Transferred Business ......................... ............33 General Information About Your Coverage ...........................I.. ......................34 Glossary................................................... ....... ........40 (Defines the Terms Shown i pe the ext of Thi u ent.) - 1 The Plan described in the following pages of this Booklet is a benefit plan of the Employer. These benefits are not insured with Aetna Life Insurance Company ("Aetna") but will be paid from the Employer's funds. Aetna will provide certain administrative services under the Plan as outlined in the Administrative Services Contract between Aetna and the Contractholder. Booklet Base: 1 — Open Choice Issue Date: June 26, 2000 Effective Date: January 1, 2000 Health Expense Coverage Health Expense Coverage is expense -incurred coverage only and not coverage for the disease or injury itself. This means that this Plan will pay benefits only for expenses incurred while this coverage is in force. Except as described in any extended benefits provision, no benefits are payable for health expenses incurred before coverage has commenced or after coverage has terminated; even if the expenses were incurred as a result of an accident, injury, or disease which occurred, commenced, or existed while coverage was in force. An expense for a service or supply is incurred on the date the service or supply is furnished. When a single charge is made for a series of services, each service will bear a pro rata share of the expense. The pro rata share will be determined by Aetna. Only that pro rata share of the expense will be considered to have been an expense incurred on the date of such service. Aetna assumes no responsibility for the outcome of any covered s s or supplies. Aetna makes no express or implied warranties concerning th IF om of any covered _,,,,,, services or supplies. 1 Prescri Drug E se v ge i erely a e f tla�iiefits in this section. It vide be co er ex ses incu all prescription drugs. There copItmu at s, a if appl cable to this Plan, deductible and efit fr Th scribed in the Booklet. , Wrage outlines the Payment Percentages that apply to the Covered Expenses described below. Covered Prescription Drug This Plan pays the benefits shown below for certain prescription drug expenses incurred Expenses for the treatment of a disease or injury. These benefits apply separately to each covered person. If a prescription drug is dispensed by a pharmacy to a person for treatment of a disease or injury, a benefit will be paid, determined from the Benefit Amount subsection, but only if the pharmacy's charge for the drug is more than the copay per prescription or refill. Benefit amounts provided under this section will not be subject to any provision under this Plan for coordination of benefits with other plans, except the provision for coordinating benefits under this Plan with any Medicare benefits. Benefit Amount The benefit amount for each covered prescription drug or refill dispensed by a preferred pharmacy will be an amount equal to the Payment Percentage of the total charges. The total charge is determined by: • the preferred pharmacy; and • Aetna. Any amount so determined will be paid to the preferred pharmacy on your behalf. In figuring the benefit amount, a Separate Brand Name Fee applies to brand name drugs in addition to any applicable copay. The amount of the Separate Brand Name Fee will be equal to the difference between the cost of the brand name drug and the generic equivalent. The Separate Brand Name Fee will apply to any brand name drug dispensed unless: • there is no generic equivalent to the brand name drug; • the pharmacy is unable to supply the generic drug at the time the prescription is presented; or • the prescriber indicates that the generic drug should not be dispensed. The Benefit Amount for each covered prescription drug or refill dispensed by a non. preferred pharmacy will be an amount equal to the Payment Percentage of the non - preferred pharmacy's charge for the drug except for an emergency condition, in which case the benefit will be payable at the preferred level of coverage. • For a device of any type unless speciDp nc ed as a pr ri on drug. • For any drug entirely consume nd ace it is p • For less than a 30 day supply anype • For more than ay sup r pio not appjy to a sup of up daes d by a m r refill. H lion cr r order harmacy. ever, is limitation does Rs which are if the prescriber has not specified the number of refills; or if the frequency or number of prescriptions or refills appears excessive under accepted medical practice standards. 4 • For any refill of a drug dispensed more than one year after the latest prescription for it or as permitted by the law of the jurisdiction in which the drug is dispensed. • For any drug provided by or while the person is an inpatient in any health care facility; or for any drug provided on an outpatient basis in any health care facility to the extent benefits are paid for it under any other part of this Plan or under any other medical or prescription drug expense benefit plan carried or sponsored by your Employer. • For any prescription drug also obtainable without a prescription on an "over the counter" basis. • For immunization agents. • For biological sera and blood products. • For nutritional supplements. • For any contraceptive drugs, except oral contraceptives. • For any smoking cessation aids or drugs. • For appetite suppressants. • For a prescription drug dispensed by a mail order pharmacy that is not a preferred pharmacy. Comprehensive Medical Expense Coverage Comprehensive Medical Expense Coverage is merely a name for the benefits in this section. It does not provide benefits covering expenses incurred for all medical care. There are exclusions, deductibles, copayment features and stated maximum benefit amounts. These are all described in the Booklet. The Summary of Coverage outlines the Payment Percentages that apply to the Covered Medical Expenses described below. Covered Medical Expenses They are the expenses for certain hospital and other medical services and supplies. They must be for the treatment of an injury or disease. Here is a list of Covered Medical Expenses. Hospital Expenses Inpatient Hospital Expenses Charges made by a hospital for giving board and room and other hospital services and supplies to a person who is confined as a full-time inpatient. Not included is any charge for daily board andr in a pri to roam over the Private Roam Limit. . Outpatient Hospital Expenses Charges made by pital f spi s ces d sup pies hick a given to a person wl,i is not c ed a 11-ti patien onAment t F c x ns hary a I cc ac' or the following services and supplies. They mustd t ape' n confined to convalesce from a disease or injury. The hpnfist s during a"Convalescent Period". B and room. This includes charges for services, such as general nursing care, made in connection with room occupancy. Not included is any charge for daily board and room in a private room over the Private Room Limit. • Use of special treatment rooms. • X-ray and lab work. • Physical, occupational or speech therapy. • Oxygen and other gas therapy. • Other medical services usually given by a convalescent facility. This does not include private or special nursing, or physicians services. • Medical supplies. Benefits will be paid for up to the maximum number of days during any one Convalescent Period. This starts on the first day a person is confined in a convalescent facility if he or she: • was confined in a hospital for at least 3 days in a row, while covered under this Plan, for treatment of a disease or injury; and • is confined in the facility within 14 days after discharge from the hospital, and • is confined in the facility for services needed to convalesce from the condition that caused the hospital stay. These include skilled nursing and physical restorative services. It ends when the person has not been confined in a hospital, convalescent facility, or other place giving nursing care for 90 days in a row. Limitations To Convalescent Facility Expenses This section does not cover charges made for treatment of: • the char e i ■ho eat fcar age • the car s h heal1 the ome as ma given given F a p a er home. and and ;Pame nter ittenf care by an R.N. or by an L.P.N. if an R.N. is not available. me xttent home health aide services for patient care. occupational, and speech therapy. lowing to the extent they would have been covered under this Plan if the person had been confined in a hospital or convalescent facility: medical supplies; drugs and medicines prescribed by a physician; and lab services provided by or for a home health care agency. There is a maximum to the number of visits covered in a calendar year. Each visit by a nurse or therapist is one visit. Each visit of up to 4 hours by a home health aide is one visit. Limitations To Home Health Care Expenses This section does not cover charges made for: • Services or supplies that are not a part of the home health care plan. • Services of a person who usually lives with you or who is a member of your or your wife's or husband's family. • Services of a social worker. • Transportation. 7 Hospice Care Expenses Charges made for the following furnished to a person for Hospice Care when given as a part of a Hospice Care Program are included as Covered Medical Expenses. Facility Expenses The charges made in its own behalf by a: • hospice facility; • hospital; • convalescent facility; which are for: • Board and room and other services and supplies furnished to a person while a full-time inpatient for: pain control; and other acute and chronic symptom management. • Not included is any charge for daily board and room in a private room over the Private Room Limit. Also not included is the charge for any day of onfinement in excess of the Maximum Number of Days for all confineme pice Care. • Services and supplies furnished to a person whileNt con fin as a ull-time inpatient. Other Expenses Charges made by a Hospice assisting the person to obtain those resources needed to meet the person's assessed needs. • Psychological and dietary counseling. • Consultation or case management services by a physician. • Physical and occupational therapy. • Part-time or intermittent home health aide services for up to 8 hours in any one day. These consist mainly of caring for the person. • Medical supplies. • Drugs and medicines prescribed by a physician. 8 Charges made by the providers below, but only if: the provider is not an employee of a Hospice Care Agency; and such Agency retains responsibility for the care of the person. • A physician for consultant or case management services. • A physical or occupational therapist. • A Home Health Care Agency for: physical and occupational therapy; part-time or intermittent home health aide services for up to 8 hours in any one day; these consist mainly of caring for the person; medical supplies; drugs and medicines prescribed by a physician; and psychological and dietary counseling. Not more than the Hospice Outpatient Maximum will be paid for all Hospice Care Expenses incurred while the person is not confined as a full-time inant. Not included are charges made: 9 Infertility Services Expenses Even though not incurred for treatment of a disease or injury, Covered Medical Expenses will include expenses incurred by a covered female for infertility if all of the following tests are met: • There exists a condition that: is a demonstrated cause of infertility; and has been recognized by a gynecologist or infertility specialist, and is not caused by voluntary sterilization or a hysterectomy; or For a female who is: under age 35, she has not been able to conceive after one year or more without contraception or 12 cycles of artificial insemination; and of tr tm in a Art, emi . per n's li me subject to a maximum of 6 courses a maximum of 6 courses of treatment in a covered Fhafftxpenses will be covered on the same basis as for disease. A course of treatment is one cycle of treatment that corresponds to one ovulation attempt In figuring the above Lifetime Maximums, Aetna will take into consideration, whether past or present, services received while covered, under a plan of benefits offered by Aetna; or one of its affiliated companies. Not covered are charges for: • Purchase of donor sperm or storage of sperm. • Care of donor egg retrievals or transfers. • Cryopreservation or storage of cryopreserved embryos. • Gestational carrier programs. • Home ovulation prediction kits. • In vitro fertilization, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and intracytoplasmic sperm injection. • Frozen embryo transfers, including thawing. • Reversal of sterilization surgery. [L Routine Physical Exams The charges made by a physician for a routine physical exam given to you, your spouse, or your dependent child may be included as Covered Medical Expenses. If charges made by a physician in connection with a routine physical exam given to a dependent child are Covered Medical Expenses under any other benefit section, no charges in connection with that physical exam will be considered Covered Medical Expenses under this section. A routine physical exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified injury or disease. Included as a part of the exam are: • X-rays, lab and other tests given in connection with the exam; and • materials for the administration of immunizations for infectious disease and testing for tuberculosis. For your dependent child: The physical exam must include at least: a review and written record of the patient's complete medical history; a check of all body systems; and a review and discussion of the exam results with the pa guardian. • For all exams given to your dependent child 4a4lge 7, will not include charges for: ' more than 6 exams perfc more than 2 eJ& perft moreman in one per ForAfort. giv o wile c ar it aen o yo ai are of the ld's year the parent or ;dical Expenses life; and the next ears f 11d's life. child ag ver, Covered Medical Expenses one ex in 24 months in a row. spouse, Covered Medical Expenses will not include 006exam in 24 months in a row, if the person is under age 65; and one exam in 12 months in a row, if the person is age 65 or over. Also included as Covered Medical Expenses are charges made by a physician for one annual routine gynecological exam. Not covered are charges for: • Services which are covered to any extent under any other group plan of your Employer. • Services which are for diagnosis or treatment of a suspected or identified injury or disease. • Exams given while the person is confined in a hospital or other facility for medical care. • Services which are not given by a physician or under his or her direct supervision. • Medicines, drugs, appliances, equipment, or supplies. • Psychiatric, psychological, personality or emotional testing or exams. • Exams in any way related to employment. • Premarital exams. • Vision, hearing or dental exams. • A physician's office visit in connection with immunizations or testing for tuberculosis. 11 Other Medical Expenses • Charges made by a physician. • Charges made by a R.N. or L.P.N. or a nursing agency for skilled nursing care. As used here, "skilled nursing care" means these services: Visiting nursing care by a R.N. or L.P.N. Visiting nursing care means a visit of not more than 4 hours for the purpose of performing specific skilled nursing tasks. Private duty nursing by a R.N. or L.P.N. if the person's condition requires skilled nursing services and visiting nursing care is not adequate. Benefits will not be paid during a calendar year for private duty nursing for any shifts in excess of the Private Duty Nursing Care Maximum Shifts. Each period of private duty nursing of up to 8 hours will be deemed to be one private duty nursing shift. Not included as "skilled nursing care" is: that part or all of any nursing care that does not require the education, training, and technical skills of a R.N. or L.P.N.; such as transportation, meal preparation, charting of vital signs, and companionship activities; or any private duty nursing care given while other health care facility; or _,__ . care provided to help a feeding, peVdWl groot jWd per day for a period of no more than 10 the occurrence of: patient medication; need for treatment of an emergency condition by a physician or the onset of symptoms indicating the likely need for such treatment; surgery; or release from inpatient confinement; or any service provided solely to administer oral medicines; except where applicable law requires that such medicines be administered by a R.N. or L.P.N. 12 • Charges for the following: Drugs and medicines which by law need a physician's prescription and for which no coverage is provided under the Prescription Drug Expense Coverage. Diagnostic lab work and X-rays. X-ray, radium, and radioactive isotope therapy. Anesthetics and oxygen. Rental of durable medical and surgical equipment. In lieu of rental, the following may be covered: The initial purchase of such equipment if Aetna is shown that: long term care is planned; and that such equipment: either cannot be rented; or is likely to cost less to purchase than to rent. Repair of purchased equipment. orthopedic shoes, foot orthotics, or other devices to support the feet. 13 National Medical Excellence Program ® (NME) The NME Program coordinates all solid organ and bone marrow transplants and other specialized care that can not be provided within an NME Patient's local geographic area. When care is directed to a facility ("Medical Facility") more than 100 miles from the person's home, this Plan will pay a benefit for Travel and Lodging Expenses, but only to the extent described below. Travel Expenses These are expenses incurred by an NME Patient for transportation between his or her home and the Medical Facility to receive services in connection with a procedure or treatment. Also included are expenses incurred by a Companion for transportation when traveling to and from an NME Patient's home and the Medical Facility to receive such services. Lodging Expenses These are expenses incurred by an NME Patient for lodging away from home while traveling between his or her home and the Medical Facility to receive services in connection with a procedure or treatment. The benefit payable for these expenses per person per night. Also included are expenses incurred while traveling with an Medical Facilit ec( tr putpbse of determining NME Travel Expenses or Lodging Expenses, a hospital or th r temporary residence from which an NME Patient travels in order to begin a period of treatment at the Medical Facility, or to which he or she travels after discharge at the end of a period of treatment, will be considered to be the NME Patient's home. 14 Explanation of Some Important Plan Provisions Travel and Lodging Benefit Maximum For all Travel Expenses and Lodging Expenses incurred in connection with any one procedure or treatment type: The total benefit payable will not exceed the Travel and Lodging Maximum per episode of care. Benefits will be payable only for such expenses incurred during a period which begins on the day a covered person becomes an NME Patient and ends on the earlier to occur of: one year after the day the procedure is performed; and the date the NME Patient ceases to receive any services from the facility in connection with the procedure. Limitations Travel Expenses and Lodging Expenses do not include, and no benefits are payable for, any charges which are included as Covered Medical Expenses under any other part of this Plan. Travel Expenses do not include expenses incurred by more than one traveling with the NME Patient. Lodging Expenses do not include expenses i night. is The more (mpanion who is Companion per hospital confinement �ctW vtff only be applied once to all hospital confinements, are separated by less than 10 days. s used to meet the Inpatient Hospital Deductible cannot be used to meet any other po tcable deductible. Expenses used to meet any other applicable deductible cannot be used to meet the Inpatient Hospital Deductible. Calendar Year Deductible This is the amount of Covered Medical Expenses you pay each calendar year before benefits are paid. There is a Calendar Year Deductible that applies to each person. Family Deductible Limit If Covered Medical Expenses incurred in a calendar year by you and your dependents and applied against the separate Calendar Year Deductibles equal the Family Deductible Limit, you and your dependents will be considered to have met the separate Calendar Year Deductibles for the rest of that calendar year. 15 Limitations Preexisting Conditions A "preexisting condition" is an injury or disease for which a person: received treatment or services; or took prescribed drugs or medicines; during the 90 days right before the person's effective date of coverage (or, if the Plan requires you to serve a probationary period, the 90 days right before the first day of the probationary period). See the Effective Date of Coverage or Late Enrollee section of the Summary of Coverage, whichever applies, to determine a person's effective date of coverage. For the first 365 days following such date, Covered Medical Expenses incurred for treatment of a preexisting condition only include the first $ 4,000 of Covered Medical Expenses for which no benefit is payable: under any other part of this Plan; or under any other group plan of your Employer. Special Rules As To A Preexisting Condition If a person had creditable coverage and such coverage terminated within 90 days prior to the date he or she enrolled (or was enrolled) in this Plan, then any limitation as to a preexisting condition under this Plan will not apply for that pers Also, if a person enrolls (or is enrollhil lanfor mediate afte any applicable probationary period has been servedad credi 1 verage which terminated within 90 days prior probati ary riod, then any limitation as to a preexisting c itithat son. Routine Mammogram Even though not incurred in connection with a disease or injury, Covered Medical Expenses include charges incurred by a female age 40 or over for one mammogram each calendar year. R Mouth, Jaws, and Teeth Expenses for the treatment of the mouth, jaws, and teeth are Covered Medical Expenses but only those