Agenda 12/13/2011 Item #16E 412/13/2011 Item 16.E.4.
EXECUTIVE SUMMARY
Recommendation to approve the Collier County Employee Benefit Plan Document and
Resolution effective January 1, 2012 to be used to administer the Group Health
Insurance and Flexible Spending Reimbursement Account programs.
OBJECTIVE: To receive approval of the Collier County Government Employee Benefit Plan Document
and Resolution effective January 1, 2012 to be used to administer the Group Health Insurance and
Flexible Spending Reimbursement Account programs.
CONSIDERATIONS: The Board of Commissioners provides group health insurance coverage to its
employees and participating agencies through a partially self- insured group health program (the Plan).
Federal and state law requires that the Plan utilizes a master Plan Document (the Policy or Plan
Document) to govern covered benefits and exclusions. The County's third party claims administrator,
Allegiance, Inc., utilizes the Document to adjudicate claims. The Plan's reinsurance carriers use the
Document to determine reinsurance pricing and reimbursement eligibility. The County's actuarial and
benefit consulting firm utilizes the Document to determine Plan rates and to comply with Florida
Department of Insurance rate filings. Finally, the Risk Management staff utilizes the Plan to administer
the overall program.
The current Plan Document was approved by the Board effective January 1, 2009. Since that time,
there have been changes to Federal law known as the Patient Protection and Affordable Care Act
(PPACA); a change of third party administration firms; and changes incorporated into the benefit Plan
design effective on January 1. 2012. Staff is recommending that the Document be updated to assure
the effective administration of the Plan and to maintain the compliance of the Plan with current law.
The highlights of the Plan Document are as follows:
1. The Plan Document recognizes Allegiance, Inc. as the third party claims administrator for the
Plan.
2. The Plan Document incorporates the provisions of the Patient Protection and Affordable Care
Act (PPACA) signed into law on March 23, 2010 as well as other state and federal laws
applicable to the Plan.
3. The Plan Document reflects changes to co- payments, deductibles and other benefit provisions
effective January 1, 2012, whose fiscal impact is incorporated into the adopted FY 12 budget.
4. The Plan Document reflects best practices Plan wording as recommend by Allegiance, Inc.
The Plan Document was prepared by Allegiance, Inc., the county's third party administrator in
conjunction with risk management staff and Willis, Inc., the county's benefits and actuarial consultant.
In addition a Resolution granting limited authority to the Director, Risk Management to serve as the
Plan Administrator for the Plan is attached. The Documents have been reviewed for legal sufficiency by
the County Attorney's Office.
Once approved by the Board of Commissioners, each employee will be provided a copy of both a
Summary Plan Description and Plan Document pursuant to the recommendation of both Willis, Inc. and
Allegiance, Inc.
FISCAL IMPACT: There is no fiscal impact associated with the approval of the Plan Document. The
group health Plan budget as anticipated by the proposed Plan Document has been approved by the
Board as part of the FY 12 adopted budget.
Packet Page -2934-
12/13/2011 Item 16.E.4.
GROWTH MANAGEMENT IMPACT: There is no growth management impact associated with the
approval of these Documents.
LEGAL CONSIDERATIONS: This item has been reviewed and approved by the County Attorney's
Office, is legally sufficient for Board action and only requires a majority vote for approval —SRT.
RECOMMENDATION: It is recommended that the Board approves the Collier County Employee
Benefit Plan Document and companion Resolution effective January 1, 2012.
PREPARED BY: Jeff Walker, CPCU, ARM, Director Risk Management
Packet Page -2935-
12/13/2011 Item 16.E.4.
COLLIER COUNTY
Board of County Commissioners
Item Number: 16.E.4.
Item Summary: Recommendation to approve the Collier County Employee Benefit Plan
Document and Resolution effective January 1, 2012 to be used to administer the Group Health
Insurance and Flexible Spending Reimbursement Account programs.
Meeting Date: 12/13/2011
Prepared By
Name: WalkerJeff
Title: Director - Risk Management,Risk Management
11/8/2011 10:14:42 AM
Submitted by
Title: Director - Risk Management,Risk Management
Name: WalkerJeff
11/8/2011 10:14:44 AM
Approved By
Name: SmithKristen
Title: Administrative Secretary,Risk Management
Date: 11/28/2011 11:08:37 AM
Name: TeachScott
Title: Deputy County Attomey,County Attorney
Date: 11/28/2011 2:57:23 PM
Name: PriceLen
Title: Administrator - Administrative Services,
Date: 11/30/2011 11:22:48 AM
Name: TeachScott
Title: Deputy County Attomey,County Attorney
Date: 12/1/20119:48:35 AM
Packet Page -2936-
Name: KlatzkowJeff
Title: County Attorney,
Date: 12/1/2011 11:52:13 AM
Name: FinnEd
Date: 12/1/20113:08:26 PM
Name: OchsLeo
Title: County Manager
Date: 12/2/20119:39:05 AM
Packet Page -2937-
12/13/2011 Item 16.E.4.
12/13/2011 Item 16.E.4.
RESOLUTION NO. 2011-
RESOLUTION GRANTING LIMITED AUTHORITY TO THE RISK MANAGEMENT
DIRECTOR TO ACT AS PLAN ADMINISTRATOR FOR THE COLLIER COUNTY
GROUP BENEFIT PLAN.
WHEREAS, the Board of Commissioners is the Plan Administrator and Fiduciary
for the Collier County Group Benefit Plan; and
WHEREAS, the. Board of Commissioners approves as needed, the various Plan
Documents which govern the administration and benefits covered under the Plan; and
WHEREAS, the Board has approved the creation of various Self- insurance Funds
as part of its budgeting process and approves annually in public session the
expenditure of public funds, including the funding of the Group Benefit Plan for its
eligible employees and their dependents; and
WHEREAS, the management of the Group Benefit Plan requires day to day
operational and financial oversight in order to effectively administer the Plan; and
WHEREAS, the Plan is subject to the privacy provisions of the Health Insurance
Portability and Accountability Act (HIPAA) and must assure the protection of personal
health information of covered members; and
WHEREAS, the Plan permits the Board to delegate certain day to day operational
and financial duties to a designee for the purpose of effectively and professionally
administering the Plan on its behalf; and
WHEREAS, the Board finds that the limited delegation of authority to the Risk
Management Director serves a valid public purpose;
NOW, THEREFORE BE IT RESOLVED BY THE BOARD OF COUNTY
COMMISSIONERS OF COLLIER COUNTY, FLORIDA that:
The Director, Risk Management shall be designated as the Plan Administrator for
the Collier County Group Benefit Plan. As the designee for the Plan, duties shall
include but not be limited to the following:
1. Administer the provisions of the Collier County Government Employee
Benefit Plan documents as approved by the Board.
2. Review and approve periodic check registers and the expenditure of
funds to claimants, providers, and vendors under the Plan.
3. Prepare the annual budget and oversee the administration of the budget
as approved by the Board.
Packet Page -2938-
12/13/2011 Item 16.E.4.
4. Assure that all State of Florida, Department of Insurance fillings are
completed as required utilizing the Board's approved actuarial consulting
firm.
5. Oversee the selection and performance of vendors hired to service the
Plan. The selection of third party claims administration firms, utilization
review and managed care companies, reinsurers, benefits consultants,
and actuarial firms shall require the approval of the Board of
Commissioners.
6. Serve as the HIPAA Privacy Officer for the Plan.
7. Perform all other functions necessary to effectuate the lawful
administration of the Plan.
The Risk Management Director shall be authorized to implement procedures as
needed to manage this program.
This Resolution adopted after motion, second and majority vote, favoring same.
DATE: , 2011
ATTEST:
DWIGHT E. BROCK, Clerk
0
, Deputy Clerk
APPROVED AS TO FORM AND
LEGAL SUFFICIENCY:
By: S�
Scott Teach
Deputy County Attorney
BOARD OF COUNTY COMMISSIONERS
COLLIER COUNTY, FLORIDA
0
Fred W. Coyle, Chairman
E
Packet Page -2939-
12/13/2011 Item 16.E.4.
PLAN DOCUMENT /SUMMARY PLAN DESCRIPTION
COLLIER COUNTY GOVERNMENT
EMPLOYEE BENEFIT PLAN
PLAN DOCUMENT EFFECTIVE DATE:
January 1, 2012
EMPLOYER IDENTIFICATION NUMBER:
59- 6000558
Collier County Government - Group #2003021
GROUP NUMBER
2003021
PLAN NUMBER
501
Packet Page -2940-
Plan Document / SPD - Effective 1/1/2012
12/13/2011 Item 16.E.4.
COVERISIGNATURE PAGE
Effective January 1, 2012, Collier County Government revised its self- funded Health Care Plan for the benefit
of eligible Employees, Retirees and their eligible Dependents entitled, COLLIER COUNTY GOVERNMENT
EMPLOYEE BENEFIT PLAN (the "Plan ").
The purpose of this Plan is to provide reimbursement for Expenses Incurred for covered services, treatment
orsupplies as a result of Medically Necessary treatmentfor Illness or Injury of the County's eligible Employees
and their eligible Dependents. The County, in conjunction with any required contributions by its Employees,
agrees to make payments to the Plan's Trust in order for payments to be made for covered services,
treatments or supplies as provided by this Plan.
The County has caused this instrument to be executed as of the day first mentioned above.
COLLIER COUNTY GOVERNMENT
LMA
TITLE:
Collier County Government - Group #2003021
Packet Page -2941-
Plan Document / SPD - Effective 1/1/2012
12/13/2011 Item 16.E.4.
TABLE OF CONTENTS
INTRODUCTION ..................................... ...............................
1
HEALTH PLAN QUALIFIERS ........................... ...............................
2
QUALIFYING PERIODS ......................... ...............................
2
QUALIFYING GUIDELINES ...................... ...............................
2
PLAN QUALIFIERS ..................... ....... ...............................
2
NEW HIRES AND NEW SPOUSES ................ ...............................
3
EMPLOYEES WHO BECOME TOTALLY DISABLED DURING THE QUALIFYING PERIOD ...
3
PPO BENEFIT ....................................... ...............................
4
SCHEDULE OF BENEFITS - PREMIUM OPTION ............ ...............................
5
SCHEDULE OF BENEFITS - SELECT OPTION ............ ...............................
10
SCHEDULE OF BENEFITS - BASIC OPTION ............. ...............................
15
PHARMACY BENEFIT ................................ ...............................
19
PREMIUM OPTION - COST SHARING PROVISIONS ...............................
19
SELECT OPTION - COST SHARING PROVISIONS .. ...............................
20
BASIC OPTION - COST SHARING PROVISIONS .... ...............................
20
COVERAGE................................. ...............................
21
SERVICE OPTIONS ........................... ...............................
21
DRUGOPTIONS .............................. ...............................
22
COINSURANCE .............................. ...............................
22
SUPPLY LIMITS .............................. ...............................
22
STEP THERAPY PROGRAM .................... ...............................
22
PRIOR AUTHORIZATION ....................... ...............................
23
EXCLUSIONS ................................ ...............................
23
MEDICAL BENEFIT DETERMINATION REQUIREMENTS ... ...............................
24
ELIGIBLE SERVICES, TREATMENTS AND SUPPLIES ..............................
24
DEDUCTIBLE................................ ...............................
24
BENEFIT PERCENTAGE ....................... ...............................
24
OUT -OF- POCKET MAXIMUM ................... ...............................
24
COPAYMENT................................ ...............................
24
MAXIMUM BENEFIT ........................... ...............................
25
APPLICATION OF DEDUCTIBLE AND ORDER OF BENEFIT PAYMENT ................
25
CHANGES IN COVERAGE CLASSIFICATION ...... ...............................
25
NEW YORK STATE EXPENSES ................. ...............................
25
MEDICAL BENEFITS ................................. ............................... 26
SMARTCHOICE PROGRAM ........................... ............................... 37
MEDICAL EXPENSE AUDIT BONUS .................... ............................... 38
NOTIFICATION PROVISIONS .......................... ............................... 39
MANDATORY CASE MANAGEMENT .................... ............................... 41
PRE - EXISTING CONDITION EXCLUSIONS ............... ............................... 42
Collier County Government - Group #2003021 i Plan Document/ SPD - Effective 1/1/2012
Packet Page -2942-
12/13/2011 Item 16.E.4.
GENERAL EXCLUSIONS AND LIMITATIONS ............. ............................... 43
COORDINATION OF BENEFITS ........................ ............................... 48
DEFINITIONS ................................ ............................... 48
ORDER OF BENEFIT DETERMINATION .......... ............................... 49
Non- Dependent/Dependent ............... ............................... 49
Child Covered Under More Than One Plan ... ............................... 49
Active or Inactive Employee ............... ............................... 50
Longer or Shorter Length of Coverage ....... ............................... 50
NoRules Apply ......................... ............................... 50
COORDINATION WITH MEDICARE .............. ............................... 50
For Working Aged ...................... ............................... 50
For Retired Persons ..................... ............................... 51
For Covered Persons who are Disabled ..... ............................... 51
For Covered Persons with End Stage Renal Disease .......................... 51
COORDINATION WITH MEDICAID ............... ............................... 51
COORDINATION WITH TRICARE /CHAMPVA ...... ............................... 51
PROCEDURES FOR CLAIMING BENEFITS .............. ............................... 52
CLAIM DECISIONS ON CLAIMS AND ELIGIBILITY .. ............................... 52
Urgent Care Claims ..................... ............................... 53
Pre - Service Claims ...................... ............................... 53
Post - Service Claims ..................... ............................... 53
Concurrent Care Review ................. ............................... 53
APPEALING AN UN- REIMBURSED PRE - SERVICE CLAIM ........................... 53
First Level of Benefit Determination Review .. ............................... 54
Second Level of Benefit Determination Review ............................... 54
APPEALING AN UN- REIMBURSED POST - SERVICE CLAIM .......................... 55
First Level of Benefit Determination Review .. ............................... 55
Second Level of Benefit Determination Review ............................... 56
INDEPENDENT EXTERNAL REVIEW ............. ............................... 56
ELIGIBILITY PROVISIONS ............................ ............................... 57
EMPLOYEE ELIGIBILITY ....................... ............................... 57
WAITING PERIOD ............................ ............................... 57
DEPENDENT ELIGIBILITY ...................... ............................... 57
EXTENDED COVERAGE FOR DEPENDENTS ...... ............................... 58
PARTICIPANT ELIGIBILITY FOR DEPENDENT COVERAGE 58
DECLINING COVERAGE ....................... ............................... 58
RETIREE ELIGIBILITY ......................... ............................... 58
EFFECTIVE DATE OF COVERAGE ...................... ............................... 59
PARTICIPANT COVERAGE ..................... ............................... 59
DEPENDENT COVERAGE ...................... ............................... 59
RETIREE COVERAGE ......................... ............................... 59
OPEN ENROLLMENT PERIOD .................. ............................... 59
SPECIAL ENROLLMENT PERIOD ................ ............................... 60
CHANGEIN STATUS .......................... ............................... 62
QUALIFIED MEDICAL CHILD SUPPORT ORDER PROVISION .............................. 63
PURPOSE................................... ............................... 63
DEFINITIONS ................................ ............................... 63
CRITERIA FOR A QUALIFIED MEDICAL CHILD SUPPORT ORDER ................... 63
PROCEDURES FOR NOTIFICATIONS AND DETERMINATIONS ...................... 64
NATIONAL MEDICAL SUPPORT NOTICE ......... ............................... 64
Collier County Government - Group #2003021
Packet Page -2943-
Plan Document / SPD - Effective 1/1/2012
12/13/2011 Item 16.E.4.
FAMILY AND MEDICAL LEAVE ........................ ............................... 65
DEFINITIONS ................................ ............................... 65
EMPLOYERS SUBJECT TO FMLA ............... ............................... 66
ELIGIBLE EMPLOYEES ........................ ............................... 66
REASONS FOR TAKING LEAVE ................. ............................... 66
ADVANCE NOTICE AND MEDICAL CERTIFICATION ............................... 66
PROTECTION OF JOB BENEFITS ............... ............................... 66
UNLAWFUL ACTS BY EMPLOYERS .............. ............................... 66
ENFORCEMENT .............................. ............................... 67
TERMINATION OF COVERAGE ........................ ............................... 68
PARTICIPANT TERMINATION ................... ............................... 68
RETIREE TERMINATION ....................... ............................... 68
DEPENDENT TERMINATION ................... ............................... 69
REINSTATEMENT OF COVERAGE ............... ............................... 69
VOLUNTARY SEPARATION INCENTIVE PROGRAM ............................... 70
CONTINUATION COVERAGE AFTER TERMINATION ...... ............................... 71
NOTIFICATION RESPONSIBILITIES .............. ............................... 71
ELECTION OF COVERAGE ..................... ............................... 72
MONTHLY PREMIUM PAYMENTS ............... ............................... 72
DISABILITY EXTENSION OF 18 -MONTH PERIOD OF CONTINUATION COVERAGE ...... 73
SECOND QUALIFYING EVENT EXTENSION OF 18 -MONTH PERIOD OF CONTINUATION
COVERAGE........................... ............................... 73
MEDICARE ENROLLMENT EXTENSION OF 18 -MONTH PERIOD OF CONTINUATION
COVERAGE........................... ............................... 73
WHEN COBRA CONTINUATION COVERAGE ENDS . ............................... 73
QUESTIONS ................................. ............................... 74
INFORM THE PLAN OF ADDRESS CHANGES ..... ............................... 75
COVERAGE FOR A MILITARY RESERVIST .............. ............................... 76
FRAUD AND ABUSE ................................. ............................... 77
MISSTATEMENT OF AGE ...................... ............................... 77
MISREPRESENTATION OF ELIGIBILITY .......... ............................... 77
MISUSE OF IDENTIFICATION CARD ............. ............................... 77
REIMBURSEMENT TO PLAN ................... ............................... 77
RECOVERY /REIMBURSEMENT /SUBROGATION .......... ............................... 78
RIGHT TO RECOVER BENEFITS PAID IN ERROR .. ............................... 78
REIMBURSEMENT ............................ ............................... 78
SUBROGATION.............................. ............................... 78
RIGHT OF OFF - SET ........................... ............................... 80
PLAN ADMINISTRATION ............................. ............................... 81
PURPOSE................................... ............................... 81
EFFECTIVE DATE ............................ ............................... 81
PLANYEAR ................................. ............................... 81
PLANSPONSOR ............................. ............................... 81
PLAN SUPERVISOR .......................... ............................... 81
NAMED FIDUCIARY AND PLAN ADMINISTRATOR .. ............................... 81
PLAN INTERPRETATION ....................... ............................... 81
CONTRIBUTIONS TO THE PLAN ................ ............................... 81
PLAN AMENDMENTS /MODIFICATION/TERMINATION .............................. 82
NOTICE OF REDUCTION OF BENEFITS .......... ............................... 82
TERMINATION OF PLAN ....................... ............................... 82
Collier County Government - Group #2003021 III Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
SUMMARY PLAN DESCRIPTIONS ............... ............................... 82
CREDITABLE COVERAGE PROCEDURES ............... ............................... 83
CERTIFICATE OF CREDITABLE COVERAGE ...... ............................... 83
CREDITABLE COVERAGE .................................................... 83
CREDITABLE COVERAGE REVIEW .............. ............................... 83
DETERMINATION OF PRIOR CREDITABLE COVERAGE ............................ 84
GENERAL PROVISIONS .............................. ............................... 85
EXAMINATION............................... ............................... 85
PAYMENT OF CLAIMS ............................... ....................... 85
LEGAL PROCEEDINGS ........................ ............................... 85
NO WAIVER OR ESTOPPEL .................... ............................... 85
VERBAL STATEMENTS ........................ ............................... 85
FREE CHOICE OF PHYSICIAN .................. ............................... 85
WORKERS' COMPENSATION NOT AFFECTED .... ............................... 86
CONFORMITY WITH LAW ...................... ............................... 86
MISCELLANEOUS............................ ............................... 86
FACILITY OF PAYMENT ....................... ............................... 86
PROTECTION AGAINST CREDITORS ............ ............................... 86
PLAN IS NOT A CONTRACT .................... ............................... 86
GENERAL DEFINITIONS ............................. ............................... 87
NOTICES......................................... ............................... 102
NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT ........................ 102
IDENTIFICATION OF FUNDING ................ ............................... 102
HIPAA PRIVACY AND SECURITY STANDARDS .......... ............................... 103
DEFINITIONS............................... ............................... 103
PRIVACY CERTIFICATION .................... ............................... 103
SECURITY CERTIFICATION ................... ............................... 104
PLANSUMMARY ................................... ............................... 105
Collier County Government - Group #2003021 Iv Plan Document / SPD - Effective 1/112012
Packet Page -2945-
12/13/2011 Item 16.E.4.
INTRODUCTION
Effective January 1, 2012, Collier County Government, hereinafter referred to as the "County" or "Employer ",
establishes the benefits, rights and privileges which will pertain to participating Employees, referred to as
"Participants," qualifying Retirees and the eligible Dependents of such Participants or Retirees, as defined,
and which benefits are provided through a fund established by the County and referred to as the 'Plan." This
booklet describes the Plan in effect as of January 1, 2012.
Coverage provided under this Plan for Employees and their Dependents will be in accordance with the
Eligibility, Effective Date, Qualified Medical Child Support Order, Termination, Family and Medical Leave Act
and other applicable provisions as stated in this Plan.
Collier County Government (the Plan Sponsor) has retained the services of an independent Plan Supervisor,
experienced in claims processing,'to handle health claims. The Plan Supervisor for the Plan is:
Allegiance Benefit Plan Management, Inc.
P.O. Box 3018
Missoula, MT 59806 -3018
We recommend that you read this booklet carefully before incurring any medical expenses. If you have
specific questions regarding coverage or benefits, you are urged to refer to the Plan Document which is
available for your review in the Personnel Office or at the office of the Plan Supervisor. If you wish, you may
call or write to Allegiance Benefit Plan Management, Inc. regarding any detailed questions you may have
concerning the Plan.
This Plan is not intended to, and cannot be used as workers compensation coverage for any employee
or any covered dependent of an employee. Therefore, this plan generally excludes claims related to
any activity engaged in forwage or profit including, but not limited to, farming, ranching, part-time and
seasonal activities. See Plan Exclusions for specific information.
The information contained in this Plan Document/Summary Plan Description is only a general
statement regarding FMLA, COBRA, USERRA, and QMCSO's. It is not intended to be and should not
be relied upon as complete legal information about those subjects. Covered Persons and Employers
should consult their own legal counsel regarding these matters.
Collier County Government - Group #2003021 1 Plan Document / SPD - Effective 1/1/2012
Packet Page -2946-
12/13/2011 Item 16.E.4.
HEALTH PLAN QUALIFIERS
Employees and their spouse may qualify under any of the three Plan Options made available under this Plan:
Premium, Select and Basic. Plan Options for Employees may be different than their spouses depending on
the results of the Plan Qualifiers. Qualifying Periods for Retirees and COBRA Participants will be the same
as they were prior to retirement or continuing coverage under COBRA. Plan Qualifiers are specific actions
to be completed by an Employee or Retiree and their spouse to determine which health Plan Option they
would qualify for the next Benefit Period.
QUALIFYING PERIODS
1. For spouses a Qualifying Period will be October 1 ending September 30 of every odd year.
2. For Employees a Qualifying Period will be October 1 ending September 30 of every even year.
QUALIFYING GUIDELINES
The following are qualifying guidelines:
1. The Qualifying Period is between October 1 ending September 30;
2. Paperwork is due to the on -site contracted Health Advocate's office by September 30 ( *no
exceptions);
3. Tobacco Users must complete qualifying criteria in their Qualifying Period;
4. Diabetics must complete qualifying criteria in their Qualifying Period.
5. Heart Smart must complete qualifying criteria in their Qualifying Period.
PLAN QUALIFIERS
The following are Plan Qualifiers for the Premium and Select Options (Plan Qualifiers were determined using
Evidence Based Medical Guidelines and may be adjusted annually):
Complete Health history questionnaire - This can be done online, at home, or at your desk. A
Kiosk is available in the Health Advocate "s office for Employees who do not have access to a
computer workstation.
2. Lab work - Lab draws will be scheduled during regular work hours on the main campus and at
various worksites by the contracted Lab provider. Calendars will be posted at all work sites. All
qualifying lab draws must be completed by Quest Diagnostics.
Eligible Employees /Spouses /Retirees /COBRA/VSIP can contact Quest Diagnostics for a remote lab
kit to be used at a Quest Diagnostics center nearest them.
3. Meet with On -site Health Advocate - Make an appointment with the Health Advocate to review the
results of your Personal Wellness Profile, which includes the lab draw, Health History Questionnaire,
and baseline measurements.
Eligible Retirees /COBRA/VSIP who do not reside in Collier County will contact the Advocates by
phone.
The following are additional Plan Qualifiers for the Premium Option:
Age /Gender Screening - (For ages 20, 25, 30, 35, 40, 43, 46, 50 and over) - Screenings, including,
pap smear, mammogram, skin screening, testicular exam and colonoscopy, must be completed at
the MedCenter, the MedCenter North or by your Primary Care Physician. A copy of the lab results
from Personal Wellness Profile should be given to the Physician at the appointment.
Collier County Government - Group #2003021
Packet Page -2947-
Plan Document / SPD - Effective 1/1/2012
12/13/2011 Item 16.E.4.
Health Plan Qualifiers
Tobacco Cessation Program - This Program is only administered through The MedCenter or The
MedCenter North. A certificate of completion must be provided to the on -site contracted Health
Advocate by September 30.
Covered Persons who do not reside in Collier County will work with the Health Advocate who will
monitor the tobacco cessation program they are engaged in. A certificate of completion must be
provided to the on -site contracted Health Advocate by September 30.
3. Pre /Diabetes Management- This is administered through The MedCenter, The MedCenter North or
by your personal Physician. Completed Diabetes form must be given to on -site contracted Health
Advocate.
Covered Persons who do not reside in Collier County will continue to work with their own provider as
well as the Health Advocate in order to submit a completed diabetes form. Completed diabetes form
must be completed by September 30.
There are no Plan Qualifiers to participate in the Basic Option. Participants, Retirees and their spouses
automatically qualify for the Basic Option if qualifying requirements for the Select or Premium Options are not
completed by September 30.
NEW HIRES AND NEW SPOUSES
All new hired Employees and newly eligible and covered spouses will be placed in the Select Option.
Employees whose effective date of coverage is before July 1 will be required to complete Plan Qualifiers by
September 30. Employees whose effective date of coverage is July 1"through September 30 will be required
to complete Plan Qualifiers by December 31. To remain in the Select Option or move to the Premium Option,
Plan Qualifiers must be completed with the appropriate time frame or the Employee or new spouse will be
placed in the Basic Option on January 1 of the following year. Employees whose effective date of coverage
is on or after October 1 who complete Plan Qualifiers by December 31 will be eligible to change Plan Options
as of January 1. Those not completing the Plan Qualifiers by December 31 will remain in the current Plan
Option and will have until September 30 of the following Benefit Period to complete Plan Qualifiers.
EMPLOYEES WHO BECOME TOTALLY DISABLED DURING THE QUALIFYING PERIOD
Employees who become Totally Disabled for six (6) months or more during the Qualifying Period and are
unable to complete the Plan Qualifiers, will remain in the Plan Option they are currently in until such time Plan
Qualifiers can be completed. Verification of the disability should be submitted to the Health Advocates Office.
"Total Disability" or "Totally Disabled" means that a person is prevented from performing the principal functions
of the person's occupation, and as a result, the person is earning less than twenty percent (20 %) of the
person's pre - disability weekly earnings due to an Accidental Injury, Illness, Mental Illness, Substance Abuse,
or Pregnancy.
Collier County Government - Group #2003021 3 Plan Document / SPD - Effective 1/1/2012
Packet Page -2948-
12/13/2011 Item 16.E.4.
PPO BENEFIT
This Plan provides benefits through a Preferred Provider Organization (PPO). A "PPO Provider" means a
physician or other licensed health care provider that agrees to provide services as part of the Preferred
Provider Organization. The Plan's Preferred Provider Organization (PPO) is any PPO Provider with whom the
Plan Supervisor has a contract or agreement which provides access to the PPG's Providers.
To determine if a Physician or health care provider qualifies as an eligible PPO Provider under this Plan,
please consult Allegiance's website at www.abpmtpa.com /ccq to access links for directories of PPO Providers.
The Benefit Percentages for Medical Benefits may vary depending on the type of service and provider
rendering the service or treatment. If a Non -PPO Provider is chosen over a PPO Provider, the Benefit
Percentage will be lower (as stated in the following Schedule of Medical Benefits), unless one of the "Non -
PPO Benefit Exceptions stated below applies.
A Non -PPO Provider is a Physician or Licensed Health Care Provider who is not under contract with a PPO
recognized by this Plan.
The following benefit provisions apply when a covered service is rendered by a Non -PPO provider:
1. Charges for an Emergency as defined by this Plan, limited to only those emergency medical
procedures necessary to treat and stabilize an eligible injury or illness and then only to the extent that
the same are necessary in order for the Covered Person to be transported, at the earliest medically
appropriate time to a PPO Hospital, clinic or other facility, or discharged will be paid at the PPO
Provider level of benefits.
2. Charges which are incurred as a result of and related to confinement in or use of a PPO Hospital,
clinic or other facility only for Non -PPO services and providers over whom or which the Covered
Person does not have any choice in or ability to select will be paid at the PPO Provider level of
benefits.
If the provider rendering service is located in Collier County and is not part of the CHP Network but
is part of the CIGNA Network, benefits will be paid at the Non -PPO Provider level of benefits.
If the provider rendering service is located outside of Collier County and is not part of the CHP
Network but is part of the CIGNA Network, benefits will be paid at the PPO Provider level of benefits.
Collier County Government - Group #2003021
Packet Page -2949-
Plan Document / SPD - Effective 1/1/2012
12/13/2011 Item 16.E.4.
SCHEDULE OF BENEFITS - PREMIUM OPTION
FOR
ELIGIBLE PARTICIPANTS AND DEPENDENTS
ALL BENEFITS PAYABLE UNDER THIS PLAN ARE SUBJECT TO THE APPLICABLE PLAN
EXCLUSIONS AND THE USUAL, CUSTOMARY AND REASONABLE LIMITS OF THE PLAN
THE BENEFIT PERIOD IS A CALENDAR YEAR
MEDICAL BENEFIT COST SHARING PROVISIONS
PPO
NON -PPO
DEDUCTIBLE
Per Covered Person per Benefit Period $400 $800
Per Family per Benefit Period $800 $1,600
The Deductible applies to all Eligible Expenses, unless specifically stated otherwise. An individual Covered
Person cannot receive credit toward the Family Deductible for more than the individual Annual Deductible.