for: • services rendered; and • supplies needed; for the following treatment of or related to conditions of the: • teeth, mouth, jaws, jaw joints; or • supporting tissues (this includes bones, muscles, and nerves). For these expenses, physician includes a dentist. Surgery needed to: • Treat a fracture, dislocation, or wound. • Cutout: teeth partly or completely impacted in the bone of the jaw; teeth that will not erupt through the gum; other teeth that cannot be removed without cttaW& into the roots of a tooth withoutl&mdWg tlnti tooth; cysts, tumors,At"thu dis d ti es • Cut iX sas mrhil is i y co re' of done in g. tonnwitho 1, plaor r it eAlter, jab rels b ting procedure when appliance theraa cat i nctprovement. or diseases. This does not include those of or related ®ell work, surgery, and orthodontic treatment needed to remove, repair, replace, restore, or reposition: • natural teeth damaged, lost, or removed; or • other body tissues of the mouth fractured or cut; due to injury. Any such teeth must have been: • free from decay; or • in good repair; and • firmly attached to the jaw bone at the time of the injury. The treatment must be done in the calendar year of the accident or the next one. 17 If: • crowns (caps); or • dentures (false teeth); or • bridgework; or • in -mouth appliances; are installed due to such injury, Covered Medical Expenses include only charges for: • the first denture or fixed bridgework to replace lost teeth; • the first crown needed to repair each damaged tooth; and • an in -mouth appliance used in the first course of orthodontic treatment after the injury. Except as provided for injury, not included are charges: • for in -mouth appliances, crowns, bridgework, dentures, tooth restorations, or any related fitting or adjustment services; whether or not the purpose of such services or supplies is to relieve pain; • for root canal therapy; • for routine tooth removal (not needing cutting of bone). Not included are charges: • to remove, repair, replace, restore or biting or chewing; • to repair, replace, or restore tililings, • for non-surgicalodontal, tm • for den 1 cleanin -mou alin •� for my nctiona apy• h is: or habits. Care In An Emergency Room • is received in the emergency room of a hospital while a person is not a full-time inpatient; and • the treatment is not emergency care; Covered Medical Expenses for charges made by the hospital for such treatment will be paid at the Reduced Payment Percentage. No benefit will be paid under any other part of this Plan for charges made by a hospital for care in an emergency room that is not emergency care. 18 Certification For Hospital Admissions This certification section applies to admissions other than those for the treatment of alcoholism, drug abuse or mental disorders. A separate section applies to such admissions. If: a person becomes confined in a hospital as a full-time inpatient; and it has not been certified that such confinement (or any day of such confinement) is necessary; and the confinement has not been ordered and prescribed by a physician who is a Preferred Care Provider; Covered Medical Expenses incurred on any day not certified during the confinement will be paid as follows: • As to Hospital Expenses incurred during the confinement: If certification has been requested and denied: No benefits will be paid for Hospital Expenses incurred for board and room. Benefits for all other Hospital Expenses will be payable at the Payment Percentage. • As to other Covered Medical Expenses: Benefits will be paid at the Payment Percentage. 19 Whether or not a day of confinement is certified, no benefit will be paid for expenses incurred on any day of confinement as a full-time inpatient if excluded by any other terms of this Plan; except that, if certification has been given for a day of confinement, the exclusion of services and supplies because they are not necessary will not be applied to expenses for hospital room and board. Certification of days of confinement can be obtained as follows: If the admission is a non -urgent admission, you must get the days certified by calling the number shown on your ID card. This must be done at least 14 days before the date the person is scheduled to be confined as a full-time inpatient. If the admission is an emergency or an urgent admission, you, the person's physician, or the hospital must get the days certified by calling the number shown on your ID card. This must be done: before the start of a confinement as a full-time inpatient which requires an urgent admission; or not later than 48 hours following the start of a confinement as a full-time inpatient which requires an emergency admission; unless it is not possible for the physician to request certification within that time. In that case, it must be done as soon as reasonably possible. In the event the Confinement starts on a Friday or Saturday, the 48 hour requirement will be extended to 72 hours. , If, in the opinion of the person's physician, it is for a longer time than already certified, you, the that more days be certified by calli done no later than on the last d at sal y for an, Lehojpital rson to be confined in, or may request on yod. This must be sent Oro tlhe hospital. A PT Certification For Convalescent Facility Admissions, Home Health Care Expenses, Hospice Care Expenses, and Skilled Nursing Care If a person incurs Covered Medical Expenses: • while confined in a convalescent facility or a hospice facility; or • for a service or a supply for home health care or hospice care while not confined as an inpatient or skilled nursing care; and it has not been certified that: such confinement or any day of it is necessary; or such other services or supplies (either specifically or as a part of a planned program of care) are necessary, and the confinement or service or supply has not been ordered or prescribed by a physician who is a Preferred Care Provider; such Covered Medical Expenses will be paid only as follows: • As to Convalescent Facility Expenses and Hospice Care Facility Expenses incurred while confined in a convalescent facility or a hospice facility: If certification has been requested and denied: No benefits will be paid for Convalescent ity ExVesospice Care Facility Expenses incurred for bo. d r Benefits for all other CSe les t F it xpenses a ospice�Care Facility Expenses i ed duri c m ent 11 be paid the P ment Percentage. If certification has not been requested and the confinement or (any day of such confinement) is necessary: Convalescent Facility Expenses or Hospice Care Facility Expenses, incurred during the confinement, up to the Excluded Amount, will not be deemed to be Covered Medical Expenses. Benefits for all other such expenses, incurred during the confinement, will be paid at the Payment Percentage. As to all other Covered Medical Expenses incurred during the confinement, benefits will be paid at the Payment Percentage. 21 • As to Covered Medical Expenses incurred for services or supplies either as stated or as a part of a planned program of care for home health care, hospice care while not confined as an inpatient, or skilled nursing care: If certification for a service or supply has been requested and denied or if certification has not been requested and the service or supply is not necessary, no benefits will be paid for the denied or unnecessary service or supply. If certification has not been requested for a service or supply and the service or supply is necessary, benefits for the necessary service or supply will be paid as follows: Expenses incurred for the service or supply, up to the Excluded Amount, will not be deemed to be Covered Medical Expenses. Benefits for all other Covered Medical Expenses incurred for the service or supply will be paid at the Payment Percentage. Whether or not a day of confinement or a service or supply has been certified, no benefit will be paid if the charges for such confinement or service or supply are excluded by any other terms of this Plan; except that: • To the extent that a day of confinement has been certified, exclusion of services and supplies because they are not necessary will 4weply to: 11 1 Convalescent Facility ExpenVs n ard; or Hospice Care �lity Ex es f roo anfar To the tent that h sery rs as bcertifi d health care, hospic are, ors nu i care a excluof v' or supplies because they are nod essaryjwothp to h service ply. To get , erti tion ou t c o tuber shown on your ID card. Such certification atust d be re a e rise is incurred. a rson'siiysician believes that the person needs more days of confinement or ervfMes or supplies beyond those which have been already certified you must call to certify more days of confinement or services or supplies. Prompt written notice will be provided to you of the days of confinement and services or supplies which have been certified. If: • services and supplies for hospice care provided to a person have been certified; and • the person later requires confinement in a hospital for pain control or acute symptom management; any other certification requirement in this plan will be waived for any such day of confinement in a hospital. 22 Certification For Hospital and Treatment Facility Admissions for Alcoholism, Drug Abuse or Mental Disorders If, in connection with the effective treatment of alcoholism or drug abuse or treatment of mental disorders, a person incurs Covered Medical Expenses while confined in a hospital or treatment facility; and it has not been certified that such confinement (or any day of such confinement) is necessary; and the confinement has not been ordered and prescribed by a physician who is a Preferred Care Provider: Covered Medical Expenses incurred on any day not certified during the confinement will be paid only as follows: With respect to expenses for hospital and treatment facility board and room: If certification has been requested and denied, or if certification has not been requested and the confinement (or any day of it) is not necessary, no benefits will be paid. If certification has not been requested and the confinenjeW04essary, such expenses, up to the Excluded Amount, will not be Cov Me Kcal Expenses. With respect to all other hospita tm t facility If or if cert ation Ilas not been ich exoeits, unk the Excluded A unt, will be C v ical Ex ses. is for c ns in a ss oft xcluded Amount will be paid at the y t Per nt f cert ati as of been requested and the confinement is not necessary, no benef pa paid. ether or not a day of confinement is certified, no benefits will be payable for Covered Medical Expenses incurred on any day of confinement as a full-time inpatient if excluded by any other terms of this Plan; except that, if certification has been given for any day of confinement, the exclusions of services and supplies because they are not necessary will not be applied to hospital and treatment facility board and room. To get the days certified, you must call the number shown on your ID card. Such certification must be obtained before confinement as a full-time inpatient, or in the case of an emergency admission, within 48 hours after the start of a confinement as a full-time inpatient or as soon as reasonably possible. If the person's physician believes that the person needs more days of confinement beyond those which have already been certified, additional days of confinement must be certified. This must be done no later than on the last day that has already been certified. 23 Treatment of Alcoholism, Drug Abuse, or Mental Disorders Certain expenses for the treatment shown below are Covered Medical Expenses. Inpatient Treatment If a person is a full-time inpatient either: • in a hospital; or • in a treatment facility; then the coverage is as shown below. Hospital Expenses for the following are covered: • Treatment of the medical complications of alcoholism or drug abuse. This means things such as cirrhosis of the liver, delirium tremens, or hepatitis. • Effective treatment of alcoholism or drug abuse. • Treatment of mental disorders. Treatment Facility Certain expenses for the effective treatment of alcoholism or d4ar, use or the treatment of mental disorders are covered. The expenses c ru hose for: If a pe of a fill-ti iuOgrent either: to facility; then the coverage is as shown below. Expenses for the effective treatment of alcoholism or drug abuse or the treatment of mental disorders are covered. For such treatment given by a hospital, treatment facility or physician, benefits will not be payable for more than the Maximum Visits in any one calendar year. 24 General Exclusions General Exclusions Coverage is not provided for the following charges: Applicable To Health Expense . Those for services and supplies necessary, as determined by Aetna, for the Coverage pP not necessa diagnosis, care, or treatment of the disease or injury involved. This applies even if they are prescribed, recommended, or approved by the person's attending physician or dentist. • Those for care, treatment, services, or supplies that are not prescribed, recommended, or approved by the person's attending physician or dentist. • Those for or in connection with services or supplies that are, as determined by Aetna, to be experimental or investigational. A drug, a device, a procedure, or treatment will be determined to be experimental or investigational if: there are insufficient outcomes data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved; or if required by the FDA, approval has not been granted for g; or a recognized national medical or dental soc' Jr regulat age cy has determined, in writing, that it is experimental ati '1, or for r uraoses: or the written prot protocol or of or pro ols d b e ating facPedure, protocols of ah her fac stu n ' bst ially th device, r tr ent, a wr infor cons t treating facility r f i st y th me drug rtreatment states eri ' e , ' ve gati al, or f earch purposes. ex Areatment; usi it pply with respect to services or supplies (other than dd i nn ction with a disease; if Aetna determines that: an be expected to cause death within one year, in the absence of effective nd the care or treatment is effective for that disease or shows promise of being effective for that disease as demonstrated by scientific data. In making this determination Aetna will take into account the results of a review by a panel of independent medical professionals. They will be selected by Aetna. This panel will include professionals who treat the type of disease involved. Also, this exclusion will not apply with respect to drugs that: have been granted treatment investigational new drug (IND) or Group c/treatment IND status; or are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute; if Aetna determines that available scientific evidence demonstrates that the drug is effective or shows promise of being effective for the disease. 25 • Those for or related to services, treatment, education testing, or training related to learning disabilities or developmental delays. • Those for care furnished mainly to provide a surrounding free from exposure that can worsen the person's disease or injury. • Those for or related to the following types of treatment: primal therapy; rolfing; psychodrama; megavitamin therapy; bioenergetic therapy, vision perception training; or carbon dioxide therapy. • Those for treatment of covered health care providers who specialize in the mental health care field and who receive treatment as a part of their training in that field. • Those for services of a resident physician or intern rendered in that capacity. • Those that are made only because there is health coverage. • Those that a covered person is not legally obliged to pay. • Those, as determined by Aetna, to be for custodial care. • Those for services and supplies: surgery performed to treat a disease or injury. Repair an injury. Surgery must be performed: in the calendar year of the accident which causes the injury; or in the next calendar year. • Those for therapy, supplies, or counseling for sexual dysfunctions or inadequacies that do not have a physiological or organic basis. /T • Those for any drugs or supplies used for the treatment of erectile dysfunction, impotence, or sexual dysfunction or inadequacy, including but not limited to: sildenafil citrate; phentolamine; apomorphine; alprostadil; or any other drug that is in a similar or identical class, has a similar or identical mode of action or exhibits similar or identical outcomes. This exclusion applies whether or not the drug is delivered in oral, injectable, or topical (including but not limited to gels, creams, ointments, and patches) forms. • Those for performance, athletic performance or lifestyle enhancement drugs or supplies. • Those for or related to sex change surgery or to any treatment of gender identity disorders. • Those for or related to artificial insemination, in vitro fertilization, or embryo transfer procedures. • Those for routine physical exams, routine vision exams, rfdsu 1 exams, routine hearing exams, immunizations, or other preve ' servicies. • Those for or in connection with marri mi child, cadjustment, pastoral, or financial counsel• Those for acupuncture thera No cl d i cupunct's performed by a physician as a of anes is i n do ith surgvered under this Flan. l Those or in c do spe therap;&e li ion does not apply to charg speec t p th is a cted to speech to a person who has lost is malformed: as a result of a severe birth defect; including harelip, webbed fingers, or toes; or as a direct result of: disease; or surgery performed to treat a disease or injury. Repair an injury. Surgery must be performed: in the calendar year of the accident which causes the injury; or in the next calendar year. • Those to the extent they are not reasonable charges, as determined by Aetna. • Those for the reversal of a sterilization procedure. 27 • Those for a service or supply furnished by a Preferred Care Provider in excess of such provider's Negotiated Charge for that service or supply. This exclusion will not apply to any service or supply for which a benefit is provided under Medicare before the benefits of the group contract are paid. Any exclusion above will not apply to the extent that: • coverage is specifically provided by name in your Booklet; or • coverage of the charges is required under any law that applies to the coverage. These excluded charges will not be used when figuring benefits. The law of the jurisdiction where a person lives when a claim occurs may prohibit some benefits. If so, they will not be paid. 28 Effect of Benefits Under Other Plans Other Plans Not Including Medicare Some persons have health coverage in addition to coverage under this Plan. When this is the case, the benefits from "other plans" will be taken into account. This may mean a reduction in benefits under this Plan. The combined benefits will not be more than the expenses recognized under these plans. In a calendar year, this Plan will pay: • its regular benefits in full; or • a reduced amount of benefits. To figure this amount, subtract B. from A. below: F41 100% of "Allowable Expenses" incurred by the The benefits payable by the "other plans". form of services rather than cash ents f 1 be used.) . oo plans claim is made. ide benefits in the cash value will rise, part or all of laim is made. Ln pate hos om and the semiprivate rate is e r the above definition unless the patient's stay necessary, either in terms of generally accepted y defined in this Plan. f d out Chether the regular benefits under this Plan will be reduced, the order in h the various plans will pay benefits must be figured. This will be done as follows using the first rule that applies: 1. A plan with no rules for coordination with other benefits will be deemed to pay its benefits before a plan which contains such rules. 2. A plan which covers a person other than as a dependent will be deemed to pay its benefits before a plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary and as a result of the Social Security Act of 1965, as amended, Medicare is: • secondary to the plan covering the person as a dependent; and • primary to the plan covering the person as other than a dependent; the benefits of a plan which covers the person as a dependent will be determined before the benefits of a plan which: • covers the person as other than a dependent; and • is secondary to Medicare. 29 Except in the case of a dependent child whose parents are divorced or separated; the plan which covers the person as a dependent of a person whose birthday comes first in a calendar year will be primary to the plan which covers the person as a dependent of a person whose birthday comes later in that calendar year. If both parents have the same birthday, the benefits of a plan which covered one parent longer are determined before those of a plan which covered the other parent for a shorter period of time. If the other plan does not have the rule described in this provision (3) but instead has a rule based on the gender of the parent and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits. 4. In the case of a dependent child whose parents are divorced or separated: a. If there is a court decree which states that the parents shall share joint custody of a dependent child, without stating that one of the parents is responsible for the health care expenses of the child, the order of benefit determination rules specified in (3) above will apply. b. If there is a court decree which makes one parent financially responsible for the medical, dental or other health care expenses of such child, the benefits of a plan which covers the child as a dependent of such parent will termined before the benefits of any other plan which covers the chil ep dent child. c. If there is not such a court If the parent with cust of ch ha of remarUthelbenefits of a plan which cove the chil a d nd of a parenty of the child will be deterrrii befor ben is a pl whichild as a dependent at the pare itho c todv Istet I st child hmarried, the benefits of a plan which ad d the parent with custody shall be determined on which covers that child as a dependent of the a nefits of a plan which covers that child as a dependent of the will be determined before the benefits of a plan which covers that child as a dependent of the parent without custody. CIO' 5. If 1, 2, 3 and 4 above do not establish an order of payment, the plan under which the person has been covered for the longest will be deemed to pay its benefits first; except that: The benefits of a plan which covers the person on whose expenses claim is based as a: • laid -off or retired employee; or • the dependent of such person; shall be determined after the benefits of any other plan which covers such person as: • an employee who is not laid -off or retired; or • a dependent of such person. If the other plan does not have a provision: • regarding laid -off or retired employees; and • as a result, each plan determines its benefits after the other; I to release or obtain any information and make or recover any payment necessary in order to administer this provision. When this provision operates to reduce the total amount of benefits otherwise payable as to a person covered under this Plan during a calendar year, each benefit that would be payable in the absence of this provision will be reduced proportionately. Such reduced amount will be charged against any applicable benefit limit of this Plan. Other Plan This means any other plan of health expense coverage under: Group insurance. Any other type of coverage for persons in a group. This includes plans that are insured and those that are not. No-fault auto insurance required by law and provided on other than a group basis. Only the level of benefits required by the law will be counted. 