The Deductible is combined for both PPO Providers and Non -PPO Providers.
OUT -OF- POCKET MAXIMUM
Per Covered Person per Benefit Period $1,300" $3,000*
Per Family per Benefit Period $2,600* $6,000*
*Deductible is not part of the Out -of- Pocket Maximum
The Out -of- Pocket Maximum applies to all Eligible Expenses, unless specifically stated otherwise. The Out -
of- Pocket Maximum is combined for both PPO Provider and Non -PPO Providers.
Expenses incurred for the following do not apply toward the Out -of- Pocket Maximum: 1) Copay; 2)
Deductibles; 3) any penalty amounts; 4) any charges defined in the General Exclusions and Limitations
Section; 5) Chiropractic Care or Dental Care expenses due to Illness or injury.
BENEFIT PERCENTAGE
Before satisfaction of Out -of- Pocket Maximum 80% 70%
After satisfaction of Out -of- Pocket Maximum 100% 100%
The Benefit Percentage applies to all Eligible Expenses, unless specifically stated otherwise. Eligible
Expenses will be paid by the Plan according to the applicable Benefit Percentage.
NON - COMPLIANCE PENALTY
See Mandatory Case Management
Non Participation in Case Management Penalty
$1,000
Non Participation in Notification Provisions
$300
MAXIMUM LIFETIME BENEFIT FOR ALL CAUSES
Unlimited
Collier County Government - Group #2003021 5 Plan Document / SPD - Effective 1/1/2012
Packet Page -2950-
12/13/2011 Item 16.E.4.
Schedule of Benefits - Premium Option
BENEFIT MAXIMUMS ARE FOR SERVICES RECEIVED FROM PPO AND NON -PPO PROVIDERS
Collier County Government - Group #2003021
Packet Page -2951-
Plan Document / SPD - Effective 1/1/2012
BENEFIT PERCENTAGE /LIMITATIONS
MEDICAL BENEFITS
PP0 NON -PPO
Acupuncture
80% after Deductible 70% after Deductible
20 Visits
Ambulance Services
80% after Deductible
70% after Deductible
Bariatric Surgery (only if pre-
80% after Deductible
70% after Deductible
approved by Smartchoice)
Chiropractor Care /Spinal 100% after $25 Copayment per
No Coverage
Manipulation /Massage Therapy Visit, Deductible Waived
Combined Maximum of 20 Visits* per Benefit
period
*Visit includes all services performed during a calendar day,
including x -rays
Diagnostic Colonoscopies (See
80 %, Deductible Waived
No Coverage
Medical Benefits)
See Preventive Care for
Screening Colonoscopies
Dental Care (due to an Illness
80 %, Deductible Waived
70% after Deductible
or Injury. See Medical
Benefits)
After benefits are exhausted
under any Dental Plan.
Durable Medical Equipment
80% after Deductible
70% after Deductible
Emergency Room Services
(Facility charges only)
Due to Medical Emergency
$50 Copayment per visit,
$50 Copayment per visit,
then 80% after Deductible
then 70% after Deductible
Non - Medical Emergency
$100 Copayment per visit,
$100 Copayment per visit,
then 80% after Deductible
then 70% after Deductible
Note: The Emergency Room Copayment will be waived if the person is admitted directly as an Inpatient
to the Hospital.
Hearing Aids (due to Accident
80% after Deductible 70% after Deductible
or Illness only)
Maximum Lifetime Benefit of 2 aids
Home Health Care
80% after Deductible
70% after Deductible
Hospice Care, including
80% after Deductible
70% after Deductible
Bereavement Counseling
Bereavement Counseling 15 visits per Family per Lifetime
Collier County Government - Group #2003021
Packet Page -2951-
Plan Document / SPD - Effective 1/1/2012
12/13/2011 Item 16.E.4.
Schedule of Benefits - Premium Option
—7
BENEFIT PERCENTAGE /LIMITATIONS
MEDICAL BENEFITS
PPO NON -PPO
Hospital Services or Long-
80% after Deductible
70% after Deductible
Term Acute Care Facility /Hosp
(facility charges)
Inpatient
Room & Board Allowance
Semi - private room rate*
Semi - private room rate*
Intensive Care Unit
80% of actual charge after Ded
70% of actual charge after Ded
Outpatient
80% after Deductible
70% after Deductible
*Room and board limited to Semi - private room rate. A private room will be considered eligible when
Medically Necessary. Charges made by a Hospital having only single or private rooms will be considered
at the least expensive rate for a single or private
Medical Records
100 %, Deductible Waived
100 %, Deductible Waived
up to maximum benefit of $100
up to maximum benefit of $100
per provider
per provider
Mental Illness
Inpatient
80% after Deductible
70% after Deductible
Outpatient
100% after $25 Copayment of
70% after Deductible
the first $500 per visit,
Deductible Waived,
then 80% after Deductible
On -Site Clinic Services
100% after $5 Copayment per
N/A
visit, Deductible Waived
The on -site clinic services are available to all eligible Participants and Dependents 15 years or older who
are covered under the Collier County Government Employee Benefit Plan. All services performed in the
clinic are covered under the $5 Copayment. A referral from the clinic to a PPO Provider will be processed
as a PPO claim.
Outpatient Hemodialysis or
80% after Deductible for the 70% after Deductible for the
Peritoneal Dialysis, including
first 40 visits per Lifetime first 40 visits per Lifetime
home
100% up to 125% of the Medicare allowable rate;
Deductible Waived for the 41St visit and all subsequent visits
Outpatient Therapies (physical,
100% after $35 Copayment of
70% after Deductible
speech, occupational, aquatic)
the first $500 per visit,
Deductible Waived,
then 80% after Deductible
Pain Management
80% after Deductible
70% after Deductible
Epidurals, facet blocks and nerve stimulators are limited to a combined Maximum Benefit of 6 procedures
per Benefit Period. Other procedures are not limited.
Collier County Government - Group #2003021
Packet Page -2952-
Plan Document / SPD - Effective 1/1/2012
12/13/2011 Item 16.E.4.
Schedule of Benefits - Premium Option
Collier County Government - Group #2003021
Packet Page -2953-
Plan Document/ SPD - Effective 1/1/2012
BENEFIT PERCENTAGE /LIMITATIONS
MEDICAL BENEFITS
Ppo NON -PPO
Physician Services
Inpatient/Outpatient Services,
80% after Deductible
70% after Deductible
except for office visits
Primary Care Physician Office
100% after $25 Copayment of
70% after Deductible
Visit Charge
the first $500 per visit,
Deductible Waived,
then 80% after Deductible
Specialist Physician Office
100% after $35 Copayment of
70% after Deductible
Visit Charge
the first $500 per visit,
Deductible Waived,
then 80% after Deductible
All Other Services /Supplies
100% of the first $500 per visit,
70% after Deductible
other than evaluation and
Deductible Waived,
management charges
then 80% after Deductible
performed in a Physician's
office.
If more than one Physician is seen in the same clinic on the same day, only one Copayment will appy.
"Primary Care Physician" includes a general practitioner, family practitioner, Internist, OB /GYN
(obstetrics /gynecology), Pediatrician, Psychiatrist, licensed nurse practitioner or Physician Assistant.
"Specialist Physician" includes any Physician practicing any branch of medicine or medical specialty who
is not otherwise a Primary Care Physician.
Preventive Care (See Medical
100 %, Deductible Waived
No Coverage
Benefits Section)
Radiation Therapy/
80% after Deductible
70% after Deductible
Chemotherapy /Home Infusion
Therapy
Routine Qualifier Services (See
100 %, Deductible Waived
No Coverage
Medical Benefits Section)
Scalp Hair Prosthesis
80% after Deductible 70% after Deductible
(wigs /hair pieces)
Maximum Lifetime Benefit one wig or hair piece
Skilled Nursing Facility and
80% after Deductible
70% after Deductible
Rehabilitation Facility
Substance Abuse /Chemical
Dependency Disorders
80% after Deductible
70% after Deductible
Inpatient
Outpatient
100% after $25 Copayment of
70% after Deductible
the first $500 per visit,
Deductible Waived,
then 80% after Deductible
Emergency Care (ambulance
80% after Deductible
80% after PPO Deductible
and emergency room)
PPO Out -of- Pocket Maximum
applies
Tobacco Cessation (through
100 %, Deductible and
N/A
The MedCenter only)
Copayment Waived
Urgent Care Facility
80% after Deductible
70% after Deductible
Collier County Government - Group #2003021
Packet Page -2953-
Plan Document/ SPD - Effective 1/1/2012
12/13/2011 Item 16.E.4.
Schedule of Benefits - Premium Option
BENEFIT PERCENTAGE /LIMITATIONS
MEDICAL BENEFITS PP0 NnN -PP(i
Weight Loss Program 100% after $25 copay per 70% after Deductible
doctor's office visit
100% for all other services
provided by the clinic
The program must be under the supervision of a licensed Physician. Patient must have a diagnosis of
Morbid Obesity or Clinically Severe Obesity. Payment is made at the time for service to provider of services
by the Covered Person. To obtain reimbursement, a copy of the prescription and paid invoices should be
submitted to Allegiance.
PPO Benefits are limited to the following Weight Loss Providers approved by the Plan: Nuviva, Dr. Porcelli -
JMP Medical, Medi - Weight Loss Clinic and Island Diet Center, and any other medically monitored providers
approved by the Plan.
Non -PPO benefits are limited to a medically monitored weight loss clinic who does not belong to a PPO
recognized by this Plan.
Eligible Expenses Include: Doctors office visit and services provided by the weight loss clinics, such as
medications, supplements, injections, blood - pressure monitoring, and dietary counseling.
Collier County Government - Group #2003021 9 Plan Document / SPD - Effective 1/1/2012
Packet Page -2954-
12/13/2011 Item 16.E.4.
SCHEDULE OF BENEFITS - SELECT OPTION
FOR
ELIGIBLE PARTICIPANTS AND DEPENDENTS
ALL BENEFITS PAYABLE UNDER THIS PLAN ARE SUBJECT TO THE APPLICABLE PLAN
EXCLUSIONS AND THE USUAL, CUSTOMARY AND REASONABLE LIMITS OF THE PLAN
THE BENEFIT PERIOD IS A CALENDAR YEAR
MEDICAL BENEFIT COST SHARING PROVISIONS
PPO
NON -PPO
DEDUCTIBLE
Per Covered Person per Benefit Period $700 $1,400
Per Family per Benefit Period $1,400 $2,800
The Deductible applies to all Eligible Expenses, unless specifically stated otherwise. An individual Covered
Person cannot receive credit toward the Family Deductible for more than the individual Annual Deductible.
The Deductible is combined for both PPO Providers and Non -PPO Providers.
OUT -OF- POCKET MAXIMUM
Per Covered Person per Benefit Period $2,500* $5,000"
Per Family per Benefit Period $5,000" $10,000*
*Deductible is not part of the Out -of- Pocket Maximum
The Out -of- Pocket Maximum applies to all Eligible Expenses, unless specifically stated otherwise. The Out -
of- Pocket Maximum is combined for both PPO Provider and Non -PPO Providers.
Expenses incurred for the following do not apply toward the Out -of- Pocket Maximum: 1) Copay; 2)
Deductibles; 3) any penalty amounts; 4) any charges defined in the General Exclusions and Limitations
Section; 5) Chiropractic Care or Dental Care expenses due to Illness or injury.
BENEFIT PERCENTAGE
Before satisfaction of Out -of- Pocket Maximum 80% 60%
After satisfaction of Out -of- Pocket Maximum 100% 100%
The Benefit Percentage applies to all Eligible Expenses, unless specifically stated otherwise. Eligible
Expenses will be paid by the Plan according to the applicable Benefit Percentage.
NON - COMPLIANCE PENALTY
See Mandatory Case Management
Non Participation in Case Management Penalty
$1,000
Non Participation in Notification Provisions
$300
MAXIMUM LIFETIME BENEFIT FOR ALL CAUSES
Unlimited
Collier County Government - Group #2003021 10 Plan Document/ SPD - Effective 1/1/2012
Packet Page -2955-
12/13/2011 Item 16.E.4.
Schedule of Benefits - Select Option
BENEFIT MAXIMUMS ARE FOR SERVICES RECEIVED FROM PPO AND NON -PPO PROVIDERS
Collier County Government - Group #2003021 11 Plan Document/ SPD - Effective 1/1/2012
Packet Page -2956-
BENEFIT PERCENTAGEILIMITATIONS
MEDICAL BENEFITS
PPO NON -PPO
Acupuncture
80% after Deductible 60% after Deductible
20 Visits
Ambulance Services
80% after Deductible
80% after Deductible
Bariatric Surgery (only if pre-
80% after Deductible
60% after Deductible
approved by Smartchoice)
Chiropractor Care /Spinal 100% after $40 Copayment per
No Coverage
Manipulation /Massage Therapy Visit, Deductible Waived
Combined Maximum of 20 Visits* per Benefit
period
"Visit includes all services performed during a calendar day,
including x -rays
Diagnostic Colonoscopies (See
80 %, Deductible Waived
No Coverage
Medical Benefits)
See Preventive Care for
Screening Colonoscopies
Dental Care (due to an Illness
80 %, Deductible Waived
60% after Deductible
or Injury. See Medical
Benefits)
After benefits are exhausted
under any Dental Plan.
Durable Medical Equipment
80% after Deductible
60% after Deductible
Emergency Room Services
(Facility charges only)
Due to Medical Emergency
$100 Copayment per visit,
$100 Copayment per visit,
then 80% after Deductible
then 80% after Deductible
Non - Medical Emergency
$100 Copayment per visit,
$100 Copayment per visit,
then 80% after Deductible
then 60% after Deductible
Note: The Emergency Room Copayment will be waived if the person is admitted directly as an Inpatient
to the Hospital.
Hearing Aids (due to Accident
80% after Deductible 60% after Deductible
or Illness only)
Maximum Lifetime Benefit of 2 aids
Home Health Care
80% after Deductible
600 after Deductible
Hospice Care, including
80% after Deductible
60% after Deductible
Bereavement Counseling
Bereavement Counseling 15 visits per Family per Lifetime
Collier County Government - Group #2003021 11 Plan Document/ SPD - Effective 1/1/2012
Packet Page -2956-
12/13/2011 Item 16.E.4.
Schedule of Benefits - Select Option
Collier County Government - Group #2003021 12 Plan Document / SPD - Effective 1/1/2012
Packet Page -2957-
BENEFIT PERCENTAGE /LIMITATIONS
MEDICAL BENEFITS
PP0 NON -PPO
Hospital Services or Long-
80% after Deductible
60% after Deductible
Term Acute Care Facility/Hosp
(facility charges)
Inpatient
Room & Board Allowance
Semi - private room rate*
Semi - private room rate*
Intensive Care Unit
80% of actual charge after Ded
60% of actual charge after Ded
Outpatient
80% after Deductible
60% after Deductible
*Room and board limited to Semi - private room rate. A private room will be considered eligible when
Medically Necessary. Charges made by a Hospital having only single or private rooms will be considered
at the least expensive rate for a single or private
Medical Records
100 %, Deductible Waived
100 %, Deductible Waived
up to maximum benefit of $100
up to maximum benefit of $100
per provider
per provider
Mental Illness
Inpatient
80% after Deductible
60% after Deductible
Outpatient
100% after $40 Copayment of
60% after Deductible
the first $500 per visit,
Deductible Waived,
then 80% after Deductible
On -Site Clinic Services
100% after $5 Copayment per
N/A
visit, Deductible Waived
The on -site clinic services are available to all eligible Participants and Dependents 15 years or older who
are covered under the Collier County Government Employee Benefit Plan. All services performed in the
clinic are covered under the $5 Copayment. A referral from the clinic to a PPO Provider will be processed
as a PPO claim.
Outpatient Hemodialysis or
80% after Deductible for the 60% after Deductible for the
Peritoneal Dialysis, including
first 40 visits per Lifetime first 40 visits per Lifetime
home
100% up to 125% of the Medicare allowable rate;
Deductible Waived for the 415` visit and all subsequent visits
Outpatient Therapies (physical,
100% after $40 Copayment of
60% after Deductible
speech, occupational, aquatic)
the first $500 per visit,
Deductible Waived,
then 80% after Deductible
Pain Management
80% after Deductible
60% after Deductible
Epidurals, facet blocks and nerve stimulators are limited to a combined Maximum Benefit of 6 procedures
per Benefit Period. Other procedures are not limited.
Collier County Government - Group #2003021 12 Plan Document / SPD - Effective 1/1/2012
Packet Page -2957-
12/13/2011 Item 16.E.4.
Schedule of Benefits - Select Option
Collier County Government - Group #2003021 13 Plan Document/ SPD - Effective 1/1/2012
Packet Page -2958-
BENEFIT PERCENTAGE /LIMITATIONS
MEDICAL BENEFITS
PP0 NON -PPO
Physician Services
Inpatient/Outpatient Services,
80% after Deductible
60% after Deductible
except for office visits
Primary Care Physician Office
100% after $40 Copayment of
60% after Deductible
Visit Charge
the first $500 per visit,
Deductible Waived,
then 80% after Deductible
Specialist Physician Office
100% after $60 Copayment of
60 % after Deductible
Visit Charge
the first $500 per visit,
Deductible Waived,
then 80% after Deductible
All Other Services /Supplies
100% of the first $500 per visit,
60% after Deductible
other than evaluation and
Deductible Waived,
management charges
then 80% after Deductible
performed in a Physician's
office.
If more than one Physician is seen in the same clinic on the same day, only one Copayment will appy.
"Primary Care Physician" includes a general practitioner, family practitioner, Internist, OB /GYN
(obstetrics /gynecology), Pediatrician, Psychiatrist, licensed nurse practitioner or Physician Assistant.
"Specialist Physician" includes any Physician practicing any branch of medicine or medical specialty who
is not otherwise a Primary Care Physician.
Preventive Care (See Medical
100 %, Deductible Waived
No Coverage
Benefits Section)
Radiation Therapy/
80% after Deductible
60% after Deductible
Chemotherapy /Home Infusion
Therapy
Routine Qualifier Services (See
100 %, Deductible Waived
No Coverage
Medical Benefits Section)
Scalp Hair Prosthesis
80% after Deductible 60% after Deductible
(wigs /hair pieces)
Maximum Lifetime Benefit one wig or hair piece
Skilled Nursing Facility and
80% after Deductible
60% after Deductible
Rehabilitation Facility
Substance Abuse /Chemical
Dependency Disorders
80% after Deductible
60% after Deductible
Inpatient
Outpatient
100% after $40 Copayment of
60% after Deductible
the first $500 per visit,
Deductible Waived,
then 80% after Deductible
Emergency Care (ambulance
80% after Deductible
80% after PPO Deductible
and emergency room)
PPO Out -of- Pocket Maximum
applies
Tobacco Cessation (through
100 %, Deductible and
N/A
The MedCenter only)
Copayment Waived
Urgent Care Facility
80% after Deductible
60% after Deductible
Collier County Government - Group #2003021 13 Plan Document/ SPD - Effective 1/1/2012
Packet Page -2958-
12/13/2011 Item 16.E.4.
Schedule of Benefits - Select Option
BENEFIT PERCENTAGE /LIMITATIONS
MEDICAL BENEFITS P O NON -PPO
Weight Loss Program 100% after $40 copay per 60% after Deductible
doctor's office visit
100% for all other services
provided by the clinic
The program must be under the supervision of a licensed Physician. Patient must have a diagnosis of
Morbid Obesity or Clinically Severe Obesity. Payment is made at the time for service to provider of services
by the Covered Person. To obtain reimbursement, a copy of the prescription and paid invoices should be
submitted to Allegiance.
PPO Benefits are limited to the following Weight Loss Providers approved by the Plan: Nuviva, Dr. Porcelli -
JMP Medical, Medi - Weight Loss Clinic and Island Diet Center, and any other medically monitored providers
approved by the Plan.
Non -PPO benefits are limited to a medically monitored weight loss clinic who does not belong to a PPO
recognized by this Plan.
Eligible Expenses Include: Doctors office visit and services provided by the weight loss clinics, such as
medications, supplements, injections, blood - pressure monitoring, and dietary counseling.
Collier County Government - Group #2003021 14 Plan Document/ SPD - Effective 1/112012
Packet Page -2959-
12/13/2011 Item 16.E.4.
SCHEDULE OF BENEFITS - BASIC OPTION
FOR
ELIGIBLE PARTICIPANTS AND DEPENDENTS
ALL BENEFITS PAYABLE UNDER THIS PLAN ARE SUBJECT TO THE APPLICABLE PLAN
EXCLUSIONS AND THE USUAL, CUSTOMARY AND REASONABLE LIMITS OF THE PLAN
THE BENEFIT PERIOD IS A CALENDAR YEAR
MEDICAL BENEFIT COST SHARING PROVISIONS
PPO
NON -PPO
DEDUCTIBLE
Per Covered Person per Benefit Period $2,000 $4,000
Per Family per Benefit Period $4,000 $8,000
The Deductible applies to all Eligible Expenses, unless specifically stated otherwise. An individual Covered
Person cannot receive credit toward the Family Deductible for more than the individual Annual Deductible.
The Deductible is combined for both PPO Providers and Non -PPO Providers.
OUT -OF- POCKET MAXIMUM
Per Covered Person per Benefit Period $8,000" $10,000*
Per Family per Benefit Period $16,000"` $20,000"
"Deductible is not part of the Out -of- Pocket Maximum
The Out -of- Pocket Maximum applies to all Eligible Expenses, unless specifically stated otherwise. The Out -
of- Pocket Maximum is combined for both PPO Provider and Non -PPO Providers.
Expenses incurred for the following do not apply toward the Out -of- Pocket Maximum: 1) Copay; 2)
Deductibles; 3) any penalty amounts; 4) any charges defined in the General Exclusions and Limitations
Section; 5) Chiropractic Care or Dental Care expenses due to Illness or injury.
BENEFIT PERCENTAGE
Before satisfaction of Out -of- Pocket Maximum 80% 60%
After satisfaction of Out -of- Pocket Maximum 100% 100%
The Benefit Percentage applies to all Eligible Expenses, unless specifically stated otherwise. Eligible
Expenses will be paid by the Plan according to the applicable Benefit Percentage.
NON- COMPLIANCE PENALTY
See Mandatory Case Management
Non Participation in Case Management Penalty
$1,000
Non Participation in Notification Provisions
$300
MAXIMUM LIFETIME BENEFIT FOR ALL CAUSES
Unlimited
Collier County Government - Group #2003021 15 Plan Document/ SPD - Effective 1/1/2012
Packet Page -2960-
12/13/2011 Item 16.E.4.
Schedule of Benefits - Basic Option
BENEFIT MAXIMUMS ARE FOR SERVICES RECEIVED FROM PPO AND NON -PPO PROVIDERS
Collier County Government - Group #2003021 16 Plan Document / SPD - Effective 1/1/2012
Packet Page -2961-
BENEFIT PERCENTAGE /LIMITATIONS
MEDICAL BENEFITS `
ppO = NON -PPO
Acupuncture
80% after Deductible 60% after Deductible
20 visits
Ambulance Services
80% after Deductible
60% after Deductible
Bariatric Surgery (only if pre-
80% after Deductible
60% after Deductible
approved by Smartchoice)
Chiropractor Care /Spinal 80% after Deductible
No Coverage
Manipulation /Massage Therapy
Combined Maximum of 20 Visits* per Benefit
period
*Visit includes all services performed during a calendar day,
including x -rays
Diagnostic Colonoscopies (See
80% after Deductible
60 %, Deductible Waived
Medical Benefits)
See Preventive Care for
Screening Colonoscopies
Dental Care (due to an Illness
80 %, Deductible Waived
60% after Deductible
or Injury. See Medical
Benefits)
After benefits are exhausted
under any Dental Plan.
Durable Medical Equipment
80% after Deductible
60% after Deductible
Emergency Room Services
(Facility charges only)
Due to Medical Emergency
80% after Deductible
80% after Deductible
Non - Medical Emergency
80% after Deductible
60% after Deductible
Hearing Aids (due to Accident
80% after Deductible 60% after Deductible
or Illness only
Maximum Lifetime Benefit of 2 aids
Home Health Care
80% after Deductible
60% after Deductible
Hospice Care, including
80% after Deductible
60% after Deductible
Bereavement Counseling
Bereavement Counseling 15 visits per Family per Lifetime
Hospital Services or Long-
80% after Deductible
60% after Deductible
Term Acute Care Facility /Hosp
(facility charges)
Inpatient
Room & Board Allowance
Semi - private room rate*
Semi - private room rate*
Intensive Care Unit
80% of actual charge after Ded
60% of actual charge after Ded
Outpatient
80% after Deductible
60% after Deductible
*Room and board limited to Semi - private room rate. A private room will be considered eligible when
Medically Necessary. Charges made by a Hospital having only single or private rooms will be considered
at the least expensive rate for a single or private
Medical Records
100 %, Deductible Waived
100 %, Deductible Waived
up to maximum benefit of $100
up to maximum benefit of $100
per provider
per provider
Collier County Government - Group #2003021 16 Plan Document / SPD - Effective 1/1/2012
Packet Page -2961-
12/13/2011 Item 16.E.4.
Schedule of Benefits - Basic Option
Collier County Government - Group #2003021 17 Plan Document / SPD - Effective 1/1/2012
Packet Page -2962-
BENEFIT PERCENTAGE /LIMITATIONS
MEDICAL BENEFITS '
PP0 NON -PPO
Mental Illness
Inpatient
80% after Deductible
60% after Deductible
Outpatient
80% after Deductible
60% after Deductible
On -Site Clinic Services
100% after $5 Copayment per
N/A
visit, Deductible Waived
The on -site clinic services are available to all eligible Participants and Dependents 15 years or older who
are covered under the Collier County Government Employee Benefit Plan. All services performed in the
clinic are covered under the $5 Copayment. A referral from the clinic to a PPO Provider will be processed
as a PPO claim.
Outpatient Hemodialysis or
80% after Deductible for the 60% after Deductible for the
Peritoneal Dialysis, including
first 40 visits per Lifetime first 40 visits per Lifetime
home
100% up to 125% of the Medicare allowable rate;
Deductible Waived for the 41st visit and all subsequent visits
Outpatient Therapies (physical,
80% after Deductible
60% after Deductible
speech, occupational, aquatic)
Pain Management
80% after Deductible
60% after Deductible
Epidurals, facet blocks and nerve stimulators are limited to a combined Maximum Benefit of 6 procedures
per Benefit Period. Other procedures are not limited.
Physician Services
Inpatient/Outpatient Services,
80% after Deductible
60% after Deductible
except for office visits
Primary Care Physician Office
60% after Deductible
Visit Charge
80% after Deductible
Specialist Physician Office
60% after Deductible
Visit Charge
80% after Deductible
All Other Services /Supplies
60% after Deductible
other than evaluation and
80% after Deductible
management charges
performed in a Physician's
office.
"Primary Care Physician" includes a general practitioner, family practitioner, Internist, OB /GYN
(obstetrics /gynecology), Pediatrician, Psychiatrist, licensed nurse practitioner or Physician Assistant.
"Specialist Physician" includes any Physician practicing any branch of medicine or medical specialty who
is not otherwise a Primary Care Physician.
Preventive Care (See Medical
100 %, Deductible Waived
No Coverage
Benefits Section)
Radiation Therapy/
80% after Deductible
60% after Deductible
Chemotherapy /Home Infusion
Therapy
Routine Qualifier Services (See
100 %, Deductible Waived
No Coverage
Medical Benefits Section)
Scalp Hair Prosthesis
80% after Deductible 60% after Deductible
(wigs /hair pieces)
Maximum Lifetime Benefit one wig or hair piece
Collier County Government - Group #2003021 17 Plan Document / SPD - Effective 1/1/2012
Packet Page -2962-
12/13/2011 Item 16.E.4.
Schedule of Benefits - Basic Option
Collier County Government - Group #2003021 18 Plan Document / SPD - Effective 1/1/2012
Packet Page -2963-
BENEFIT PERCENTAGE /LIMITATIONS
MEDICAL BENEFITS
PPO NON -PPO
Skilled Nursing Facility and
80% after Deductible
60% after Deductible
Rehabilitation Facility
Substance Abuse /Chemical
Dependency Disorders
80% after Deductible
60% after Deductible
Inpatient
Outpatient
80% after Deductible
60% after Deductible
Emergency Care (ambulance
80% after Deductible
80% after PPO Deductible
and emergency room)
PPO Out -of- Pocket Maximum
applies
Tobacco Cessation (through
100°/x, Deductible and
N/A
The MedCenter only)
Copayment Waived
Urgent Care Facility
80% after Deductible
60% after Deductible
Weight Loss Program
80% after Deductible for
60% after Deductible
doctor's office visit
100% after Deductible for all
other services provided by the
clinic
The program must be under the supervision of a licensed Physician. Patient must have a diagnosis of
Morbid Obesity or Clinically Severe Obesity. Payment is made at the time for service to provider of services
by the Covered Person. To obtain reimbursement, a copy of the prescription and paid invoices should be
submitted to Allegiance.
PPO Benefits are limited to the following Weight Loss Providers approved by the Plan: Nuviva, Dr. Porcelli -
JMP Medical, Medi - Weight Loss Clinic and Island Diet Center, and any other medically monitored providers
approved by the Plan.
Non -PPO benefits are limited to a medically monitored weight loss clinic who does not belong to a PPO
recognized by this Plan.
Eligible Expenses Include: Doctors office visit and services provided by the weight loss clinics, such as
medications, supplements, injections, blood - pressure monitoring, and dietary counseling.
Collier County Government - Group #2003021 18 Plan Document / SPD - Effective 1/1/2012
Packet Page -2963-
12/13/2011 Item 16.E.4.
PHARMACY BENEFIT
Prescription drug charges are payable only through the Plan's Pharmacy Benefit Management (PBM)
program, which program is sponsored in conjunction with and is an integral part of this Plan. Coinsurance
does not serve to satisfy the Medical Benefits Annual Deductible or Out -of- Pocket Maximum. The Pharmacy
Benefit Manager (PBM) will provide separate information for details regarding Network pharmacies,
Preferred Brand prescriptions and Specialty Drugs upon enrollment for coverage under this Plan.
Generics preferred - Physician choice (DAW2) - If the Physician does not prescribe "Dispense as Written ",
and there is a generic alternative for the prescription drug, and the Covered Person chooses a brand name
instead, the Covered Person must pay the difference in cost between the generic and brand name medication
plus the applicable brand coinsurance amount.
If the Physician prescribes a brand name drug and communicates on the prescription "Dispense as Written"
(DAW), the Covered Person will pay the brand name coinsurance only.
Proton Pump Inhibitors (PPI's) Benefit - The "over- the - counter' form of Prilosec ( Prilosec OTC) will be
covered the same as if it were a generic prescription drug.