31 Effect of A Health Maintenance Organization Plan (HMO Plan) On Coverage If you are in an Eligible Class and have chosen coverage under an HMO Plan offered by your Employer, you and your eligible dependents will be excluded from Health Expense Coverage (except Vision Care, if any) on the date of your coverage under such HMO Plan. If you are in an Eligible Class and are covered under an HMO Plan, you can choose to change to coverage for yourself and your covered dependents under this Plan. If you: • Live in an HMO Plan enrollment area and choose to change coverage during an open enrollment period, coverage will take effect on the first day of the contract period which follows the open enrollment period. There will be no rules for waiting periods or preexisting conditions. • Live in an HMO Plan enrollment area and choose to change coverage when there is not an open enrollment period, coverage will take effect only if and when Aetna gives its written consent. • Move from an HMO Plan enrollment area or if the HMO discontinues and you choose to change coverage within 31 days of the move or the discontin , coverage will take effect on the date you elect such coverage. There wil no restrictions for waiting periods or preexisting conditions. If yo se to nge overage after 31 days, coverage will take effect only if whe a Aetna g s it written consent. Any extensions of benefits and his n f is lity or pre ancy�w'll not always apply on and after ate of ang a M Ian. The ill aly only if the person is t covere once r th Pla taus he in a hospital not ffiliate th the If ive deuce th he an provides an extension f bene r disa it r e ncy verage is Plan will be extended. The xtensi be fo th e I � th i e an for the same conditions as the HMO Plan p vid It w' no to n the first to occur of: riod; and the nd ofkon th ate t is not confined. No benefits will be paid for any charges for services rendered or supplies furnished under an HMO Plan. 32 Effect of Medicare Health Expense Coverage will be changed for any person while eligible for Medicare. A person is "eligible for Medicare" if he or she: • is covered under it; • is not covered under it because of: having refused it; having dropped it; having failed to make proper request for it. These are the changes: All health expenses covered under this Plan will be reduced by any Medicare benefits available for those expenses. This will be done before the health benefits of this Plan are figured. Charges used to satisfy a person's Part B deductible under Medicare -will be applied under this Plan in the order received by Aetna. Two or mr received at the same time will be applied starting with the largest rst. Medicare benefits will be taken into account y persoor she iseligible for Medicare. This will be done not or she io WdicnrP Business If the coverage of any person under any part of this Plan replaces any prior coverage of the person, the rules below apply to that part. "Prior coverage" is any plan of group accident and health coverage that has been replaced by coverage under part or all of this Plan; it must have been sponsored by your Employer (i.e., transferred business). The replacement can be complete or in part for the Eligible Class to which you belong. Any such plan is prior coverage if provided by another group contract or any benefit section of this Plan. Coverage under any section of this Plan will be in exchange for all privileges and benefits provided under any like prior coverage. Any benefits provided under such prior coverage may reduce benefits payable under this Plan. 33 General Information About Your Coverage Termination of Coverage Coverage under this Plan terminates at the first to occur of. • When employment ceases. • When the group contract terminates as to the coverage. • When you are no longer in an Eligible Class. (This may apply to all or part of your coverage.) • When you fail to make any required contribution. Your Employer will notify Aetna of the date your employment ceases for the purposes of termination of coverage under this Plan. This date will be either the date you cease active work or the day before the next premium due date following the date you cease active work. Your Employer will use the same rule for all employees. If are not at work on this date due to one of the following, employment may be d to c ntinue up to the limits shown below. If you are not at work due to di stopped by your Employer, but continued until e absence. r employment end of the calendar Class of retired employees. If you are shown in the Retirement Eligibility section; and If no Eligible Class of retired employees is shown, there is no coverage for retired employees. If you cease active work, ask your Employer if any coverage can be continued. Dependents Coverage Only A dependent's coverage will terminate at the first to occur of.. • Termination of all dependents' coverage under the group contract. • When a dependent becomes covered as an employee. • When such person is no longer a defined dependent. • When your coverage terminates. 34 Handicapped Dependent Health Expense Coverage for your fully handicapped child may be continued past the Children maximum age for a dependent child if the child has not been issued a personal medical conversion policy. Your child is fully handicapped if: • he or she is not able to earn his or her own living because of mental retardation or a physical handicap which started prior to the date he or she reaches the maximum age for dependent children; and • he or she depends chiefly on you for support and maintenance. Proof that your child is fully handicapped must be submitted to Aetna no later than 31 days after the date your child reaches the maximum age. Coverage will cease on the first to occur of: • Cessation of the handicap. • Failure to give proof that the handicap continues. • Failure to have any required exam. • Termination of Dependent Coverage as to your child for any reason other than reaching the maximum age. Aetna will have the right to require proof of the conti uation he handicap. Aetna also has the right to examine your child as often as n d while th and' ap continues at its own expense. An exam will not be r or ten than year after 2 years from the date your child reache a im' a Medical Expense benefits will be available to him or her while disabled for up to 12 months. Health Expense benefits will cease when the person becomes covered under any group plan with like benefits. (This does not apply if his or her coverage ceased because the benefit section ceased as to your Eligible Class.) If this provision applies to you or one of your covered dependents, see the section Conversion of Medical Expense Coverage for information which may affect you. 35 Conversion of Medical This Plan permits certain persons whose Medical Expense Coverage has ceased to convert Expense Coverage to a personal medical policy. No medical exam is needed. You and your family members may convert when all coverage ceases because your employment ceases or you cease to be in an eligible class. You may not convert if coverage ceases because the group contract has discontinued as to your medical coverage. The personal policy may cover: • you only; or • you and all of your family members who are covered under this Plan when your coverage ceases; or • if you die before you retire, all your family members, or your spouse only, who are covered under this Plan when your coverage ceases. Also, if your own coverage continues, your dependents can apply if they cease to be a dependent as defined in this Plan. You may convert when you become a retired employee. If this Plan permits retired employees to continue Medical Expense Coverage, and you choose to do so, this conversion privilege will not again be available to you. The personal policy must be applied for within 31 days after otherwise cease without a provision to continue co ge for days start on the date coverage actually ce es ev if the pe benefits because the person is totajy Aetna may decl It is On if: covered, insurance policy; .rage teases or would -ed e�r►ployees. The 31 is s 11 eligible for 04 iver the policy. benefits available under or medical expense indemnity corporation subscriber contract; 'any other group contract; any statute, welfare plan or program; and that with the converted policy, would result in overinsurance or match benefits. No one has the right to convert if you have been covered under this Plan for less than 3 months. Also, no person has the right to convert if: • he or she has used up the maximum benefit; or • he or she becomes eligible for any other Medical Expense Coverage under this Plan. 01 The personal policy form, and its terms, will be of a type, for group conversion purposes: • as required by law or regulation; or • as then offered by Aetna under your Employer's conversion plan. ft will not provide coverage which is the same as coverage under this Plan. The level of coverage may be less and an overall Lifetime Maximum Benefit will apply. The personal policy may contain either or both of: • A statement that benefits under it will be cut back by any like benefits payable under this Plan after your coverage ceases. • A statement that Aetna may ask for data about your coverage under any other plan. This may be asked for on any premium due date of the personal policy. If you do not give the data, expenses covered under the personal policy may be reduced by expenses which are covered or provided under those plans. The personal policy will state that Aetna has the right to refuse renewal under some conditions. These will be shown in that policy. If you or your dependent want to convert: • Your Employer should be asked for a copy of the "Notice onver ion Privilege and Request" form. • Send the completed form to the adpe,n. If a person is eligible to conver foill sent abou a pers nalpolicy for which he or she ply.he first mium f pe o 1 pbe id me the person applies for at poli The pr i e 1 bo rate for the person's class and age, icy ill tke effect on the day after coverage terminates under this Plan. Type of Coverage Coverage under this Plan is non -occupational. Only non -occupational accidental injuries and non -occupational diseases are covered. Any coverage for charges for services and supplies is provided only if they are furnished to a person while covered. Conditions that are related to pregnancy may be covered under this Plan. The Summary of Coverage will say if they are. Physical Examinations Aetna will have the right and opportunity to have a physician or dentist of its choice examine any person for whom certification or benefits have been requested. This will be done at all reasonable times while certification or a claim for benefits is pending or under review. This will be done at no cost to you. 37 Legal Action No legal action can be brought to recover under any benefit after 3 years from the deadline for filing claims. Additional Provisions Assignments Aetna will not try to reduce or deny a benefit payment on the grounds that a condition existed before a person's coverage went into effect, if the loss occurs more than 2 years from the date coverage commenced. This will not apply to conditions excluded from coverage on the date of the loss. The following additional provisions apply to your coverage. • You cannot receive multiple coverage under this Plan because you are connected with more than one Employer. • In the event of a misstatement of any fact affecting your coverage under this Plan, the true facts will be used to determine the coverage in force. This document describes the main features of this Plan. Additional provisions are described elsewhere in the Plan Document on file with your Employer. If you have any questions about the terms of this Plan or about the proper payment of benefits, you may obtain more information from your Employer. Your Employer hopes to continue this Plan indefinitely but, ith alligroup plans, this Plan may be changed or discontinued as to all or,a�class of nlovaec Coverage may be of Recovery of Benefits Paid s a co n to pv fits der this expenses incurred by a covered rson a injury f whi a third party may be liable: The 11, to nefits it has paid, be subrogated to (has the right to pur e) all , hts ecovery of covered persons against: h third party; or a person's insurance carrier in the event of a claim under the uninsured or underinsured auto coverage provision of an auto insurance policy. • The Plan shall have the right to recover from the covered person amounts received by judgment, settlement, or otherwise from: such third party or his or her insurance carrier; or any other person or entity, which includes the auto insurance carrier which provides the covered person's uninsured or underinsured auto insurance coverage. • The covered person (or person authorized by law to represent the covered person if he or she is not legally capable) shall: execute and deliver any documents that are required; and do whatever else is necessary to secure such rights. 38 Recovery of Overpayment If a benefit payment is made by Aetna, to or on behalf of any person, which exceeds the benefit amount such person is entitled to receive in accordance with the terms of the group contract, this Plan has the right: • to require the return of the overpayment on request; or • to reduce by the amount of the overpayment, any future benefit payment made to or on behalf of that person or another person in his or her family. Such right does not affect any other right of recovery this Plan may have with respect to such overpayment. Reporting of Claims A claim must be submitted to Aetna in writing. It must give proof of the nature and extent of the loss. Your Employer has claim forms. All claims should be reported promptly. The deadline for filing a claim for any benefits is 90 days after the date of the loss causing the claim. If, through no fault of your own, you are not able to meet the deadline for filing claim, your claim will still be accepted if you file as soon as possible. Unless you are legally incapacitated, late claims will not be covered if they are filed mo 2 years after the deadline. Ipp Payment of Benefits Benefits will be paid as soon as ne ssa ri n proof tothe claim is received. 1 All bene are payNei to . ow r, this Pl has t ri pay any health nefits a serviii .his 1r be don or have told Aetna otherwise ty the t ou file i�rwease. any benefit to any of your relatives whom it believes be done if the benefit is payable to you and you are a minor It can also be done if a benefit is payable to your Records of Expenses Keep complete records of the expenses of each person. They will be required when a claim is made. Very important are: Names of physicians, dentists and others who furnish services. Dates expenses are incurred. Copies of all bills and receipts. kill Glossary The following definitions of certain words and phrases will help you understand the benefits to which the definitions apply. Some definitions which apply only to a specific benefit appear in the benefit section. If a definition appears in a benefit section and also appears in the Glossary, the definition in the benefit section will apply in lieu of the definition in the Glossary. Board and Room Charges Charges made by an institution for board and room and other necessary services and supplies. They must be regularly made at a daily or weekly rate. Brand Name Drug A prescription drug which is protected by trademark registration Companion This is a person whose presence as a Companion or caregiv ece ary to enable an NME Patient: to receive services in connection w' ureor- nt on an inpatient or outpatient basis; orto travel to and fr the fac' wh tre eted given. is Is lic s o proideV d pro ,the following on an inpatient basis for persons care by a R.N., or by a L.P.N. directed by a full-time R.N.; and Physical restoration services to help patients to meet a goal of self -care in daily living activities. • Provides 24 hour a day nursing care by licensed nurses directed by a full-time R.N. • Is supervised full-time by a physician or R.N. • Keeps a complete medical record on each patient. • Has a utilization review plan. • Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, for mental retardates, for custodial or educational care, or for care of mental disorders. • Makes charges. 40 Copay This is a fee, charged to a person, which represents a portion of the applicable expense. As to a prescription drug dispensed by a preferred pharmacy, this is the fee charged to a person at the time the prescription drug is dispensed payable directly to the pharmacy for each prescription or refill at the time the prescription or refill is dispensed. For drugs dispensed as packaged kits, the fee applies to each kit at the time it is dispensed. In no event will the copay be greater than the prescription, kit, or refill. As to a prescription drug dispensed by a non -preferred pharmacy, this is the amount by which the total charge for the prescription drug is reduced before benefits are payable. It is specified in the Summary of Coverage. Custodial Care This means services and supplies furnished to a person mainly to help him or her in the activities of daily life. This includes board and room and other institutional care. The person does not have to be disabled. Such services and supplies are custodial care without regard to: • by whom they are prescribed; or • by whom they are recommended; or • by whom or by which they are per& Dentist This mea work he c This is lis of a Pr re roviders for the class of employees of which you e a Cop so is' irectory are given to your Employer to give to you. u ble edical and Surgical Equipment h means no more than one item of equipment for the same or similar purpose, and the accessories needed to operate it, that is: • made to withstand prolonged use; • made for and mainly used in the treatment of a disease or injury; • suited for use in the home; • not normally of use to person's who do not have a disease or injury; • not for use in altering air quality or temperature; • not for exercise or training. Not included is equipment such as: whirlpools; portable whirlpool pumps; sauna baths; massage devices; overbed tables; elevators; communication aids; vision aids; and telephone alert systems. 41 Effective Treatment of Alcoholism Or Drug Abuse This means a program of alcoholism or drug abuse therapy that is prescribed and supervised by a physician and either: • has a follow-up therapy program directed by a physician on at least a monthly basis; or • includes meetings at least twice a month with organizations devoted to the treatment of alcoholism or drug abuse. These are not effective treatment: • Detoxification. This means mainly treating the aftereffects of a specific episode of alcoholism or drug abuse. • Maintenance care. This means providing an environment free of alcohol or drugs. Emergency Admission One where the physician admits the person to the hospital or treatment facility right after the sudden and, at that time, unexpected onset of a change in the person's physical or mental condition: Emergency Condition This means a recent and severe medical condition, including, but not limited to, severe pain, which would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in: • placing the person's health in serious jeopardy; or • serious impairment to bodily function; or • serious dysfunction of a body part or organ; or • in the case of a pregnant woman, serious jeopardy to the health of the fetus. Generic Drug A prescription drug which is not protected by trademark registration, but is produced and sold under the chemical formulation name. Home Health Care Agency This is an agency that: • mainly provides skilled nursing and other therapeutic services; and • is associated with a professional group which makes policy; this group must have at least one physician and one R.N.; and • has full-time supervision by a physician or a R.N.; and • keeps complete medical records on each person; and • has a full-time administrator; and • meets licensing standards. Home Health Care Plan This is a plan that provides for care and treatment of a disease or injury. The care and treatment must be: • prescribed in writing by the attending physician; and • an alternative to confinement in a hospital or convalescent facility. physical and occupational therapy; and part-time home health aide services which mainly consist of caring for terminally ill persons; and inpatient care in a facility when needed for pain control and acute and chronic symptom management. 43 Has personnel which include at least: one physician; and one R.N.; and one licensed or certified social worker employed by the Agency. • Establishes policies governing the provision of Hospice Care. • Assesses the patient's medical and social needs. • Develops a Hospice Care Program to meet those needs. • Provides an ongoing quality assurance program. This includes reviews by physicians, other than those who own or direct the Agency. • Permits all area medical personnel to utilize its services for their patients. • Keeps a medical record on each patient. • Utilizes volunteers trained in providing services for non -medical needs. • Has a full-time administrator. Hospice Care Program This is a written plan of Hospice Care, which: • Is established by and reviewed from time to time by a physician attending the person; and appropriate personnel of a • Is designed to provide: and social needs; and care to be given to meet those needs. Wiice Facility This is a facility, or distinct part of one, which: • Mainly provides inpatient Hospice Care to terminally ill persons. • Charges its patients. • Meets any licensing or certification standards set forth by the jurisdiction where it is. • Keeps a medical record on each patient. • Provides an ongoing quality assurance program; this includes reviews by physicians other than those who own or direct the facility. • Is run by a staff of physicians; at least one such physician must be on call at all times. • Provides, 24 hours a day, nursing services under the direction of a R.N. • Has a full-time administrator. 1E] Hospital This is a place that: • Mainly provides inpatient facilities for the surgical and medical diagnosis, treatment, and care of injured and sick persons. • Is supervised by a staff of physicians. • Provides 24 hour a day R.N. service. • Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, or a nursing home. • Makes charges. L.P.N. This means a licensed practical nurse. Mail Order Pharmacy An establishment where prescription drugs are legally dispensed by mail. Mental Disorder This is a disease commonly understood to"be a mental disorder whether or not it has a physiological or organic basis and for which treatment is genin ided by or under the direction of a mental health professional such as a psychichologist or a psychiatric social worker. A mental disorder inclu; but is to: • Alcoholism and drug abuse. • Schizophrenia. • Bipolar disorder. • Pervasive Mental • Panictoressive rder. i Major i der pure of efils under this Plan, mental disorder will include alcoholism and ase o any separate benefit for a particular type of treatment does not apply to sm and drug abuse. NME Patient This is a person who: • requires any of the NME procedure and treatment types for which the charges are a Covered Medical Expense; and • contacts Aetna and is approved by Aetna as an NME Patient; and • agrees to have the procedure or treatment performed in a hospital designated by Aetna as the most appropriate facility. 117 Necessary A service or supply furnished by a particular provider is necessary if Aetna determines that it is appropriate for the diagnosis, the care or the treatment of the disease or injury involved. To be appropriate, the service or supply must: be care or treatment, as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the person's overall health condition; be a diagnostic procedure, indicated by the health status of the person and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the person's overall health condition; and as to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any alternative service or supply to meet the above tests. In determining if a service or supply is appropriate under the circumstances, Aetna will take into consideration: Negotiated Charge This is the maximum charge a Preferred Care Provider has agreed to make as to any service or supply for the purpose of the benefits under this Plan. 46 Non -Occupational Disease A non -occupational disease is a disease that does not: • arise out of (or in the course of) any work for pay or profit; or • result in any way from a disease that does. A disease will be deemed to be non -occupational regardless of cause if proof is furnished that the person: • is covered under any type of workers' compensation law; and • is not covered for that disease under such law. Non -Occupational Injury A non -occupational injury is an accidental bodily injury that does not: • arise out of (or in the course of) any work for pay or profit, or • result in any way from an injury which does. Non -Preferred Care This is a health care service or supply furnished by a health care provider that is not a Preferred Care Provider; if, as determined by Aetna: • the service or supply could have been provided • the provider is of a type that falls into one or rd in the Directory. • medical service or supply; or • dental service or supply; Prefer Care Provider-, and of the ca orie of providers listed Ina, I a y which is party to -u r ance with its terms, or an urgent admission. furnished to prevent or to diagnose or to correct a misalignment: • of the teeth; or • of the bite; or • of the jaws or jaw joint relationship; whether or not for the purpose of relieving pain. Not included is: • the installation of a space maintainer; or • a surgical procedure to correct malocclusion. 1 47 Other Health Care This is a health care service or supply that is neither Preferred Care nor Non -Preferred Care. Pharmacy An establishment where prescription drugs are legally dispensed. Physician This means a legally qualified physician. Preferred Care This is a health care service or supply furnished by: • a Preferred Care Provider; or • a health care provider that is not a Preferred Care Provider for an emergency condition when travel to a Preferred Care Provider is not feasible. Preferred Care Provider This is a health care provider that has contracted to furnish services or supplies for a Negotiated Charge; but only if the provider is, with Aetna's cons eluded in the Directory as a Preferred Care Provider for: • the service or supply involved; and • the class of employees of whichwye Preferred Ph cy A pharm cy, mclu a m%led der acy, hich is a ntract with Aetna � dispen drugs to onsJer this Pl bu I . in drug under the terms of its contract V�n 'erson, while acting within the scope of his or her license, who has the legal authority to write an order for a prescription drug. Prescription An order of a prescriber for a prescription drug. If it is an oral order, it must promptly be put in writing by the pharmacy. Prescription Drugs Any of the following: • A drug, biological, or compounded prescription which, by Federal Law, may be dispensed only by prescription and which is required to be labeled "Caution: Federal Law prohibits dispensing without prescription". • An injectable drug prescribed to be self-administered or administered by any other person except one who is acting within his or her capacity as a paid healthcare professional. Covered injectable drugs include insulin. • Disposable needles and syringes which are purchased to administer a covered injectable prescription drug. • Disposable diabetic supplies. 48 R.N. This means a registered nurse. Reasonable Charge Only that part of a charge which is reasonable is covered. The reasonable charge for a service or supply is the lowest of: the provider's usual charge for furnishing it; and the charge Aetna determines to be appropriate, based on factors such as the cost of providing the same or a similar service or supply and the manner in which charges for the service or supply are made; and the charge Aetna determines to be the prevailing charge level made for it in the geographic area where it is furnished. In determining the reasonable charge for a service or supply that is: • unusual; or • not often provided in the area; or • provided by only a small number of providers in the area; Aetna may take into account factors, such as: • the complexity; • the degree of skill needed; • the type of specialty of the • the range of services or sul • the prevailing the in otl is is rate. Ittwillge the a medical prognosis of 6 months or less to live. Treatment Facility (Alcoholism Or Drug Abuse) This is an institution that: • Mainly provides a program for diagnosis, evaluation, and effective treatment of alcoholism or drug abuse. • Makes charges. • Meets licensing standards. • Prepares and maintains a written plan of treatment for each patient. The plan must be based on medical, psychological and social needs. It must be supervised by a physician. • Provides, on the premises, 24 hours a day: Detoxification services needed with its effective treatment program. Infirmary -level medical services. Also, it provides, or arranges with a hospital in the area for, any other medical services that may be required. Supervision by a staff of physicians. Skilled nursing care by licensed nurses who are directed by a full-time R.N. 49 Treatment Facility (Mental Disorder) This is an institution that: • Mainly provides a program for the diagnosis, evaluation, and effective treatment of mental disorders. • Is not mainly a school or a custodial, recreational or training institution. • Provides infirmary -level medical services. Also, it provides, or arranges with a hospital in the area for, any other medical service that may be required. • Is supervised full-time by a psychiatrist who is responsible for patient care and is there regularly. • Is staffed by psychiatric physicians involved in care and treatment. • Has a psychiatric physician present during the whole treatment day. • Provides, at all times, psychiatric social work and nursing services. • Provides, at all times, skilled nursing care by licensed nurses who are supervised by a full-time R.N. • Prepares and maintains a written plan of treatment for each patient based on medical, psychological and social needs. The plan must be supervised by a psychiatric physician. • Makes charges. • Meets licensing standards. Urgent Admission One where the physician admits the person to • the onset of or change in a • the diagnosis of a disease; • an injury cause n acc re'hough to require from the date the need for the 50 Continuation of Coverage In accordance with federal law (PL 99-272) as amended, your Employer is providing under Federal Law covered persons with the right to continue their health expense coverage under certain circumstances. You or your dependents may continue any health expense coverage then in effect, if coverage would terminate for the reasons specified in sections A or B below. You and your dependents may be required to pay up to 102% of the full cost to the Plan of this continued coverage, or, as to a disabled individual whose coverage is being continued for 29 months in accordance with section A, up to 150% of the full cost to the Plan of this continued coverage for any month after the 18th month. Subject to the payment of any required contribution, health expense coverage may also be provided for any dependents you acquire while the coverage is being continued. Coverage for these dependents will be subject to the terms of this Plan regarding the addition of new dependents. Continuation shall be available as follows: A. Continuation of Coverage on Termination of Employment or Loss of Eligibility If your coverage would terminate due to: • termination of your employment for any reason other than gross misconduct; or + your loss of eligibility under this Plan due to a reductiVinumber of hours you work; you may elect to continue coverage for your d younts, or your dependents may each elect to contin s or r own cohis election must include an agreement to pa uir o bution. ur dependents must elect to continue coveragehin da f later to date coverage would termin d the you m er orms yoigible dependents of an rights u this s Ion. Cov ' e will t r at n' hic er of the is�heearfiest to occur: • e d of a 18 th riod the ate of the event which would have caused v e to t4 rmi • e e of a 9-m th period after the date of the event which would have caused covera inate, but only if prior to the end of the above 18-month period, ou your dependent provides notice to your Employer, in accordance with section D below, that you or your dependent has been determined to have been disabled under Title II or XVI of the Social Security Act on the date of, or within 60 days of, the event which would have caused coverage to terminate. Coverage may be continued: for the individual determined to be disabled; and for any family member (employee or dependent) of the disabled individual for whom coverage is already being continued; and for your newborn or newly adopted child who was added after the date continued coverage began. • The date that the group contract discontinues in its entirety as to health expense coverage. However, continued coverage will be available to you under another plan sponsored by your Employer. • The date any required contributions are not made. • The first day after the date of the election that the individual is covered under another group health plan. However, continued coverage will not terminate until such time that the individual is no longer affected by a preexisting condition exclusion or limitation under such other group health plan. • The first day after the date of the election that the individual becomes enrolled in benefits under Medicare. This will not apply if contrary to the provisions of the Medicare Secondary Payer Rules or other federal law. • As to all individuals whose coverage is being continued in accordance with the terms of the second bulleted item above, the first day of the month that begins more than 30 days after the date of the final determination under Title 11 or XVI of the Social Security Act that the disabled individual whose coverage is being so continued is no longer disabled. B. Continuation of Coverage Under Other Circumstances If coverage for a dependent would terminate due to: • your death; • your divorce; • your ceasing to pay any required contributions for coverage as to a dependent spouse from whom you are legally separated; • the dependent's ceasing to be a dependent child as defined under this Plan; or • the dependent's loss of eligibility under this Plan because you become entitled to benefits under Medicare; the dependent may elect to continue his or her own coverage. The election to continue coverage must be made within 60 days of the later to occur of the date coverage would terminate and the date your Employer informs your dependents, subject to any notice requirements in section D below, of their continuation rights under this section. The election must include an agreement to pay any required contribution. Coverage for a dependent will terminate on the first to occur of: The end of a 36-month period after the date of the event which would have caused coverage to terminate. The date that the group contract discontinues in its coverage. However, continued coverage will be a, under another plan sponsored by your Em r. The date any required contributio no ade. le nt tthec c)Jer, nti ed co aim expense dependents iered under terminate until condition becomes enrolled in I cover foru or your dependents is being continued for a period specified der s A, and during this period one of the qualifying events under the above tion B occurs, this period may be increased. In no event will the total period of continuation provided under this provision for any dependent be more than 36 months. Such a qualifying event, however, will not act to extend coverage beyond the original 18-month period for any dependents (other than a newborn or newly adopted child) who were added after the date continued coverage began. D. Notice Requirements If coverage for you or your dependents: • is being continued for 18 months in accordance with section A; and • it is determined under Title II or XVI of the Social Security Act that you or your dependent was disabled on the date of, or within 60 days of, the event in section A which would have caused coverage to terminate; you or your dependent must notify your Employer of such determination within 60 days after the date of the determination, and within 30 days after the date of any final determination that you or your dependent is no longer disabled. If coverage for a dependent would terminate due to: • your divorce; • your ceasing to pay any required contributions for coverage as to a dependent spouse from whom you are legally separated; or • the dependent's ceasing to be a dependent child as defined under this Plan; you or your dependent must provide notice to your Employer of the occurrence of the event. This notice must be given within 60 days after the later of a occurrence of the event and the date coverage would terminate due tot nce of the event. If notice is not provided within the abov cified timLri s, continuation under this section will not be o y or your nts. - Continuation of Coverage This continuation of coverage section applies only for the period of any approved family During an Approved Leave of or medical leave (approved FMLA leave) required by Family and Medical Leave Act of Absence Granted to Comply 1993 (FMLA). If your Employer grants you an approved FMLA leave for a period in With Federal Law excess of the period required by FMLA, any continuation of coverage during that excess period will be determined by your Employer. If your Employer grants you an approved FMLA leave in accordance with FMLA, you may, during the continuance of such approved FMLA leave, continue Health Expense Benefits for you and your eligible dependents. At the time you request the leave, you must agree to make any contributions required by your Employer to continue coverage. If any coverage your Employer allows you to continue has reduction rules applicable by reason of age or retirement, the coverage will be subject to such rules while you are on FMLA leave. Coverage will not be continued beyond the first to occur of: The date you are required to make any contribution and you fail to do so. The date your Employer determines your approved FMLA leave ' rminated. The date the coverage involved discontinues as to your eli ' c as However, coverage for health expenses will be available to under otheplan sponsored by your Employer. Any coverage being continued a d nd wi of be con ued be7ond the date it would otherwise terminate. its t ate ause yoPppro A leave is deemed y ma on the dterminationbe eligible for e a n t same tgh your employment n fo oss ct, on such date. If this Plan provides any other 'age or ample, upon termination of employment, death, divorce trued dependent), you (or your eligible dependents) may be eligible on the date your Employer determines your approved FMLA leave ate of the event for which the continuation is available. If you acquire a new dependent while your coverage is continued during an approved FMLA leave, the dependent will be eligible for the continued coverage on the same terms as would be applicable if you were actively at work, not on an approved FMLA leave. If you return to work for your Employer following the date your Employer determines the approved FMLA leave is terminated, your coverage under this Plan will be in force as though you had continued in active employment rather than going on an approved FMLA leave provided you make request for such coverage within 31 days of the date your Employer determines the approved FMLA leave to be terminated. If you do not make such request within 31 days, coverage will again be effective under this Plan only if and when this Plan gives its written consent. If any coverage being continued terminates because your Employer determines the approved FMLA leave is terminated, any Conversion Privilege will be available on the same terms as though your employment had terminated on the date your Employer determines the approved FMLA leave is terminated. Summary of Coverage Employer: Open Choice Sample ASC: 920090 SOC: 1A Issue Date: June 26, 2000 Effective Date: January 1, 2000 The benefits shown in this Summary of Coverage are available for you and your eligible dependents. Eligibility Employees You are in an Eligi lass i location Avour Em er in I Dependents it you ifter tt&Flig1ble Class. ptoyed at a Providers. Your Eligible Class, is the Effective Date of this ice active work for your Employer or, if later, F— You may cover your: • wife or husband; and • unmarried children who are under 19 years of age. Any other unmarried child under age 23 who goes to school on a regular basis and depends solely on you for support will be covered as a dependent. Your children include: • Your biological children. • Your adopted children. • Your stepchildren. • Any other child you support who lives with you in a parent -child relationship. No person may be covered both as an employee and dependent and no person may be covered as a dependent of more than one employee. Open Choice 1 09/26/01 Enrollment Procedure You will get a form to fill out. This form will allow your Employer to deduct your contributions from your pay. Be sure to sign and return it within 31 days of your eligibility. Your contributions toward the cost of this coverage will be deducted from your pay and are subject to change. The rate of any required contributions will be determined by your Employer. See your Employer for details. Effective Date of Coverage Employees Your coverage will take effect on the later to occur of: • your Eligibility Date; and • the date you return your signed form. Late Enrollee "Le Enro "person (including yourself) for whom you do not elect Health Imp - se Co erage within 31 days of the date the person becomes eligible for such Enrollment Procedure You may elect coverage for a Late Enrollee only during the annual late entrant enrollment period established by your Employer. Coverage for a Late Enrollee will become effective on the first day of the second calendar month following the end of the late entrant enrollment period during which you elect coverage for the Late Enrollee. Any preexisting condition limitation will apply to a Late Enrollee. 