There is no coordination of benefits for Pharmacy Benefits.
PREMIUM OPTION - COST SHARING PROVISIONS
Pharmacy Benefit Deductible (combined Retail and Mail Order) per Benefit Period
Per Covered Person .............................. ............................... $50
PerFamily .................................... ............................... $100
Pharmacy Benefit Out -of- Pocket Maximum per Benefit Period
Per Covered Person ............................. ............................... $450
PerFamily .................................... ............................... $900
Pharmacy Coinsurance is waived after satisfaction of the Pharmacy Out -of- Pocket Maximum.
Premium O ption - Co, insurance per Prescription, ::
Drug Type Retail - PBM Network Member Submit" Mail Order
Generic 20% 20% 20%
Preferred Brand 20% 20% 20%
Non - Preferred Brand 40% 40% 40%
*For Member Submit prescriptions, the PBM will reimburse the contract cost of the prescription drug, less
the applicable Coinsurance per Prescription. Contract cost is the PBM's discounted cost of the prescription
drug. Reimbursement will not exceed what the PBM would have reimbursed for a Network Prescription.
Collier County Government - Group #2003021 19 Plan Document / SPD - Effective 1/1/2012
Packet Page -2964-
12/13/2011 Item 16.E.4.
Pharmacy Benefit
SELECT OPTION - COST SHARING PROVISIONS
Pharmacy Benefit Deductible (combined Retail and Mail Order) per Benefit Period
Per Covered Person ............................. ............................... $200
PerFamily .................................... ............................... $400
Pharmacy Benefit Out -of- Pocket Maximum per Benefit Period
Per Covered Person ............................. ............................... $600
PerFamily ................................... ............................... $1,200
Pharmacy Coinsurance is waived after satisfaction of the Pharmacy Out -of- Pocket Maximum.
....
SelectOption = Coinsurance pe r Prescription , �.. `A` ..
Drug Type
Retail - PBM Network
Member Submit*
Mail Order
Generic
20%
20%
20%
Preferred Brand
20%
20%
20%
Non - Preferred Brand
40%
40%
40%
*For Member Submit prescriptions, the PBM will reimburse the contract cost of the prescription drug, less
the applicable Coinsurance per Prescription. Contract cost is the PBM's discounted cost of the prescription
drug. Reimbursement will not exceed what the PBM would have reimbursed for a Network Prescription.
BASIC OPTION - COST SHARING PROVISIONS
Pharmacy Benefit Deductible (combined Retail and Mail Order) per Benefit Period
Per Covered Person ............................. ............................... $400
PerFamily .................................... ............................... $800
Pharmacy Benefit Out -of- Pocket Maximum per Benefit Period
Per Covered Person ............................ ............................... $1,000
PerFamily ................................... ............................... $2,000
Pharmacy Coinsurance is waived after satisfaction of the Pharmacy Out -of- Pocket Maximum.
Basic.Optiori Coinsurance per Prescription
Drug Type Retail - PBM Network Member Submit* Mail Order
Generic 30% 30% 30%
Preferred Brand 30% 30% 30%
Non - Preferred Brand 50% 50% 50%
*For Member Submit prescriptions, the PBM will reimburse the contract cost of the prescription drug, less
the applicable Coinsurance per Prescription. Contract cost is the PBM's discounted cost of the prescription
drug. Reimbursement will not exceed what the PBM would have reimbursed for a Network Prescription.
Collier County Government - Group #2003021 20 Plan Document / SPD - Effective 1/1/2012
Packet Page -2965-
12/13/2011 Item 16.E.4.
Pharmacy Benefit
COVERAGE
Coverage for prescription drugs will include only those drugs requiring a written prescription of a Physician
or Licensed Health Care Provider, if within the scope of practice of the Licensed Health Care Provider, and
that are Medically Necessary for the treatment of an Illness or Injury.
Coverage also includes prescription drugs or supplies that require a written prescription of a Physician or
Licensed Health Care Provider, if within the scope of practice of the Licensed Health Care Provider, as follows:
1. Self- administered contraceptives.
Contraceptive Management, injectable contraceptives and contraceptive devices are covered
under the Medical Benefits of this Plan.
2. Tretinoin agents used in the treatment of acne and /or for cosmetic purposes (Retin A) subject to
medical review.
3. Erectile Dysfunction non - injectables subject to medical review.
4. Weight management subject to medical review.
5. Serums, toxoids and vaccines subject to medical review.
6. Legend vitamins (oral only).
7. Legend fluoride products (oral only).
8. Diabetic supplies, including syringes, needles, swabs, blood test strips (glucose or ketone), blood
glucose calibration solutions, urine tests, lancets and lancet devices.
SERVICE OPTIONS
The Program includes the following Service Options for obtaining prescriptions under the Pharmacy Benefit:
PBM Network Prescriptions: Available only through a retail pharmacy that is part of the PBM Network. The
pharmacy will bill the Plan directly for that part of the prescription cost that exceeds the Coinsurance
(Coinsurance amount must be paid to pharmacy at time of purchase). The prescription identification card
is required for this option.
Member Submit Prescriptions: Available only if the prescription identification card cannot be used because
a pharmacy is not part of the PBM Network, or the prescription identification card is not used at a PBM
pharmacy. Prescriptions must be paid for at the point of purchase and the prescription drug receipt
must be submitted to the Pharmacy Benefit Manager (PBM), along with a reimbursement form (Direct
Reimbursement). The PBM will reimburse the contract cost of the prescription drug, less the
applicable Coinsurance per Prescription. Contract cost is the PBM's discounted cost of the
prescription drug. Reimbursement will not exceed what the PBM would have reimbursed for a
Network Prescription.
Mail Order Prescriptions: Available only through a licensed pharmacy that is part of the PBM Network which
fills prescriptions and delivers them to Covered Persons through the United States Postal Service, United
Parcel Service or other delivery service. The pharmacy will bill the Plan directly for prescription costs
that exceed the Coinsurance.
Collier County Government - Group #2003021 21 Plan Document / SPD - Effective 1/1/2012
Packet Page -2966-
12/13/2011 Item 16.E.4.
Pharmacy Benefit
Specialty Drug(s): These medications are generic or non - generic drugs classified by the Plan and listed by
the PBM as Specialty Drugs and require special handling (e.g., most injectable drugs other than insulin).
Specialty drugs must be obtained from a preferred specialty pharmacy. Only your first prescription can be
obtained at a network retail pharmacy. All subsequent refills must be obtained through a preferred
specialty pharmacy. A list of specialty drugs and preferred specialty pharmacies may be obtained
from the PBM or Plan Supervisor.
DRUG OPTIONS
The drug options available are:
Generic: Those drugs and supplies listed in the most current edition of the Physicians Desk Reference or by
the PBM Program as generic drugs.
Preferred Brand: Non - generic drugs and supplies listed as "Preferred Brand" by the PBM Program as stated
in a written list provided to Covered Persons and updated from time to time.
Non - Preferred Brand: Copyrighted or patented brand name drugs (Non- Generic) which are not recognized
or listed as Preferred Brand drugs or supplies by the PBM Program.
COINSURANCE
"Coinsurance" means a dollar amount fixed percentage per prescription payable to the pharmacy at the time
of service. Coinsurance amounts are specifically stated in this section. Coinsurance is not payable by the
Plan and does not serve to satisfy the Medical Benefits Annual Deductible or Out -of- Pocket Maximum.
SUPPLY LIMITS
Supply is limited to 30 days for PBM Network or Member Submit Prescriptions and 90 -days for Mail Order
Prescriptions.
Prescription drug refills are not allowed until 75% of the prescribed day supply is used.
The amount of certain medications are limited to promote safe, clinically appropriate drug usage. If you have
exceeded a limit and your physician believes you need an additional supply of a medication, itwill be reviewed
for medical necessity. A current list of applicable quantity limits can be obtained by contacting the PBM at the
number listed on your identification card.
STEP THERAPY PROGRAM
Step Therapy is a program especially for people who take prescription drugs regularly for ongoing conditions
like arthritis and high blood pressure. Ithelps you getan effective medication to treatyour condition while
keeping your costs as low as possible.
In Step Therapy, drugs are grouped in categories based on cost:
1. Front -line drugs - Step 1 drugs are generic drugs proven to be safe, effective and affordable. These
drugs should be tried first because they can provide the same health benefit as more expensive drugs,
at a lower cost.
2. Back -up drugs - Step 2 and Step 3 drugs are brand -name drugs like those that you see advertised
on TV. There are lower -cost brand drugs (Step 2) and higher -cost brand drugs (Step 3). Back -up
drugs typically cost more than front -line drugs.
Collier County Government - Group #2003021 22 Plan Document / SPD - Effective 1/1/2012
Packet Page -2967-
12/13/2011 Item 16.E.4.
Pharmacy Benefit
The next time your doctor writes you a prescription, ask your doctor if a generic medication listed below as
a front -line drug is right for you. It makes good sense to ask for these drugs first because, for most everyone,
they work as well as brand -name drugs, and they almost always cost less. And, because these drugs have
been on the market for a long time, they have a more established safety record than newer drugs.
If you have tried a front -line drug, or your doctor decides one of these drugs isn't appropriate for you, then your
doctor can prescribe a back -up drug. Ask your doctor if one of the lower -cost brands (Step 2 drugs) is
appropriate. Remember, you can always get a higher -cost brand -name drug at a higher copayment if the
front -line or Step 2 back -up drugs aren't right for you. Your doctor can call 800 -417 -8164 to request a prior
authorization for the medication.
Step Therapy helps you get the most out of your prescription drug benefit. For more information on the
how Step Therapy works and how it benefits you, watch this short video at: www.StepTherapvFacts.com.
PRIOR AUTHORIZATION
Certain drugs require approval before the drug can be dispensed. A current list of drugs that require prior
authorization can be obtained by contacting the PBM at the number listed on your identification card.
EXCLUSIONS
Prescription drugs or supplies in the following categories are specifically excluded:
1. Cosmetic only indications, including but not limited to, photo -aged skin products (Renova); Hair
Growth Agents (Propecia, Vaniga); Injectable cosmetics (botox cosmetic); and depigmentation
products used for skin conditions requiring a bleaching agent.
2. Legend homeopathic drugs.
3. Fertility agents, oral, vaginal and injectable.
4. Erectile dysfunction injectables.
5. Allergen injectables.
6. Smoking cessation products.
7. Over - the - counter equivalents and non - legend medications (OTC), except when approved for Proton
Pump Inhibitors.
8. Blood monitors and kits (glucose or ketone)*.
9. Durable Medical Equipment*.
10. Experimental or Investigational drugs.
*Eligible for coverage under the Medical Benefits, subject to all provisions and limitations of this Plan.
Collier County Government - Group #2003021 23 Plan Document / SPD - Effective 1/1/2012
Packet Page -2968-
12/13/2011 Item 16.E.4.
MEDICAL BENEFIT DETERMINATION REQUIREMENTS
ELIGIBLE SERVICES, TREATMENTS AND SUPPLIES
Services, treatments or supplies are eligible for coverage if they meet all of the following requirements:
1. They are administered, ordered or provided by a Physician or other eligible Licensed Health Care
Provider; and
2. They are Medically Necessary for the diagnosis and treatment of an Illness or Injury or they are
specifically included as a benefit if not Medically Necessary; and
3. Charges do not exceed the Usual, Customary and Reasonable limits of the Plan; and
4. They are not excluded under any provision or section of this Plan.
Treatments, services or supplies excluded by this Plan may be reimbursable if such charges are
approved by the Plan Administrator prior to beginning such treatment. Prior approval is limited to
medically accepted non - experimental or investigational treatments, services, or supplies, which, in
the opinion of the Plan Administrator, are more cost effective than a covered treatment, service or
supply for the same Illness or Injury, and which benefit the Covered Person.
DEDUCTIBLE
The Deductible is stated in the Schedule of Medical Benefits according to the Plan Option selected. The
Deductible applies to Expenses Incurred during each Benefit Period, unless specifically waived, but it applies
only once for each Covered Person within a Benefit Period. Also, if members of a Family have satisfied
individual Deductible amounts that collectively equal the Deductible per Family, as stated in the Schedule of
Medical Benefits, during the same Benefit Period, no further Deductible will apply to any member of that
Family during that Benefit Period. An individual Covered Person cannot receive credittoward the Family
Deductible for more than the Individual Annual Deductible as stated in the Schedule of Medical
Benefits.
BENEFIT PERCENTAGE
The Benefit Percentage is stated in the Schedule of Medical Benefits according to the Plan Option selected.
The Plan will pay the Benefit Percentage of the Eligible Expense indicated.
OUT -OF- POCKET MAXIMUM
The Out -of- Pocket Maximum, per Covered Person or Family, whichever is applicable, is stated in the
Schedule of Medical Benefits and includes amounts in excess of the Benefit Percentage paid by the Plan.
The Annual Deductible is not part of the Out -of- Pocket Maximum. Expenses Incurred in a single Benefit
Period after satisfaction of the Out -of- Pocket Maximum per Covered Person or per Family, whichever is
applicable, will be paid at 100% of the Eligible Expense for the remainder of the Benefit Period. An individual
Covered Person cannot receive credit toward the Family Out -of- Pocket Maximum for more than the
Individual Out -of- Pocket Maximum as stated in the Schedule of Medical Benefits.
COPAYMENT
Copayments are stated in the Schedule of Medical Benefits according to the Plan Option selected. A
Copayment is the portion of the medical expense that is the responsibility of the Covered Person. A
Copayment is applied for each occurrence of such covered medical service and is not applied toward
satisfaction of the Deductible or Out -of- Pocket Maximum and will continue to apply after satisfaction of the
Out -of- Pocket Maximum.
Collier County Government - Group #2003021 24 Plan Document/ SPD - Effective 1/1/2012
Packet Page -2969-
12/13/2011 Item 16.E.4.
Medical Benefit Determination Requirements
MAXIMUM BENEFIT
The amount payable by the Plan will not exceed any Maximum Benefit or Maximum Lifetime Benefit as stated
in the Schedule of Medical Benefits, for any reason.
APPLICATION OF DEDUCTIBLE AND ORDER OF BENEFIT PAYMENT
Deductibles will be applied to Expenses Incurred in the chronological order in which they are adjudicated by
the Plan. Expenses Incurred will be paid by the Plan in the chronological order in which they are adjudicated
by the Plan. The manner in which the Deductible is applied and Expenses Incurred are paid by the Plan will
be conclusive and binding on all Covered Persons and their assignees.
CHANGES IN COVERAGE CLASSIFICATION
A change in coverage that decreases a benefit of this Plan will become effective on the stated effective date
of such change with regard to all Covered Persons to whom it applies.
NEW YORK STATE EXPENSES
This Plan has voluntarily elected to make public goods payments directly to the Office of Pool Administration
in conformance with HCRA provisions and New York State Department of Health (Department) requirements.
Collier County Government - Group #2003021 25 Plan Document / SPD - Effective 1/1/2012
Packet Page -2970-
12/13/2011 Item 16.E.4.
MEDICAL BENEFITS
Charges for the following Medical Benefits are payable as stated in the Schedule of Medical Benefits and
subject to all terms and conditions of this Plan. Medical Benefits include:
1. Acupuncture: Acupuncture performed by a licensed Health Care Provider will be payable as stated
and limited in the Schedule of Benefits.
2. Allergy Services: Allergy testing, treatment and serum. Allergy injections will be payable under the
Physician's Office Visit benefit.
3. Ambulance Service: Commercial or ground or air ambulance service to the nearest facility where
Emergency care or treatment can be rendered; or from one facility to another for care; or from a
facility to the patient's home when Medically Necessary.
4. Ambulatory Surgical Center: Services and supplies provided by an Ambulatory Surgical Center.
5. Anesthetics /Oxygen: The cost and administration of an anesthetic or for oxygen and other gases
and their administration.
6. Aquatic Therapy: Medically Necessary aquatic or pool therapies.
7. Autism Spectrum Disorder: Testing and treatment for Autism Spectrum Disorder is covered the
same as any other Illness or Injury, including treatment forABA (Applied Behavioral Analysis) therapy.
8. Bariatric Surgery: Medically Necessary surgical treatment and follow -up care for Morbid
Obesity /Clinically Severe Obesity, including complications, only if approved by Smartchoice. See
Smartchoice Program for further details.
9. Birthing Center: Services and supplies furnished by a Birthing Center.
10. Blood and Blood Derivatives: Blood transfusions, blood processing, blood transporting, blood
handling, administration, and the cost of blood, plasma and blood derivatives. Any credit allowable
for replacement of blood plasma by donor or blood insurance will be deducted from the total Eligible
Expense.
11. Bone Density Testing: Medically Necessary diagnosis and treatment of osteoporosis for high -risk
individuals who: a) are estrogen deficient and at clinical risk for osteoporosis, b) have vetebral
abnormalities; c) are receiving long term glucocorticoid (steroid) therapy; d) have primary
hyperparathyroidism; or e) have a family history of osteoporosis.
12. Cardiac Rehabilitation: Cardiac Rehabilitation services which are rendered: a) underthe supervision
of a Physician; and b) in connection with a myocardial infarction, coronary occlusion or coronary
bypass surgery; and c) initiated within twelve (12) weeks after other treatment for the medical
condition ends; and d) in a medical care facility.
Expenses in connection with Phase III cardiac rehabilitation, including, but not limited to
Occupational Therapy or work hardening programs will not be considered eligible. Phase III
is defined as the general maintenance level of treatment, with no further medical
improvements being made, and exercise therapy that no longer requires the supervision of
medical professionals.
13. Cataract Surgery: Initial pair of eyeglasses, contact lenses or an intraocular lens following a
Medically Necessary surgical procedure to the eye, aphakic patients, or soft lenses or sclera shells
intended for use as corneal bandages.
Collier County Government - Group #2003021 26 Plan Document / SPD - Effective 1/1/2012
Packet Page -2971-
12/13/2011 Item 16.E.4.
Medical Benefits
14. Chiropractic Care /Spinal Manipulation: Skeletal adjustments, manipulation, or other treatment in
connection with the correction by manual or mechanical means of structural imbalance or subluxation
in the human body, including x -rays will be payable as shown in the Schedule of Benefits.
15. Circumcision: Services and supplies related to circumcision.
16. Cleft Lip and/or Cleft Palate: Cleft lip and cleft palate treatment for a child under age eighteen (18),
including medical, dental, Speech Therapy, audiology and nutrition services, but only if they are
prescribed by the treating Physician or surgeon and the Physician or surgeon certifies that the
services are Medically Necessary.
17. Contraceptive Management: Contraceptive Management, regardless of Medical Necessity.
"Contraceptive Management" means Physician fees related to a prescriptive contraceptive device,
obtaining a prescription for contraceptives, purchasing, fitting, injecting, implantation or placement of
any contraceptive device or removal of IUD regardless of Medical Necessity. Contraceptive supplies
or devices available without a Physician's prescription or contraceptives provided over - the - counter
are excluded.
18. Dental Care:
A. Dental services and x -rays rendered by a Dentist or Dental Surgeon for the treatment of a
fractured jaw or Accidental Injury to sound natural teeth. Dental Services will be eligible if
treatment begins within ninety (90) days of the accident and will continue to be eligible until
the treatment is completed.
B. General anesthesia and hospitalization services in assuring the safe delivery of necessary
dental care provided to a Covered Person of any age who:
1) Is determined by a licensed Dentist and the attending Physician to require necessary
dental treatment in a Hospital or Ambulatory Surgical Center because of a
significantly complex dental condition or a developmental disability in which patient
management has proved ineffective; or
2). 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.
Dental services due to Illness or injury will be payable as shown in the Schedule of Benefits, subject
to review by the Plan. A letter of Medical Necessity from the attending Physician and the Dentist's
treatment plan must be submitted to the Plan Supervisor before charges will be considered.
19. Diabetic Supplies: Diabetic supplies, other than those that are specifically covered under the
Pharmacy Benefit, for the treatment of gestational, Type I or Type II diabetes. Custom made diabetic
shoes when Medically Necessary and prescribed by a physician.
20. Diagnostic Testing, X -ray and Laboratory Services: Diagnostic testing, x -ray and laboratory tests,
including electrocardiograms, electroencephalograms, pneumoencephalograms, basal metabolism
tests, CAT scans, MRIs, microscopic tests, or similar well - established diagnostic tests generally
accepted by Physicians throughout the United States.
Collier County Government - Group #2003021 27 Plan Document / SPD - Effective 1/1/2012
Packet Page -2972-
12/13/2011 Item 16.E.4.
Medical Benefits
21. Durable Medical Equipment: The rental of a wheelchair, Hospital bed, respirator or other Durable
Medical Equipment required for therapeutic use will be payable as shown in the Schedule of Benefits,
subject to the following:
A. The equipment must be prescribed by a Physician and needed in the treatment of an Illness
or Injury; and
B. The equipment will be provided on a rental basis, or the purchase of this equipment if
economically justified, whichever is less. If the purchase is not medically feasible, rental
charges will be paid without limitation based upon purchase price. Any amount paid to rent
the equipment will be applied towards the purchase price. In no event will the rental cost of
Durable Medical Equipment exceed the purchase price of the item; and
C. Benefits will be limited to standard models, as determined by the Plan; and
D. The Plan will pay for only ONE of the following: a manual wheelchair, motorized wheelchair
or motorized scooter, unless Medically Necessary due to growth of the person or changes
to the person's medical condition require a different product, as determined by the Plan; and
E. If the equipment is purchased, benefits will be payable for subsequent repairs, excluding
batteries, necessary to restore the equipment to a serviceable condition. If such equipment
cannot be restored to a serviceable condition, replacement will be considered eligible, subject
to prior approval by the Plan. In all cases, repairs or replacement due to abuse or misuse,
as determined by the Plan, are not covered; and
F. Expenses for the rental or purchase of any type of air conditioner, air purifier, or any other
device or appliance will not be considered eligible.
22. Emergency Room Services: Treatment in a Hospital emergency room, including professional
services will be payable as shown in the Schedule of Benefits.
23. Hearing Aids: Hearing aids and their fittings when due to an Accidental Injury or Illness will be
payable as shown in the Schedule of Benefits.
24. Hemodialysis /Peritoneal Dialysis: Treatment of a kidney disorder by hemodialysis or peritonial
dialysis as an Inpatient in a Hospital or other facility, or for expense in an Outpatient facility or in the
Covered Person's home, including the training of one attendant to perform kidney dialysis at home.
The attendant may be a family member. When home care replaced Inpatient or Outpatient dialysis
treatments, the Plan will pay for rental of dialysis equipment and expendable medical supplies for use
in the Covered Person's home as shown under the Durable Medical Equipment benefit. Outpatient
hemodialysis or peritoneal dialysis is limited as shown in the Schedule of Benefit.
25. Home Health Care: Services provided by a Home Health Care Agency to a Covered Person in the
home will be payable as shown in the Schedule of Benefits. The following are considered eligible
home health care services in accordance with a Home Health Care Plan for the following services:
A. Part -time or intermittent nursing care by a Registered Nurse (R.N.) or by a Licensed Practical
Nurse (L.P.N.), a vocational nurse, or public health nurse who is under the direct supervision
of a Registered Nurse;
B. Home health aides;
C. Medical supplies, drugs and medicines prescribed by a Physician, and laboratory services
provided by or on behalf of a Hospital.
Collier County Government - Group #2003021 28 Plan Document/ SPD -Effective 1/1/2012
Packet Page -2973-
12/13/2011 Item 16.E.4.
Medical Benefits
Home Health Care specifically excludes the following:
A. Services and supplies not included in the approved Home Health Care Plan.
B. Services of a person who ordinarily resides in the home of the Covered Person, or who is a
Close Relative of the Covered Person who does not regularly charge the Covered Person for
services.
C. Services of any social worker.
D. Transportation services.
E. Housekeeping services.
Custodial Care
26. Home Infusion Services: Home infusion services ordered by a Physician and provided by a home
infusion therapy organization licensed and approved within the state in which the services are
provided. A home infusion therapy organization is a health care facility that provides home infusion
therapy services and skilled nursing services. Home infusion therapy services include the
preparation, administration, orfurnishing of parenteral medications, orparenteral orenteral nutritional
services to a Covered Person by a home infusion therapy organization. Services also include
education for the Covered Person, the Covered Person's caregiver, or a family member. Home
infusion therapy services include pharmacy, supplies, equipment and skilled nursing services when
billed by a home infusion therapy organization.
Skilled nursing services billed by a home health agency are covered under the Home Health
Care Benefit.
27. Hospice Care: Services provided by a Hospice within any one Hospice Benefit Period will be payable
as shown in the Schedule of Benefits. The following are considered eligible Hospice services:
A. Room and Board, including any charges made by the facility as a condition of occupancy, or
on a regular daily or weekly basis such as general nursing services. If private room
accommodations are used, the daily Room and Board charge allowed will not exceed the
facility's average Semi - Private charges or an average Semi - Private rate made by a
representative cross section of similar institutions in the area.
B. Nursing care by a Registered Nurse (R.N.), a Licensed Practical Nurse (L.P.N.), a public
health nurse who is under the direct supervision of a Registered Nurse.
C. Medical supplies, including drugs and biologicals and the use of medical appliances.
D. Physician's services.
E. Services, supplies, and treatments deemed Medically Necessary and ordered by a licensed
Physician.
F. Counseling services by a licensed social worker or a licensed pastoral counselor for the
patient's immediate family.
G. Bereavement counseling services by a licensed social worker or a licensed pastoral
counselor for the patient's immediate family. (The bereavement services must be furnished
within six (6) months after the patient's death and payable up to limits shown in Schedule of
Benefits.
Collier County Government - Group #2003021 29 Plan Document / SPD - Effective 1/1/2012
Packet Page -2974-
12/13/2011 Item 16.E.4.
Medical Benefits
The term "Patient's Immediate Family" as used herein means the patient's spouse, parents, and /or
dependent children who are covered under the Plan.
"Hospice Benefit Period" means a specified amount of time during which the Covered Person
undergoes treatment by a Hospice. Such time period begins on the date the attending Physician of
a Covered Person certifies a diagnosis of terminal Illness, and the Covered Person is accepted into
a Hospice program. The period will end the earliest of six months from this date or at the death of the
Covered Person. A new Hospice Benefit Period may begin if the attending Physician certifies that
the patient is still terminally ill; however, additional proof will be required by the Plan Administrator
before a new Hospice Benefit Period can begin.
28. Hospital Services or Long -Term Acute Care Facility /Hospital: The following are considered
eligible charges payable as shown in the Schedule of Benefits:
A. Daily Room and Board in a Semi - Private Room (or private room if no Semi - Private room is
available orwhen confinement in a private room is Medically Necessary) and general nursing
services, or confinement in an Intensive Care Unit, not to exceed the applicable limits shown
in the Schedule of Medical Benefits.
B. Medically Necessary Hospital Miscellaneous Expenses otherthan Room and Board furnished
by the Hospital, including Inpatient miscellaneous service and supplies, Outpatient Hospital
treatments for chronic conditions and emergency room use, Physical Therapy treatments,
hemodialysis, and x -ray.
C. Nursery neonatal units, general nursing services, including Hospital Miscellaneous Expenses
for services and supplies, Physical Therapy, hemodialysis and x -ray, care or treatment of
Injury or Illness, congenital defects, birth abnormalities or premature delivery incurred by a
Newborn Dependent.
29. Massage Therapy or Rolfing: Massage therapy or rolfing for a medical condition, only if services
are performed by a licensed provider, payable as shown in the Schedule of Benefits.
30. Maternity /Pregnancy: Expenses incurred by the covered Employee or a Dependent Spouse for
Pregnancy, including charges for prenatal care, childbirth, miscarriage, and any medical complications
arising out of or resulting from Pregnancy. Expenses for Amniocentesis testing and Cystic fibrosis
testing will also be eligible. Elective induced abortions are eligible only when carrying the fetus to full
term would seriously endanger the life of the mother. If complications arise after the performance of
any abortion, any expenses incurred to treat those complications will be eligible, whether the abortion
was eligible or not.
31. Medical and Surgical Supplies: Dressings, sutures, casts, splints, trusses, crutches, braces,
custom -made orthotics, and other Medically Necessary supplies ordered by a Physician. Foot
orthotics are covered under the Podiatry benefit.
32. Medical Records: Charges for producing medical records will be payable as shown in the Schedule
of Benefits.
33. Mental Illness: The following are considered eligible Mental Illness services and are payable as
shown in the Schedule of Benefits:
A. Physician or Licensed Health Care Provider charges for diagnosis and Medically Necessary
Psychiatric Care and treatment.
B. Charges for well - established medically accepted diagnostic testing generally accepted by
Physicians in the United States.
Collier County Government - Group #2003021 30 Plan Document/ SPD - Effective 1/1/2012
Packet Page -2975-
12/13/2011 Item 16.E.4.
Medical Benefits
C. Charges for Inpatient and partial hospitalization, for Medically Necessary treatment, for the
same services as are covered for hospitalization for physical Illness or Injury by this Plan.
D. Charges for Medically Necessary treatment at a Psychiatric Facility.
34. Midwife Services: Services by a Certified Nurse Midwife (CNM) who is a registered nurse and
enrolled in either the certification maintenance program or the continuing competency assessment
program through the American College of Nurse Midwives (ACNM).
"Certified Nurse Midwife" means an individual who has received advanced nursing training and is
authorized to use the designation of "CNM" and who is licensed by the state or regulatory agency in
the state in which the individual performs such nursing services.
Services of a direct -entry midwife or lay midwife or the practice of direct -entry midwifery will not be
considered eligible. A Direct -entry midwife is one practicing midwifery and licensed pursuant to the
state in which services are performed and who is not a licensed Certified Nurse Midwife.
35. Nutritional Supplements: Physician prescribed nutritional supplements or other enteral
supplementation necessary to sustain life, including rental or purchase of equipment used to
administer nutritional supplements or other enteral supplementation. Special dietary treatment for
phenylketonuria (PKU) when prescribed by a Physician.
Over - the - counter nutritional supplements or infant formulas will not be considered eligible even if
prescribed by a Physician.
36. Occupational Therapy: Occupational Therapy rendered by an occupational therapist on an
Outpatient basis under the recommendation of a Physician whose primary purpose is to provide
medical care for an Illness or Injury. Expenses for Maintenance Therapy, or therapy primarily for
recreational or social interaction will not be considered eligible.
37. Orthognathic Surgery: Orthognathic surgery and related charges. Any orthodontic expenses related
to orthognathic surgery will not be considered eligible.
38. Orthopedic Appliance: Purchase of Orthopedic Appliances or replacement or repair of Orthopedic
Appliances.
39. Physical Therapy: Physical Therapy rendered by an physical therapist on an Outpatient basis under
the recommendation of a Physician whose primary purpose is to provide medical care for an Illness
or Injury. Expenses for Maintenance Therapy, or therapy primarily for recreational or social interaction
will not be considered eligible.
40. Physician Services: Services of a licensed Physician or Licensed Health Care Provider for medical
care and /or treatments, including office, home visits, Hospital Inpatient care, Hospital Outpatient
visits /exams, clinic care, and surgical opinion consultations will be payable as shown in the Schedule
of Benefits.
Diagnostic x -ray and laboratory services which are ordered on the same day as the office visit, but
performed or read at a later date and /or at another facility will be considered as part of the office visit.
Charges are eligible for drugs intended for use in a physicians' office or settings other than home use
that are billed during the course of an evaluation or management encounter.
Collier County Government - Group #2003021 31 Plan Document / SPD - Effective 1/1/2012
Packet Page -2976-
12/13/2011 Item 16.E.4.
Medical Benefits
When two or more Surgical Procedures occur during the same operative session, charges will be
considered as follows:
A. When multiple or bilateral Surgical Procedures are performed that increase the time and
amount of patient care, 100% of the Eligible Expense will be considered for the Major
Procedure; and 50% of the Eligible Expense will be considered for each of the lesser
procedures, except for contracted or negotiated services. Contracted or negotiated services
will be reimbursed at the contracted or negotiated rate.
B. When an incidental procedure is performed through the same incision, only the Eligible
Expense forthe Major Procedure will be considered. Examples of incidental procedures are:
excision of a scar, appendectomy at the time of other abdominal surgery, lysis of adhesions,
etc.
When an assisting Physician or non - physician is required to render technical assistance during a
Surgical Procedure, the charges for such services will be limited to 20% of the primary surgeon's
Eligible Expense for the Surgical Procedure.
41. Podiatry: Treatment for the following foot conditions: a) weak, unstable or flat feet; b) bunions, when
an open cutting operation is performed; c) non - routine treatment of corns or calluses; d) toenails when
at least part of the nail root is removed or Medically Necessary by diagnosis (i.e. PVD); e) any
Medically Necessary surgical procedure required for a foot condition; or f) custom -made orthotics,
including orthopedic shoes when an integral part of a leg brace.
42. Pre - admission Testing: Outpatient pre- admission testing performed within seven (7) days prior to
a scheduled Inpatient Hospitalization or surgery.
43. Prescription Drugs: Drugs requiring the written prescription of a Physician or a Licensed Health
Care Provider and Medically Necessary for the treatment of an Illness or Injury. Coverage also
includes prescription contraceptive drugs not available through the Pharmacy Benefit regardless of
Medical Necessity.
Conditions of coverage for outpatient prescription drugs and supplies available through the
Pharmacy Benefit are as stated in the Pharmacy Benefit section of the Plan.
44. Preventive Care: The following are eligible Preventive Care Services:
A. Routine Wellness care for children and adults for the following:
1) Routine physical examinations by a Physician or Licensed Health Care Provider,
which will include a medical history, physical examination, developmental
assessment, and anticipatory guidance as directed by a Physician or Licensed
Health Care Provider and associated routine testing provided or ordered at the time
of the examination; and
2) Routine immunizations according to the schedule of immunizations which is
recommended by the Advisory Committee on Immunization Practices (ACIP) that
have been adopted by the Director of the Centers for Disease Control and
Prevention.
B. Prostate Specific Antigen (PSA) test for men or digital rectal exams for men starting at age
forty (40).
Collier County Government - Group #2003021 32 Plan Document / SPD - Effective 1/1/2012
Packet Page -2977-
12/13/2011 Item 16.E.4.
Medical Benefits
C. Recommended preventive services as set forth in the recommendations of the United States
Preventive Services Task Force (Grade A and B rating), the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention, and the
guidelines supported by the Health Resources and Services Administration. The complete
list of recommendations and guidelines can be viewed at:
hftp: / /www.healthcare.gov/ center /regulations/ prevention /recommendations.html.
D. Office visit charges only if the primary purpose of the office visit is to obtain a recommended
Preventive Care service identified above.
"Preventive Care" means routine treatment or examination provided when there is no objective
indication or outward manifestation of impairment of normal health or normal bodily function, which
is not provided as a result of any Injury or Illness. Charges will be payable as shown in the Schedule
of Benefits.
Expenses payable under this Preventive Care benefit will not be subject to the Medical
Necessity provisions of this Plan. "Charges for Preventive care that involve excessive,
unnecessary or duplicate tests are specifically excluded."
Charges for treatment of an active Illness or Injury are subject to the plan provisions,
limitations and exclusions and are not eligible in any manner under Preventive Care.
45. Private Duty Nursing: Service of a Registered Nurses (R.N.'s) or Licensed Practical Nurse (L.P.N.)
for private duty nursing. Special duty nursing services are excluded as follows:
A. Which would ordinarily be provided by the Hospital staff or its Intensive Care Unit (the
Hospital benefit of the Plan pays for general nursing services by Hospital staff); or
B. When private duty nurse is employed solely for the convenience of the patient or the patient's
Family or for services which would consist primarily of bathing, feeding, exercising,
homemaking, moving the patient, giving medication or acting as a companion, sifter or when
otherwise deemed not Medically Necessary as requiring skilled nursing care.
46. Prosthetic Appliance: Artificial limbs, eyes, larynx, or other Prosthetic Appliance for replacement
when necessary due to an Illness or Injury. Charges for the repair or replacement will only be
included as an eligible expense when required due to a pathological change or replacement is less
expensive than repair of existing equipment. Replacement due to normal wear and tear and
deterioration is not considered eligible.
47. Radiation Therapy /Chemotherapy: Radium and radioactive isotope therapy, and chemotherapy
treatment will be payable as shown in the Schedule of Benefits.
48. Reconstructive Breast Surgery: Reconstructive breast surgery subsequent to any mastectomy,
limited to the following:
A. Reconstruction of the breast(s) upon which the mastectomy was performed, including
implants;
B. Surgical procedures and reconstruction of the non - affected breast to produce a symmetrical
appearance, including implants;
C. Non - surgical treatment of lymphedemas and other physical complications of mastectomy,
including non - surgical prostheses and implants for producing symmetry.
Collier County Government - Group #2003021 33 Plan Document / SPD - Effective 1/1/2012
Packet Page -2978-
12/13/2011 Item 16.E.4.
Medical Benefits
Specifically excluded from this benefit are expenses for the following:
A. Solely Cosmetic procedures unrelated to producing a symmetrical appearance;
B. Breast augmentation procedures unrelated to producing a symmetrical appearance;
C. Implants for the non - affected breast unrelated to producing a symmetrical appearance;
D. Non - surgical prostheses or any other procedure unrelated to producing a symmetrical
appearance.
49. Rehabilitation Facility: Inpatient care provided in a Rehabilitation Facility will be payable as shown
in the Schedule of Benefits, provided such confinement a) is under the recommendation and general
supervision of a Physician; b) begins after discharge from a required Hospital or Skilled Nursing
Facility confinement; c) is forthe purpose of receiving medical care necessary for convalescence from
the conditions causing or contributing to the precedent Hospital or Skilled Nursing Care confinement;
and d) is not for Custodial Care.
See the Skilled Nursing Care benefit for services and supplies provided for confinements in a Skilled
Nursing Facility.
50. Newborn Care: Newborn care, including Hospital nursery expenses and routine pediatric care while
confined following birth will be considered as part of the newborn's expense.
If the Newborn is ill, suffers an Injury, or requires care other than routine care, benefits will be
provided on the same basis as any other eligible expense.
51. Routine Qualifier Services: The following qualifier services will be payable as shown in the
Schedule of Benefits and as shown below for Covered Employees and spouses only:
Plan Qualifiers
Paid 100% by Plan
Qualifier Guidelines
Lab Draw
Must be completed by all
Odd year - spouses
Employees / Spouses to qualify
Even year - employees
for Select or Premium Options
Pap Smear,
Must be completed according to
Age 20, 25, 30, 35, 40, 43, 46, 50 &
Mammogram
age guidelines to qualify for the
over
Premium Option
Skin Screening
Must be completed according to
Age 20, 25, 30, 35, 40, 43, 46, 50 &
age guidelines to qualify for the
over
Premium Option
Testicular Exam
Must be completed according to
Age 20, 25, 30, 35, 40, 43, 46, 50 &
age guidelines to qualify for the
over
Premium Option
Colonoscopy
Must be completed according to
Age 50 and every 10 years thereafter
age guidelines to qualify for the
"Note that if newly covered
Premium Option
employees and spouse age 50 and
older, first colonoscopy is covered
under the qualifiers regardless of age.
After initial then will follow above age
requirements.
Collier County Government - Group #2003021 34 Plan Document / SPD - Effective 111/2012
Packet Page -2979-
12/13/2011 Item 16.E.4.
Medical Benefits
52. Scalp Hair Prosthesis: Purchase of a scalp hair prosthesis when necessitated by hair loss due to
the medical condition known as alopecia areata, or as the result of hair loss due to radiation or
chemotherapy for diagnosed cancer will be payable as shown in the Schedule of Benefits.
53. Skilled Nursing Facility: Charges made by a Skilled Nursing Facility for the following services and
supplies furnished by the facility during convalescent confinement. Only charges in connection with
convalescence from the Illness or Injury for which the Covered Person was Hospital - confined will be
eligible for benefits. These expenses include:
A. Room and Board, including any charges made by the facility as a condition of occupancy, or
on a regular daily or weekly basis such as general nursing services. If private room
accommodations are used, the daily Room and Board charge allowed will not exceed the
facility's average Semi - Private charges or an average Semi - Private rate made by a
representative cross section of similar institutions in the area.
B. Medical services customarily provided by the Skilled Nursing Facility, with the exception of
private duty or special nursing services and Physicians' fees.
C. Drugs, biologicals, solutions, dressings and casts, furnished for use during the Convalescent
Period, but no other supplies.
54. Sleep Disorders: Treatment of or related to sleep disorders.
55. Speech Therapy: Services provided by a licensed speech therapist for Speech Therapy, also called
speech pathology, and audio diagnostic testing services for diagnosis and treatment of speech and
language disorders. Outpatient Speech Therapy will be payable as shown in the Schedule of
Benefits when all of the following criteria are met:
A. There is a documented condition or delay in development that can be expected to improve
with therapy within a reasonable time.
B. Improvement would not normally be expected to occur without intervention.
C. Treatment is not rendered for stuttering.
D. Treatment is not rendered for behavioral or learning disorders.
E. Treatment is rendered for a condition that is the direct result of a diagnosed neurological,
muscular, or structural abnormality affecting the organs of speech.
F. Therapy has been prescribed by the speech language pathologist or Physician and includes
a written treatment plan with estimated length of time for therapy, along with a statement
certifying all above conditions are met.
56. Sterilization: Voluntary sterilization procedures.
57. Substance Abuse /Chemical Dependency: Coverage under this benefit includes the following
services:
A. Physician or Licensed Health Care Provider charges for diagnosis and Medically Necessary
treatment, including but not limited to group therapy.
B. Charges for well - established medically accepted diagnostic testing generally accepted by
Physicians in the United States.
Collier County Government - Group #2003021 35 Plan Document / SPD - Effective 1/1/2012
Packet Page -2980-
12/13/2011 Item 16.E.4.
Medical Benefits
C. Charges for in- patient or partial hospitalization, for Medically Necessary treatment, for the
same services as are covered for hospitalization for physical Illness or Injury by this Plan.
D. Charges for Medically Necessary treatment, including aftercare, at an Alcoholism and /or
Chemical Dependency Treatment Facility.
58. Temporomandibular Joint Dysfunction (TMJ): Surgical and non - surgical treatment of
Temporomandibular Joint Dysfunction (TMJ).
The treatment of jaw joint disorders (TMJ) includes conditions of structures linking the jawbone and
skull and complex muscles, nerves, and other tissues related to the temporomandibular joint.
Treatment includes, but is not limited to: orthodontics; physical therapy; and any appliance that is
attached to or rests on the teeth.
59. Testosterone Injections: Medically Necessary expenses for testosterone injections and related office
visit.
60. Tobacco Cessation: Tobacco cessation programs offered through the Med Center only are payable
as shown in the Schedule of Benefits. This includes but is not limited to the following: a) one -on -one
visits with clinician; b) one -on -one visit with a certified dietician; c) educational materials; and d)
cessation products (prescription and over - the - counter gums, patches, etc.).
61. Organ or Tissue Transplant Procedures: Services and supplies in connection with non -
Experimental or non - Investigational organ or tissue transplant procedures, subject to the following
conditions:
A. A second opinion is recommended prior to undergoing any transplant procedure. This
second opinion should concur with the attending Physician's findings regarding the Medical
Necessity of such procedure. The Physician rendering this second opinion must be qualified
to render such a service either through experience, specialist training or education, or such
similar criteria, and must not be affiliated in any way with the Physician who will be performing
the actual surgery.
B. If the donor is covered under this Plan, expenses Incurred by the donor will be considered
for benefits to the extent that such expenses are not payable by the recipient's plan.
C. If the recipient is covered under this Plan, expenses Incurred by the recipient will be
considered for benefits. If the donor is not covered under this Plan, reference provision E.
D. If both the donor and the recipient are covered under this Plan, Expenses Incurred by each
person will be treated separately for each person.
E. The Eligible Expense of securing an organ from the designated live donor, a cadaver or
tissue bank, including the surgeon's fees, anesthesiology, radiology, and pathology fees for
the removal of the organ, and a Hospital's charge for storage or transportation of the organ,
will be considered eligible. In no event will benefits be payable in excess of the applicable
benefit limits still available to the recipient.
62. Weight Loss Program: The program must be underthe supervision of a licensed Physician. Patient
must have a diagnosis of Morbid Obesity or Clinically Severe Obesity. Eligible expenses include
physician office visits and services provided by the weight loss clinics, such as medications,
supplements, injections, blood - pressure monitoring and dietary counseling. Charges will be payable
as shown in the Schedule of Benefits.
63. Urgent Care Facility: Services and supplies provided by an Urgent Care Facility will be payable as
shown in the Schedule of Benefits.
Collier County Government - Group #2003021 36 Plan Document / SPD - Effective 1/1/2012
Packet Page -2981-
Smartchoice is a health management program for specific members covered underthis Plan. Those members
would be identified as diagnosed with Morbid Obesity or Clinically Severe Obesity and interested in surgical -
weight loss procedures that are considered Medically Necessary for Morbid Obesity or Clinically Severe
Obesity. Smartchoice does not apply to any other approved medically supervised programs.
The Smartchoice Lifestyle management program focuses on long -term weight loss and improved health. It
includes assessment, education, and monitoring of a treatment plan agreed upon by your physician. A care
plan will be developed with goals outlined. A registered nurse (R.N.) manages all aspects of the program.
A Covered Person must enroll in the Smartchoice Program and actively participate for twelve (12) consecutive
months in the Smartchoice program prior to consideration for pre - certification of any gastric by -pass surgery
and six consecutive months following the surgery. Recommendation regarding request for gastric procedures
limited to: Bariatric Surgery, Gastric Stapling, Laparoscopic Gastric Bypass, Roux -en -Y Gastric Bypass
(RYGB), Vertical Banded Gastroplasty (VBG).
The following criteria will be used for pre - certifying benefits for the above procedures:
1. A clinical history of unsuccessful diet and other weight management programs.
2. Must receive a positive assessment of surgery risk - benefit from all evaluating staff members of the
pre- surgery program.
3. Must be at least 18 years of age and less than 70 years of age.
The following is specifically excluded:
Surgical procedures except for Roux -En -Y Divided Bypass Surgery or laparoscopic adjustable gastric
banding) surgery.
2. Any expenses incurred for which all of the conditions of the Smartchoice Program have not been met.
3. Any redo or revision of a prior bariatric surgical procedure.
4. A second bariatric surgical procedure, whether or not the first procedure was performed while covered
under this plan or not.
Please contact Smartchoice for further information. (239) 659 -7740.
Collier County Government - Group #2003021 37 Plan Document / SPD - Effective 1/1/2012
Packet Page -2982-
12/13/2011 Item 16.E.4.
MEDICAL EXPENSE AUDIT BONUS
The Plan offers an incentive to all Covered Persons to encourage examination and self- auditing of eligible
medical bills to ensure the amounts billed by any provider accurately reflect the services and supplies received
by the Covered Person. The Covered Person is asked to review all medical charges and verify that each
itemized service has been received and that the bill does not represent either an overcharge or a charge for
services never received. This self- auditing procedure is strictly voluntary; however, it is to the advantage of
the Plan as well as the Covered Person to avoid unnecessary payment of health care costs.
In the event a self -audit results in elimination or reduction of benefits paid, 50% of the amount saved will be
reimbursed directly to the Participant (subject to $10 minimum payment and a $500 maximum payment per
Calendar Year), provided the savings are accurately documented, and satisfactory evidence is submitted to
the Plan Supervisor (e.g. a copy of the incorrect bill and a copy of the corrected billing).
This self -audit credit is in addition to the payment of all other applicable plan benefits for legitimate medical
expenses.
This credit will not be payable for expenses in excess of the Usual, Customary and Reasonable charges which
are not covered under the Plan, regardless of whether benefits paid are reduced.
Collier County Government - Group #2003021 38 Plan Document / SPD - Effective 1/1/2012
Packet Page -2983-
12/13/2011 Item 16.E.4.
NOTIFICATION PROVISIONS
Community Health Partners
(239) 659 -7770 or (888)- 594 -9008
To ensure the most appropriate care is provided, and to control the costs of this Plan, the Plan contains a
notification provision. The notification provision requires that a Covered Person call Community Health
Partners (CHP) at least twenty -four (24) hours before an elective (pre- arranged, non - emergency) overnight
stay in a Hospital. It also requires notification twenty -four (24) hours before MRI or CT Scans are done on an
Outpatient basis. If any one of these procedures is performed in the emergency room, no pre - notification is
required.
For a non - emergency hospitalization, CHP will evaluate the proposed admission plan and length of stay. CHP
will certify the number of days appropriate. In making these determinations, the diagnosis, physical status and
any other complicating conditions of the patient will be taken into account. CHP will review any x -ray and
laboratory results and confer with the attending Physician if necessary. The decision to be admitted will
always rest with the patient and the Physician. The notification process will let the patient know, before
expenses are incurred, whether or not the admission would be certified. Benefits will only be available for the
number of days that have been certified. If the confinement will last longer than the number of days certified,
CHP must be notified. At this point, CHP will conduct a Continued Stay Review. The Continued Stay Review
will be conducted in much the same way as the initial notification. The case will be reviewed with the attending
Physician to determine any additional Inpatient days. Benefits will not be available for any days beyond those
certified.
If a Covered Person is admitted to the Hospital or receives one of the listed Outpatient procedures on an
Emergency basis, the Covered Person must call CHP within seventy -two (72) hours following the
admission, test, or procedure. (If Emergency admission occurs on a weekend or holiday, notification can be
extended to the first business day following the Emergency admission).
Notification can come from the Covered, the Hospital, or the Physician. However, the Covered Person is
ultimately responsible for the notification. It is strongly recommended, therefore, that the Covered Person
makes the call.
Notification requires only a brief phone call to CHP at (239) 659 -7770 or toll free at (888) 594 -9008. If the call
is made after hours, the following information must be left on CHP's confidential voice mail:
1. Employee's name
2. Employee ID number
3. Patient's name and relationship to the Employee
4. The name of the Hospital where the procedure will take place (if applicable)
5. The procedure to be performed
6. The name and telephone number of the Physician
It is vital the call occurs within the time frames list above. If notification is not made, eligible expenses will
be reduced by $300 per procedure or confinement except for Urgent Care claims as stated in the
Procedures for Claiming Benefits section.
If notification is not provided within the times outlined, CHP will review the claim to determine whether the
admission, test, or procedure was Medically Necessary. Irrespective of the eventual determination by CHP,
the penalty will still be applied and cannot be rescinded.
Collier County Government - Group #2003021 39 Plan Document / SPD - Effective 1/1/2012
Packet Page -2984-
12/13/2011 Item 16.E.4.
Notification Provisions
Hospital stays in connection with childbirth for either the mother or Newborn may not be less than forty -eight
(48) hours following a vaginal delivery or ninety -six (96) hours following a cesarean section. These
requirements can only be waived by the attending Physician in consultation with the mother. The Covered
Person or provider is not required to notify CHP of the maternity admission, unless the stay extends past the
applicable forty -eight (48) or ninety -six (96) hour stay. A Hospital stay begins at the time of delivery or for
deliveries outside the Hospital, the time the Newborn or mother is admitted to a Hospital following birth, in
connection with childbirth.
If the patient is unconscious, in a coma or unable to contact CHP due to Illness or Injury rendering the patient
physically or mentally incapable, the notification requirement will be waived until the patient is able to contact
CHP. Certification will be retroactive to the date of admission.
Collier County Government - Group #2003021 40 Plan Document/ SPD - Effective 1/1/2012
Packet Page -2985-
Community Health Partners (CHP) will monitor a Covered Person's emerging risk, a condition or diagnosis
that may be potentially significant by utilizing several different methods such as Verisk Medical Intelligence,
Notification request, Pharmacy and TPA reports.
When a Covered Person has been identified with emerging risk they will be encouraged to enroll in Case
Management and actively participate in their care plan. Active participation is described as, communicating
with their Case Manager on a weekly basis until less intensity is needed determined by the Case Manager
or the Covered Person is disenrolled from program. Communication may be in the form of letters, phone calls,
face to face meetings or encrypted emails. If a Covered Person cancels an appointment with the case
manager, it is the Covered Person's responsibility to reschedule with 48 business hours. If a Covered Person
refuses to participate and their level of medical and pharmacy spend combined exceeds $100,000 in a six (6)
month period, they will receive a monetary benefit adjustment for failure to participate.
First Contact: Covered Persons will be contacted by a Case Manager as soon as a trend is identified to enroll
the Covered Person into Case Management. Initially a letter will be sent from Community Health Partners
advising the Covered Person they have been identified to participate in Case Management and will be
contacted within one week. The letter will provide the Case Manager's contact information and ask the
Covered Person to be pro- active and reach out to the case manager and communicate the best time to
schedule a call with the Covered Person.
Second Contact: If no- response, the Case Manager will confirm with the Human Resource Department that
they have the most current contact information. A second call will be place within 48 business hours.
Third Contact: Third call will be place to the Covered Person within another 48 business hour cycle. This call
will be placed after normal business hours between 5 and 7pm.
Fourth contact: Certified letter requiring a signature will be sent to the Covered Person's current home
address. This letter will outline the attempts made to contact the Covered Person as well as the potential
benefit adjustment due to failure to participate.
While participation in case management is voluntary, declining to participate or declining to continue to
participate in case management services when requested by the Plan will result in an additional Copayment
of $1,000 for non - participation of the condition for which case management was declined. The additional
Copayment imposed by this provision will not accrue towards the Out -of- Pocket Maximum or change after
satisfaction of the annual Out -of- Pocket Maximum.
Collier County Government - Group #2003021 41 Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
PRE - EXISTING CONDITION EXCLUSIONS
Expenses Incurred resulting from treatment of Pre - existing Conditions are excluded from coverage under the
Plan as specified below:
1. For a period of twelve (12) consecutive months from the Enrollment Date.
2. In the case of a Late Enrollee only, for a period of eighteen (18) consecutive months from the
Enrollment Date.
All Pre - existing Condition exclusionary periods will commence on the Enrollment Date.
All Pre - existing Condition exclusionary periods set out in this Plan will be reduced on a day for day basis for
any period(s) of Creditable Coverage that occurred prior to a Covered Person's Enrollment Date, provided
there has been no break in the Creditable Coverage exceeding sixty -three (63) consecutive days prior to the
Covered Person's Enrollment Date. The Waiting Period imposed by this Plan will not be considered to be a
break in Creditable Coverage.
Pre - existing Condition Exclusions will not apply to any of the following:
1. Pregnancy related expenses.
2. A Covered Person who is less than nineteen (19) years of age.
3. A genetic predisposition to a disease or condition without a diagnosis of a condition related to the
genetic information.
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Expenses Incurred for the following are not considered eligible under this Plan:
Abortions: Expenses related to elective abortions, except as specified under the Maternity benefit
under Medical Benefits.
2. Acupuncture: Acupuncture except as specified under Medical Benefits.
3. Adoption: Expenses for adoption will not be considered eligible.
4. Against Medical Advice: Complications that directly result from acting against medical advice, non-
compliance with specific physician's orders or leaving an inpatient facility against medical advice will
not be considered eligible.
5. Artificial Organ: Expenses for insertion or maintenance of artificial organ implant procedures
6. Biofeedback: Expenses for biofeedback will not be considered eligible, unless pre- determined for
Medical Necessity.
7. Cardiac Rehabilitation: Expenses in connection with Phase I II cardiac rehabilitation, including, but
not limited to occupational therapy or work hardening programs will not be considered eligible. Phase
III is defined as the general maintenance level of treatment, with no further medical improvements
being made, and exercise therapy that no longer requires the supervision of medical professionals.
8. Chelation Therapy: Expenses for chelation therapy will not be considered eligible, unless due to
heavy metal poisoning. Chelation therapy reduces the plaque deposits in the arteries and other parts
of the body.
Close Relative: Services rendered by a Physician or Licensed Health Care Provider who is a Close
Relative of the Covered Person, or resides in the same household of the Covered Person and who
does not regularly charge the Covered Person for services.
10. Cognitive and Kinetic Therapy: Expenses for cognitive therapy and kinetic therapy will not be
considered eligible. Cognitive therapy is defined as therapy which embraces mental activities
associated with thinking, learning, and memory. Kinetic therapy is defined as therapy related to
motion or movement (i.e. the study of motion, acceleration or rate of change). This exclusion will not
apply to expenses related to a neurological brain impairment resulting from an acute major Illness.
11. Complications: Expenses for care, services or treatment required as a result of complications from
a treatment not covered under the Plan will not be considered eligible or that are the result of any
medical complication resulting from a treatment, service or supply which is, or was at the time the
charge was incurred, excluded from coverage under this Plan will not be considered eligible. This
exclusion does not apply to complications from abortions as specified under Medical Benefits.
12. Convalescent Care: Expenses for hospitalization when such confinement occurs primarily for
physiotherapy, hydrotherapy, convalescent or rest care, or any routine physical examinations, tests
or treatments not connected with the actual Illness or Injury will not be considered eligible.
13. Convenience /Personal Comfort: Services or supplies used primarily for cosmetic, personal comfort,
convenience, hygiene, beautification items, television or telephone use that are not related to
treatment of a medical condition.
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12/13/2011 Item 16.E.4.
General Exclusions and Limitations
14. Cosmetic: Expenses in connection with the care or treatment of, surgery performed for, or as the
result of, a Cosmetic procedure. This exclusion will not apply when such treatment is rendered
to correct a condition resulting from an Accidental Injury or an Illness, or when rendered to
correct a congenital anomaly for a covered Dependent child.
15. Counseling: Expenses for marital counseling, family counseling, recreational counseling or milieu
therapy. Group therapy will not be considered eligible, except for the treatment of Substance Abuse
and /or Chemical Dependency.
16. Custodial Care: Expenses related to Custodial Care will not be considered eligible.
17. Dental Care: Expenses Incurred in connection with dental care, treatment, x -rays, general anesthesia
or Hospital expenses will not be considered eligible, except as specified under Medical Benefits.
18. Developmental Delays: Expenses in connection with the treatment of developmental delays,
including, but not limited to Speech Therapy, Occupational Therapy, Physical Therapy, and any
related diagnostic testing will not be considered eligible. This exclusion does not apply to any Autism
Spectrum Disorder.
19. Education orTraining: Expenses for professional services on an Outpatient basis in connection with
disorders of any type or cause, that can be credited towards earning a degree or furtherance of the
education or training of a Covered Person regardless of the diagnosis will not be considered eligible.
20. Charges for any services or supplies to the extent that benefits are otherwise provided under this
Plan, or under any other plan of group benefits that the Participant's Employer contributes to or
sponsors.
21. Experimental / Investigational: Expenses for services, supplies ortreatments or procedures, surgical
or otherwise which are Experimental or Investigational, except for treatment for ABA (Applied
Behavioral Analysis) therapy.
22. Foot Care: Expenses for routine foot care will not be considered eligible for the following services:
A. Cutting or removal of corns and calluses;
B. Trmming, cutting, clipping, or debriding of nails;
C. Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the
use of skin creams to maintain skin tone of either ambulatory or bedfast patients; and
D. Any other service performed in the absence of localized Illness, Injury or symptoms involving
the foot.
23. Gambling Addition: Expenses for services related to gambling addiction will not be considered
eligible.
24. Genetic Testing: Expenses for genetic testing or genetic counseling will not be considered eligible,
except amniocentesis testing and cystic fibrosis testing as specified under Medical Benefits.
25. Governmental Agency: Expenses for services or supplies which are obtained from any
governmental agency without cost by compliance with laws or regulations enacted by any
governmental body. Also, charges .to the extent that the Covered Person could have obtained
payment, in whole or in part, if he or she had applied for coverage or obtained treatment under any
federal, state or other governmental program or in a treatment facility operated by a government
agency, except where required by law, such as for cases of medical emergencies or for coverage
provided by Medicaid are not considered eligible.
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12/13/2011 Item 16.E.4.
General Exclusions and Limitations
26. Hair Loss: Expenses for hair transplant procedures, wigs and artificial hairpieces or drugs which are
prescribed to promote hair growth, except as specified under Medical Benefits.
27. Hearing Exams /Aids: Expenses for routine hearing examinations and hearing aids, including fitting
thereof, will not be considered eligible, except newborn hearing screenings and those hearing aids
specified under Medical Benefits.
28. Homeopathic Treatment: Expenses for homeopathic, naturopathic and holistic medical procedures
will not be eligible.
29. Human Subject Study: Expenses which are performed subject to the Covered Person's informed
consent under a treatment protocol that explains the treatment or procedure as being conducted
under a human subject study experiment will not be considered eligible.
30. Hypnotherapy: Expenses for hypnotherapy will not be considered eligible.
31. Illegal Charges: Expenses for services, treatment or supplies not considered legal in the United
States.
32. Incurred by a Non - Covered Person: Expenses Incurred by persons other than the Covered Person
receiving treatment or Expenses for treatment, services or supplies not actually rendered to or
received and used by the Covered Person will not be considered eligible.
33. Infertility: Expenses related to or in connection with fertility studies, sterility studies, procedures to
restore or enhance fertility, artificial insemination, or in -vitro fertilization, or any other assisted
reproductive technique.
34. Mailing: Expenses for mailing and /or shipping and handling expenses will not be considered eligible.
35. Maintenance Therapy: Expenses for Maintenance Therapy of any type when the individual has
reached the maximum level of improvement will not be considered eligible.