2 09/26/01 Exceptions A person will not be considered to be a Late Enrollee if all of the following are met: • you did not elect Health Expense Coverage for the person involved within 31 days of the date you were first eligible (or during an open enrollment) because at that time: the person was covered under other "creditable coverage" as defined below; and you stated, in writing, at the time you submitted the refusal that the reason for the refusal was because the person had such coverage; and • the person loses such coverage because: of termination of employment in a class eligible for such coverage; of reduction in hours of employment; your spouse dies; you and your spouse divorce or are legally separated; such coverage was COBRA continuation and such continuation was exhausted; or the other plan terminates due to the employer's failure to the p emium or for any other reason; and • you elect coverage within 31 days o e t erson los age for one of the above reasons. As used above, "cr ble co ge" on' rior medic cove ge as defined in the Healt nsuranc tabil y, d � untabili s Act o 19 ). Such overag ludes c ge s on roup or i „ i basis; Medicare, Medicaid; ilitary Bored a c e; rog of th tan Health Service; a state health �enefit ris 1; t F I plo Health Benefit Plan (FEHBP); a public health plan a in t reg ti d any health benefit plan under Section 5(e) of the are not considered a Late Enrollee, Health Expense Coverage will become effective date of the election. Any limitation as to a preexisting condition may apply. 3 09/26/01 Additional Exceptions Also, a person will not be considered a Late Enrollee if you did not elect, when the person was first eligible, Health Expense Coverage for: • A spouse or child who meets the definition of a dependent, but you elect it later and within 31 days of a court order requiring you to provide such coverage for your dependent spouse or child. Such coverage will become effective on the date of the court order. Any limitation as to a preexisting condition may apply. • Yourself and you subsequently acquire a dependent, who meets the definition of a dependent, through marriage, and you subsequently elect coverage for yourself and any such dependent within 31 days of acquiring such dependent. Such coverage will become effective on the date of the election. Any limitation as to a preexisting condition may apply. • Yourself and you subsequently acquire a dependent, who meets the definition of a dependent, through birth, adoption, or placement for adoption, and you subsequently elect coverage for yourself and any such dependent within 31 days of acquiring such dependent. Such coverage will become effective on the date of the child's birth, the date of the child's adoption, or the date the child is placed with you for adoption, whichever is applicable. Any limitation as to a preexisting condition may apply. • Yourself and your spouse and you subsequently acquire a dependent, who meets the definition of a dependent, through birth, adoption, or placement f doption, and you subsequently elect coverage for yourself, your spouse, anJdathe uch ependent within 31 days of acquiring such dependent. Such cove wille ffective on the date of the child's birth, the date of the child'dop t , or the child is placed with you for adoption, whichever is may apply. ng-condition Coverage for the child will become effective on the date the child is placed with you for adoption. If request is not made within such 31 days, coverage for the child will be subject to all of the terms of this Plan. Special Rules Which Apply to Any provision in this Plan that limits coverage as to a preexisting condition will not apply a Child Who Must Be Covered to effect the initial health coverage for a child who meets the definition of dependent and Due to a Qualified Medical for whom you are required to provide health coverage as the result of a qualified medical Child Support Order child support order issued on or after the date your coverage becomes effective; provided you make written request for such coverage within 31 days of the court order. Coverage for the child will become effective on the date of such court order. If request is not made within such 31 days, coverage for the child will be subject to all of the terms of this Plan. If you are the non -custodial parent, proof of claim for such child may be given by the custodial parent. Benefits for such claim will be paid to the custodial parent. 09/26/01 Health Expense Coverage, Employees and Dependents Your Booklet spells out the period to which each maximum applies. These benefits apply separately to each covered person. Read the coverage section in your Booklet for a complete description of the benefits payable. If a hospital or other health care facility does not separately identify the specific amounts of its room and board charges and its other charges, Aetna will use the following allocations of these charges for the purposes of the group contract: Room and board charges: 40% Other charges: 60% This allocation may be changed at any time if Aetna finds that such action is warranted by reason of a change in factors used in the allocation. Prescription Drug Payment Percentage 100% as to: Preferred PhamtA 'if Generic Drugs * but no more than a 90 day maximum supply. )VA $ 20 $10 $ 20 $10 ption or Refill Mail Order Drug Supply of over 30 days* $ 40 $ 20 5 09/26/01 Comprehensive Medial Expense Coverage All maximums included in this Plan are combined maximums between Preferred Care and Non -Preferred Care, where applicable, unless specifically stated otherwise. Certification Requirement Certain types of care must be certified as necessary to avoid a reduction in the benefits payable. Read the Comprehensive Medical Expense Coverage section of the Booklet for details of the types of care affected, how to get certification and the effect on your benefits of failure to obtain certification. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Skilled Nursing Care. Excluded Amount $ 400 This Excluded Amount applies separately to each type of admission and care listed above. The Benefits Payable After any applicable deductible, the Health Expense calendar year are paid at the Payment Percenta Medical Expense which is incurred, a an provided later in this Booklet.Ifies fi a ry Care Provider is utili ed. A Ped are vi agreed to provide s es or a " goti ble tinder this Plan in a type of Covered vel which may be :then a Preferred tider who has Employer for a Expense, it cannot be Calendar Year Deductible tible will not apply to preferred care or other health care during the rest of that calendar year. Covered Medical Expenses incurred during the rest of that calendar year for preferred care and other health care will not be applied against the person's Calendar Year Deductible. This Calendar Year Deductible applies to all expenses except: The following expenses incurred for Preferred Care: • Fees of a physician for non -surgical office visits • Covered Medical Expenses incurred for a routine mammogram Family Deductible Limit $ 500 If Covered Medical Expenses incurred in a calendar year by you and your dependents and applied against the separate Calendar Year Deductibles equal $ 200, the Calendar Year Deductible will not apply to expenses incurred for preferred and other health care during the rest of that calendar year for you and your dependents. Inpatient Hospital Deductible $ 100 [OWN17L1I1 However, for a confinement of a well newborn child that starts on the day of birth, this Inpatient Hospital Deductible will not exceed the hospital's actual charge for board and room for the first day of confinement on which the child's coverage is in force. This Inpatient Hospital Deductible applies to all Inpatient Hospital Expenses, except those incurred for Preferred Care. Payment Percentage The Payment Percentage applies after any deductible amounts. For Hospital Expenses Non -Preferred Preferred Care Care Other Health Care 90% 70% 80% For Physicians Fees Non -surgical Office Visits - 100% after a $ 5 copay 70% 80% Other - 90% 70% 80% For Physical Exam Expenses Refer to applicable category of For Hospice Car enses For hosnil charge r to j of "H sp' enses" above. o "Physician Fees" above. incurred for a routine mammogram 100% 70% 100% as to: National Medical Excellence Travel and Lodging Expenses 80%* as to: Convalescent Facility Expenses Home Health Care Expenses All Other Medical Expenses for which a Payment Percentage is not otherwise shown. 7 09/26/01 *However, if the providers of services or supplies for which expenses are incurred are of a type that has contracted in sufficient numbers, as determined by Aetna, to furnish services or supplies for a Negotiated Charge, then the Payment Percentage will be the applicable Preferred Care or Non -Preferred Care Payment Percentage as specified above for Hospital Expenses. Such types of providers may include, but are not limited to: Home Health Care agencies; Diagnostic laboratories; Durable Medical Equipment suppliers; Ambulance services. To be sure that you will receive the full benefit available under this Plan, you should verify the provider's status by calling either the provider or the toll -free number shown on your ID card. Reduced Payment Percentage 50% as to: Non -emergency care in an emergency room. Payment Percentage and Special Maximums for Alc lism, Drug Abuse and Mental Disorders 30 20 09/26/01 Payment Limits These limits apply only to Covered Medical Expenses which are payable at a rate greater than 50% and not applied against any deductible or copay amount. They do not apply to Covered Medical Expenses which are incurred for the treatment of alcoholism, drug abuse, and mental disorders while not confined as a full-time inpatient. Payment Limit which Applies to Expenses for a Person When a person's Covered Medical Expenses for which no benefits are paid because of the Payment Percentage reach $ 1,000 in a calendar year, benefits will be payable at 100% for all of his or her Covered Medical Expenses to which this limit applies and which are incurred in the rest of that calendar year, except those for Non -Preferred Care. When the amount reaches $ 2,000, then benefits will be payable at 100% for all of his or her Covered Medical Expenses to which this limit applies and which are incurred in the rest of that calendar year, including those for Non -Preferred Care. Payment Limit which Applies to Expenses for a Family When a family's Covered Medical Expenses for which no benefits are paid because of the Payment Percentage reach $ 2,000 in a calendar year, benefits will be payable at 100% for all of their Covered Medical Expenses to which this limit applies and which are incurred in the rest of that calendar year, except those for Nan-Preferre en the amount reaches $ 4,000, then benefits will be payable at 100% for al heir overed Medical Expenses to which this limit applies and which curred in a resi of that calendar Maximum Number of Days Outpatient Maximum Private Duty Nursing Care Maximum Shifts National Medical Excellence Lodging Expenses Maximum Travel and Lodging Maximum Private Room Limit the benefits 120 days of convalescent facility mfinement. 30 $ 5,000 70 per calendar year $ 50.00 $ 10,000 The institution's semiprivate rate. Lifetime Maximum Benefit: There is no Lifetime Maximum Benefit (overall limit) that applies to the Comprehensive Medical benefits described in the Booklet. The only maximum benefit limits are those specifically mentioned in your Booklet. Pregnancy Coverage Benefits are payable for pregnancy -related expenses of female employees and dependents on the same basis as for a disease. In the event of an inpatient confinement, such benefits will be payable for inpatient care of the covered person and any newborn child for: a minimum of 48 hours following a vaginal delivery; and a minimum of 96 hours following a cesarean delivery. If a person is discharged earlier, benefits will be payable for 2 post -delivery home visits by a health care provider. Normally, the expenses must be incurred while the person is covered under this Plan. If expenses are incurred after the coverage ceases, they will be considered for benefits only if satisfactory evidence is furnished to Aetna that the person has been totally disabled since her coverage terminated. Prior Plans: Any pregnancy benefits payable by previous group medical coverage will be subtracted from medical benefits payable for the same expenses under this Plan. Sterilization Coverage Health Expense Coverage: Benefits are payable for charges made in connection with any procedure performed for sterilization of a person, including voluntary sterilization, on the same basis as for a disease. Adjustment Rule If, for any reason, a person is e ' ci adjusted as provided elsewher the increase is subject y Acti or: section ofhis Sum of C ase. ral nount off ra'e, coverage will be on file wour mployer. Any iin ElfeDa of Coverage the ad .WWffient becomes effective are payable in is. In other words, there are no vested rights to i in effect prior to the date of any adjustment. This Summary of Coverage replaces any Summary of Coverage previously in effect under your plan of health benefits. Requests for coverage other than that to which you are entitled in accordance with this Summary of Coverage cannot be accepted. KEEP THIS SUMMARY OF COVERAGE WITH YOUR BOOKLET 10 09/26/01 Additional Information Provided by Sample Company The following information is provided to you in accordance with the Employee Retirement Income Security Act of 1974 (ERISA). It is not a part of your booklet. Your Plan Administrator has determined that this information together with the information contained in your booklet is the Summary Plan Description required by ERISA. In furnishing this information, Aetna is acting on behalf of your Plan Administrator who remains responsible for complying with the ERISA reporting rules and regulations on a timely and accurate basis. Employer Identification NumbeF: xxxx Plan Number: xxxx Agent for Service of Legal Process: xxxx End of Plan Year: xxxx Source of Contributions: xxxx Procedure for Amending the Plan: The Employer may amend the Plan from time to time by a written instrument signed by xxxx. Claim Procedures ERISA Rights Your booklet contains information on reporting claims. Claim forms may be obtained at your place of employment. These forms tell you how and when to file a claim. If your claim is denied in whole or in part, you will receive a written notice of the denial from Aetna Life Insurance Company. The notice will explain the reason for the denial and the review procedures. You may request a review of the denied claim. The request must be submitted, in writing, to Aetna Life Insurance Company within 60 days after you receive the notice. Include your reasons for requesting the review. Your claim will be reviewed and ordinarily you will be notified of the final decision within 60 days of receipt of your request. If special circumstances require an extension of time, you will be notified of such extension during the 60 days following receipt of your request. As a participant in the group benefits plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974. ERISA provides that all plan participants shall be entitled to: Examine, without charge, at the Plan Administrator's offii locations such as worksites and union halls, n docui contracts, collective bargaining agre an' opies of detailed at dther specified ;in luding insurance tents filed by the written request to aree for the financial report. The Plan Administrator is nt with a copy of this summary annual report, on to g rights for plan participants, ERISA imposes obligations upon the who are responsible for the operation of the employee benefit plan. The people who operate your plan, called 'fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your claim for a welfare benefit is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have the right to have the plan review and reconsider your claim. Under ERISA there are steps you can take to enforce the above rights. For instance, if you request materials from the plan and do not receive them within 30 days you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay up to $ 110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. If it should happen that plan fiduciaries misuse the plan's money or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. If you have any questions about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, you should contact: • the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory; or • the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington D.C. 20210. Statement of Rights under the Under federal law, group health plans and health insurance issuers offering group health Newborns' and Mothers' insurance coverage generally may not restrict benefits for any hospital length of stay in Health Protection Act connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also, under federal law, plans and issuers may not set the level of benefits or out-of- pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of- pocket costs, you may be required to obtain precertification. For information on precertification, contact your plan administrator. riving benefits for after the appearance; will p ed con tion with the attending physician and the 11 be bje o t e annual deductibles and coinsurance provisions that Piave any questions about our coverage of mastectomies and reconstructive surgery, contact the Member Services number on the back of your ID card. RIDER [AETNA U.S. HEALTHCARE, INC.] (FLORIDA) PRESCRIPTION PLAN RIDER [Group Agreement Effective Date: [Aetna U.S. Healthcare, Inc.] ("HMO") and Contract Holder agree to offer to Members the HMO Prescription Plan, subject to the following provisions: The Definitions section of the Certificate is amended to include the following definitions: • Brand Name Prescription Drug(s) - Prescription drugs and insulin with a proprietary name assigned to it by the manufacturer or distributor and so indicated by MediSpan or any other similar publication designated by HMO or an affiliate. Brand Name Prescription Drugs do not include those drugs classified as Generic Prescription Drugs as defined below. + Contracted Rate - The negotiated rate between HMO or an affiliate and the Participating Retail or Mail Order Pharmacy. • Drug Formulary - A listing of prescription drugs and insulin established by HMO or an affiliate which includes both Brand Name Prescription Drugs, and Generic Prescription Drugs. This list is subject to periodic review and modification by HMO or an affiliate. An updated copy of the Drug Formulary shall be available at any time upon request by the Member. • Drug Formulary Exclusions List - a list of prescription drugs excluded from the Drug Formulary, subject to change from time to time at the sole discretion of HMO. • Generic Prescription Drug(s) - Prescription drugs and insulin, whether identified by its chemical, proprietary, or non-proprietary name, that is accepted by the U.S. Food and Drug Administration as therapeutically equivalent and interchangeable with drugs having an identical amount of the same active ingredient. • Maintenance Drugs - A listing of prescription drugs or medications established by HMO or an affiliate which is subject to periodic review and modification by HMO or an affiliate. The list consists of prescription drugs or medications that are taken for extended periods of time, and which do not vary frequently in terms of dosage (such as high blood pressure medication). • Non -Formulary Prescription Drug(s) - A product or drug not listed on the Drug Formulary which includes drugs listed on the Drug Formulary Exclusions List. • Participating Mail Order Pharmacy - A Pharmacy which has contracted with HMO or an affiliate to provide covered outpatient prescription drugs or medicines, and insulin to Members by mail or other carrier. + Participating Retail Pharmacy - A community pharmacy which has contracted with HMO or an affiliate to provide covered Outpatient prescription drugs to Members. HMO/FL RQ)ER-RX-2000-2 (l 1/99) Precertification Program. For certain outpatient prescription drugs, prescribing Physicians must contact HMO or an affiliate to request and obtain coverage for such drugs. The list of drugs requiring precertification is subject to change by HMO or an affiliate. An updated copy of the list of drugs requiring precertification shall be available upon request by the Member. Step Therapy Program. A form of precertification under which certain prescription drugs will be excluded from coverage, unless a first -line therapy drug(s) is used first by the Member. The list of step therapy drugs is subject to change by HMO or an affiliate. An updated copy of the list of drugs subject to step therapy shall be available upon request by the Member. Therapeutic Interchange Program. The Therapeutic Interchange Program substitutes one covered prescription drug product for another upon the prescribing Physician's approval, where said prescription drugs products are considered therapeutically equivalent and clinically efficacious. The Covered Benefits section of the Certificate is amended to add the following provision: [[Option 1.1 A. [Outpatient Prescription Drug [Closed] Formulary Benefit ] Medically Necessary outpatient prescription drugs and insulin are covered when listed on the Drug Formulary. The Drug Formulary is subject to change at the sole discretion of HMO or an affiliate. In addition, Generic and Brand Non -Formulary Drugs approved by HMO, except those listed on the Drug Formulary Exclusions List, are also covered, subject to the Limitations and Exclusions section of this rider and the Certificate. Coverage of these Non -Formulary Drugs are subject to change from time to time at the sole discretion of HMO. Some items are covered only with prior authorization from HMO. Prescriptions must be written by a Provider licensed to prescribe federal legend prescription drugs subject to the terms, HMO policies, and the Limitations and Exclusions section described in this rider and the Certificate. Coverage of prescription drugs may, in HMO's sole discretion, be subject to Precertification, Step Therapy, Therapeutic Interchange Programs or other HMO requirements or limitations. Items covered by this rider are subject to drug utilization review by HMO and/or Member's Participating Pharmacy. Not all Brand Name Prescription Drugs are covered. Member's Participating Physician or Participating Retail or Mail Order Pharmacy may seek a medical exception to obtain coverage for drugs listed on the Drug Formulary Exclusions List [or drugs for which coverage is denied through Step Therapy, Precertification, and Therapeutic Interchange Programs or other HMO limitations or