36. Maternity /Pregnancy: Expenses for maternity expenses incurred by a Dependent other than an
Employee's spouse will not be considered eligible.
37. Medically Necessary: Expenses for services, supplies or treatments or procedures, surgical or
otherwise, not recognized as generally accepted and Medically Necessary for the diagnosis and /or
treatment of an active Illness or Injury.
38. Missed Appointments /Not Rendered In Physical Presence: Expenses for completion of claim
forms, missed appointments, telephone consultations, or for treatment which is not rendered by or
in the physical presence of a Physician or Licensed Health Care Provider, expedited processing fees,
shipping and handling feels will not be considered eligible.
39. No Legal Obligation: Expenses for which the Covered Person is not, in the absence of this
coverage, legally obligated to pay, or for which a charge would not ordinarily be made in the absence
of this coverage.
40. Non - Medical Expenses: Expenses for non - medical expenses such as training, education,
instructions or educational materials, even if they are performed, provided or prescribed by a
Physician are not considered eligible, except as specified under Medical Benefits.
41. Non - Prescription Contraceptives: Charges for contraceptives supplies or devices available without
a Physician's prescription or contraceptives provided over - the - counter.
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12/13/2011 Item 16.E.4.
General Exclusions and Limitations
42. Not Performed Under the Direction of a Physician: Expenses for services and supplies which are
not prescribed or performed by or under the direction of a Physician will not be considered eligible.
43. Nutritional Supplements: Expenses for non - prescription vitamins or nutritional supplements.
44. Obesity: Expenses in connection with services or supplies provided for the treatment of obesity and
weight reduction, including bariatric surgery or any other related bariatric procedure, except as
specified for Bariatric Surgery under Medical Benefits or as specified underthe Weight Loss Program.
45.Prior to Effective Date: Expenses for services rendered or started, or supplies furnished prior to the
effective date of coverage under the Plan, or after coverage is terminated under the Plan, except as
specifically provided for in the Plan provisions.
46. Refractive Errors: Expenses for any surgical, medical or Hospital services and /or supplies rendered
in connection with radial keratotomy, LASIK or any other procedure designed to correct
farsightedness, nearsightedness or astigmatism.
47. Routine Care: Expenses for routine medical examinations, routine health check -ups or preventive
immunizations not necessary for the treatment of an Injury or Illness, except as specified under
Medical Benefits.
48. Sales Tax: Expenses for sales tax will not be considered eligible.
49. Sexual dysfunction: Expenses for any services, care or treatment for sexual dysfunction, trans-
sexualism, gender dysphoria or sexual reassignment including related drugs, medications, surgery,
medical or Psychiatric Care or treatment will not be considered eligible, except as specified under
Medical Benefits.
50. Stand -by Physician: Expenses for technical medical assistance or stand -by Physician services will
not be considered eligible.
51. Sterilization: Expenses resulting from or in connection with the reversal of an elective sterilization
procedure.
52. Surrogate: Expenses related to surrogate services will not be considered eligible.
53. Tobacco Cessation: Expenses for tobacco cessation programs, including tobacco deterrents not
incurred thru The MedCenter will not be considered eligible except as specified under the Health Plan
Qualifiers section. See Medical Benefits.
54. Travel: Expenses Incurred for travel by any person for any reason will not be considered eligible.
55. Useful to Persons in Absence of Illness or Injury: Expenses for services, treatments or supplies
that may be useful to persons in the absence of Illness or Injury such as air conditioners, purifiers,
humidifiers, special furniture, bicycles, whirlpools, dehumidifiers, exercise equipment, health club
memberships, etc., whether or not they have been prescribed or recommended by a Physician.
56. Usual, Customary and Reasonable: Expenses in excess of the Usual, Customary and Reasonable
limits of the Plan will not be considered eligible.
57. Vision Care: Expenses in connection with eye refractions, the purchase or fitting of eyeglasses or
contact lenses, except as specifically listed as a covered expense following cataract surgery.
58. War: Expenses which are caused by or arising out of war or act of war, (whether declared or
undeclared), civil unrest, armed invasion or aggression, or caused during service in the armed forces
of any country.
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12/13/2011 Item 16.E.4.
General Exclusions and Limitations
59. Weekend Admissions: Expenses for care and treatment billed by a Hospital for non - Medical
Emergency admissions on a Friday or Saturday will not be considered eligible, unless surgery is
scheduled within twenty -four (24) hours.
60. Work Related: Expenses Incurred by the Covered Person for all services and supplies resulting from
any Illness or Injury which occurs in the course of employment for wage or profit, or in the course of
any volunteer work when the organization, for whom the Covered Person is volunteering, has elected
or is required by law to obtain coverage for such volunteer work under state or federal workers'
compensation laws or other legislation, including Employees' compensation or liability laws of the
United States (collectively called "Workers' Compensation "). This exclusion applies to all such
services and supplies resulting from a work - related Illness or Injury even though:
A. Coverage for the Covered Person under Workers' Compensation provides benefits for only
a portion of the services Incurred;
B. The Covered Person's employer /volunteer organization has failed to obtain such coverage
required by law;
C. The Covered Person waived his /her rights to such coverage or benefits;
D. The Covered Person fails to file a claim within the filing period allowed by law for such
benefits;
E. The Covered Person fails to comply with any other provision of the law to obtain such
coverage or benefits; or
F. The Covered Person is permitted to elect not to be covered by Workers' Compensation but
failed to properly make such election effective.
G. The Covered Person is permitted to elect not to be covered by Workers' Compensation and
has affirmatively made that election.
This exclusion will not apply to household and domestic employment, employment not in the
usual course of the trade, business, profession or occupation of the Covered Person or
employer, or employment of a Dependent member of an employer's family for whom an
exemption may be claimed by the Employer under the Internal Revenue Code.
Collier County Government - Group #2003021 47 Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
COORDINATION OF BENEFITS
The Coordination of Benefits provision prevents the payment of benefits which exceed the Allowable Expense.
It applies when the Participant or Dependent who is covered by this Plan is or may also be covered by any
other plan(s). This Plan will always pay either its benefits in full or a reduced amount which, when added to
the benefits payable by the other plan(s), will not exceed 100% of Allowable Expense. Only the amount paid
by this Plan will be charged against the Plan maximums.
In the event of a motor vehicle or premises accident; or an act of violence with the intent to disrupt electronic,
communications, or any other business system, this Plan will be secondary to any auto "no fault" and
traditional auto "fault" type contracts, homeowners, commercial general liability insurance and any other
medical benefits coverage.
The Coordination of Benefits provision applies whether or not a claim is filed under the other plan or plans.
If needed, authorization is hereby given this Plan to obtain information as to benefits or services available from
the other plan or plans, or to recover overpayments.
All benefits contained in the Plan Document are subject to this provision.
DEFINITIONS
"Allowable Expense" as used herein means:
If the claim as applied to the primary plan is subject to a contracted or negotiated rate, Allowable
Expense will be equal to that contracted or negotiated amount.
If the claim as applied to the primary plan is not subject to a contracted or negotiated rate, but the
claim as applied to the secondary plan is subject to a contracted or negotiated rate, the Allowable
Expense will be equal to that contracted or negotiated amount of the secondary plan.
If the claim as applied to the primary plan and the secondary plan is not subject to a contracted or
negotiated rate, then the Allowable Expense will equal to the secondary plan's chosen limits for non -
contracted providers.
"Plan" as used herein means any Plan providing benefits or services for or by reason of medical, dental or
vision treatment, and such benefits or services are provided by:
Group insurance or any other arrangement for coverage for Covered Persons in a group whether on
an insured or uninsured basis, including but not limited to:
A. Hospital indemnity benefits; and
B. Hospital reimbursement -type plans which permit the Covered Person to elect indemnity at
the time of claims; or
2. Hospital or medical service organizations on a group basis, group practice and other group pre-
payment plans; or
3. Hospital or medical service organizations on an individual basis having a provision similar in effect
to this provision; or
4. A licensed Health Maintenance Organization (H.M.O.); or
Any coverage for students which is sponsored by, or provided through a school or other educational
institution; or
Collier County Government - Group #2003021 48 Plan Document / SPD - Effective 1/1/2012
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y
12/13/2011 Item 16.E.4.
Coordination of Benefits
6. Any coverage under a Governmental program, and any coverage required or provided by any statute;
or
7. Automobile insurance; or
8. Individual automobile insurance coverage on an automobile leased or owned by the County or any
responsible third -party tortfeasor; or
9. Individual automobile insurance coverage based upon the principles of "No- Fault" coverage; or
10. Homeowner or premise liability insurance, individual or commercial.
"Plan" will be construed separately with respect to each policy, contract, or other arrangement for benefits or
services, and separately with respect to that portion of any such policy, contract, or other arrangement which
reserves the right to take the benefits or services of other Plans into consideration in determining its benefits
and that portion which does not.
ORDER OF BENEFIT DETERMINATION
Non- Dependent/Dependent
The plan that covers the person as other than a dependent, (e.g., as an employee, member,
subscriber, retiree) is primary and the plan that covers the person as a dependent is secondary.
Child Covered Under More Than One Plan
A. The primary plan is the plan of the parent whose birthday is earlier in the year if:
1) The parents are married;
2) The parents are not separated (whether or not they have ever been married), or
3) A court decree awards joint custody without specifying that one parent has the
responsibility to provide health care coverage.
B. If both parents have the same birthday, the plan that has covered either of the parents longer
is primary.
C. If the specific terms of a court decree state that one of the parents is responsible for the
child's health care expenses or health care coverage and the plan of that parent has actual
knowledge of those terms, that plan is primary. If the parent with financial responsibility has
no coverage for the child's health care services or expenses, but that parent's spouse does,
the spouse's plan is primary. This subparagraph will not apply with respect to any claim
determination period, Benefit Period or Plan Year during which benefits are paid or provided
before the entity has actual knowledge.
D. If the parents are not married or are separated (whether or not they were ever married) or are
divorced, and there is no court decree allocating responsibility for the child's health care
services or expenses, the order of benefit determination among the plans of the parents and
the parents' spouses (if any) is:
1) the plan of the custodial parent
2) the plan of the spouse of the custodial parent
3) the plan of the non - custodial parent
4) the plan of the spouse of the non - custodial parent
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12/13/2011 Item 16.E.4.
Coordination of Benefits
3. Active or Inactive Employee
The Plan that covers a person as an employee who is neither laid -off nor retired (or as that
employee's dependent) is primary. If the other plan does not have this rule, and if, as a result, the
plans do not agree on the order of benefits, this rule will not be followed.
4. Longer or Shorter Length of Coverage
If the preceding rules do not determine the order of benefits, the plan that has covered the person for
the longer period of time is primary.
A. To determine the length of time a person has been covered under a plan, two plans will be
treated as one if the Covered Person was eligible under the second within 24 hours after the
first ended.
B. The start of a new plan does not include:
1) A change in the amount or scope of a plan's benefits
2) A change in the entity that pays, provides, or administers the plan's benefits; or
3) A change from one type of plan to another (such as from a single employer plan to
that of a multiple - employer plan).
C. A person's length of time covered under a plan is measured from the person's first date of
coverage under that plan. If that date is not readily available for a group plan, the date the
person first became a member of the group will be used as the date from which to determine
the length of time the person's coverage under the present plan has been in force.
No Rules Apply
If none of these preceding rules determines the primary plan, the Allowable Expense will be
determined equally between the plans.
COORDINATION WITH MEDICARE
Medicare Part A or Part B will be considered a plan for the purposes of coordination of benefits. This
Plan will coordinate benefits with Medicare whether or not the Covered Person is actually receiving
Medicare Benefits. This means that the plan will only pay the amount that Medicare would not have
covered, even if the Covered Person does not elect to be covered under Medicare. Also, failure to
enroll in Medicare Part B when a person is initially eligible may result in the person being assessed
a significant surcharge by Medicare for late enrollment in Part B.
For Working Aged
A covered Employee who is eligible for Medicare Part A or Part B as a result of age may be covered
under this Plan and be covered under Medicare, in which case this Plan will pay primary. A covered
Employee, eligible for Medicare Part A or Part B as a result of age, may elect not to be covered under
this Plan. If such election is made, coverage under this Plan will terminate.
A covered Dependent, eligible for Medicare Part A or Part B as a result of age, of a covered
Employee may also be covered under this Plan and be covered under Medicare, in which case the
Plan again will pay primary. A covered Dependent, eligible for Medicare Part A or Part B as a result
of age, may elect not to be covered under this Plan. If such election is made, coverage under this
Plan will terminate.
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12/13/2011 Item 16.E.4.
Coordination of Benefits
2. For Retired Persons
Medicare is primary and the Plan will be secondary for the covered Retiree if he /she is an individual
who is enrolled in Medicare Part A or Part B as a result of age and retired.
Medicare is primary and the Plan will be secondary for the covered Retiree's Dependent who is
enrolled in Medicare Part A or B if both the covered Retiree and his /her covered Dependent are
enrolled in Medicare Part A or Part B as a result of age and retired.
Medicare is primary for the Retiree's Dependent when the Retiree is not enrolled for Medicare Part
A or Part B as a result of age and the Retiree's Dependent is enrolled in Medicare Part A or Part B
as a result of age.
For Covered Persons who are Disabled
The Plan is primary and Medicare will be secondary for the covered Employee or any covered
Dependent who is eligible for Medicare by reason of disability, if the Employee is actively employed
by the Employer.
The Plan is secondary and Medicare will be primary for the covered Employee or any covered
Dependent who is eligible for Medicare by reason of disability if the Employee is retired or otherwise
not actively working for the Employer.
4. For Covered Persons with End Stage Renal Disease
Except as stated below*, for Employees or Retirees and their Dependents, if Medicare eligibility is due
solely to End Stage Renal Disease (ESRD), this Plan will be primary only during the first thirty (30)
months of Medicare coverage. Thereafter, this Plan will be secondary with respect to Medicare
coverage, unless after the thirty -month period described above, the Covered Person has no dialysis
for a period of twelve (12) consecutive months and:
A. Then resumes dialysis, at which time the Plan will again become primary for a period of thirty
(30) months; or
B. The Covered Person undergoes a kidney transplant, at which time the Plan will again
become primary for a period of thirty (30) months.
*If a Covered Person is covered by Medicare as a result of disability, and Medicare is primary for that
reason on the date the Covered Person becomes eligible for Medicare as a result of End Stage Renal
Disease, Medicare will continue to be primary and the Plan will be secondary.
COORDINATION WITH MEDICAID
If a Covered Person is also entitled to and covered by Medicaid, the Plan will always be primary and Medicaid
will always be secondary coverage.
COORDINATION WITH TRICARE /CHAMPVA
If a Covered Person is also entitled to and covered under TRICARE /CHAMPVA, the Plan will always be
primary and TRICARE /CHAMPVA will always be secondary coverage. TRICARE coverage will include
programs established under its authority, known as TRICARE Standard, TRICARE Extra and TRICARE
Prime.
If the Covered Person is eligible for Medicare and entitled to veterans benefits through the Department of
Veterans Affairs (VA), the Plan will always be primary and the VA will always be secondary for non - service
connected medical claims. For these claims, the Plan will make payment to the VA as though the Plan was
making payment secondary to Medicare.
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12/13/2011 Item 16.E.4.
PROCEDURES FOR CLAIMING BENEFITS
Claims must be submitted to the Plan within twelve (12) months after the date services or treatments are
received or completed. Non - electronic claims may be submitted on any approved claim form, available from
the provider. The claim must be completed in full with all the requested information. A complete claim must
include the following information:
• Date of service;
• Name of the Participant;
• Name and date of birth of the patient receiving the treatment or service and his /her
relationship to the Participant;
• Diagnosis [code] of the condition being treated;
• Treatment or service [code] performed;
• Amount charged by the provider for the treatment or service; and
• Sufficient documentation, in the sole determination of the Plan Administrator, to support the
medical necessity of the treatment or service being provided and sufficient to enable the Plan
Supervisor to adjudicate the claim pursuant to the terms and conditions of the Plan.
When completed, the claim must be sent to the Plan Supervisor, Allegiance Benefit Plan Management, Inc.,
at P.O. Box 3018, Missoula, Montana 59806 -3018, (855) 333 -1004 or through any electronic claims
submission system or clearinghouse to which Allegiance Benefit Plan Management, Inc. has access.
A claim will not, under any circumstances, be considered for payment of benefits if initially submitted to the
Plan more than twelve (12) months from the date that services were incurred.
Upon termination of the Plan, final claims must be received within three (3) months of the date of termination,
unless otherwise established by the Plan Administrator.
CLAIMS WILL NOT BE DEEMED SUBMITTED UNTIL RECEIVED BY THE PLAN SUPERVISOR.
The Plan will have the right, in its sole discretion and at its own expense, to require a claimant to undergo a
medical examination, when and as often as may be reasonable, and to require the claimant to submit, or
cause to be submitted, any and all medical and other relevant records it deems necessary to properly
adjudicate the claim.
CLAIM DECISIONS ON CLAIMS AND ELIGIBILITY
Claims will be considered for payment according to the Plan's terms and conditions, industry- standard claims
processing guidelines and administrative practices not inconsistent with the terms of the Plan. The Plan may,
when appropriate or when required by law, consult with relevant health care professionals and access
professional industry resources in making decisions about claims that involve specialized medical knowledge
or judgment. Initial eligibility and claims decisions will be made within the time periods stated below. For
purposes of this section, "Covered Person" will include the claimant and the claimant's Authorized
Representative; "Covered Person" does not include a health care provider or other assignee, and said health
care provider or assignee does not have an independent right to appeal an Adverse Benefit Determination
simply by virtue of the assignment of benefits.
"Authorized Representative" means a representative authorized by the claimant to act on their behalf in
pursuing a benefit claim or appeal of an Adverse Benefit Determination. The claimant must authorize the
representative in writing, and this written authorization must be provided to the Plan. The Plan will recognize
this Authorized Representative when the Plan receives the written authorization.
INFORMATION REGARDING URGENT CARE CLAIMS IS PROVIDED TO YOU UNDER THE
DISCLOSURE REQUIREMENTS OF APPLICABLE LAW; THE PLAN DOES NOT MAKE TREATMENT
DECISIONS. ANY DECISION TO RECEIVE TREATMENT MUST BE MADE BETWEEN THE PATIENT
AND HIS OR HER HEALTHCARE PROVIDER; HOWEVER, THE PLAN WILL ONLY PAY BENEFITS
ACCORDING TO THE TERMS, CONDITIONS, LIMITATIONS AND EXCLUSIONS OF THIS PLAN.
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12/13/2011 Item 16.E.4.
Procedures for Claiming Benefits
1. Urgent Care Claims - An Urgent Care Claim is any claim for medical care or treatment with respect
to which:
A. In the judgment of a prudent layperson possessing an average knowledge of health and
medicine could seriously jeopardize the life or health of the claimant or the ability of the
claimant to regain maximum function; or
B. In the opinion of a Physician with knowledge of the claimant's medical condition, would
subject the claimant to severe pain that cannot be adequately managed without the care or
treatment that is the subject of the claim.
There are no Urgent Care requirements under this Plan and therefore, there are no rights to
appeal a pre- service Urgent Care claim denial.
2. Pre - Service Claims - Pre - Service Claims must be submitted to the Plan before the Covered Person
receives medical treatment or service. A Pre - Service Claim is any claim for a medical benefit which
the Plan terms condition the Covered Person's receipt of the benefit, in whole or in part, on approval
of the benefit before obtaining treatment. Pre - Service Claims are procedures stated in the Plan
Document which, the Plan recommends be utilized before a Covered Person obtains medical care.
3. Post - Service Claims - A Post - Service Claim is any claim for a medical benefit under the Plan with
respect to which the terms of the Plan do not condition the Covered Person's receipt of the benefit,
or any part thereof, on approval of the benefit prior to obtaining medical care, and for which medical
treatment has been obtained prior to submission of the claim(s).
In most cases, initial claims decisions on Post - Service Claims will be made within thirty (30) days of
the Plan's receipt of the claim. The Plan will provide timely notice of the initial determination once
sufficient information is received to make an initial determination, but no later than thirty (30) days
after receiving the claim.
4. Concurrent Care Review - For patients who face early termination or reduction of benefits for a
course of treatment previously certified by the Plan, a decision by the Plan to reduce or terminate
benefits for ongoing care is considered an Adverse Benefit Determination. (Note: Exhaustion of the
Plan's benefit maximums is not an Adverse Benefit Determination.) The Plan will notify the Covered
Person sufficiently in advance to allow an appeal for uninterrupted continuing care before the benefit
is reduced or terminated. Any request to extend an Urgent Care course of treatment beyond the
initially prescribed period of time must be decided within twenty -four (24) hours of the Plan's receipt
of the request. The appeal for ongoing care or treatment must be made to the Plan at least twenty -
four (24) hours prior to the expiration of the initially - prescribed period.
APPEALING AN UN- REIMBURSED PRE - SERVICE CLAIM
If a claim is denied in whole or in part, the Covered Person will receive written notification of the Adverse
Benefit Determination. A claim denial will be provided by the Plan showing:
1. The reason the claim was denied;
2. Reference(s) to the specific plan provision(s) or rule(s) upon which the decision was based which
resulted in the Adverse Benefit Determination;
3. Any additional information needed to perfect the claim and why such information is needed; and
4. An explanation of the Covered Person's right to appeal the Adverse Benefit Determination for a full
and fair review and the right to bring a civil action following an Adverse Benefit Determination on
appeal.
Collier County Government - Group #2003021 53 Plan Document / SPD - Effective 1/112012
Packet Page -2998-
12/13/2011 Item 16.E.4.
Procedures for Claiming Benefits
If a Covered Person does not understand the reason for any Adverse Benefit Determination, he or she should
contact the Plan Supervisor at the address or telephone number shown on the claim denial.
The Covered Person must appeal the Adverse Benefit Determination before the Covered Person may
exercise his or her right to bring a civil action. This Plan provides two (2) levels of benefit
determination review and the Covered Person must exercise both levels of review before bringing a
civil action.
To initiate the first level of benefit review, the Covered Person must submit in writing an appeal or a request
for review of the Adverse Benefit Determination to the Plan within one hundred eighty (180) days after the
Adverse Benefit Determination. The Covered Person should include any additional information supporting
the appeal or the information required by the Plan which was not initially provided and forward it to the Plan
Supervisor within the 180-daytime period. Failure to appeal the Adverse Benefit Determination within the 180 -
day time period will render the determination final. Any appeal received after the 180 -day time period has
expired will receive no further consideration.
Appeals or requests for review of Adverse Benefit Determinations for Pre - Service Claims must be
submitted in writing to Community Health Partners, P.O. Box 9529, Naples, FL 34101. Supporting
materials may be submitted via facsimile at (239) 659 -7799.
Appeals or requests for review of Adverse Benefit Determinations for Post - Service Claims must be
submitted to the Plan in writing to P.O. Box 1269, Missoula, MT 59806 -1269. Supporting materials may
be submitted via mail, electronic claims submission process, facsimile (fax) or electronic mail (e- mail).
First Level of Benefit Determination Review
The first level of benefit determination review is done by Community Health Partners (CHP). CHP
will research the information initially received and determine if the initial determination was
appropriate based on the terms and conditions of the Plan and other relevant information. Notice of
the decision on the first level of review will be sent to the Covered Person within fifteen (15) days
following the date CHP receives the request for reconsideration.
If, based on CHP's review, the initial Adverse Benefit Determination remains the same and the
Covered Person does not agree with that benefit determination, the Covered Person must initiate the
second level of benefit review. The Covered Person must request the second review in writing and
send it to CHP, not later than sixty (60) days after receipt of CHP's decision from the first level of
review. Failure to initiate the second level of benefit review within the 60 -day time period will render
the determination final
2. Second Level of Benefit Determination Review
The Plan Administrator will review the claim in question along with the additional information
submitted by the Covered Person. The Plan will conduct a full and fair review of the claim by the Plan
Administrator who is neither the original decisionmaker nor the decisionmaker's subordinate. The
Plan Administrator cannot give deference to the initial benefit determination. The Plan Administrator
may, when appropriate or if required by law, consult with relevant health care professionals in making
decisions about appeals that involve specialized medical judgment. Where the appeal involves issues
of medical necessity or experimental treatment, the Plan Administrator will consult with a health care
professional with appropriate training who was neither the medical professional consulted in the initial
determination or his or her subordinate.
After a full and fair review of the Covered Person's appeal, the Plan will provide a written or electronic
notice of the final benefit determination, which contains the same information as notices for the initial
determination, within fifteen (15) days.
Collier County Government - Group #2003021 54 Plan Document / SPD - Effective 1/1/2012
Packet Page -2999-
12/13/2011 Item 16.E.4.
Procedures for Claiming Benefits
APPEALING AN UN- REIMBURSED POST - SERVICE CLAIM
If a claim is denied in whole or in part, the Covered Person will receive written notification of the Adverse
Benefit Determination. A claim Explanation of Benefits (EOB) will be provided by the Plan showing:
The reason the claim was denied;
2. Reference(s) to the specific plan provision(s) or rule(s) upon which the decision was based which
resulted in the Adverse Benefit Determination;
3. Any additional information needed to perfect the claim and why such information is needed; and
4. An explanation of the Covered Person's right to appeal the Adverse Benefit Determination for a full
and fair review and the right to bring a civil action following an Adverse Benefit Determination on
appeal.
If a Covered Person does not understand the reason for any Adverse Benefit Determination, he or she should
contact the Plan Supervisor at the address or telephone number shown on the EOB form.
The Covered Person must appeal the Adverse Benefit Determination before the Covered Person may
exercise his or her right to bring a civil action. This Plan provides two (2) levels of benefit
determination review and the Covered Person must exercise both levels of review before bringing a
civil action.
To initiate the first level of benefit review, the Covered Person must submit in writing an appeal or a request
for review of the Adverse Benefit Determination to the Plan within one hundred eighty (180) days after the
Adverse Benefit Determination. The Covered Person should include any additional information supporting
the appeal or the information required by the Plan which was not initially provided and forward it to the Plan
Supervisor within the 180 -day time period. Failure to appeal the Adverse Benefit Determination within the 180 -
day time period will render the determination final. Any appeal received after the 180 -day time period has
expired will receive no further consideration.
Appeals or requests for review of Adverse Benefit Determinations must be submitted to the Plan in
writing to P.O. Box 1269, Missoula, MT 59806 -1269. Supporting materials may be submitted via mail,
electronic claims submission process, facsimile (fax) or electronic mail (e- mail).
First Level of Benefit Determination Review
The first level of benefit determination review is done by the Plan Supervisor. The Plan Supervisor
will research the information initially received and determine if the initial determination was
appropriate based on the terms and conditions of the Plan and other relevant information. Notice of
the decision on the first level of review will be sent to the Covered Person within thirty (30) days
following the date the Plan Supervisor receives the request for reconsideration.
If, based on the Plan Supervisor's review, the initial Adverse Benefit Determination remains the same
and the Covered Person does not agree with that benefit determination, the Covered Person must
initiate the second level of benefit review. The Covered Person must request the second review in
writing and send it to the Plan Supervisor, not later than sixty (60) days after receipt of the Plan
Supervisor's decision from the first level of review. Failure to initiate the second level of benefit review
within the 60 -day time period will render the determination final.
Collier County Government - Group #2003021 55 Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
Procedures for Claiming Benefits
2. Second Level of Benefit Determination Review
The Plan Administrator will review the claim in question along with the additional information
submitted by the Covered Person. The Plan will conduct a full and fair review of the claim by the Plan
Administrator who is neither the original decisionmaker nor the decisionmaker's subordinate. The
Plan Administrator cannot give deference to the initial benefit determination. The Plan Administrator
may, when appropriate or if required by law, consult with relevant health care professionals in making
decisions about appeals that involve specialized medical judgment. Where the appeal involves issues
of medical necessity or experimental treatment, the Plan Administrator will consult with a health care
professional with appropriate training who was neitherthe medical professional consulted in the initial
determination or his or her subordinate.
After a full and fair review of the Covered Person's appeal, the Plan will provide a written or electronic
notice of the final benefit determination within a reasonable time, but no later than thirty (30) days from
the date the appeal is received by the Plan at each level of review. .
All claim payments are based upon the terms contained in the Plan Document, on file with the Plan
Administrator and the Plan Supervisor. The Covered Person may request, free of charge, more detailed
information, names of any medical professionals consulted and copies of relevant documents, as defined in
and required by law, which were used by the Plan to adjudicate the claim.
INDEPENDENT EXTERNAL REVIEW
After exhaustion of all appeal rights stated above, a Covered Person may also request a final independent
external review of any Adverse Benefit Determination involving a question of Medical Necessity, or other issue
requiring medical expertise for resolution.
To assert this right to independent external medical review, the Covered Person must request such review
in writing within one hundred twenty (120) days after a decision is made upon the second level benefit
determination above.
If an independent external review is requested for a Pre - Service Claim, CHP will forward the entire record on
appeal, within ten (10) days, to an independent external review organization (IRO) selected randomly. The
IRO will notify the Covered Person of its procedures to submit further information.
If an independent external review is requested for a Post - Service Claim, the Plan Supervisor will forward the
entire record on appeal, within ten (10) days, to an independent external review organization (IRO) selected
randomly. The IRO will notify the Covered Person of its procedures to submit further information.
The IRO will issue a final decision within forty -five (45) days after receipt of all necessary information.
The decision of the IRO will be final and binding except that the Covered Person shall have an additional right
to appeal the matter to a court with jurisdiction.
Collier County Government - Group #2003021 56 Plan Document / SPD - Effective 1/1/2012
Packet Page -3001-
12/13/2011 Item 16.E.4.
ELIGIBILITY PROVISIONS
If both the husband and wife are employed by the County, and both are eligible for Dependent Coverage,
either the husband or wife, but not both, may elect Dependent Coverage for their eligible Dependents. No one
can be covered under this Plan as both an Employee and a Dependent. No one can be covered under this
Plan as a Dependent by more than one Participant.
EMPLOYEE ELIGIBILITY
An Employee is eligible to participate in this Plan who is employed by the County on a continuing and regular
basis for at least twenty (20) hours per week.
An Employee is not eligible while on active military duty if that duty exceeds a period of thirty -one (31)
consecutive days.
WAITING PERIOD
With respect to a person covered by a previous plan or previous group health insurance of the Employer on
the effective date of this Plan, the effective date of coverage under this Plan will be the effective date of the
Plan.
With respect to an eligible employee, coverage under the Plan will not start until the Employee completes a
Waiting Period, which commences on the Enrollment Date (eligibility date) and will be either of the following:
If the Enrollment Date occurs on the first day of the month, the Waiting Period is waived; or
If the Enrollment Date occurs on any day other than the first day of the month, the Waiting Period will
end on the first day of the month following the Enrollment Date.