requirements]. Such exception requests shall be made by the Provider to the Precertification department of Aetna U.S. Healthcare's Pharmacy Management Department. Coverage granted as a result of a medical exception shall be based on an individual, case by case Medical Necessity determination and coverage will not apply or extend to other Members.] HMO/FL RIDER-RX-2000-2 (11/99) [[Option 2.1 A. [Outpatient Prescription Drugs [Open Formulary] Benefit] Medically Necessary outpatient prescription drugs and insulin are covered when prescribed by a Provider licensed to prescribe federal legend prescription drugs or medicines subject to the terms, HMO policies, limitations and exclusions described in the Certificate and this rider. Coverage is based on HMO's or an affiliate's determination, in its sole discretion, if a prescription drug is covered. Some items are covered only with prior authorization from HMO. Items covered by this rider are subject to drug utilization review by HMO and/or Member's Participating Provider and/or Member's Participating Pharmacy. Not all Brand Name Prescription Drugs are covered. ] [B. 1. Each prescription is limited to a maximum [30; 341 day supply when filled at a Participating Retail Pharmacy or [90; 1001 day supply when filled by the Participating Mail Order Pharmacy designated by HMO. Except in an emergency or urgent care situation, or when the Member is traveling outside the HMO Service Area, prescriptions must be filled at a Participating Retail or Mail Order Pharmacy. [Coverage of prescription drugs may, in HMO's sole discretion, be subject to Precertification, Step Therapy, Therapeutic Interchange Programs or other HMO requirements or limitations.] ] [B. 2. Coverage for Maintenance Drugs, beyond the [31; 341 day supply, is available under this Prescription Plan benefit. To be covered on this extended basis, the prescription drug must be a Maintenance Drug on the list of drugs approved by HMO or an affiliate and Medically Necessary for the Member's illness or injury. [The prescription must be originally filled for up to a [31; 34] day supply by the Participating Retail Pharmacy and be covered under this rider. Thereafter, the Maintenance Drug is covered for up to a [90; 100] day supply upon a written prescription by a Provider licensed to prescribe federal legend prescription drugs provided based upon the Provider's prescribed directions, the next refill will be considered an initial prescription, and will be covered up to a maximum 34 day supply. ] All [90; 100] day supply prescriptions must be filled by a Participating Retail or Mail Order Pharmacy. This Maintenance Drug list is subject to change in HMO's or an affiliate's sole discretion, without notice to Members or Contract Holder.] C. FDA approved prescription drugs are covered when the off -label use of the drug has not been approved by the FDA for that indication, provided that such drug is recognized for treatment of such indication in one of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information), or the safety and effectiveness of use for this indication has been adequately demonstrated by at least one study published in a nationally recognized peer reviewed journal. Coverage of off label use of these drugs may, in HMO's sole discretion, be subject to Precertificatiion Program, Step Therapy Program or other HMO requirements or limitations. D. Emergency Prescriptions - Emergency prescriptions are covered subject to the following terms: When a Member needs a prescription filled and Member does not have access to a Participating Retail Pharmacy in an Emergency or Urgent Care situation, or when the Member is traveling outside of the HMO Service Area, HMO will reimburse the Member as described below. HMO/FL RIDER-RX-2000-2 (11/99) When a Member obtains an Emergency or Urgent Care prescription at a non -Participating Retail Pharmacy, Member must directly pay the pharmacy in full for the cost of the prescription. Member is responsible for submitting a request for reimbursement in writing to HMO with a receipt for the cost of the prescription. Reimbursement requests are subject to professional review by HMO to determine if the event meets HMO's requirements. Upon approval of the claim, HMO will directly reimburse the Member [75%; 100%] of [the cost; the HMO's Contracted Rate with Participating Pharmacy] of the prescription, less the applicable Copayment specified below and any brand name cost differentials as applicable. Coverage for items obtained from non -Participating Pharmacies is limited to items obtained in connection with covered Emergency and Out -of -Area Urgent Care services. When a Member obtains an Emergency or Urgent Care prescription at any Participating Retail Pharmacy, including out of area Participating Retail Pharmacies, Member will pay to the Participating Retail Pharmacy the Copayment(s), plus the brand name cost differentials where applicable and as described below. HMO will not cover claims submitted as a direct reimbursement request from a Member for a prescription purchased at a Participating Retail Pharmacy except upon professional review and approval by HMO in it's sole discretion. E. Mail Order Prescription Drugs. Subject to the terms and limitations set forth in this rider, Medically Necessary outpatient Prescription drugs are covered when dispensed by the Participating Mail Order Pharmacy designated by HMO and when prescribed by a [Participating] Provider licensed to prescribe federal legend prescription drugs. [Members are required to obtain prescriptions greater than a [30; 341 day supply from the designated Participating Mail Order Pharmacy.] Outpatient prescription drugs will not be dispensed by a Participating Mail Order Pharmacy in quantities that are less than a [30; 341 day supply or more than a [90; 1001 day supply (if the Provider prescribes such amounts). F. Additional Optional Benefits. The following prescription drugs, medicines, and supplies are also covered subject to the terms described in this rider: Diabetic Supplies. The following diabetic supplies are covered if Medically Necessary upon prescription or upon Participating Physician's order only at a Participating Retail or Mail Order Pharmacy, the Member must pay a separate Copayment for each item. 1. Diabetic needles/syringes. 2. Test strips for glucose monitoring and/or visual reading. 3. Diabetic test agents. 4. Lancets/lancing devices. 5. Alcohol swabs. [ • Contraceptives. The following contraceptives and contraceptive devices are covered upon prescription or upon the Participating Physician's order only at a Participating Retail or Mail Order Pharmacy: 1. Oral contraceptives. 2. Diaphragms, one per (365 consecutive day period; calendar year]. 3. Depo provera. The prescription plan Copayment applies for each vial up to a maximum of 5 vials per calendar year. 4. Norplant and IUDs are covered when obtained from a Participating Physician, The Participating Physician will provide insertion and removal of the device. An office visit Copayment will apply, if any.] HMO/FL RIDER-RX-2000-2 (11/99) [• Injectable Infertility Drugs. [10%; 20%; 30%; 40%; 50%] of the Contracted Rate per prescription or refill for prescription drugs used for the purpose of treating Infertility. These include, and are subject to change by HMO or an affiliate, urofollitropin, menotropin, human chorionic gonadotropin, progesterone. ] [ • Lifestyle/Performance Drugs. Sildenafil Citrate, phentolamine, apomorphine and alprostadil in oral and topical (including but not limited to gels, creams, ointments and patches) forms or any other form internally or externally are covered for Members. Coverage includes any prescription drug in oral or topical form that is in a similar or identical class, has a similar or identical mode of action or exhibits similar or identical outcomes. Coverage is limited to [1-15] pills or other form, determined cumulatively among all forms, for unit amounts as determined by HMO to be similar in cost to oral forms, per [30; 341 day supply. [Mail order and [90; 1001 day supplies are not covered.] Copayments: [The Member is responsible for a Copayment in the amount listed in this rider for [Non-Formulary][Formulary] Brand Name Drugs.]] [G]. Copayments: Member is responsible for the Copayment specified in this rider. The Copayment, if any, is payable directly to the Participating Retail or Mail Order Pharmacy for each prescription at the time the prescription is dispensed. If the Member obtains more than a [30; 34] day supply of prescription drugs or medicines at the Participating Mail Order Pharmacy, not to exceed a [90;100] day supply, [one; two; three] Copayments are payable for each supply dispensed. The Copayment is not subject to the Annual Maximum Out -of -Pocket Limit set forth in the Schedule of Benefits for the medical plan, if any. [If the Physician prescribes, or the Member requests, a covered Brand Name Prescription Drug when a generic equivalent is available, the Member will pay the difference in cost between the Brand Name Prescription Drug and the Generic Prescription Drug equivalent, plus the applicable Copayment.] [If the Physician prescribes a covered Brand Name Prescription Drug where a Generic Prescription Drug equivalent is available and specifies "Dispense As Written' (DAW), the Member will pay the Copayment for the Brand Name Prescription Drug. If the Member requests a covered Brand Name Prescription Drug where a Generic Prescription Drug equivalent is available the Member will pay the difference in cost between the Brand Name Prescription Drug and the Generic Prescription Drug equivalent, plus the applicable Copayment.] [The Member is responsible for a Copayment in the amount of [$0; $1.00; $2.00; $2.50; $3.00; $4.00; $5.00; $6.00; $7.00; $7.50; $8.00; $10.00; $12.00; $15.00; $20.00; $25.00; $30.00; $35.00; $40.00; 10%; 20%; 30%; 40%; 50% of the Contracted Rate] per prescription or refill[.] [for a [Generic] [Formulary ] Prescription Drug.] [The Member is responsible for a Copayment in the amount of [$0; $1.00; $2.00; $2.50; $3.00; $4.00; $5.00; $6.00; $7.00; $7.50; $8.00; $10.00; $12.00; $15.00; $20.00; $25.00; $30.00; $35.00; $40.00; 10%; 20%; 30%; 40%; 50% of the Contracted Rate] per prescription or refill for a [Brand Name] [Formulary] Prescription Drug.] [The Member is responsible for a Copayment in the amount of [$0; $1.00; $2.00; $2.50; $3.00; $4.00; $5.00; $6.00; $7.00; $7.50; $8.00; $10.00; $12.00; $15.00; $20.00; $25.00; $30.00; $35.00; $40.00; 10%; 20%; 30%; 40%; 50% of the Contracted Rate] per prescription or refill for a [Brand Name] [or Generic] Non -Formulary Prescription Drug.] HMO/PL. RIDER-RX-2000-2 (11/99) EXCLUSIONS AND LIMITATIONS The Limitations and Exclusions section of the Certificate is amended to include the following limitations and exclusions: A. Exclusions. Unless specifically covered under this rider, the following are not covered: 1. Any drug which does not, by federal or state law, require a prescription order (i.e., an over- the - counter (OTC) drug or for which an equivalent over the counter product in strength and dosage form, is available even when a prescription is written, unless otherwise covered by HMO. 2. Any drug determined not to be Medically Necessary for the treatment of disease or injury unless otherwise covered under this rider. 3. Any charges for the administration or injection of prescription drugs or injectable insulin and other injectable drugs covered by HMO. 4. Cosmetic or any drugs used for cosmetic purposes or to promote hair growth, including but not limited to health and beauty aids. 5. Needles and syringes, except diabetic needles and syringes. 6. Any medication which is consumed or administered at the place where it is dispensed, or while a patient is in a hospital, or similar facility; or take home prescriptions dispensed from a Hospital pharmacy upon discharge, unless the pharmacy is a Participating Retail Pharmacy. 7. Immunization or immunological agents, including but not limited to, biological sera, blood, blood plasma or other blood products administered on an outpatient basis, allergy sera and testing materials. 8. Drugs used for the purpose of weight reduction (i.e., appetite suppressants), including the treatment of obesity. 9. Any refill in excess of the amount specified by the prescription order. Before recognizing charges, HMO may require a new prescription or evidence as to need, if a prescription or refill appears excessive under accepted medical practice standards. 10. Any refill dispensed more than one (1) year from the date the latest prescription order was written, or as otherwise permitted by applicable law of the jurisdiction in which the drug is dispensed. 11. Drugs prescribed for uses other than uses approved by the Food and Drug Administration (FDA) under the Federal Food, Drug and Cosmetic Law and regulations, or any drug labeled "Caution: Limited by Federal Law to Investigational Use", or experimental drugs except as otherwise covered under this rider. 12. Medical supplies, devices and equipment and non -medical supplies or substances regardless of their intended use. 13. Test agents and devices including but not limited to diabetic test agents. 14. Injectable drugs used for the purpose of treating infertility, unless otherwise covered by HMO. 15. Injectables except for insulin. 16. Oral and implantable contraceptives and contraceptive devices, unless otherwise covered under this rider. 17. Prescription orders filled prior to the effective date or after the termination date of the coverage provided by this rider. 18. Replacement for lost or stolen prescriptions. HMO/FL RIDER-RX-2000-2 (11/99) 19. Sildenafil citrate, phentolamine, apomorphine and alprostadil in oral [,injectable] and topical (including but not limited to gels, creams, ointments and patches) forms, any prescription drug in oral, topical or any other form that is in a similar or identical class, has a similar or identical mode of action or exhibits similar or identical outcomes unless otherwise covered under this rider. 20. Performance, athletic performance or lifestyle enhancement drugs and supplies. 21. Drugs and supplies when not indicated or prescribed for a medical condition as determined by HMO or otherwise specifically covered under this rider or the medical plan. 22. Drugs dispensed by other than a Participating Retail or Mail Order Pharmacy, except as Medically Necessary for treatment of an emergency or urgent care condition. 23. Medication packaged in unit dose form. (Except those products approved for payment by HMO). 24. Prophylactic drugs for travel. 25. Drugs recently approved by the FDA, but which have not yet been reviewed by the Aetna U.S. Healthcare Pharmacy Management Department and Therapeutics Committee. 26. Drugs for the convenience of Members or for preventive purposes unless covered by HMO in its sole discretion. 27. Drugs listed on the Formulary Exclusions List unless otherwise covered through a medical exception as described in this rider or covered under [Option 2] of this rider. [2$]. [Nutritional supplements.] [29]. [ Smoking cessation aids or drugs.] [30]. [Growth Hormones.] B. Limitations: 1. A Participating Retail or Mail Order Pharmacy may refuse to fill a prescription order or refill when in the professional judgment of the pharmacist the prescription should not be filled. 2. Non -Emergency and non -Urgent Care prescriptions will be covered only when filled at a Participating Retail Pharmacy or the designated Mail Order Pharmacy. Refer to the Certificate for a description of Emergency and Urgent Care coverage. HMO will not reimburse Members for out-of-pocket expenses for prescriptions purchased from a Participating Retail Pharmacy or a non - Participating Retail Pharmacy in non -Emergency, non -Urgent Care situations. HMO retains the right to review all requests for reimbursement and in its sole discretion make reimbursement determinations subject to the Grievance Procedure section of the Certificate. 3. Members are required to present their ID card at the time the prescription is filled. A Member who fails to verify coverage by presenting the ID card will not be entitled to direct reimbursement from HMO except in an Emergency or Urgent Care situation and Member will be responsible for the entire cost of the prescription. 4. The Continuation and Conversion section of the Certificate is hereby amended to include the following provision: The conversion privilege does not apply to the HMO Prescription Plan. 5. HMO is not responsible for the cost of any prescription drug for which the actual charge to the Member is less than the required Copayment or for any drug for which no charge is made to the recipient. HMO/FL RIDER-RX-2000-2 (I 1/99) 5. Member will be charged the Non -Formulary Prescription Drugs Copayment for prescription drugs covered on an exception basis. [CONTRACT HOLDER [AETNA U.S. HEALTHCARE, INC-] By: By: Title: Date: HMO/FL RIDER-RX-2000-2 (I 1/99) No Text CHANGES TO DOCUMENTS CLARIFICATION OF BENEFITS AND POLICIES Q&A 1 City of Tamarac RFP No. 00-26R 1. Are dependent grand -children covered? HMO Eligibility Requirements to Enroll a Grandchild The grandparent must: Have legal custody or legal responsibility (whether the dependent child is on plan or not) including evidence of legal custody/responsibility Have the grandchild residing with them and being dependent on them for support; Have the approval of their employer; Enroll the child through their employer within 31 days from the date of obtaining custody or legal responsibility. PPO Coverage is required for the child of a dependent (grandchild) if the employee claims the child as a dependent on income tax. It is not necessary that the grandchild reside with the employee but s/he must be dependent upon the employee for support. Coverage can remain in force as long as a child meets the standard grandchildren eligibility criteria and the plan definition of dependent. 2. Is COBRA conversion information automatically sent to the member? HMO/QPOS Members must contact Aetna's Conversion Unit to initiate conversion privilege. The City is responsible for giving notice of the conversion privilege in accordance with its normal procedures. A e t n a U. S. H e a l t h c a r e 1 0- 0 4- 0 1 CLARIFICATION OF BENEFITS AND POLICIES Q&A 2 City of Tamarac RFP No. 00-26R PPO The City will be supplied with "Notice of Conversion Privilege and Request" forms. Members will be responsible for requesting these forms from The City. They will then be responsible for completing and forwardng to the address shown. Aetna's Individual Billing Administration System Option If The City elects for us to do the notification piece of the COBRA billing, the initial notification (after qualifying event) will inform of the conversion policy and then 90 days prior to expiration of the continuee's COBRA coverage we will then notify the continuee of the conversion policy. 3. Is Chiropractor & Allergist co -pay required for each visit? ■ Chiropractor- specialist copay is required for each office visit. ■ Allergist- Depends on how the provider bills for the visits. (i.e., Allergy shots do not require a copayment. However, if the doctor performs another clinical service at the same visit, then we will indicate on the EOB that copay is required. 4. Are members notified of the removal of formulary drugs? Yes, every member is notified in writing. 5. Can members receive non -formulary drugs through the mail? Yes 6. Will we provide quarterly claims reports? A e t n a U. S. H e a l t h c a r e® 1 0- 0 4- 0 1 CLARIFICATION OF BENEFITS AND POLICIES Q&A 3 City of Tamarac RFP No. 00-26R Yes, underwriter approval granted. 7. Is there a benefit for Infertility? Basic Infertility Services: Infertility testing done which is covered in the provider's office without a referral through direct access (GYN or infertility specialist). Comprehensive Infertility Benefits The Aetna U.S. Healthcare infertility program must authorize comprehensive infertility benefits. Services include: ■ Surgery ■ 6 cycles of ovulation inductions in a lifetime (including ultrasounds and blood work for members who are on medication) ■ 6 cycles of insemination in a lifetime 8. Clarify the Dependent age limit. Florida: Coverage is provided for dependents to the age of 25 if full time students or fully dependent on the employee. 9. Is Depo-Provera covered? Depo-Provera is covered for contraceptives under the pharmacy rider. Other uses require authorizations. 10. What is the earliest release of future renewals? A e t n a U. S. H e a l t h c a r e 1 0- 0 4- 0 1 CLARIFICATION OF BENEFITS AND POLICIES Q&A 4 City of Tamarac RFP No. 00-26R Early renewal request granted for September 1. 11. Can Aetna make changes to the specified Copay? We would not change the copay off -anniversary unless there is a legislative change requiring us to do so. At renewal however, we reserve the right to make changes to the copayment schedule. 12. Explain Premiums Due: Aetna is a prepaid comprehensive health plan and all payments are due on the I" or 151" of the month for that month of coverage, depending on your billing cycle. There is a 30 day grace period for paying premiums. 