No Waiting Period will be considered a break in coverage for purposes of applying Creditable Coverage even
if an eligible person maintains no Creditable Coverage during said Waiting Period.
DEPENDENT ELIGIBILITY
An eligible Dependent includes any person who is a citizen, resident alien, or is otherwise legally present in
the United States or in any other jurisdiction that the related Participant has been assigned by the Employer,
and who is either:
The Participant's legal spouse of the opposite sex, according to the marriage laws of the state where
the marriage was first solemnized or established.
An eligible Dependent does not include a spouse who is legally separated or divorced from the
Participant and has a court order or decree stating such from a court of competent jurisdiction.
2. The Participant's Dependent child who meets all of the following "Required Eligibility Conditions ":
A. Is a natural child; step - child; legally adopted child; a child who has been Placed with the
Participant for adoption and for whom as part of such placement the Participant has a legal
obligation for the partial or full support of such child, including providing coverage under the
Plan pursuant to a written agreement; a person for whom the Participant has been appointed
the legal guardian by a court of competent jurisdiction prior to the person attaining nineteen
(19) years of age; and
Collier County Government - Group #2003021 57 Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
Eligibility Provisions
B. Is less than twenty -six (26) years of age. A Dependent child is eligible until the end of the
Calendar Year in which twenty -six (26) years of age is attained. This requirement is waived
if the Participant's child is mentally handicapped /challenged or physically
handicapped /challenged, provided that the child was incapable of self- supporting
employment and was chiefly dependent upon the Participant for support and maintenance
prior to end of the Calendar month in which he /she attained twenty -six (26) years of age.
Proof of incapacity must be furnished to the Plan Administrator upon request, and additional
proof may be required from time to time; and
Dependents on active military duty for more than thirty-one (31) consecutive days are not eligible.
EXTENDED COVERAGE FOR DEPENDENTS
An Extended - Coverage Child as defined by Florida Statute 627.6562 who is twenty -six (26) years of age but
less than thirty (30) years of age may continue to be an eligible Dependent if the Dependent child was covered
under this Plan on the last day of the Calendar Year after the Dependent child attains twenty -six (26) years
of age and meets all of the following criteria required by Florida Statute:
1. Unmarried without Dependents of their own; and
2. A Florida resident or a full or part-time student; and
3. Not provided coverage under any other health plan or policy; and
4. Not entitled to coverage under Medicare.
The eligible Employee must make an election to continue coverage for the Extended - Coverage Child, and file
an Affidavit of Dependent Eligibility, within thirty -one (31) days following the date such child ceases to satisfy
the eligibility requirements for eligible Dependent coverage under the Plan. If an eligible Employee fails to
make an election to continue coverage under this provision within the time frame or if coverage under this
provision terminates, the child will be eligible to make an election to continue coverage in accordance with the
COBRA Continuation Coverage section of this Plan.
The eligible Employee or Extended - Coverage Child is required to pay the entire amount of the cost of
coverage for the Extended - Coverage Child under this provision in accordance with the same procedures
established under the COBRA Continuation of Coverage section of this Plan.
PARTICIPANT ELIGIBILITY FOR DEPENDENT COVERAGE
Each Employee will become eligible for Dependent Coverage on the latest of: 1) the date the Employee
becomes eligible for Participant coverage; or 2) the date on which the Employee first acquires a Dependent.
DECLINING COVERAGE
If an eligible person declines coverage under this Plan, he /she will state his /her reason(s) for declining, in
writing. Failure to provide those reasons in writing may result in the Plan refusing enrollment at a later date
or imposing a Pre - existing Condition Limitation period of up to eighteen (18) months as a Late Enrollee.
RETIREE ELIGIBILITY
An Employee is eligible to continue coverage under this Plan as a Retiree if they are a Qualifying Retiree of
Collier County Government. Eligible Dependents of a Qualifying Retiree may also continue coverage under
this Plan. Qualifying Retirees must meet the requirements of Florida Statute 112.0801.
Collier County Government - Group #2003021 58 Plan Document / SPD - Effective 1/1/2012
Packet Page -3003-
12/13/2011 Item 16.E.4.
EFFECTIVE DATE OF COVERAGE
All coverage under the Plan will commence at 12:01 A.M. in the time zone in which the Covered Person
permanently resides, on the date such coverage becomes effective.
PARTICIPANT COVERAGE
Participant coverage under the Plan will become effective on the date the Employee satisfies the applicable
eligibility requirements and Waiting Period, provided that application for such coverage is made on the Plan's
enrollment form within thirty -one (31) days immediately following the Enrollment Date.
An eligible Employee who declines Participant coverage under the Plan during the Initial Enrollment Period
will be able to become covered later in only two situations, Open Enrollment and Special Enrollment.
DEPENDENT COVERAGE
Each Participant who requests Dependent Coverage on the Plan's enrollment form will become covered for
Dependent Coverage as follows:
On the Participant's effective date of coverage, if application for Dependent Coverage is made on the
Plan's enrollment form within thirty -one (31) days immediately following the Participant's Enrollment
Date. This subsection applies only to Dependents who are eligible on the Participant's effective date
of coverage. Enrollment under this subsection will not be considered Late Enrollment.
2. In the event a Dependent is acquired after the Participant's effective date of coverage as a result of
a legal guardianship or in the event that a Participant is required to provide coverage as a result of
a valid court order, or if the Dependent is acquired as a result of operation of law, Dependent
Coverage will begin on the first day of the month following the Plan's receipt of an enrollment form
and copy of said court order, if applicable. Enrollment under this subsection will not be considered
Late Enrollment.
RETIREE COVERAGE
Coverage for a Qualifying Retiree and eligible Dependents will become effective on the first day of the month
following the date of retirement, provided that application for coverage is made on the Plan's enrollment form
with thirty -one (31) days from the last day of the month following the date of retirement.
The Open Enrollment Period will begin November 1" and will end as determined by the Plan Administrator.
During any Open Enrollment Period an Employee and the Employee's eligible Dependents, who are not
covered under this plan, may request Participant or Dependent coverage. Coverage must be requested on
the Plan's enrollment form. Also during any Open Enrollment Period, Participants and their covered
Dependents will be able to make a change in coverage under this Plan. A person who enrolls during an Open
Enrollment Period will be considered a Late Enrollee, and subject to a maximum eighteen (18) month Pre-
existing Condition exclusionary period, except for individuals eligible for the first time or whose initial eligibility
coincides with the Open Enrollment Period.
Coverage or changes requested during any Open Enrollment Period will begin on January 1" immediately
following the Open Enrollment Period and will remain in effect until the next January 1 ", except as otherwise
allowed during a Special Enrollment Period.
Collier County Government - Group #2003021 59 Plan Document/ SPD - Effective 1/1/2012
Packet Page -3004-
12/13/2011 Item 16.E.4.
Effective Date of Coverage
SPECIAL ENROLLMENT PERIOD
In addition to other enrollment times allowed by this Plan, certain persons may enroll during the Special
Enrollment Periods described below. An eligible person who makes a special enrollment request during any
such applicable Special Enrollment Period will not be considered a Late Enrollee.
. "Special Enrollment Period" means a period of time allowed under this Plan, other than the eligible person's
Initial Enrollment Period or an Open Enrollment Period, during which an eligible person can request coverage
under this Plan as a result of certain events that create special enrollment rights.
Coverage will become effective on the date of the event if the Employee or Retiree makes a special enrollment
request, verbally or in writing, within thirty -one (31) days of any special enrollment event and application for
such coverage is made on the Plan's enrollment form within sixty (60) days of the event.
1. An eligible Employee or Retiree who is not enrolled and eligible Dependents, including step children,
who are acquired under the following specific events may enroll and become covered:
A. Marriage to the Employee or Retiree;
B. Birth of the Employee's or Retiree's child; or
C. Adoption of a child by the Employee or Retiree, provided the child is under the age of 19; or
D. Placement for Adoption with the Employee or Retiree, provided such Employee or Retiree
has a legal obligation for the partial or full support of such child, including providing coverage
under the Plan pursuant to a written agreement and the child is under the age of 19.
2. A Participant may enroll eligible Dependents, including step children, who are acquired under the
following specific events:
A. Marriage to the Participant or the covered Retiree;
B. Birth of the Participant's or covered Retiree's child; or
C. Adoption of a child by the Participant or covered Retiree, provided the child is under the age
of 19; or
D. Placement for Adoption with the Employee or Retiree, provided such Employee or Retiree
has a legal obligation for the partial orfull support of such child, including providing coverage
under the Plan pursuant to a written agreement and the child is under the age of 19.
The spouse of a Participant (Covered Employee) or covered Retiree, may enroll and will become
covered on the date of the following specific events:
A. Marriage to the Participant or covered Retiree;
B. Birth of the Participant's or covered Retiree's child; or
C. Adoption of a child by the Participant or covered Retiree, provided the child is under the age
of 19; or
D. Placement for Adoption with the Employee or Retiree, provided such Employee or Retiree
has a legal obligation for the partial or full support of such child, including providing coverage
under the Plan pursuant to a written agreement and the child is under the age of 19.
Collier County Government - Group #2003021 60 Plan Document / SPD - Effective 1/1/2012
Packet Page -3005-
12/13/2011 Item 16.E.4.
Effective Date of Coverage
4. The following individuals may enroll and become covered when coverage under another health care
plan or health insurance is terminated due to loss of eligibility or if employer contributions to the other
coverage have been terminated (Loss of Coverage), subject to the following:
A. If the eligible Employee or Retiree loses coverage, the eligible Employee or Retiree who lost
coverage and any eligible Dependents of the eligible Employee or Retiree may enroll and
become covered.
B. If an eligible Dependent loses coverage, the eligible Dependent who lost coverage and the
eligible Employee or Retiree may enroll and become covered.
Further, Loss of Coverage means only one of the following:
A. COBRA Continuation Coverage under another plan and the maximum period of COBRA
Continuation Coverage under that other plan has been exhausted; or
B. Group or insurance health coverage that has been terminated as a result of termination of
Employer contributions" towards that other coverage; or
C. Group or insurance health coverage (includes other coverage that is Medicare) that has been
terminated only as a result of a loss of eligibility for coverage for any of the following:
1) Legal separation or divorce of the eligible Employee or Retiree;
2) Cessation of Dependent status;
3) Death of the eligible Employee or Retiree;
4) Termination of employment of the eligible Dependent;
5) Reduction in the number of hours of employment of the eligible Dependent;
6) Termination of the eligible Dependent's employer's plan; or
7) Any loss of eligibility after a period that is measured by reference to any of the
foregoing; or
8) Any loss of eligibility for individual or group coverage because the eligible Employee,
Retiree or Dependent no longer resides, lives or works in the service area of the
HMO or other such plan.
*Employer contributions include contributions by any current or former employer that was
contributing to the other non -COBRA coverage.
A loss of eligibility for coverage does not occur if coverage was terminated due to a failure of the
Employee, Retiree or Dependent to pay premiums on a timely basis or coverage was terminated for
cause.
Individuals may enroll and become covered when coverage under Medicaid or any state children's
insurance program recognized under the Children's Health Insurance Program Reauthorization Act
of 2009 is terminated due to loss of eligibility, subject to the following:
A. A request for enrollment must be made either verbally or in writing within sixty (60) days after
this special enrollment event, and written application for such coverage must be made within
ninety (90) days after such event.
B. If the eligible Employee or Retiree loses coverage, the eligible Employee or Retiree who lost
coverage and any eligible Dependents of the eligible Employee or Retiree may enroll and
become covered.
C. If an eligible Dependent loses coverage, the eligible Dependent who lost coverage and the
eligible Employee or Retiree may enroll and become covered.
Collier County Government - Group #2003021 61 Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
Effective Date of Coverage
6. Individuals who are eligible for coverage under this Plan may enroll and become covered on the date
they become entitled to a Premium Assistance Subsidy authorized under the Children's Health
Insurance Program Reauthorization Act of 2009. The date of entitlement shall be the date stated in
the Premium Assistance Authorization entitlement notice issued by the applicable state agency (CHIP
or Medicaid). A request for enrollment, either verbal or in writing, must be made within sixty (60) days
after this special enrollment event, and written application for such coverage must be made in writing
within ninety (90) days after such event.
CHANGE IN STATUS
If a Covered Dependent under this Plan becomes an eligible Employee of the County, he /she may continue
his /her coverage as a Participant only.
If an eligible Employee who is covered as a Participant of this Plan ceases to be an Employee of the County,
but is eligible to be covered as a Dependent. under another Employee /Participant, he /she may elect to
continue his /her coverage as a Dependent of such Employee /Participant.
Application for coverage due to a Change in Status must be made on the Plan's enrollment form, within thirty -
one (31) days immediately following the date the Employee becomes or ceases to be an eligible Employee.
A Change in Status will not be deemed to be a break or termination of coverage and will not operate to reduce
or increase any coverage or accumulations toward satisfaction of the deductible and Out -of- Pocket Maximum
to which the Covered Person was entitled prior to the Change in Status.
Collier County Government - Group #2003021 62 Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
QUALIFIED MEDICAL CHILD SUPPORT ORDER PROVISION
PURPOSE
Although the Collier County Government Employee Benefit Plan is not a Plan covered under ERISA, the Plan
Administrator adopts the following procedures, pursuant to Section 609(a) of ERISA, to determine whether
Medical Child Support Orders are qualified in accordance with ERISA's requirements, to administer payments
and other provisions under Qualified Medical Child Support Orders (QMCSOs), and to enforce these
procedures as legally required. The County adopts ERISA standards to comply with child support
enforcement obligation of Part D of Title IV of the Social Security Act of 1975 as amended.
DEFINITIONS
For QMCSO requirements, the following definitions apply:
"Alternate Recipient" means any child of a Participant who is recognized under a Medical Child
Support Order as having a right to enroll in this Plan with respect to the Participant.
2. "Medical Child Support Order" means any state orcourtjudgment, decree or order (including approval
of settlement agreement) issued by a court of competent jurisdiction, or issued through an
administrative process established under State law and which has the same force and effect of law
under applicable State law and:
A. Provides for child support for a child of a Participant under this Plan, or;
B. Provides for health coverage for such a child under state domestic relations laws (including
community property laws) and relates to benefits under this Plan; and
C. Is made pursuant to a law relating to medical child support described in Section 1908 of the
Social Security Act.
3. "Plan" means this self- funded Employee Health Benefit Plan, including all supplements and
amendments in effect.
4. "Qualified Medical Child Support Order" means a Medical Child Support Order which creates
(including assignment of rights) or recognizes an Alternate Recipient's right to receive benefits to
which a Participant or Qualified Beneficiary is eligible under this Plan, and has been determined by
the Plan Administrator to meet the qualification requirements as outlined under "Procedures" of this
provision.
CRITERIA FOR A QUALIFIED MEDICAL CHILD SUPPORT ORDER
To be qualified, a Medical Child Support Order must clearly:
Specify the name and the last known mailing address (if any) of the Participant and the name and
mailing address of each Alternate Recipient covered by the order, except that, to the extent provided
in the order, the name and mailing address of an official of a State or a political subdivision thereof
may be substituted for the mailing address of any such Alternate Recipient; and
2. Include a reasonable description of the type of coverage to be provided by the Plan to each Alternate
Recipient, or the manner in which such type of coverage is to be determined; and
Specify each period to which such order applies.
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12/13/2011 Item 16.E.4.
Qualified Medical Child Support Order Provision
In order to be qualified, a Medical Child Support Order must not require the Plan to provide any type or form
of benefits, or any option, not otherwise provided under the Plan except to the extent necessary to meet the
requirements of Section1908 of the Social Security Act (relating to enforcement of state laws regarding child
support and reimbursement of Medicaid).
PROCEDURES FOR NOTIFICATIONS AND DETERMINATIONS
In the case of any Medical Child Support Order received by this Plan:
The Plan Administrator will promptly notify the Participant and each Alternate Recipient of the receipt
of such order and the plan's procedures for determining whether Medical Child Support Orders are
qualified orders; and
2. Within a reasonable period after receipt of such order, the Plan Administrator will determine whether
such order is a Qualified Medical Child Support Order and notify the Participant and each Alternate
Recipient of such determination.
NATIONAL MEDICAL SUPPORT NOTICE
If the Plan Administrator of a group health plan which is maintained by the Employer of a noncustodial parent
of a child, or to which such an employer contributes, receives an appropriately completed National Medical
Support Notice as described in Section 401(b) of the Child Support Performance and Incentive Act of 1998
in the case of such child, and the Notice meets the criteria shown above for a qualified order, the Notice will
be deemed to be a Qualified Medical Child Support Order in the case of such child.
Collier County Government - Group #2003021 64 Plan Document/ SPD - Effective 1/1/2012
Packet Page -3009-
12/13/2011 Item 16.E.4.
FAMILY AND MEDICAL LEAVE ACT OF 1993
The Family and Medical Leave Act (FMLA) requires Employers who are subject to FMLA to allow their
"eligible" Employees to take unpaid, job - protected leave. The Employer may also require or allow the
Employee to substitute appropriate paid leave, including, but not limited to, vacation and sick leave, if the
Employee has earned or accrued it. The maximum leave required by FMLA is twelve (12) workweeks in any
twelve (12) month period for certain family and medical reasons and a maximum combined total of twenty -six
(26) workweeks during any twelve (12) month period for certain family and medical reasons and for a serious
injury or illness of a member of the Armed Forces to allow the Employee, who is the spouse, son, daughter,
parent, or next of kin to the member of the Armed Forces, to care for that member of the Armed Forces. In
certain cases, this leave may be taken on an intermittent basis rather than all at once, or the Employee may
work a part -time schedule.
DEFINITIONS
For these Family and Medical Leave Act of 1993 provisions only, the following definitions apply:
1. "Member of the Armed Forces" includes members of the National Guard or Reserves who are
undergoing medical treatment, recuperation, or therapy
2. "Next of Kin" means the nearest blood relative to the service member
3. "Parent" means Employee's biological parent or someone who has acted as Employee's parent in
place of Employee's biological parent when Employee was a son or daughter.
4. "Serious health condition" means an illness, injury impairment, or physical or mental condition that
involves:
A. Inpatient care in a hospital, hospice, or residential medical facility; or
B. Continuing treatment by a health care provider (a doctor of medicine or osteopathy who is
authorized to practice medicine or surgery as appropriate, by the state in which the doctor
practices or any other person determined by the Secretary of Labor to be capable of
providing health care services).
5. "Serious injury or illness" means an injury or illness incurred in the line of duty that may render the
member of the Armed Forces medically unfit to perform his or her military duties.
6. "Son or daughter" means Employee's biological child, adopted child, stepchild, foster child, a child
placed in Employee's legal custody, or a child for which Employee is acting as the parent in place of
the child's natural blood related parent. The child must be:
A. Under the age of eighteen (18); or,
B. Over the age of eighteen (18), but incapable of self -care because of a mental or physical
disability.
"Spouse" means Employee's husband or wife as defined or recognized under State law in the State
where the Employee resides.
Collier County Government - Group #2003021 65 Plan Document/ SPD - Effective 1/1/2012
Packet Page -3010-
12/13/2011 Item 16.E.4.
Family and Medical Leave Act
EMPLOYERS SUBJECT TO FMLA
In general, FMLA applies to any employer engaged in interstate commerce or in any industry or activity
affecting interstate commerce who employs 50 or more Employees for each working day during each of 20
or more calendar work weeks in the current or preceding Calendar Year. FMLA also applies to those persons
described in Section 3(d) of the Fair Labor Standards Act, 29 U.S.C. 203(d). The FMLA applies to
government entities, including branches of the United States government, state governments and political
subdivisions thereof.
ELIGIBLE EMPLOYEES
Generally, an Employee is eligible for FMLA leave only if the Employee satisfies all of the following
requirements as of the date on which any requested FMLA leave is to commence: (1) has been employed by
the Employer for a total of at least twelve months (whether consecutive or not); (2) the Employee has worked
(as defined under the Fair Labor Standards Act) at least 1,250 hours during the twelve -(12) month period
immediately preceding the date the requested leave is to commence; (3) the Employee is employed in any
state of the United States, the District of Columbia or any Territories or possession of the United States; and
(4) at the time the leave is requested, the Employee is employed at a work site where 50 or more Employees
are employed by the Employer within 75 surface miles of the work site.
REASONS FOR TAKING LEAVE
FMLA leave must be granted (1) to care for the Employee's newborn child; (2) to care for a child placed with
the Employee for adoption or foster care; (3) to care for the Employee's spouse, son, daughter, or parent, who
has a serious health condition; (4) because the Employee's own serious health condition prevents the
Employee from performing his or her job; or (5) because of a qualifying exigency, as determined by the
Secretary of Labor, arising out of the fact that a spouse, son, daughter or parent of the Employee is on active
duty or has been called to active duty in the Armed Forces in support of a contingency operation (i.e., a war
or national emergency declared by the President or Congress).
ADVANCE NOTICE AND MEDICAL CERTIFICATION
Ordinarily, an Employee must provide thirty (30) days advance notice when the requested leave is
"foreseeable." If the leave is not foreseeable, the Employee must notify the Employer as soon as is
practicable, generally within one to two working days. An employer may require medical certification to
substantiate a request for leave requested due to a serious health condition. If the leave is due to the
Employee's serious health condition, the Employer may require second or third opinions, at the Employer's
expense, and a certification of fitness to return to work prior to allowing the Employee to return to work.
PROTECTION OF JOB BENEFITS
For the duration of FMLA leave, the Employer must maintain the Employee's health coverage under any
"group health plan" on the same conditions as coverage would have been provided if the Employee had been
in Active Service during FMLA leave period. Taking FMLA leave cannot result in the loss of any employment
benefit that accrued prior to the start of an Employee's leave, unless the loss would have occurred even if the
Employee had been in Active Service.
UNLAWFUL ACTS BY EMPLOYERS
Employers cannot interfere with, restrain or deny the exercise of any right provided under the FMLA or to
manipulate circumstances to avoid responsibilities under the FMLA. Employers may not discharge, or
discriminate against any person who opposes any practice made unlawful by the FMLA or who may be
involved in a proceeding under or relating to the FMLA.
Collier County Government - Group #2003021 66 Plan Document / SPD - Effective 1/1/2012
Packet Page -3011-
12/13/2011 Item 16.E.4.
Family and Medical Leave Act
ENFORCEMENT
The U.S. Department of Labor is authorized to investigate and resolve complaints of FMLA violations. An
eligible Employee may also bring a civil action against an employer for FMLA violations. The FMLA does not
supersede any federal or state law prohibiting discrimination, and does not supersede any state or local law
or collective bargaining agreement which provides greater family or medical leave rights. For additional
information, contact the nearest office of Wage and Hour Division, listed in most telephone directories under
U.S. Government, Department of Labor.
Collier County Government - Group #2003021 67 Plan Document / SPD - Effective 1/112012
Packet Page -3012-
12/13/2011 Item 16.E.4.
TERMINATION OF COVERAGE
PARTICIPANT TERMINATION
Participant coverage will automatically terminate immediately upon the earliest of the following dates, except
as provided in any Continuation of Coverage Provision:
1. On the last day of the month in which the Participant's employment terminates; or
2. On the last day of the month in which the Participant ceases to be eligible for coverage; or
3. The date the Participant fails to make any required contribution for coverage; or
4. The date the Plan is terminated; or
5. The date the County terminates the Participant's coverage; or
6. The date the Participant dies; or
7. The date the Participant enters the armed forces of any country as a full -time member, if active duty
is to exceed thirty -one (31) days; or
8. On the last day of the month in which the Plan receives the Plan's Health Coverage Waiver Form for
the Participant.
A Participant whose Active Service ceases because of Illness or Injury or as a result of any other approved
leave of absence may remain covered as an Employee in Active Service for a period of twelve (12) weeks,
or such other length of time that is consistent with and stated in the County's current Employee Personnel
Policy Manual or pursuant to the Family and Medical Leave Act. Coverage under this provision will be subject
to all the provisions of FMLA if the leave is classified as FMLA leave.
If a Participant's coverage is to be continued during disability, approved leave of absence or temporary lay off,
the amount of his or her coverage will be the same as the Plan benefits in force for an active Employee,
subject to the Plan's right to amend coverage and benefits.
RETIREE TERMINATION
Coverage for a Retiree and eligible Dependents may continue until the earliest of the following dates:
The date the Retiree fails to make any required contribution for coverage; or
2. The date the Plan is terminated; or
3. The date the County terminates the Retiree's coverage; or
4. The date the Retiree dies; or
5. The date the Retiree enters the armed forces of any country as a full -time member, if active duty is
to exceed thirty -one (31) days.
Collier County Government - Group #2003021 68 Plan Document / SPD - Effective 1/1/2012
Packet Page -3013-
12/13/2011 Item 16.E.4.
Termination of Coverage
If a Retiree becomes deceased or terminates coverage under this plan once the Retiree is eligible for
Medicare, the spouse and eligible Dependent children who are covered at the time of the Retiree's death or
termination of coverage may remain covered under the Plan until the earlier of the following:
The date the spouse becomes eligible for Medicare or eligible for any other individual or group health
insurance or coverage; or
2. The date the Dependent child ceases to be eligible under this plan or becomes eligible for any other
individual or group health insurance or coverage.
DEPENDENT TERMINATION
Each Covered Person, whether Participant or Dependent, is responsible for notifying the Plan
Administrator, within sixty (60) days after loss of Dependent status due to death, divorce, legal
separation or ceasing to be an eligible Dependent child. Failure to provide this notice may result in
loss of eligibility for COBRA Continuation Coverage After Termination.
Coverage for a Dependent will automatically terminate immediately upon the earliest of the following dates,
except as provided in any Continuation of Coverage Provision:
On the last day of the month in which the Dependent ceases to be an eligible Dependent as defined
in the Plan; or
2. On the last day of the month in which the Participant's coverage terminates under the Plan; or
3. On the last day of the month in which the Participant ceases to be eligible for Dependent Coverage;
or
-4. The date the Participant fails to make any required contribution for Dependent Coverage; or
5. The date the Plan is terminated; or
6. The date the County terminates the Dependent's coverage; or
7. On the last day of the month in which the Participant dies; or
8. The date the Dependent enters the armed forces of any country as a full -time member if active duty
is to exceed thirty -one (31) days; or
9. On the last day of the month in which the Plan receives the Plan's Health Coverage Waiver Form for
the Dependent whose coverage is to be terminated.
REINSTATEMENT OF COVERAGE
An Employee whose coverage terminates by reason of termination of employment or reduction in hours and
who again becomes eligible for coverage under the Plan will be treated like a new employee.
Collier County Government - Group #2003021 69 Plan Document/ SPD - Effective 1/1/2012
Packet Page -3014-
12/13/2011 Item 16.E.4.
Termination of Coverage
VOLUNTARY SEPARATION INCENTIVE PROGRAM
Medical coverage provided by the County will be extended for those Employees eligible for the Voluntary
Separation Incentive Program (VSIP). The Voluntary Separation Incentive Program (VSIP) will be extended
to any regular full -time Employee who meets the eligibility criteria set forth by the action of the Board of County
Commissioners. Under this Plan, if an eligible Employee chooses to take part in the program, the County will
continue to pay the full premium costs for that Employee's medical benefits for a period of three (3) years, or
will provide a financial incentive in lieu of benefits if the Employee so chooses.
Eligible Employees may elect to continue coverage at their current participation level (single or
family).
Employees will not pay any premiums - the County will pay the premium costs for up to three (3)
years.
Eligible Employees may select a blended option of medical and dental coverage, together with a
partial cash payment.
Eligible Employees will have a period of sixty (60) days to enroll. The plan enrollment period begins and ends
as determined by the Employer. Employees who meet the Florida Retirement System (FRS) eligibility criteria
outlined above between the dates specified by the Employer may also participate in this program. To
participate, those who fall into this category will be required to enroll during the sixty (60) day window, but
would not be considered to be enrolled into the Plan until the date they become eligible under Florida
Retirement System (FRS) guidelines. Employees have a period of seven (7) calendar days during which time
to change or revoke their participation. After that time period, their election is considered final.
Collier County Government - Group #2003021 70 Plan Document / SPD - Effective 1/1/2012
Packet Page -3015-
12/13/2011 Item 16.E.4.
CONTINUATION COVERAGE AFTER TERMINATION
Under the Public Health Service Act, as amended, Employees and their enrolled Dependents may have the
right to continue coverage beyond the time coverage would ordinarily have ended. The law applies to
employers who normally employ twenty (20) or more Employees.
The Plan Administrator is Collier County Government; 3311 East Tamiami Trail, Building D, Naples, FL 34112;
(239) 252 -8461. COBRA Continuation Coverage for the Plan is administered by Allegiance COBRA Services,
Inc.; P.O. Box 2097; Missoula, MT 59806, 406 - 721 -2222.
COBRA Continuation Coverage is available to any Qualified Beneficiary whose coverage would otherwise
terminate due to any Qualifying Event. COBRA Continuation Coverage under this provision will begin on the
first day following the date of the Qualifying Event.
1. Qualifying Events for Participants, for purposes of this section, are the following events, if such event
results in a loss of coverage under this Plan:
A. The termination (other than by reason of gross misconduct) of the Participant's employment
B. The reduction in hours of the Participant's employment.
2. Qualifying Events for covered Dependents, for purposes of this section are the following events, if
such event results in a loss of coverage under this Plan:
A. Death of the Participant or Retiree.
B. Termination of the Participant's employment.
C. Reduction in hours of the Participant's employment.
D. The divorce or legal separation of the Participant or Retiree from his or her spouse.
E. A covered Dependent child ceases to be a Dependent as defined by the Plan.
3. Qualifying Events for covered Retirees, for purposes of this section are:
A. Bankruptcy, if the covered Retiree retired on or before the date of any substantial elimination
of group health coverage due to bankruptcy.
4. Qualifying Events for the Dependents of Covered Retirees, for purposes of this section are:
A. Bankruptcy, if the Dependent was a Qualified Beneficiary of a covered Retiree on or before
the day before the bankruptcy qualifying event.
NOTIFICATION RESPONSIBILITIES
The Covered Person must notify the Employer of the following Qualifying Events within sixty (60) days after
the date the event occurs. The Employer must notify the Plan Administrator of any of the following:
1. Death of the Participant or Retiree.
2. The divorce or legal separation of the Participant or Retiree from his or her spouse.
3. A covered Dependent child ceases to be a Dependent as defined by the Plan.
Collier County Government - Group #2003021 71 Plan Document / SPD - Effective 1/1/2012
Packet Page -3016-
12/13/2011 Item 16.E.4.
Continued Coverage After Termination
The Employer must notify the Plan Administrator of the following Qualifying Events within thirty (30) days after
the date of the event occurs:
Termination (other than by reason of gross misconduct) of the Participant's employment.
2. Reduction in hours of the Participant's employment.
ELECTION OF COVERAGE
When the Plan Administrator is notified of a Qualifying Event, the Plan Administrator will notify the Qualified
Beneficiary of the right to elect continuation of coverage. Notice of the right to COBRA Continuation Coverage
will be sent by the Plan no later than fourteen (14) days after the Plan Administrator is notified of the Qualifying
Event.
A Qualified Beneficiary has sixty (60) days from the date coverage would otherwise be lost or sixty (60) days
from the date of notification from the Plan Administrator, whichever is later, to notify the Plan Administrator
that he or she elects to continue coverage under the Plan. Failure to elect continuation within that period will
cause coverage to end.
MONTHLY PREMIUM PAYMENTS
A Qualified Beneficiary is responsible for the full cost of continuation coverage. Monthly premium for
continuation of coverage must be paid in advance to the Plan Administrator. The premium required under the
provisions of COBRA is as follows:
1. For a Qualified Beneficiary: The premium is the same as applicable to any other similarly situated
non -COBRA Participant plus an additional administrative expense of up to a maximum of two percent
(2 %).
2. Social Security Disability: For a Qualified Beneficiary continuing coverage beyond eighteen (18)
months due to a documented finding of disability by the Social Security Administration within 60 days
after becoming covered under COBRA, the premium may be up to a maximum of 150% of the
premium applicable to any other similarly situated non -COBRA Participant.
3. For a Qualified Beneficiary with a qualifying Social Security Disability who experiences a second
Qualifying Event:
A. If another Qualifying Event occurs during the initial eighteen (18) months of COBRA
coverage, such as a death, divorce or legal separation, the monthly fee for qualified disabled
person may be up to a maximum of one hundred and two percent (102 %) of the applicable
premium.
B. If the second Qualifying Event occurs during the nineteenth (19`h) through the twenty -ninth
(29`h) month (the Disability Extension Period), the premium for a Qualified Beneficiary may
be up to a maximum of one hundred fifty percent (150 %) of the applicable premium.
Payment of claims while covered under this COBRA Continuation Coverage Provision will be contingent upon
the receipt by the Employer of the applicable monthly premium for such coverage. The monthly premium for
continuation coverage under this provision is due the first of the month for each month of coverage. A grace
period of thirty (30) days from the first of the month will be allowed for payment. Payment will be made in a
manner prescribed by the Employer.
Collier County Government - Group #2003021 72 Plan Document / SPD - Effective 1/1/2012
Packet Page -3017-
12/13/2011 Item 16.E.4.
Continued Coverage After Termination
DISABILITY EXTENSION OF 18 -MONTH PERIOD OF CONTINUATION COVERAGE
If the Qualified Beneficiary who is covered under the Plan is determined by the Social Security Administration
to be disabled at any time before the qualifying event or within sixty (60) days after the qualifying event, and
the Plan Administrator is notified in a timely fashion, the Qualified Beneficiary covered under the Plan can
receive up to an additional 11 months of COBRA Continuation Coverage, for a total maximum of 29 months.
The Plan Administrator must be provided with a copy of the Social Security Administration's disability
determination letter within sixty (60) days after the date of the determination and before the end of the original
18 -month period of COBRA Continuation Coverage. This notice should be sent to: Allegiance COBRA
Services, Inc.; P.O. Box 2097; Missoula, MT 59806.
SECOND QUALIFYING EVENT EXTENSION OF 18 -MONTH PERIOD OF CONTINUATION COVERAGE
If another qualifying event occurs while receiving COBRA Continuation Coverage, the spouse and dependent
children of the Employee can get additional months of COBRA Continuation Coverage, up to a maximum of
thirty -six (36) months. This extension is available to the spouse and dependent children if the former
employee dies or becomes divorced or legally separated. The extension is also available to a dependent child
when that child stops being eligible under the Plan as a dependent child. In all of these cases, the Plan
Administrator must be notified of the second qualifying event within sixty (60) days of the second
qualifying event. This notice must be sent to: Allegiance COBRA Services, Inc.; P.O. Box 2097;
Missoula, MT 59806. Failure to provide notice within the time required will result in loss of eligibility
for COBRA Continuation Coverage.
MEDICARE ENROLLMENT EXTENSION OF 18 -MONTH PERIOD OF CONTINUATION COVERAGE
The dependents of a former employee are eligible to elect COBRA Continuation Coverage if they lose
coverage as a result of the former employee's enrollment in Part A, Part B or Part D of Medicare, whichever
occurs earlier.
When the former employee enrolls in Medicare before the Qualifying Event of termination, or reduction in
hours, of employment occurs, the maximum period for COBRA Continuation Coverage for the spouse and
dependent children ends on the later of:
Eighteen (18) months after the Qualifying Event of termination of employment or reduction in hours
of employment; or
2. Thirty -six (36) months after the former employee's enrollment in Medicare.
When the former employee enrolls in Medicare after the Qualifying Event of termination, or reduction in hours,
of employment, the maximum period for COBRA Continuation Coverage for the spouse and dependent
children ends eighteen (18) months after the Qualifying Event, unless a second Qualifying Event, as described
above occurs within that eighteen (18) month period.
WHEN COBRA CONTINUATION COVERAGE ENDS
COBRA Continuation Coverage and any coverage under the Plan that has been elected with respect to any
Qualified Beneficiary will cease on the earliest of the following:
On the date the Qualified Beneficiary becomes covered under another group health plan or health
insurance, unless the other group health plan contains a provision excluding or limiting coverage for
a Pre - existing Condition applicable to a condition of the Qualified Beneficiary under this Plan.
However, if the exclusionary period does not apply due to prior Creditable Coverage, COBRA
continuation coverage ends. Coverage will not be terminated as stated until the pre- existing
exclusionary period of the other coverage is no longer applicable.
This exception applies to all Qualified Beneficiaries.
Collier County Government - Group #2003021 73 Plan Document / SPD - Effective 1/1/2012
Packet Page -3018-
2.
3.
4.
5.
6.
12/13/2011 Item 16.E.4.
Continued Coverage After Termination
On the date, after the date of election for COBRA Continuation Coverage, that the Qualified
Beneficiary becomes enrolled in Medicare (either Part A, B or D);
On the first date that timely payment of any premium required under the Plan with respect to COBRA
Continuation Coverage for a Qualified Beneficiary is not made to the Plan Administrator.
On the date the Employer ceases to provide any group health plan coverage to any Employee.
On the date of receipt of written notice that the Qualified Beneficiary wishes to terminate COBRA
Continuation Coverage.
On the date that the maximum coverage period for COBRA Continuation Coverage ends, as follows:
A. Eighteen (18) months for a former employee who is a Qualified Beneficiary as a result of
termination, or reduction in hours, of employment;
B. Eighteen (18) months for a Dependent who is a Qualified Beneficiary unless a second
Qualifying Event occurs within that eighteen month period entitling that Dependent to an
additional eighteen (18) months;
C. For the Dependent who is a Qualified Beneficiary as a result of termination, or reduction in
hours, of employment of the former employee if that former employee enrolled in Medicare
before termination, or reduction in hours, of employment, the later of eighteen (18) months
from the Qualifying Event, or thirty -six (36) months following the date of enrollment in
Medicare.
D. On the first day of the month beginning thirty (30) days after a Qualified Beneficiary is
determined to be no longer disabled by the Social Security Administration if the Qualified
Beneficiary was found to be disabled on or within the first sixty (60) days of the date of the
Qualifying Event and has received at least eighteen (18) months of COBRA Continuation
Coverage. COBRA Continuation Coverage will also terminate on such date for all
Dependents who are Qualified Beneficiaries as a result of the Qualifying Event unless that
Dependent is entitled to a longer period of COBRA Continuation Coverage without regard to
disability.
E. Twenty -nine (29) months for any Qualified Beneficiary if a Disability Extension Period of
COBRA Continuation Coverage has been granted for such Qualified Beneficiary.
F. Thirty -six (36) months for all other Qualified Beneficiaries.
G. In the case of a Qualifying Event that is a bankruptcy, the date of death for the Qualified
Beneficiary who is a retired employee.
H. In the case of a Qualifying Event that is a bankruptcy, the earlier of the date of the Qualified
Beneficiary's death or thirty-six (36) months following the retired employee's death for the
Qualified Beneficiary who is a surviving spouse or dependent child of the retired employee.
On the same basis that the Plan can terminate for cause the coverage of a similarly situated non -
COBRA Participant.
QUESTIONS
Any questions about COBRA Continuation Coverage should be directed to Allegiance COBRA Services, Inc.
or contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits
Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are
available through EBSA's website at www.dol.gov /ebsa.
Collier County Government - Group #2003021 74 Plan Document / SPD - Effective 1/1/2012
Packet Page -3019-
12/13/2011 Item 16.E.4.
Continued Coverage After Termination
INFORM THE PLAN OF ADDRESS CHANGES
In order to protect the Employee's family's rights, the Employee should keep the Plan Administrator
informed of any changes in the addresses of family members. The Employee should also keep a copy,
for his /her records, of any notices sent to the Plan Administrator.
Collier County Government - Group #2003021 75 Plan Document / SPD - Effective 1/112012
Packet Page -3020-
12/13/2011 Item 16.E.4.
COVERAGE FOR A MILITARY RESERVIST
To the extent required by the Uniform Services Employment and Reemployment Rights Act (USERRA), the
following provisions will apply:
In any case in which a Covered Person has coverage under this Plan, and such Covered Person is
absent from employment with Employer by reason of service in the uniformed services, the Covered
Person may elect to continue coverage under this Plan for himself or herself and his or her eligible
Dependents as provided in this subsection. The maximum period of coverage under such an election
will be the lesser of:
A. The twenty -four (24) month period beginning on the date on which the Covered Person's
absence begins; or
B. The period beginning on the date on which the Covered Person's absence begins and ending
on the day after the date on which the Covered Person fails to apply for or return to a position
of employment, as required by USERRA.
An eligible person who elects to continue Plan coverage under this Section may be required to pay
not more than one hundred two percent (102 %) of the full premium under the Plan (determined in the
same manner as the applicable premium under Section 498013(f)(4) of the Internal Revenue Code of
1986) associated with such coverage for the Employer's other Employees, except that in the case of
a person who performs service in the uniformed services for less than thirty -one (31) days, such
person may not be required to pay more than the regular Employee share, if any, for such coverage.
3. In the case of a person whose coverage under the Plan is terminated by reason of service in the
uniformed services, an exclusion or Waiting Period may not be imposed in connection with the
reinstatement of such coverage upon reemployment if an exclusion or Waiting Period would not have
been imposed under the Plan had coverage of such person by the Plan not been terminated as a
result of such service. This paragraph applies to the Employee who notifies the Employer of his or
her intent to return to employment in a timely manner as defined by USERRA, and is reemployed and
to any Dependent who is covered by the Plan by reason of the reinstatement of the coverage of such
Employee. This provision will not apply to the coverage of any Illness or Injury determined by
the Secretary of Veterans Affairs to have been caused by or aggravated during, performance
of service in the uniformed services.
Collier County Government - Group #2003021 76 Plan Document/ SPD - Effective 1/1/2012
Packet Page -3021-
12/13/2011 Item 16.E.4.
FRAUD AND ABUSE
THIS PLAN IS SUBJECT TO FEDERAL LAW WHICH PERMITS CRIMINAL PENALTIES FOR
FRAUDULENT ACTS COMMITTED AGAINST THE PLAN. STATE LAW MAY ALSO APPLY.
Anyone who knowingly defrauds or tries to defraud the Plan, or obtains Plan funds through false statements
orfraudulent schemes, may be subject to criminal prosecution and penalties. The following may be considered
fraudulent:
1. Falsifying eligibility criteria for a Dependent, including such as marital status, age, or full -time student
status, to get or continue coverage for that Dependent when not otherwise eligible for coverage;
2. Falsifying orwithholding medical history or information required to calculate benefits or determine pre-
existing conditions when no creditable coverage exists;
3. Falsifying or altering documents to get coverage or benefits;
4. Permitting a person not otherwise eligible for coverage to use a Plan ID card to get Plan benefits; or
5. Submitting a fraudulent claim or making untruthful statements to the Plan to get reimbursement from
the Plan for services that may or may not have been provided to a Covered Person.
The Plan Administrator, in its sole discretion, may take additional action against the Participant or Covered
Person, including, but not limited to terminating the Participant or Covered Person's coverage under the Plan.
MISSTATEMENT OF AGE
If the Covered Person's age was misstated on an enrollment form or claim, the Covered Person's eligibility
or amount of benefits, or both, will be adjusted to reflect the Covered Person's true age. If the Covered Person
was not eligible for coverage under the Plan or for the amount of benefits received, the Plan has a right to
recover any benefits paid by the Plan. A misstatement of age will not continue coverage that was otherwise
properly terminated or terminate coverage that is otherwise validly in force.
MISREPRESENTATION OF ELIGIBILITY
If a Participant misrepresents a Dependent's marital status, age, full -time student status, dependent child
relationship or other eligibility criteria to get coverage for that Dependent, when he or she would not otherwise
be eligible, coverage for that Dependent will terminate as though never effective.
MISUSE OF IDENTIFICATION CARD
If a Covered Person permits any person who is not otherwise eligible as a Covered Person to use an ID card,
the Plan Sponsor may, at the Plan Sponsor's sole discretion, terminate the Covered Person's coverage.
REIMBURSEMENT TO PLAN
Payment of benefits by the Plan for any person who was not otherwise eligible for coverage under this Plan
but for whom benefits were paid based upon fraud as defined in this section must be reimbursed to the Plan
by the Participant. Failure to reimburse the Plan upon request may result in an interruption or a loss of
benefits by the Participant and Dependents.
Collier County Government - Group #2003021 77 Plan Document / SPD - Effective 1/1/2012
Packet Page -3022-
12/13/2011 Item 16.E.4.
RECOVERY /REIMBURSEMENT /SUBROGATION
By enrollment in this Plan, Covered Persons agree to the provisions of this section as a condition precedent
to receiving benefits under this Plan. Failure of a Covered Person to comply with the requirements of this
section may result in the Plan pending the payment of benefits.
RIGHT TO RECOVER BENEFITS PAID IN ERROR
If the Plan makes a payment in error to or on behalf of a Covered Person or an assignee of a Covered Person
to which that Covered Person is not entitled, or if the Plan pays a claim that is not covered, the Plan has the
right to recover the payment from the person paid or anyone else who benefitted from the payment. The Plan
can deduct the amount paid from the Covered Person's future benefits, or from the benefits for any covered
Family member even if the erroneous payment was not made on that Family member's behalf.
Payment of benefits by the Plan for Participants' spouses, ex- spouses, or children, who are not eligible for
coverage under this Plan, but for whom benefits were paid based upon inaccurate, false information provided
by, or information omitted by, the Employee will be reimbursed to the Plan by the Employee. The Employee's
failure to reimburse the Plan after demand is made, may result in an interruption in or loss of benefits to the
Employee, and could be reported to the appropriate governmental authorities for investigation of criminal
fraud.
The Plan may recover such amount by any appropriate method that the Plan Administrator, in its sole
discretion, will determine.
The provisions of this section apply to any Physician or Licensed Health Care Provider who receives an
assignment of benefits or payment of benefits under this Plan. If a Physician or Licensed Health Care
Provider fails to refund a payment of benefits, the Plan may refuse to recognize future assignments of benefits
to that provider.
REIMBURSEMENT
The Plan's right to Reimbursement is separate from and in addition to the Plan's right of Subrogation. If the
Plan pays benefits for medical expenses on a Covered Person's behalf, and another party was responsible
or liable for payment of those medical expenses, the Plan has a right to be reimbursed by the Covered Person
for the amounts the Plan paid.
Accordingly, if a Covered Person, or anyone on his or her behalf, settles, is reimbursed or recovers money
from any person, corporation, entity, liability coverage, no -fault coverage, uninsured coverage, underinsured
coverage, or other insurance policies or funds for any accident, Injury, condition or Illness for which benefits
were provided by the Plan, the Covered Person agrees to hold the money received in trust for the benefit of
the Plan. The Covered Person agrees to reimburse the Plan, in first priority, from any money recovered from
a liable third party, for the amount of all money paid by the Plan to the Covered Person or on his or her behalf
or that will be paid as a result of said accident, Injury, condition or Illness. Reimbursement to the Plan will be
paid first, in its entirety, even if the Covered Person is not paid for all of his or her claim for damages and
regardless of whether the settlement, judgment or payment he or she receives is for or specifically designates
the recovery, or a portion thereof, as including health care, medical, disability or other expenses or damages.
SUBROGATION
The Plan's right to Subrogation is separate from and in addition to the Plan's right to Reimbursement.
Subrogation is the right of the Plan to exercise the Covered Person's rights and remedies in order to recover
from any third party who is liable to the Covered Person for a loss or benefits paid by the Plan. The Plan may
proceed through litigation or settlement in the name of the Covered Person, with or without his or her consent,
to recover benefits paid under the Plan.
Collier County Government - Group #2003021 78 Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
Recovery/Reimbursement /Subrogation
The Covered Person agrees to subrogate to the Plan any and all claims, causes of action or rights that he or
she has or that may arise against any entity who has or may have caused, contributed to or aggravated the
accident, Injury, condition or Illness for which the Plan has paid benefits, and to subrogate any claims, causes
of action or rights the Covered Person may have against any other coverage, including but not limited to
liability coverage, no -fault coverage, uninsured motorist coverage, underinsured motorist coverage, or other
insurance policies, coverage or funds.
In the event that a Covered Person decides not to pursue a claim against any third party or insurer, the
Covered Person will notify the Plan, and specifically authorize the Plan, in its sole discretion, to sue for,
compromise or settle any such claims in the Covered Person's name, to cooperate fully with the Plan in the
prosecution of the claims, and to execute any and all documents necessary to pursue those claims.
The Following Paragraphs Apply to Both Reimbursement and Subrogation:
Under the terms of this Plan, the Plan Supervisor is not required to pay any claim where there is
evidence of liability of a third party unless the Covered Person signs the Plan's Third -Party
Reimbursement Agreement and follows the requirements of this section. However, the Plan, in its
discretion, may instruct the Plan Supervisor not to withhold payment of benefits while the liability of
a party other than the Covered Person is being legally determined. If a repayment agreement is
requested to be signed, the Plan's right of recovery through Reimbursement and /or Subrogation
remains in effect regardless of whether the repayment agreement is actually signed.
2. If the Plan makes a payment which the Covered Person, or any other party on the Covered Person's
behalf, is or may be entitled to recover against any liable third party, this Plan has a right of recovery,
through reimbursement or subrogation or both, to the extent of its payment.
The Covered Person will cooperate fully with the Plan Administrator, its agents, attorneys and
assigns, regarding the recovery of any benefits paid by the Plan from any liable third party. This
cooperation includes, but is not limited to, make full and complete disclosure in a timely manner of
all material facts regarding the accident, Injury, condition or Illness to the Plan Administrator; report
all efforts by any person to recover any such monies; provide the Plan Administrator with any and all
requested documents, reports and other information in a timely manner, regarding any demand,
litigation or settlement involving the recovery of benefits paid by the Plan; and notify the Plan
Administrator of the amount and source of funds received from third parties as compensation or
damages for any event from which the Plan may have a reimbursement or subrogation claim.
4. Covered Persons will respond within ten (10) days to all inquiries of the Plan regarding the status of
any claim they may have against any third parties or insurers, including but not limited to liability, no-
fault, uninsured and underinsured insurance coverage. The Covered Person will notify the Plan
immediately of the name and address of any attorney whom the Covered Person engages to pursue
any personal Injury claim on his or her behalf.
5. The Covered Person will not act, fail to act, or engage in any conduct directly, indirectly, personally
or through third parties, either before or after payment by the Plan, the result of which may prejudice
or interfere with the Plan's rights to recovery hereunder. The Covered Person will not conceal or
attempt to conceal the fact that recovery has occurred or will occur.
6. The Plan will not pay or be responsible, without its written consent, for any fees or costs associated
with a Covered Person pursuing a claim against any third party or coverage, including, but not limited
to, attorney fees or costs of litigation. Monies paid by the Plan will be repaid in full, in first priority,
notwithstanding any anti - subrogation, "made whole," "common fund" or similar statute, regulation,
prior court decision or common law theory unless a reduction or compromise settlement is agreed to
in writing or required pursuant to a court order or as limited by Florida state law.
Collier County Government - Group #2003021 79 Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
Recovery/Reimbursement /Subrogation
RIGHT OF OFF -SET
The Plan has a right of off -set to satisfy reimbursement claims against Covered Persons for money received
by the Covered Person from a third party, including any insurer. If the Covered Person fails or refuses to
reimburse the Plan for funds paid for claims, the Plan may deny payment of future claims of the Covered
Person, up to the full amount paid by the Plan and subject to reimbursement for such claims. This right of off-
set applies to all reimbursement claims owing to the Plan whether or not formal demand is made by the Plan,
and notwithstanding any anti - subrogation, "common fund," "made whole" or similar statutes, regulations, prior
court decisions or common law theories.
Collier County Government - Group #2003021 80 Plan Document / SPD - Effective 1/1/2012
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PLAN ADMINISTRATION
PURPOSE
12/13/2011 Item 16.E.4.
The purpose of the Plan Document is to set forth the provisions of the Plan which provide for the payment or
reimbursement of all or a portion of the claim. The terms of this Plan are legally enforceable and the Plan is
maintained for the exclusive benefit of eligible Employees and their covered Dependents.
EFFECTIVE DATE
The effective date of the Plan is January 1, 2000, restated January 1, 2012.
PLAN YEAR
The Plan Year will commence January 15` and end on the last day of December of each year.
PLAN SPONSOR
The Plan Sponsor is Collier County Government.
PLAN SUPERVISOR
The Supervisor of the Plan is Allegiance Benefit Plan Management, Inc.
NAMED FIDUCIARY AND PLAN ADMINISTRATOR
The Named Fiduciary is Collier County Government, a political subdivision of the State of Florida, who has
the authority to control and manage the operation and administration of the Plan. The Plan Administrator will
have the authority to amend the Plan, to determine its policies, to appoint and remove other service providers
of the Plan, to fix their compensation (if any), and exercise general administrative authority over them and the
Plan. The Plan Administrator has the sole authority and responsibility to review and make final decisions on
all claims to benefits hereunder. The Plan Administrator may delegate responsibilities for the operation and
administration of the Plan. The authority to perform the day to day Plan Administration duties as described
in this paragraph is delegated to the Director, Risk Management (the designee), or his or her equivalent,
whichever is applicable, of the County. The Director, Risk Management may temporarily delegate these
responsibilities, as needed. This delegation shall not include the final selection of a Plan Supervisor, Actuarial
firm, Benefits Consulting firm, or Reinsurance Stop Loss Carrier. This delegation shall include the review and
approval of weekly claims disbursements reports and check registers presented to the Plan Administrator by
the Plan Supervisor.
PLAN INTERPRETATION
The Named Fiduciary and the Plan Administrator have full discretionary authority to interpret and apply all Plan
provisions including, but not limited to, resolving all issues concerning eligibility and determination of benefits.
The Plan Administrator may contract with an independent administrative firm to process claims, maintain Plan
data, and perform other Plan- connected services. Final authority to interpret and apply the provisions of the
Plan rests exclusively with the Plan Administrator. Decisions of the Plan Administrator made in good faith will
be final and binding.
Collier County Government - Group #2003021 81 Plan Document/ SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
Plan Administration
CONTRIBUTIONS TO THE PLAN
The amount of contributions to the Plan are to be made on the following basis:
The County will from time to time evaluate the costs of the Plan and determine the amount to be
contributed by the County, if any, and the amount to be contributed, if any, by each Participant.
If the County terminates the Plan, the County and Participants will have no obligation to contribute
to the Plan after the date of termination.
PLAN AMENDMENTS /MODIFICATION/TERMINATION
The Plan Document contains all the terms of the Plan and may be amended at any time by the Plan
Administrator. Any changes will be binding on each Participant and on any other Covered Persons referred
to in this Plan Document. The authority to amend the Plan is delegated by the Plan Administrator to the
Director, Risk Management, or his or her equivalent, whichever is applicable, of the County. Any such
amendment, modification, revocation or termination of the Plan will be authorized and signed by the Director,
Risk Management, or his or her equivalent, whichever is applicable, of the County, pursuant to a resolution,
granting that individual the authority to amend, modify, revoke or terminate this Plan. A copy of the executed
policy will be supplied to the Plan Supervisor. Written notification of any amendments, modifications,
revocations or terminations will be given to Plan Participants within one - hundred and twenty (120) days of
such decision, except for notices of reduction of benefits.
NOTICE OF REDUCTION OF BENEFITS
All changes or amendments to this Plan that directly or indirectly reduce any benefit or coverage under the
Plan, including any increase in contribution for coverage required from a Participant, will be reported to all
eligible Participants and Dependents within sixty (60) days of the date such change or amendment is adopted.
TERMINATION OF PLAN
The County reserves the right at any time to terminate the Plan by a written notice. All previous contributions
by the County will continue to be issued for the purpose of paying benefits and fixed costs under provisions
of this Plan with respect to claims arising before such termination, or will be used for the purpose of providing
similar health benefits to Participants, until all contributions are exhausted.
SUMMARY PLAN DESCRIPTIONS
Each Participant covered under this Plan will be issued a Summary Plan Description (SPD) describing the
benefits to which the Covered Persons are entitled, the required Plan procedures for eligibility and claiming
benefits and the limitations and exclusions of the Plan.
Collier County Government - Group #2003021 82 Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
CREDITABLE COVERAGE PROCEDURES
CERTIFICATE OF CREDITABLE COVERAGE
The Plan will provide Certificate of Creditable Coverage for coverage underthis Plan as required bythe United
States Public Health Service to any Covered Person or the Covered Person's designated and authorized
agent, guardian, conservator, health care plan or health insurance as follows:
1. At the time the Covered Person ceases to be covered under this Plan; and,
2. At the time a Covered Person ceases to be covered by the COBRA Continuation Coverage provided
by this Plan, if any; and,
3. At any other time that a request is made on behalf of the Covered Person for such certification, but
not later than twenty four (24) months after cessation of coverage as set out in subparagraphs 1 and
2 above, whichever is later.
CREDITABLE COVERAGE
An eligible Employee or Dependent under this Plan may submit to the Plan, Certificate of Creditable Coverage
from any prior health insurance or health care plan under which said Employee or Dependent had coverage,
forthe purpose of reducing, on a day for day basis, any Pre - existing Condition Exclusion imposed by this Plan
for which the eligible Employee or Dependent had applicable Creditable Coverage under any prior insurance
or health care coverage.
An eligible Employee or Dependent has a right to request and receive a Certificate of Creditable Coverage
from any insurance carrier or health care plan under which he /she had coverage on or after July 1, 1996.
In the event that the eligible Employee or Dependent is unable to obtain a Certificate of Creditable Coverage
from a prior insurance carrier or health care plan, the Plan Administrator may provide assistance to obtain the
same.
CREDITABLE COVERAGE REVIEW
Upon the Plan's receipt of a Certificate of Creditable Coverage regarding prior coverage by any enrollee for
coverage under this Plan, the Plan acting on its own or through a firm contracted to provide services to the
Plan, will send to such enrollee a written confirmation of the amount of prior Creditable Coverage, if any, to
which the enrollee will be entitled against any Pre - existing Condition Exclusion period under this Plan. Such
written confirmation will be provided to the enrollee within thirty (30) days of receipt of the certification by the
Plan.
In the event that an enrollee disagrees with the Plan's calculation of any prior Creditable Coverage, the
enrollee will send written notice of said disagreement to the Plan, together with a written request for review
of the calculation, within fifteen (15) days of receipt of the Plan's written confirmation. Failure to submit a
written notice of disagreement and request for review of the calculation within the time limit required in this
section will be deemed a waiver of any further review.
Upon receipt by the Plan of a notice of disagreement and request for review, the Plan will review the
calculations, and will either affirm those calculations or revise its calculation and determination of prior
Creditable Coverage. The Plan Administrator will notify the enrollee, in writing, of its decision after review
within thirty (30) days after receipt of the notice of disagreement and request for review. The Plan
Administrator's decision regarding prior Creditable Coverage will be final and binding upon the Plan and any
Covered Person under the Plan.
Collier County Government - Group #2003021 83 Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
Creditable Coverage Procedures
DETERMINATION OF PRIOR CREDITABLE COVERAGE WHEN A CERTIFICATION IS UNAVAILABLE
If an enrollee is unable to obtain a Certificate of Creditable Coverage, for prior coverage, after having
exhausted all reasonable efforts to obtain the same, such an enrollee may request in writing that the Plan
make a determination whether he or she is entitled to prior Creditable Coverage based upon other evidence
and information. Said request must be submitted to and received by the Plan within sixty (60) days of the
effective date of coverage of the person for whom the request is made.
Upon receipt by the Plan of a request to determine prior Creditable Coverage in the absence of a Certification,
the Plan will require that the person for whom the request is made provide to the Plan all evidence in support
of such request within sixty (60) days of the initial request. A longer period of time, up to an additional sixty
(60) days, may be granted, to submit evidence, upon written request and good cause for the same. Evidence
submitted will include in every case, a sworn affidavit by the person for whom the determination is to be made,
or by that person's parent or guardian, if the person is a minor, or is incompetent or unable to execute such
an affidavit. The affidavit will contain the following information:
1. The name of the prior insurance carrier(s), benefit plan(s) or other payor(s) of medical benefits under
which prior Creditable Coverage is asserted to exist.
The date(s) that coverage commenced and ended under any such prior insurance, benefit plan or
other payor.
The address, if known, of the insurance carrier(s), benefit plan(s) or other payor(s).
4. The nature of the coverage under the prior insurance, benefit plan(s) or other benefit payor(s).
5. A description of the efforts undertaken to obtain Certifications of prior Creditable Coverage, and the
results of those efforts.
6. The names, and addresses or telephone numbers, of former employers, insurance agents, human
resource personnel, third party administrators, HMO's or medical providers that may have knowledge
of the asserted prior coverage.
Any other information that the affiant deems relevant.
The affidavit, together with any other documentation submitted, including, but not limited to Summary Plan
Descriptions or Policies indicating prior coverage, pay stubs indicating deduction of premium amounts,
Explanations of Benefits from prior coverage, written statements from persons with knowledge of prior
coverage, and medical bills indicating payment by insurance or benefit plans, will be reviewed and considered
by the Plan. Subsequent to such review, the Plan will provide a written determination of prior Creditable
Coverage, if any, within thirty (30) days after the submission of the last item of evidence on behalf of the
enrollee, or ninety (90) days from the enrollee's initial request for determination under this section, whichever
occurs first. The Plan's determination will be final and binding upon the Plan and all Covered Persons under
the Plan.