13. Clarify what actions would cause us to terminate a member if they do not choose a PCP. Aetna provides coverage to members as directed by eligibility feeds from our customers, verifying dependent status as needed. If an HMO member fails to select a PCP at enrollment, the member will receive a letter asking him or her to contact member services by phone, by automated voice response, or by Internet to make a PCP selection. The certificate of coverage under HMO Procedure, clause A, further states that until a PCP is selected, benefits will be limited to coverage for care of Emergency Medical Conditions. PPO Members are not required to select a PCP. Members may choose providers in or out of the network for primary and specialist care. A e t n a U. S. H e a l t h c a r e" 1 0- 0 4- 0 1 CLARIFICATION OF BENEFITS AND POLICIES Q&A 5 City of Tamarac RFP No. 00-26R 14. Clarify the open enrollment period ERISA guidelines relative to municipalities as the plan sponsor. Page 5 of the HMO contract specifies 31-90 days. Aetna provided a sample -only contract during the RFP process. The actual contract would be customized to 31 days for the state of Florida contract. Aetna defers to The City for contact of legal counsel regarding municipality -specifics. We provide for newly eligible employees and dependents to be added only at the following times: ■ Within 31 days of the eligibility date ■ At the next open enrollment ■ Within 31 days of termination of coverage due to spouse's layoff or termination of employment provided evidence of such is submitted to us We also allow enrollment for all HIPAA qualifying events Qualifying events include: ■ A marriage of the employee ■ The birth, proposed adoption, or adoption of a child of the employee A late applicant qualifies for medical benefits when other group coverage is lost due to one of the qualifying events below: ■ Cessation of COBRA or state continuation (the allowable length of continuation must be exhausted) ■ Cessation of incapacitated children ■ Coverage change from full-time to part-time status ■ Company out of business resulting in loss of coverage for spouse/dependents ■ Death of employee ■ Divorce or legal separation ■ Employer termination of medical plan A e t n a U. S. H e a l t h c a r e® 1 0- 0 4- 0 1 CLARIFICATION OF BENEFITS AND POLICIES Q&A 6 City of Tamarac RFP No. 00-26R ■ Employer termination of dependents' medical coverage ■ Employer termination of combined Medical/Dental coverage ■ Employer termination of dependents' combined Medical/Dental coverage ■ Layoff ■ Loss of Medicaid ■ Retirement of spouse Finally, if the customer has a flex or cafeteria plan in operation in accordance with Section 125 of the Internal Revenue Code, we will accept enrollments for eligible members within 31 days of their eligibility date due to the following events, and in addition to the above events, provided that documentation of the 125 plan is submitted to us: ■ The termination or commencement of employment of the employee's spouse ■ The taking of unpaid leave of absence of the employee or employee's spouse ■ Significant change in health coverage of employee or spouse attributable to spouse's employment 15. At what point will Aetna not arrange services for its members? Aetna's Group Agreement, Administration of Agreement Section, clause O. Inability to Arrange Services states that due to circumstances not within the reasonable control of HMO, including but not limited to major disaster, epidemic, etc., the rendition of medical or hospital benefits or other services are delayed or rendered impractical, that the HMO will have no liability or obligation due to delay or failure to provide services, except to refund unearned prepaid premium. However, the HMO is required to make good -faith effort to provide or arrange for the provisions of services, taking into account the impact of the event. 16. HMO contract page 10, Q. Workers' Compensation report monthly filing. Can this be removed? A e t n a U. S. H e a l t h c a r e® 1 0- 0 4- 0 1 CLARIFICATION OF BENEFITS AND POLICIES Q&A 7 City of Tamarac RFP No. 00-26R Removal of the language in this section would require a custom contract. However, compliance with this provision would not be monitored for the City of Tamarac as long as the City is willing to respond to Aetna, Inc. on any specific Workers Compensation claim information requests. 17. In the PPO contract section "Conversion of Medical Expense Coverage", is this referring to coordination of benefits? This section explains the process after medical coverage has ended, and what the rights are in order to convert. 18. Is blood transfusion covered? Blood transfusion is covered on the HMO and referred QPOS contracts. Under the non -referred QPOS and PPO plans this is not a covered benefit. Local blood banks in arrangement with hospitals provide this benefit. Our decision not to cover blood transfusions is competitive with other local carriers. 19. In the HMO contract on page 11, it talks about direct access providers, but does not specify Chiropractor. Is Chiropractor direct access? Yes, Chiropractor is direct access in the state of Florida. 20. HMO contract page 13 states that members must see PCP for referral to services relating to outpatient substance abuse (Detoxification). Clarify. Aetna U. S. He aIthcare�' 1 0 - 0 4 - 0 1 CLARIFICATION OF BENEFITS AND POLICIES Q&A 8 City of Tamarac RFP No. 00-26R Members can call member services or the behavioral health provider (Magellan) directly at (800)424-5678 to be referred for substance abuse benefits. 21. Is outpatient prescriptions covered under the drug rider? Yes. 22. Can the "Actively at work" definition be removed from the contract? Yes. In accordance with HIPAA, members who are not actively -at - work, or who are confined, become eligible for coverage on the group's effective date. 23. Does deductible carryover apply to this plan? Deductible carryover applies only to the out of network benefits on the QPOS plan, and only if the City furnishes prior carrier information electronically in a requested format at group's installation. 24. Explain the transition of care as it pertains to pregnancies. We provide for the transition of members who are enrolling in our plan, are moving from one network plan to another, or are receiving care from a physician whose contract has been discontinued with us within the last 90 days for reasons other than quality deficiencies. Members transitioning into the plan must select a participating PCP. If a pregnant member is being treated by a nonparticipating obstetrician, generally she will be required to transfer to the care of a participating obstetrician unless she has completed 27 weeks of her pregnancy. If she has completed 27 weeks of her pregnancy on the A e t n a U. S. H e a l t h c a r e 0 1 0- 0 4- 0 CLARIFICATION OF BENEFITS AND POLICIES Q&A 9 City of Tamarac RFP No. 00-26R plan effective date, care can continue with her nonparticipating obstetrician at the preferred level of benefit. In some instances, these rules may vary in accordance with state law. 25. What is the age limit for mammograms on the PPO? All Aetna U.S. Healthcare female members are eligible for mammogram routine screening and diagnostic when medically indicated and authorized by the physician or as recommended by Aetna U.S. Healthcare Check Referral Program via annual reminders. No age limitations apply. A e t n a U. S. H e a l t h c a r e° 1 0- 0 4- 0 1 Explanation of bracketed items indicated in sample contract as [ ] QPOS: 1. The brackets [ ] in the QPOS UCR rider would be removed and the effective date of the policy would print. It will be included once the UCR Rider has been put into Production. 2. In the "Term of Rates" section, the client's rates will be detailed in the final contract? "Premium Due Dates" section, will it say [Ist]? If the .Protection Start and Stop Cycle is 1; if it is Cycle 2 then it will say 15. Client should refer to Employer Application for selection. Premiums section E, F, depends on the protection starts & stops that the client specifies on the Employer Application. 3. Contract holder termination section D, 7 will only be included if the Group is an Association. HMO 1. In this document on page 11, section D, routine eye exam - Plan Design Benefits sheet includes a $10 copay for Routine Eye Exams. 2. Same section: preventive dental- will be excluded because we did not quote 3. Page 13, section I. All the [ ] pieces included because we quoted the mental health as a rider. The state has mandated mental health benefits and the mental health benefit was included in the quote. Page 16 section 4. Respite Care is standardly included. The definition of Respite Care appears on page 48 in the HMO COC. 5. Page 16 section P. Goes with the DME rider we quoted. The "Replacement" paragraph is included only when the DME rider is purchased. Same as pg. 22 bottom. 6. The TMJ exclusion is standardly included. The exclusion is bracketed because it is filed with the Insurance Department so that it can be included or excluded. E RATES Financial Information - - Revised Contract/Policy Period: 12 months (January 1, 2002 to January 1, 2003) Contract State: Florida Pooling Point: $60,000 Benefits: HMO, QPOS, PPO Medical (HMO with $10 Specialist) Net Monthly Rate Per Monthly Coverage Lives Employee Premium HMO - Florida _ Employee Only 131 $224.20 Employee & Family 144 $581.50 Subtotal 275 $113,106.00 HMO - Connecticut Employee Only 1 $224.20 Employee & Family 0 $581.50 Subtotal 1 $224.00 QPOS - Florida Employee Only 7 $278.40 Employee & Family 15 $649.50 Subtotal 22 $1 1,691.00 QPOS - Connecticut Employee Only 0 $278.40 Employee & Family 0 $649.50 Subtotal 0 $0.00 PPO Medical Employee Only 15 $328.55 Employee & Family 13 $800.00 Subtotal 28 $15,328.00 Total Monthly Premium $140,349.00 Total Annual Premium $1,684,188.00 Conditions of Quote: Employer contributions meet Aetna minimum requirements. Participation meets Aetna minimum requirements - Note: Refer to the Quotation Assumptions in the Financial Information document for any applicable caveats. Aetna U.S. Healthcare 09/25/01 Financial information - COBRA 1 City of Tamarac, Florida Our rates exclude the following charges for COBRA Direct Billing. If this service is elected, these charges will be billed as incurred. For 2002, these are the individual billing services we offer for COBRA and the associated fees: COBRA Installation or Restructure Fee $2,600.00 (one time fee) For a direct billing arrangement setup within a control number. Payable only in the first year. A full or partial charge may also be applied for restructures after the initial setup. For example, whenever new records must be established for existing continuees who are being moved to a new or revised control, suffix, or account structure. COBRA Services Included Account maintenance Billing and collection Dedicated account consultant for plan sponsor issues Dedicated customer call center with toll -free number Dedicated processing center Delinquent monitoring Funds distribution Member record maintenance Monthly management reports Weekly eligibility COBRA Notification (first class mail) - Optional Service For each qualified beneficiary the employer has requested us to send out enrol lment/notification materials after a qualifying event. Fees vary based on method we receive source information from the customer: PC Diskette or Electronic File - Standard Format Paper - Standard Format Paper - Non -Standard Format Specialized Services Sending HIPAA Certification Notices (per certificate) HIPAA notices produced from the Individual Billing System as a separate service from AAS produced certificates. These fees are for policy periods between January 1, 2002 to December 31, 2002 and are subject to adjustment for policy periods after those dates. $13.50 (COBRA fee PP/PM) $10.40 per participant notice $11.50 per participant notice $15.50 per participant notice $4.40 Aetna U.S. Healthcare 06/12/01 Financial Information - Prospective 1 City of Tamarac, Florida Contract/Policy Period: 12 months (01/01/2002 to 01/01/2003). Quotation Information, We have based our quote on benefits that are outlined in the Plan Assumptions, and Design and Benefits section of our proposal. Any changes made Requirements to the quoted plans of benefits included in this proposal may result in an adjustment to our quoted rates/fees. We will administer our medical and dental plans according to Aetna standards and guidelines. Our costs are developed on the following basis: The net rates illustrated assume an effective date of January 1, 2002. The total estimated premium is the amount that would be charged if the assumed number of employees and dependents used in the development of the quotation remain the same at final enrollment. We reserve the right to change rates if any of the following occurs: A The final benefit provisions, account structure, and services change from those proposed. A The number of enrolled employees changes by more than 10 percent (or 33 employees) from the employee count (326) identified in this quote. A The enrolled member -to -employee ratio increases by more than 15 percent (or up to 2.55) from the 2.22 ratio assumed for this quote. A The percentage of enrolled retirees increases by more than 15 percent (or up to 5 retirees) from the 9.5 percent (31 retirees) assumed for this quote. Visit our websitc: www.aetnaushe.com 06/12/01 Financial Information - Prospective 2 City of Tamarac, Florida A For contributory plans, this proposal assumes that at least 75 percent of eligible employees will enroll in the employer - sponsored medical plan offered. Employee's who are enrolled in their spouse's plan may be excluded from total eligibles in the calculation when determining the 75 percent requirement as long as at least 50 percent of all eligible employees enroll in the Aetna plan. One -hundred percent participation is assumed when the plan is offered on a non-contributory basis. This proposal has been based in part on the medical/health information provided in the original census and request for proposal. Should additional information become available or is uncovered as part of our normal underwriting and installation process, or if there is any other material change under which the plan operates, we reserve the right to modify our rates. If any of the above requirements are not met, we reserve the right to change rates. On the initial effective date we will compare actual enrollment to the enrollment statistics used for this quotation, and revise rates if the above requirements have not been met. In addition, as part of our renewal rating we will compare average enrollment for the policy period to that on the effective date, and further revise rates if there have been further changes to above requirements. Underwriting Our quotation includes the following provisions: Information, Assumptions, and A For contributory medical and pharmacy plans, this proposal Requirements has assumed that the employer will contribute a minimum of 75 percent of the employee's cost or 50 percent of the total cost of the plan. We reserve the right to modify our proposal should any change in employer contribution levels be made on/or before the effective date of coverage. A For non-contributory plans, all employees and dependents are offered a choice of medical list all products offered coverage on a non-contributory basis. A For full replacement plans, this proposal assumes that Aetna will be offered as the sole carrier. Visit our website: www.aetnaushc.com 06/12/01 Financial Information - Prospective 3 City of Tamarac, Florida A Pre-existing Conditions (PEC) —(Does not apply to HMO, QPOS) - If an individual has a PEC and incurs expenses for that condition in the first 365 days after the individual's enrollment date, benefits for such expenses will not be covered losses under the plan. This exclusion does not apply to the first $4,000 of such covered expenses incurred under the plan. A PEC is an injury or disease for which a plan participant received either treatment or services, or took prescribed drugs or medicine, during the 90 days before the individual's enrollment date. Enrollment date is the effective date of the individual's coverage under the plan or, if earlier, the first day of any applicable probationary period. The PEC rule is waived for individuals who become covered under this plan, exclusive of any applicable probationary period, within 90 days following their termination of coverage under a prior plan of "creditable" coverage. It is also waived for newborns covered within 31 days of birth, and adopted children covered within 31 days of placement for adoption. The PEC rule does not apply to pregnancies. The plan will be administered in accordance with provisions of applicable law or regulation that are more liberal than those indicated above. The PEC rule does not apply to any HMO -based products that might be offered within this proposal. A Late Enrollees - Whenever an individual applies for coverage under the plan after the individual's initial enrollment period, and the individual does not qualify for enrollment during a special enrollment period (see below), the individual will be considered a late enrollee. Coverage for all late enrollees will automatically be postponed until the plan's next open enrollment period, and the individual will be subject to the plan's PEC rule. A late enrollee's PEC period will begin on the first day of the late enrollee's coverage. (For plans that do not have an open enrollment period, a late enrollee enrollment period of 31 days will occur two months prior to the plan's next renewal date.) A Special Enrollment Periods - Special enrollment rules apply to employees and/or dependents who are eligible, but not enrolled, for coverage under the terms of the plan, and who, when they initially declined enrollment, were covered under Visit our website: www.aetnaushe.com 06/12/01 Financial Information - Prospective 4 City of Tamarac, Florida another group health plan or had other health insurance coverage. An employee or dependent is eligible to enroll during a special enrollment period if, when the employee declined enrollment for the employee or dependent, the individual stated in writing that coverage under another group health plan or other health insurance was the reason for declining enrollment. (This requirement will only apply if the plan required such a statement and the employee was given notice of the requirement and the consequences of not providing the statement.) One of the following two conditions must also be met in order to be eligible to enroll during a special enrollment period: - When the employee declined enrollment for the employee or dependent, the employee or dependent had COBRA continuation under another plan that has since been exhausted. - If the other coverage that applied to the employee or dependent when enrollment was declined was not under a COBRA continuation provision, either the other coverage has been terminated as a result of the loss of eligibility, or employer contributions toward that coverage have been terminated. Loss of eligibility includes a loss of coverage as a result of legal separation, divorce, death, termination of employment, reduction in hours of employment and any loss of eligibility after a period that is measured by reference to one of the above causes. To qualify for the special enrollment, individuals who meet the above requirements must request enrollment no later than 31 days after one of the events described above. The effective date of their coverage will be the date of election. If the plan offers dependent coverage, individuals becoming a dependent through marriage, birth, or adoption, will have a special enrollment period for 31 days from the date of the event. If the employee is eligible for enrollment, but not enrolled, the employee may also enroll during this period. In the case of the birth or adoption of a child, the spouse of the employee may also be enrolled as a dependent if the spouse is otherwise eligible for coverage but not already enrolled. Coverage for individuals enrolling during a dependent special enrollment Visit our website: www.actnaushe.com 06/12/01 Financial Information - Prospective 5 City of Tamarac, Florida period becomes effective as of the date of the event described above. Visit our website: www.actnaushe.com 06/12/01 Financial Information - Prospective 6 City of Tamarac, Florida Quoted Services For PPO customers, we provide the following standard services: A Account Management - Analysis of experience Availability of a medical conversion product - Calculation of reserves Expected cost projections for budgeting purposes Generic employee communication materials - Installation of the plan and resolution of servicing issues Maintenance of exposure data for consulting/plan design/plan analysis purposes A Claim Administration/Adjudication - Application of COB - Application of medical necessity criteria - Application of R&C (surgery, common provider services, X-ray, and lab) - Bulk payment to improve cash flow - Certification of employee/dependent eligibility - Claim forms and envelopes - C1aimCheck editing of CPT billing practices - Claims audits; services of professional auditors -- Computerized claim payment system - Computerized hospital duration guidelines - Fraud prevention - Investigative staff - Maintenance of employee and dependent data, including eligibility and claim history - Maintenance of financial records for seven years - Maintenance of plan information for automatic claim calculation - Mental/nervous condition claim controls - Production and distribution of checks and EOBs, when applicable - Provider flags for utilization/fraud control - Provider TIN reporting (1099) - Turnaround time - 80 percent of all claims in 12 calendar days (16 days for POS claims) Visit our websitc: www.aetnaushc.com 06/12/01 Financial Information - Prospective 7 City of Tamarac, Florida A Eligibility Reporting - Flexibility in the transmission media we can accept - Online eligibility inquiry and update capabilities A Health Care Cost Management Services - Audits, including hospital audit program Automatic comparison of prior to current treatment Availability of our integrated Patient Management programs (additional charges may apply) Chiropractic and podiatric guideline application - Claim cost -containment coordinators - COB administration - Disability income duration guideline application - Elimination of duplicate bills - Generic drug education - Generic hospital audit program - Individual case management - Medical consultant staff - Nurse consultant staff - Peer review organization affiliation - Provider flag edits - Specialized fraud team A Member Services - Toll -free number for members and providers to access claim and patient management services, ask questions, and resolve problems A Plan Services - Counseling on federal and state regulatory requirements - Drafting and printing of plan documents - ID cards - Underwriting advice for late entrants A Statistical Reporting and Analysis - Annual accounting - Health care information reports (cumulative quarterly) - Standard coding (CPT-4, PAS, ICD-9, ADA, etc.) Visit our website: www.aetnaushc.com 06/12/01 Financial Information - Prospective S City of Tamarac, Florida For HMO and QPOS®customers, we provide the following standard services: ♦ Actuarial ♦ Billing and Premium Collection ♦ Claims Payment ♦ Marketing Communication Materials ♦ Member Service ♦ Underwriting ♦ Utilization Management Standard Summary Plan Description (SPD) preparation and production is included in premiums. Customization of SPDs would entail additional charges. Visit our website: www.aetnaushc.com 06/12/01 Financial Information - Prospective 9 City of Tamarac, Florida We develop an implementation management plan outlining the tasks to be accomplished by both groups and establishing target dates for completion. Through the implementation process, team members work together, contributing their specialized skills and talents toward a successful goal. A Account Structure - Our quote is based on 1 control number, 1 suffix, 1 premium account, and 1 claim account. A Billing - We prepare a monthly employee benefit statement listing additions, cancellations, and changes to the number of insureds processed since the previous statement. The customer pays the premium billed in this statement. A Eligibility Information - For PPO customers, in order to provide services accurately and efficiently, we must have the most up-to-date, accurate eligibility information on each employee and dependent. We gather and maintain this information from the enrollment data the customer provides. Our eligibility consultants then enter the enrollment, change, and termination information. Or the customer may use EZLink TM, our no -charge, web -based benefits and human resources administration solution that provides online eligibility, enrollment, account maintenance, billing, and reporting. For HMO and QPOS° customers, we accept electronic eligibility files from the customer. We can receive full population files performing a full comparison of our eligibility system and the file from the customer. We also can receive changes -only files from the customer. In this format, the customer only sends us any current changes. Our customer service areas take changes over the phone that do not impact billing. For example, members can call to change their addresses or PCPs directly over the phone. We can take termination information from customers when they pay their bill. Customers have the ability to complete a termination on their invoice. Or the customer may use EZLinkTM, our no - charge, web -based benefits and human resources administration solution that provides online eligibility, enrollment, account maintenance, billing, and reporting. Visit our website: www.aetnaushc.com 06/12/01 Financial Information - Prospective 10 City of Tamarac, Florida ♦ ID Cards - Once we receive the customer's eligibility information, the time it takes to produce IDs varies depending on the style of the ID: - Standard IDs - The cost of standard ID cards are included in our proposed premium. Initial orders of these IDs take about one week. Subsequent orders can be filled overnight. - Special IDs - Initial orders of these IDs, which show the customer's logo in black and white, take about two weeks. Subsequent orders can be filled overnight. - Custom IDs - Initial orders of these IDs, which show the customer's logo or special colors or designs, take about four to six weeks. Subsequent orders can be filled overnight. For PPO customers, we issue two standard ID cards to eligible employees. The ID card displays employee name, employee ID number, customer name, applicable copay amounts, and address and toll -free telephone number of the assigned service center. For HMO and QPOS° customers, we issue one standard ID card to eligible members. The ID card displays member name, member number, PCP number, applicable copay amounts, and address and toll -free telephone number of the assigned service center. ♦ Printing - For PPO customers, our quotation includes printing expenses for our standard booklet/certificates. An initial supply equal to 1.5 times the number of employees will be provided. For HMO and QPOS customers, we do not charge printing as a separate expense. ♦ Commissions - The customer's agent/broker may qualify for an incentive commission payment based upon his/her sales results with Aetna. This producer incentive payment will not be charged to the customer's retention. Our quotation does not include commissions. Visit our websitc: www.aetnaushc.com 06/12/01 Financial Information - Prospective City of Tamarac, Florida A Taxes - Our quotation includes any applicable state premium taxes. A Claim Process - Employees and providers send claims directly to the assigned service center for processing. We check eligibility using our claims payment system. Customers and/or members can contact our customer service professionals by referring to the toll -free telephone number printed on the ID cards. A Explanation of Benefits (EOB) - For PPO customers, we distribute an EOB form to employees, except where there is no member liability. Our claim system automatically suppresses an EOB where benefits are assigned and the member's liability is either zero or consists of a copayment only. Claim checks for in -network benefits, as well as for assigned benefits, are sent directly to the provider. All other claim checks are sent to the employee. A Processed Claim Transactions (PCT) - We define a PCT, for medical or dental benefits, as any transaction with respect to a benefit request or predetermination of dental benefits for expenses incurred or expected to be incurred by one claimant in any one calendar year for a major line of coverage, including but not limited to a benefit payment, benefit denial, pended benefit request or decision on an appeal of a denied benefit request. These are some of the actions that can produce a separate PCT: - Expenses are submitted for more than one family member. - Expenses are incurred under more than one coverage. We consider Comprehensive Medical, Comprehensive Dental and Basic Dental, and Medicare supplement as separate coverages. - Expenses are incurred in two or more calendar years. - A transaction involves more than three assigned providers. - A transaction involves more than six expense lines on an EOB statement. - A dental precertification is produced. - Covered expense is applied to a deductible. - A claim is pended and an EOB is sent to the employee. Visit our website: www.aetnaushe.corn 06/12/01 Financial Information - Prospective 12 City of Tamarac, Florida ♦ Fiduciary Responsibility - We will assume claim fiduciary responsibilities. ♦ Run-in - Processing related to claims incurred prior to the effective date of the plan is excluded. ♦ Claim History Transfer - There is no cost associated with receiving claim history files electronically from the prior carrier. These files are needed to administer deductible and internal maximums. There will be a charge for files received in a format other than electronically; costs are based on the complexity and format of the data. ♦ COBRA - COBRA law requires that, in a takeover situation, an insurer must cover the employer's existing COBRA participants if requested to do so in writing. Our quotation includes existing COBRA participants. We request the following from our customers during the installation process- - A list of covered participants by name and Social Security Number (and address if available). A statement certifying that the information contained in the list is complete and accurate. The customer must agree to hold Aetna harmless if any COBRA violation results from a discrepancy in this list. Visit our websitc: www.aetnaushc.com 06/12/01 Financial Information - Prospective 13 City of Tamarac, Florida Funding Description Prospective rating is a financial arrangement that provides a degree of insurance protection to customers. Advantages © Low billing rates ® Budgetable plan cost © No deficit carry -forward ® Full insurance protection and services ® ERISA claim fiduciary services ® Insurance certificates How It Works The customer prefunds the group benefit cost by paying us a monthly premium based upon predetermined rates multiplied by the insured volume or lives. Pre -Renewal Activity The rates charged to the customer during the contract year are based on the cost allocation formula projected to be in effect at the end of the contract year. Our quoted rates take into account the level of benefits and services we expect to provide to the customer during the contract year, such as the type of benefits administration and claim settlement provided. Rates exclude direct charges such as the actual expenses for loading prior claim history into our claim system or for providing COBRA direct -- billing services. However, we reserve the right to evaluate our rates to determine if any adjustment is warranted based on the caveats listed in the First Year Costs section (i.e., more than a 10 percent variance in lives, more than a 15 percent variance in the enrolled member -to - employee ratio, etc.). Prior to the plan anniversary date, we will prepare a policyholder - level summary of monthly claims. The renewal rates will be calculated based on expected claims and other plan characteristics. The renewal rates will become effective on the plan anniversary date. As the insurer, we issue claim payment checks and retain full ERISA claim fiduciary responsibility. 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L < > «.y R 000e mmm§ a m CL /\ /\ , §S � 77m/ 0.2 27\ 2 2= o\ ��o coco, >p. \\ 000/>�%�) 2)a) co /±\ &&a {�))°7)ƒ\ (gym (k \§\ m §§2k /\{� )zZ )) m%§� ±d# »/ ' Agra maw ®% z 0 a .. §) )0 )k �) ,0 a/ ." »»yz¥ z z z z z» 1 » I ¥ LLL-lJ-->-- J I y 2. E - 2 $ D _§k{§ ] ^� f a) e co CL 0 § (a \gy m ® \#$2 J \2kE5 J \ § ®® )) k °�§I k @ �4@{$ 3 A [[\«ID �() 2§)� )��\ } \ )�§§� D k ) . �](D 0 )§jtk //j/\ 7p±q o , 72>>{ )ƒ± zf�)/J}) } \ $j��/ < ajƒ/\\ 0 Vision Ones Discount Program Taking care of your vision is important to your overall health. We believe routine vision care can help maintain your good health as well as your productivity on the job. That is why we automatically include our Vision One Discount Program with your health plan, at no cost to you. The Vision One discount program offers your family savings on eye exams, glasses and contact lenses at Vision One locations. Most Vision One providers also participate in our network of independent participating providers. Eligible family members may also receive 15 percent off the provider's usual retail charge for Lasik surgery — the laser vision correction procedure — offered by Cale/LCA-Vision LLC through the national Lasik network of LCA Vision, Inc. Vision Care Benefits If you want a routine eye exam more frequently than covered under your medical plan, Vision One will provide you with a discount for the exam when you obtain it from a Vision One network provider.** If you need a vision exam other than a routine checkup, consult your participating primary care physician who can refer you to the appropriate participating eye care provider for evaluation and treatment. In California, this program is in addition to an annual vision screening performed by your primary care physician for the purpose of determining vision loss available to members as part of their preventive care benefits. Allowance for Eyeglasses and Prescription Contact Lenses Your plan may offer an allowance to help you with the purchase of eyeglasses or prescription contact lenses. See your plan documents to determine if an allowance applies. There are two ways you can get any applicable allowance: Purchase your prescription eyewear or prescription contact lenses at a Vision One location and your allowance will automatically be deducted from your discounted bill at the point of purchase. Call Vision One at 1-800-793-8616 for the location nearest you. 2. Purchase your prescription eyeglasses or prescription contact lenses at any eye care provider and mail the paid receipt to us.*** You'll be reimbursed up to the maximum amount specified in your plan documents. However, to get the Vision One discount in addition to the allowance, you must make your purchase at a Vision One participating provider. Prescription Contact Lens Mail -Order Replacement After you purchase your first pair of prescription contact lenses locally, you can get additional pairs through the mail. And you can get any remaining allowance and the Vision One discount, too. Call the Vision One Contact Lens Replacement Center at 1-800-391-LENS (5367). **Some plans do not include a routine eye exam. Refer to your plan documents for a complete list of benefits and exclusions. ***Aetna U.S. Healthcare', P.O. Box 1125, Blue Bell, PA 19422-0770. www.aetna.com This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. To contact the plan if you are a member, call the number on your ID card; all others, call 1-800-323-9930. Vision One is a registered trademark of Cole Managed Vision. Aetna U.S. Healthcare is a for -profit HMO. Vision One is a discount -only program, which may be in addition to any plan benefits. Vision One providers are solely responsible for the products and services provided under the discount program. Aetna U.S. Healthcare does not endorse any vendor, product or service associated with this program. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan or program benefits and does not constitute a contract. Consult your plan documents (Schedule of Benefits, Certificate of Coverage, Group Insurance Certificate) to determine governing contractual provisions, including procedures, exclusions and limitations relating to your plan. All the terms and conditions of your plan or program are subject to applicable laws, regulations and policies. All benefits are subject to coordination of benefits. Aetna U.S. Healthcare does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna U.S. Healthcare or its affiliates. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. This program is offered through Aetna U.S. Healthcare Inc., Aetna U.S. Healthcare Inc. (DE), Aetna U.S. Healthcare of California Inc., Aetna U.S. Healthcare of the Carolinas Inc., Aetna U.S. Healthcare of Georgia, Inc., Aetna U.S. Healthcare of Illinois Inc., Aetna U.S. Healthcare of North Texas Inc., Aetna U.S. Healthcare of Washington Inc., U.S. Healthcare, Inc. d/b/a Aetna U.S. Healthcare, Aetna Life Insurance Company, U.S. Health Insurance Company and/or Corporate Health Insurance Company. Specific products may not be available on both a self -funded and insured basis. The information in this document is subject to change without notice. I'M n a tJS Healthcare Available in Spanish. Disponible en Espanol. C92001 Aetna U.S. Healthcare Inc. 10.03.300.1 (8/01) No Text EMPLOYER APPLICATION Tj A, -7 ml� AETNA US HEALTHCARE EMPLOYER APPLICATION FORM 1. GROUP INFORMATION GROUP NUMBER: (For Internal Use Only) Company Name: City of Tamarac NO. ELIGIBLE: Parent Co. Name: NO. ENROLLED: Contract Address: 7525 NW 881h Avenue IMO Yes —Yes City: Tamarac State: FI Zip Code: 33321 No Federal Tax ID No. SIC Code: NA CSA Number Required (See Section 2) Contact Name: Maria Oman -on Title:;; ,der. A- n$�rncj Will customer submit Telephone: -_ 254_724_1350 enrollments electronically? E-mail Address: Yes _ No E-mail Contact Name: Will EZLink be used: Prior NYLCare Customer?: �No _Yes If Yes, list NYLC Group Number: Yes `No Prior CHI Customer?: ALNo _Yes If Yes, list CHI Group Number: Prior CHA Customer?: _3L No Yes If Yes, list CHA Group Number: Group Category: Prior Prudential Customer?: X No _Yes If Yes, list Pru. Group Number: National Acct. Prudential Acct. Structure: _ Duplicate PHC Structure _ New Structure Middle Market If current AUSHC Customer, Identify AUSHC Group Number: Standard Risk (Small) Site Address: same Site Address: City: State: Zip: City: State: Zip: Eligible / Enrolled: / Eligible / Enrolled: / Site Address: Site Address: City: State: Zip: City: State: Zip: Eligible / Enrolled: / Eligible / Enrolled: / 2. BENEFIT INFORMATION Enter Service Areas to LEASE ATTACH SIGN RATE OUOTATION(S) FOR EACH PLAN AND SERVICE AREA be included, by Region: Mid -Atlantic: Service Area: DE, NJ, PA Quote ID: Control No. Suffix Account: Northeast: (7 digits) (3 digits) (5 dlglts) NY, CT, MA, NH, RI, Benefit Description: VT, ME Service Area: Southeast: Quote ID: FL, wash DC, VA, NC, Control No. Suffix Account: SC, GA, AL, MD, PR (7 digits) (3 digits) (5 digits) Benefit Description: Mid -West: IL, TN, KY, IN, OH, Service Area: WI, MI, WV Quote ID: Control No. Suffix Account: West Central: (7 digits) (3 digits) (5 digits) TX, LA, MT, WY, CO, Benefit Description: NM, ND, SD, NE, KS, OK, MN, IA, MO Service Area: Quote ID: West: Control No. Suffix Account: CA, AZ, WA, OR, (7 digits) (3 digits) (5 digits) NV, ID, UT, AK, HI Benefit Description: 3. BENEFIT EXCLUSIONS / COMMENTS NB903 Employer Application 1 rev: 2-13-01 EMPLOYER APPLICATION FORM (Cont'd) Company Name: City of Tamarac Group Number: 4. ELIGIBILITY 11 ®Next premium due date Calendar year' Next renewal* *Group analysis approval required. Custom ID Cards requested: ©No Yes If Plan Sponsor elects to verify student status or requires Custom ID cards, refer to the following website for additional paperwork requirements. Click here to go to the HMO Eligibility Web Site. New Hires: Standard: dependents up to age 19, students to age 23; covered to next premium due date. Other (must attach special rates from group analysis if greater than 25). Handicap Provision (must attach group analysis memo). Covered to: Dependents to Age Students to Age Handicap Prior to Age 25 State of Florida 25 State. of.Florid a New hire waiting period: 30 days for regular ee's, 0 days for m'ai74ers r Appointed and Exec . New Hire Effective Date: Termination of Coverage: a. Ex 1st of the month following the waiting period. a. ®End of the month b. ❑ 15th of the month following the waiting period. b. Date of termination c. ❑ Immediately following the waiting period. Must Select Protection Stops: Must Select Protection Starts:DA [—]B ❑A [-]B d. ® Date of hire. Customer must have a new hire wait period of 000 (zero) days. NOTE: Protection Starts and Stops must be Must Select Protection Starts: ®A FJB consistent Protection Starts A: If premium due date is the 1 st of the month and if membership is effective between the 1 st and the 15th of the month, inclusive, the premium for the whole month will be paid. If membership is effective between the 16th and the 31 ist of the month, inclusive, no premium will be paid for the first month of membership. If premium due date is the 15th of the month and if membership is effective between the 15th and the 31 st of the month, inclusive, the premium for the whole month will be paid. If membership is effective between the 1st and the 14th, inclusive, no premium will be paid for the first month of membership. Protection Starts B: For all newly eligible employees whose coverage does not begin on the premium due date, one-half the monthly premium will be paid. For all newly eligible members whose coverage begins on a premium due date, a full month's premium will be paid. II 5. GROUP TYPE (check all that aDD10 II National Account (50): Manager �x Key Account (51): Rep Coder National Key Account (52): ❑ Broker Account (20/25): Broker Manager Broker Name Address City General Agent (if applicable) Agent Name Address City State: Phone: _ ZIP: Phone: State: ,ZIP: Medicaid (60) COBRA (42) Corporate (01) Medicare (40) (quote must be attached and subgroup 50 set up) Other Small Group (10) AUSHC Def. Small Group (11) State Reform Def. F-Ismall Broker Group (25) AUSHC Def. Small Broker Group (26) State Reform Def. F-]NY City Municipality (32) ❑ NY City Mun. Key Acct. (53) Non -NY City Municipality (33) Non -NY City Mun. Key Acct. (54) Managed Care Coordinators (70) House Account (55) AUSHC Def. House Account (56) State Reform Def. Federal/Public Sector (30) State Government (35) NB903 Employer Application 2 rev: 2-13-01 EMPLOYER APPLICATION FORM (Cont'd) Company Name: City of Tamarac Group Number: 6. EMPLOYEE ELIGIBILITY ELIGIBLE CLASS OF EMPLOYEES: CONTRIBUTION POLICY: Active full-time working a minimum of 25 hrs./wk.* Employees will not contribute *State mandated minimum hours may be different ® Employees will contribute Other (questionnaire required and group analysis approval) Does group have a flex plan under Section 125 of the Internal Revenue Code? Yes Has the group been uninsured 3 months or more prior to issue? Yes QPOS APO 20 % Single 20 % Family F�No HMO �No 0% Single gnu a�Y 7. BILLING INFORMATION BILLING ADDRESS: Name KiM%berly Frisbie _ Address 7525 NW 88th Avenue City Tamarac State FI Zip Code: 33321 Consolidate:QNo 7 Yes (Complete Consolidation Request Form) One Invoice: Yes E]No Self Bill:E]No ©Yes* Multiple Invoices: Elyes DNo *Will Customer Receive Invoice (Y/N): N COBRA Billing: (if Applicable) ROSTER SEQUENCE: Set up subgroup for COBRA enrollees: Order of importance (1-5) 1=Highest priority Bill: Group Yes (attach signed quotation) Member ID No. Soc. Sec. Number Home F]No Alpha (last name) Group No. TPA*F] Name Group Plan Grps. Location No. Address City State Zip *TPA - Requires an additional COBRA subgroup to be set up. 8. CONTRACT INFORMATION Effective Date 1/1/2002 Tier Structure Renewal Month January Tier Structure (enter 2, 3, or 4): 2 9. EMPLOYER AUTHORIZATION It is understood and agreed that this application is part of the enrollment process and this application is subject to Aetna US Healthcare corporate approval. I have signed rate quotations for the agreed upon plan offerings. Employer Signature Title Date NB903 Employer Application 3 rev; 2-13-01 EMPLOYER APPLICATION FORM (Cont'd) Company Name: City of Tamarac Group Number: 10. MARKETING REPRESENTATIVE APPROVAL I verify that the above information is accurate a lete to he best Sole Carrier [H]Yes No of my knowledge. If NO, other carrier(s) Marketing Representative Signature Print Name and Phone No: JJF94ton LIZ If YES, total: Sales Office: South Florida, Plantation 0 HMO Products Date 10/4/2001 OHMO Products Indemnity New Business Rep. Code Self -Insured under the traditional plan Est. Rep. Code JRS Yes ONo Forward all completed paperwork to the appropriate HMO Employer Services Region(s) for processing. Refer to NB902 - HMO Regional Service Center Information Form NOTE: Group Analysis approval Is necessary for any changes which deviate from the standard contract NB903 Employer Application 4 rev; 2-13-01