Collier County Government - Group #2003021 84 Plan Document / SPD - Effective 1/1/2012
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GENERAL PROVISIONS
EXAMINATION
12/13/2011 Item 16.E.4.
The Plan will have the right and opportunity to have the Covered Person examined whenever Injury or Illness
is the basis of a claim when and so often as it may reasonably require to adjudicate the claim. The Plan will
also have the right to have an autopsy performed in case of death to the extent permitted by law.
PAYMENT OF CLAIMS
All Plan benefits are payable to a Participant, Qualified Beneficiary or Alternate Recipient, whichever is
applicable. All or a portion of any benefits payable by the Plan may, at the Covered Person's option and
unless the Covered Person requests otherwise in writing not later than the time of filing the claim, be paid
directly to the health care provider rendering the service, if proper written assignment is provided to the Plan.
No payments will be made to any provider of services unless the Covered Person is liable for such expenses.
If any benefits remain unpaid at the time of the Covered Person's death or if the Covered Person is a minor
or is, in the opinion of the Plan, legally incapable of giving a valid receipt and discharge for any payment, the
Plan may, at its option, pay such benefits to the Covered Person's legal representative or estate. The Plan,
in its sole option, may require that an estate, guardianship or conservatorship be established by a court of
competent jurisdiction prior to the payment of any benefit. Any payment made under this subsection will
constitute a complete discharge of the Plan's obligation to the extent of such payment and the Plan will not
be required to oversee the application of the money so paid.
LEGAL PROCEEDINGS
No action at law or equity will be brought to recover on the Plan prior to the expiration of sixty (60) days after
proof of loss has been filed in accordance with the requirements of the Plan, nor will such action be brought
at all unless brought within three (3) years from the expiration of the time within which proof of loss is required
by the Plan.
NO WAIVER OR ESTOPPEL
No term, condition or provision of this Plan will be waived, and there will be no estoppel against the
enforcement of any provision of this Plan, except by written instrument of the party charged with such waiver
or estoppel. No such written waiver will be deemed a continuing waiver unless specifically stated therein, and
each such waiver will operate only as to the specific term or condition waived and will not constitute a waiver
of such term or condition for the future or as to any act other than that specifically waived.
VERBALSTATEMENTS
Verbal statements or representations of the Plan Administrator, its agents and Employees, or Covered
Persons will not create any right by contract, estoppel, unjust enrichment, waiver or other legal theory
regarding any matter related to the Plan, or its administration, except as specifically stated in this subsection.
No statement or representation of the Plan Administrator, its agents and Employees, or Covered Persons will
be binding upon the Plan or a Covered Person unless made in writing by a person with authority to issue such
a statement. This subsection will not be construed in any manner to waive any claim, right or defense of the
Plan or a Covered Person based upon fraud or intentional material misrepresentation of fact or law.
FREE CHOICE OF PHYSICIAN
The Covered Person will have free choice of any licensed Physician, Licensed Health Care Provider or
surgeon and the patient - provider relationship will be maintained.
Collier County Government - Group #2003021 85 Plan Document / SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
General Provisions
WORKERS' COMPENSATION NOT AFFECTED
This Plan is not in lieu of, supplemental to Workers' Compensation and does not affect any requirement for
coverage by Workers' Compensation Insurance.
CONFORMITY WITH LAW
If any provision of this Plan is contrary to any law to which it is subject, such provision is hereby amended to
conform to the minimum requirements of the applicable law. Only that provision which is contrary to applicable
law will be amended to conform; all other parts of the Plan will remain in full force and effect.
MISCELLANEOUS
Section titles are for convenience of reference only, and are not to be considered in interpreting this Plan.
No failure to enforce any provision of this Plan will affect the right thereafter to enforce such provision, nor will
such failure affect its right to enforce any other provision of the Plan.
FACILITY OF PAYMENT
Whenever payments which should have been made under this Plan in accordance with this provision have
been made under any other plan or plans, the Plan will have the right, exercisable alone and in its sole
discretion, to pay to any insurance company or other organization or person making such other payments any
amounts it determines in order to satisfy the intent of this provision. Amounts so paid will be deemed to be
benefits paid under this Plan and to the extent of such payments, the Plan will be fully discharged from liability
under this Plan.
The benefits that are payable will be charged against any applicable maximum payment or benefit of this Plan
rather than the amount payable in the absence of this provision.
PROTECTION AGAINST CREDITORS
No benefit payment under this Plan will be subject in any way to alienation, sale, transfer, pledge, attachment,
garnishment, execution or encumbrance of any kind, and any attempt to accomplish the same will be void,
except an assignment of payment to a provider of Covered Services. If the Plan Administrator finds that such
an attempt has been made with respect to any payment due or which will become due to any Participant, the
Plan Administrator, in its sole discretion, may terminate the interest of such Participant or former Participant
in such payment. In such case, the Plan Administrator will apply the amount of such payment to or for the
benefit of such Participant or covered Dependents or former Participant, as the Plan Administrator may
determine. Any such application will be a complete discharge of all liability of the Plan with respect to such
benefit payment.
PLAN IS NOT A CONTRACT
The Plan Document constitutes the primary authority for plan administration. The establishment,
administration and maintenance of this Plan will not be deemed to constitute a contract of employment, give
any Participant of the County the right to be retained in the service of the County, or to interfere with the right
of the County to discharge or otherwise terminate the employment of any Participant.
Collier County Government - Group #2003021 86 Plan Document/ SPD - Effective 1/1/2012
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12/13/2011 Item 16.E.4.
GENERAL DEFINITIONS
Certain words and phrases in this Plan Document are defined below. If the defined term is not used in this
document, the term does not apply to this Plan.
Masculine pronouns used in this Plan Document will include either the masculine or feminine gender unless
the context indicates otherwise.
Any words used herein in the singular or plural will include the alternative as applicable.
ACCIDENTAL INJURY
"Accidental Injury" means an Injury sustained as a result of an external force or forces that is /are sudden,
direct and unforeseen and is /are exact as to time and place. A hernia of any kind will only be considered as
an Illness.
ACTIVE SERVICE
"Active Service" means that an Employee is in service with the County on a day which is one of the County's
regularly scheduled work days and that the Employee is performing all of the regular duties of his /her
employment with the County on a regular basis, either at one of the County's business establishments or at
some location to which the County's business requires him /her to travel.
ADVERSE BENEFIT DETERMINATION
"Adverse Benefit Determination" means any of the following: a denial, reduction, or termination of, or a failure
to provide or make payment, in whole or in part, for a benefit, including any such denial, reduction, termination,
or failure to provide or make payment that is based on a determination of a Participant's or beneficiary's
eligibility to participate in the Plan, and including, with respect to group health plans, a denial, reduction, or
termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the
application of any utilization review, as well as a failure to cover an item or service for which benefits are
otherwise provided because it is determined to be Experimental or Investigational or not Medically Necessary
or appropriate.
ALCOHOLISM
"Alcoholism" means a morbid state caused by excessive and compulsive consumption of alcohol that
interferes with the patient's health, social or economic functioning.
ALCOHOLISM AND /OR CHEMICAL DEPENDENCY TREATMENT FACILITY
"Alcoholism and /or Chemical Dependency Treatment Facility" means a licensed institution which provides a
program for diagnosis, evaluation, and effective treatment of Alcoholism and /or Chemical Dependency;
provides detoxification services needed with its effective treatment program; provides infirmary-level medical
services or arranges with a Hospital in the area for any other medical services that may be required; is at all
times supervised by a staff of Physicians; provides at all times skilled nursing care by licensed nurses who
are directed by a full -time Registered Nurse (R.N.); prepares and maintains a written plan of treatment for
each patient based on medical, psychological and social needs which is supervised by a Physician; and meets
licensing standards.
AMBULANCE SERVICE
"Ambulance Service" means an entity, its personnel and equipment, including, but not limited to, automobiles,
airplanes, boats or helicopters, which are licensed to provide Emergency medical and Ambulance services
in the state in which the services are rendered.
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12/13/2011 Item 16.E.4.
General Definitions
AMBULATORY SURGICAL CENTER
"Ambulatory Surgical Center' (also called same -day surgery center or Outpatient surgery center) means a
licensed establishment with an organized staff of Physicians and permanent facilities, either freestanding or
as a part of a Hospital, equipped and operated primarily for the purpose of performing surgical procedures and
which a patient is admitted to and discharged from within a twenty -four (24) hour period. Such facilities must
provide continuous Physician and registered nursing services whenever a patient is in the facility. An
Ambulatory Surgical Center must meet any requirements for certification or licensing for ambulatory surgery
centers in the state in which the facility is located.
"Ambulatory Surgical Center" does not include an office or clinic maintained by a Dentist or Physician for the
practice of dentistry or medicine, a Hospital emergency room or trauma center.
AUTISM SPECTRUM DISORDER
"Autism Spectrum Disorder' means the following disorders as defined in the most recent edition of the
Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association: 1) autistic
disorder; 2) Asperger's Syndrome; and 3) pervasive developmental disorder not otherwise specified.
BENEFIT PERCENTAGE
"Benefit Percentage" means that portion of Maximum Eligible Expenses payable by the Plan, which is stated
as a percentage in the Schedule of Benefits.
BENEFIT PERIOD
"Benefit Period" refers to a time period of one year, which is either a Calendar Year or other annual period,
as shown in the Schedule of Benefits. Such Benefit Period will terminate on the earliest of the following dates:
The last day of the one year period so established; or
2. The day the Maximum Lifetime Benefit applicable to the Covered Person becomes paid; or
3. The date the Plan terminates.
BIRTHING CENTER
A "Birthing Center' means a freestanding or hospital based facility which provides obstetrical delivery services
under the supervision of a Physician, and through an arrangement or an agreement with a Hospital.
CALENDAR YEAR
"Calendar Year" means a period of time commencing on January 1 and ending on December 31 of the same
year.
CLOSE RELATIVE
"Close Relative" means the spouse, parent, brother, sister, child, or in -laws of the Covered Person.
COBRA
"COBRA" means Sections 2201 through 2208 of the Public Health Service Act [42 U.S.C. § 300bb -1 through
§ 300bb -8], which contains provisions similar to Title X of the Consolidated Omnibus Budget Reconciliation
Act of 1985, as amended.
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12/13/2011 Item 16.E.4.
General Definitions
COBRA CONTINUATION COVERAGE
"COBRA Continuation Coverage" means continuation coverage provided under the provisions of the Public
Health Service Act referenced herein under the definition of "COBRA ".
CONVALESCENT NURSING FACILITY
See "Skilled Nursing Facility ".
COSMETIC
"Cosmetic" means services or treatment ordered or performed solely to change a Covered Person's
appearance rather than for the restoration of bodily function.
COUNTY
"County" means Collier County Government or any affiliated agencies or boards that have adopted this Plan
for its Employees.
COVERED PERSON
"Covered Person" means any Participant or Dependent of a Participant meeting the eligibility requirements
for coverage and properly enrolled for coverage as specified in the Plan.
CREDITABLE COVERAGE
"Creditable Coverage" means health or medical coverage under which a Covered Person was covered, prior
to that Covered Person's Enrollment Date under this Plan, which prior coverage was under any of the
following:
1. A group health plan.
2. Health insurance coverage.
3. Part A, Part B or Part C of Title XVIII of the Social Security Act (Medicare).
4. Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under
Section 1928 (program for distribution of pediatric vaccines).
5. Chapter 55 of Title 10, United States Code (TRICARE).
6. A medical care program of the Indian Health Service or a tribal organization.
7. A state health benefits risk pool.
8. The Federal Employee Health Benefits Program.
9. A public health plan, including any plan established or maintained by a State, the US Government,
a foreign country or any political subdivision of the foregoing.
10. A health benefit plan under Section 5 (e) of the Peace Corps Act.
11. The State Children's Health Insurance Program.
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CUSTODIAL CARE
"Custodial Care" means the type of care or service, wherever furnished and by whatever name called, which
is designed primarily to assist a Covered Person in the activities of daily living. Such activities include, but
are not limited to: bathing, dressing, feeding, preparation of special diets, assistance in walking or in getting
in and out of bed, and supervision over medication which can normally be self- administered.
DEDUCTIBLE
"Deductible" means a specified dollar amount that must be incurred before the Plan will pay any amount for
any benefit during each Benefit Period.
DENTIST
"Dentist" means a person holding one of the following degrees— Doctor of Dental Science, Doctor of Medical
Dentistry, Master of Dental Surgery or Doctor of Medicine (oral surgeon) -- who is legally licensed as such to
practice dentistry in the jurisdiction where services are rendered, and the services rendered are within the
scope of his or her license.
A "Dentist' will not include the Covered Person or any Close Relative of the Covered Person who does not
regularly charge the Covered Person for services.
DEPENDENT
"Dependent" means a person who is eligible for coverage under the Dependent Eligibility subsection of this
Plan.
DEPENDENT COVERAGE
"Dependent Coverage" means eligibility for coverage under the terms of the Plan for benefits payable as a
consequence of Eligible Incurred Expenses for an Illness or Injury of a Dependent.
DURABLE MEDICAL EQUIPMENT
"Durable Medical Equipment" means equipment which is:
1. Able to withstand repeated use, i.e., could normally be rented, and used by successive patients; and
2. Primarily and customarily used to serve a medical purpose; and
3. Not generally useful to a person in the absence of Illness or Injury.
ELIGIBLE EXPENSES
"Eligible Expenses" means the maximum amount of any charge for a covered service, treatment or supply that
may be considered for payment by the Plan, including any portion of that charge that may be applied to the
Deductible or used to satisfy the Out -of- Pocket Maximum. Eligible Expenses are equal to the actual billed
charge or UCR, whichever is less or a contracted or negotiated rate, if applicable.
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EMERGENCY
"Emergency" means a medical condition manifesting itself by acute symptoms which occur suddenly and
unexpectedly and for which the Covered Person receives medical care no later than 48 hours after the onset
of the condition. Emergency is any medical condition for which a reasonable and prudent layperson,
possessing average knowledge of health and medicine, would expect that failure to seek immediate medical
attention would result in death, more severe or disabling medical condition(s), or continued severe pain without
cessation in the absence of medical treatment. Emergency may include, but is not limited to, severe Injury,
hemorrhaging, poisoning, loss of consciousness or respiration, fractures, convulsions, injuries reasonably
likely to require sutures, severe acute pain, severe burns, prolonged high fever and symptoms normally
associated with heart attack or stroke.
"Emergency" will specifically exclude usual out - patient treatment of childhood diseases, flu, common
cold, pre -natal examinations, physical examinations and minor sprains, lacerations, abrasions and
minor burns, and other medical conditions usually capable of treatment at a clinic or doctor's office
during regular working hours.
EMPLOYEE
"Employee" means a person employed by the Employer on a continuing and regular basis who is a common -
law Employee and who is on the Employer's W -2 payroll.
Employee does not include any employee leased from another employer, including but not limited to
those individuals defined in Code Section 414(n), or an individual classified by the Employer as a
contract worker, independent contractor, temporary, seasonal or casual employee, whether or not any
such persons are on the Employer's W -2 payroll, or any individual who performs services for the
Employer but who is paid by a temporary or other employment agency such as "Kelly," "Manpower,"
etc.
EMPLOYER
"Employer" means Collier County Government or any affiliated agencies or boards that have adopted this Plan
for its Employees.
ENROLLMENT DATE
"Enrollment Date" means the date a person becomes eligible for coverage under this Plan or the eligible
person's effective date of coverage under this Plan, whichever occurs first. For Late Enrollees, Enrollment
Date will always be the effective date of coverage under this Plan.
EXPERIMENTAUINVESTIGATIONAL
"Experimental /Investigational" means:
1. Any drug or device that cannot be lawfully marketed without approval of the U.S. Food and Drug
Administration and approval for marketing has not been given at the time the drug or device is
furnished; or
2. Any drug, device, medical treatment or procedure for which the patient informed consent document
utilized with the drug, device, treatment or procedure, was reviewed and approved by the treating
facility's Institutional Review Board or other body serving a similar function, or if federal law requires
such review or approval; or
3. That the drug, device or medical treatment or procedure is under study, prior to or in the absence of
any clinical trial, to determine its maximum tolerated dose, its toxicity, or its safety, or
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General Definitions
4. That based upon Reliable Evidence, the drug, device, medical treatment or procedure is the subject
of an on -going phase I or phase II clinical trial. (A Phase III clinical trial recognized by the National
Institute of Health is not considered Experimental or Investigational.) For chemotherapy regimens,
a Phase II clinical trial is not considered Experimental or Investigational when both of these criteria
are met:
A. The regimen or protocol has been the subject of a completed and published Phase II clinical
trial which demonstrates benefits equal to or greater than existing accepted treatment
protocols, and
B. The regimen or protocol listed by the National Comprehensive Cancer Network is supported
by level of evidence Phase I or Phase IIA only; or
5. Based upon Reliable Evidence, any drug, device, medical treatment or procedure that the prevailing
opinion among experts is that further studies or clinical trial are necessary to determine the maximum
tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with generally medically
accepted means of treatment or diagnosis; or
6. Any drug, device, medical treatment or procedure used in a manner outside the scope of use for
which it was approved by the FDA or other applicable regulatory authority (U.S. Department of Health,
The Centers for Medicare and Medicaid Services (CMS), American Dental Association, American
Medical Association.)
"Reliable Evidence" means only reports and articles published in authoritative medical and scientific literature;
the written protocol or protocols used by a treating facility or the protocol(s) of another facility studying
substantially the same drug, device, medical treatment or procedure; or the informed consent document used
by the treating facility or by another facility studying substantially the same drug, device, medical treatment
or procedure.
FAMILY
"Family" means a Participant and his or her eligible Dependents as defined herein.
FMLA
"FMLA" means Family and Medical Leave Act.
H I PAA
"HIPAK means the Health Insurance Portability and Accountability Act of 1996, as amended.
HOME HEALTH CARE AGENCY
"Home Health Care Agency" means an organization that provides skilled nursing services and therapeutic
services (home health aide services, physical therapy, occupational therapy, speech therapy, medical social
services) on a visiting basis, in a place of residence used as the Covered Person's home. The organization
must be Medicare certified and licensed within the state in which home health care services are provided.
HOME HEALTH CARE PLAN
"Home Health Care Plan" means a program for continued care and treatment administered by a Medicare
certified and licensed Home Health Care Agency, for the Covered Person who may otherwise have been
confined as an Inpatient in a Hospital or Skilled Nursing Facility or following termination of a Hospital
confinement as an Inpatient and is the result of the same related condition for which the Covered Person was
hospitalized and is approved in writing by the Covered Person's attending Physician.
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HOSPICE
"Hospice" means a health care program providing a coordinated set of services rendered at home, in
Outpatient settings or in institutional settings for Covered Persons suffering from a condition that has a
terminal prognosis. A Hospice must have an interdisciplinary group of personnel which includes at least one
Physician and one Registered Nurse (R.N.), and it must maintain central clinical records on all patients. A
Hospice must meet the standards of the National Hospice Organization (NHO) and applicable state licensing
requirements.
HOSPITAL
"Hospital" means an institution which meets all of the following conditions:
It is engaged primarily in providing medical care and treatment to ill and injured persons on an
emergent or inpatient basis at the patient's expense; and
2. It is licensed as a hospital or a critical access hospital under the laws of the jurisdiction in which the
facility is located; and
3. It maintains on its premises the facilities necessary to provide for the diagnosis and treatment of an
Illness or an Injury or provides for the facilities through arrangement or agreement with another
hospital; and
4. It provides treatment by or under the supervision of a physician or osteopathic physician with nursing
services by registered nurses as required under the laws of the jurisdiction in which the facility is
licensed; and
5. It is a provider of services under Medicare. This condition is waived for otherwise Eligible Incurred
Expenses outside of the United States; and
6. It is not, other than incidentally, a place for rest, a place for the aged, a place for drug addicts, a place
for alcoholics, or a nursing home.
HOSPITAL MISCELLANEOUS EXPENSES
"Hospital Miscellaneous Expenses" mean the actual charges made by a Hospital on its own behalf for services
and supplies rendered to the Covered Person which are Medically Necessary for the treatment of such
Covered Person. Hospital Miscellaneous Expenses do not include charges for Room and Board or for
professional services, regardless of whether the services are rendered under the direction of the Hospital or
otherwise.
ILLNESS
"Illness" means a bodily disorder, Pregnancy, disease, physical sickness, mental illness, orfunctional nervous
disorder of a Covered Person.
INCURRED EXPENSES OR EXPENSES INCURRED
"Incurred Expenses" or "Expenses Incurred" means those services and supplies rendered to a Covered
Person. Such expenses will be considered to have occurred at the time or date the treatment, service or
supply is actually provided.
INITIAL ENROLLMENT PERIOD
"Initial Enrollment Period" means the time allowed by this Plan for enrollment when a person first becomes
eligible for coverage.
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INJURY
"Injury" means physical damage to the Covered Person's body which is not caused by disease or bodily
infirmity.
INPATIENT
"Inpatient" means the classification of a Covered Person when that person is admitted to a Hospital, Hospice,
or Skilled Nursing Facility for treatment, and charges are made for Room and Board to the Covered Person
as a result of such treatment.
INPATIENT CONFINEMENT DAY
"Inpatient Confinement Day" means any day a person is classified as Inpatient. An Inpatient Confinement Day
will commence at 12:01 A.M. and will be calculated using a calendar day.
INTENSIVE CARE UNIT
"Intensive Care Unit" means a section, ward, orwing within the Hospital which is separated from otherfacilities
and:
Is operated exclusively for the purpose of providing professional medical treatment for critically ill
patients;
2. It has special supplies and equipment necessary for such medical treatment available on a standby
basis for immediate use; and
It provides constant observation and treatment by Registered Nurses (R.N.'s) or other highly- trained
Hospital personnel.
LATE ENROLLMENT OR LATE ENROLLEE
"Late Enrollment" or "Late Enrollee" means an eligible person who makes application for Participant or
Dependent Coverage under this Plan other than during the Initial Enrollment Period or a Special Enrollment
Period.
LICENSED HEALTH CARE PROVIDER
"Licensed Health Care Provider" means any provider of health care services who is licensed or certified by
any applicable governmental regulatory authority to the extent that services are within the scope of the license
or certification and are not specifically excluded by this Plan.
LICENSED PRACTICAL NURSE
"Licensed Practical Nurse" means an individual who has received specialized nursing training and practical
nursing experience, and is licensed to perform such nursing services by the state or regulatory agency
responsible for such licensing in the state in which that individual performs such services.
LICENSED SOCIAL WORKER
"Licensed Social Worker' means a person holding a Masters Degree (M.S.W.) in social work and who is
currently licensed as a social worker in the state in which services are rendered, and who provides counseling
and treatment in a clinical setting for Mental Illnesses.
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MAINTENANCE THERAPY
"Maintenance Therapy" means medical and non - medical health - related services that do not seek to cure, or
that which are provided during periods when the medical condition of the patient is not changing, or does not
require continued administration by medical personnel.
MAXIMUM LIFETIME BENEFIT
"Maximum Lifetime Benefit" means the maximum benefit payable while a person is covered under this Plan.
The Maximum Lifetime Benefit will not be construed as providing lifetime coverage, or benefits for a person's
Illness or Injury after coverage terminates under this Plan.
MEDICAID
"Medicaid" means that program of medical care and coverage established and provided by Title XIX of the
Social Security Act, as amended.
MEDICALLY NECESSARY
"Medically Necessary" means treatment, tests, services or supplies provided by a Hospital, Physician, or other
Licensed Health Care Provider which are not excluded under this Plan and which meet all of the following
criteria:
1. Are to treat or diagnose an Illness or Injury; and
2. Are ordered by a Physician or Licensed Health Care Provider and are consistent with the symptoms
or diagnosis and treatment of the Illness or Injury; and,
3. Are not primarily for the convenience of the Covered Person, Physician or other Licensed Health Care
Provider; and,
4. Are the standard or level of services most appropriate for good medical practice that can be safely
provided to the Covered Person and are in accordance with the Plan's Medical Policy; and,
5. Are not of an Experimental /Investigational or solely educational nature; and,
6. Are not provided primarily for medical or other research; and,
7. Do not involve excessive, unnecessary or repeated tests; and,
8. Are commonly and customarily recognized by the medical profession as appropriate in the treatment
or diagnosis of the diagnosed condition; and,
9. Are approved procedures or meet required guidelines or protocols of the Food and Drug
Administration (FDA) or The Centers For Medicare /Medicaid Services (CMS), pursuant to that entity's
program oversight authority based upon the medical treatment circumstances.
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12/13/2011 Item 16.E.4.
General Definitions
MEDICAL POLICY
"Medical Policy" means a policy adopted by the Plan which is created and updated by physicians and other
medical providers and is used to determine whether health care services including medical and surgical
procedures, medication, medical equipment and supplies, processes and technology meet the following
nationally accepted criteria:
Final approval frolic the appropriate governmental regulatory agencies;
2. Scientific studies showing conclusive evidence of improved net health outcome; and
In accordance with any established standards of good medical practice.
MEDICARE
"Medicare" means the programs established under the "Health Insurance for the Aged Act," Public Law 89 -97
under Title XVIII of the Federal Social Security Act, as amended, to pay for various medical expenses for
qualified individuals, specifically those who are eligible for Medicare Part A, Part B or Part D as a result of age,
those with end -stage renal disease, or with disabilities.
MENTAL ILLNESS
"Mental Illness" means a medically recognized psychological, physiological, nervous or behavioral condition,
affecting the brain, which can be diagnosed and treated by medically recognized and accepted methods, but
will not include Alcoholism, Chemical Dependency or other addictive behavior. Conditions recognized
by the Diagnostic Statistical Manual (the most current edition) will be included in this definition.
MORBID OBESITY /CLINICALLY SEVERE OBESITY
"Morbid Obesity /Clinically Severe Obesity" means maintaining a Body Mass Index (BMI) of 40 or more for a
period of at least 12 consecutive months, or a BMI of at least 35 for a period of at least 12 consecutive
months, combined with at least one of the following conditions which must be documented by a physician as
life- threatening:
Severe sleep apnea;
2. Pickwickian syndrome;
3. Congestive heart failure;
4. Cardiomyopathy;
5. Insulin dependent or oral medication dependent diabetes;
6. Severe Musculoskeletal dysfunction;
7. Gastric Esophageal Reflux Disorder;
8. Pulmonary edema; or
9. Hypertension.
Body Mass Index (BMI) is calculated by dividing a person's weight (in kilograms) by his /her height squared
(in meters).
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NAMED FIDUCIARY
"Named Fiduciary" means the Plan Administrator which has the authority to control and manage the operation
and administration of the Plan.
NEWBORN
"Newborn" refers to an infant from the date of his /her birth until the initial Hospital discharge or until the infant
is fourteen (14) days old, whichever occurs first.
OCCUPATIONAL THERAPY
"Occupational Therapy" means a program of care ordered by a Physician which is forthe purpose of improving
the physical, cognitive and perceptual disabilities that influence the Covered Person's ability to perform
functional tasks related to normal life functions or occupations, and which is for the purpose of assisting the
Covered Person in performing such functional tasks without assistance.
ORTHOPEDIC APPLIANCE
"Orthopedic Appliance" means a rigid or semi -rigid support used to restrict or eliminate motion in a diseased,
injured, weak or deformed body member.
OUT -OF- POCKET MAXIMUM
"Out -of- Pocket Maximum" means the maximum dollar amount, as stated in the Schedule of Medical Benefits,
that any Covered Person or Family will pay in any Benefit Period for covered services, treatments or supplies.
OUTPATIENT
"Outpatient" means a Covered Person who is receiving medical care, treatment, services or supplies at a
clinic, a Physician's office, a Licensed Health Care Provider's office or at a Hospital if not a registered
bedpatient at that Hospital, Psychiatric Facility orAlcoholism and /or Chemical Dependency Treatment Facility.
PARTICIPANT
"Participant" means an Employee of the County who is eligible and enrolled for coverage under this Plan.
PHYSICAL THERAPY
"Physical Therapy" means a plan of care ordered by a Physician and provided by a licensed physical therapist,
to return the Covered Person to the highest level of motor functioning possible.
PHYSICIAN
"Physician" means a person holding the degree of Doctor of Medicine, Dentistry or Osteopathy, or Optometry
who is legally licensed as such.
"Physician" does not include the Covered Person or any Close Relative of the Covered Person who does not
regularly charge the Covered Person for services.
PLACEMENT OR BEING PLACED FOR ADOPTION
"Placement" or "Being Placed for Adoption" means the assumption and retention of a legal obligation for total
or partial support of a child by a person with whom the child has been placed in anticipation of the child's
adoption. The child's placement for adoption with such person ends upon the termination of such legal
obligation.
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12/13/2011 Item 16.E.4.
General Definitions
PLAN
"Plan" means the Collier County Government Employee Benefit Plan, the Plan Document and any other
relevant documents pertinent to its operation and maintenance.
PLAN ADMINISTRATOR
"Plan Administrator' means the County and /or its designee which is responsible for the day -to -day functions
and management of the Plan. The Plan Administrator may employ persons or firms to process claims and
perform other Plan- connected services. For the purposes of any applicable state legislation of a similar
nature, the County will be deemed to be the Plan Administrator of the Plan unless the County designates an
individual or committee to act as Plan Administrator of the Plan.
PLAN SUPERVISOR
"Plan Supervisor" means the person or firm employed by the Plan to provide consulting services to the Plan
in connection with the operation of the Plan and any other functions, including the processing and payment
of claims. The Plan Supervisor is Allegiance Benefit Plan Management, Inc. The Plan Supervisor provides
ministerial duties only, exercises no discretion over plan assets and will not be considered a fiduciary as
defined by any other State or Federal law or regulation.
PRE - EXISTING CONDITION
"Pre- Existing Condition" means an Injury or Illness of a Covered Person, except for Pregnancy, for which the
Covered Person has been under the care of a Physician or Licensed Health Care Provider, or has received
medical advice, diagnosis, treatment, services or care, including prescription drugs, within the six (6) month
period immediately preceding his /her Enrollment Date. Pregnancy will never be considered a Pre - Existing
Condition for any reason.
PREGNANCY
"Pregnancy" means a physical condition commencing with conception, and ending with miscarriage or birth.
PREVENTIVE CARE
"Preventive Care" means routine examinations or services provided when there is no objective indication or
outward manifestation of impairment of normal health or normal bodily function, which is not provided for
treatment or diagnosis of any Injury or Illness.
PROSTHETIC APPLIANCE
"Prosthetic Appliance" means a device or appliance that is designed to replace a natural body part lost or
damaged due to Illness or Injury, the purpose of which is to restore full or partial bodily function or appearance,
or in the case of Covered Dental Benefit, means any device which replaces all or part of a missing tooth or
teeth.
PSYCHIATRIC CARE
"Psychiatric Care," also known as psychoanalytic care, means treatment for a Mental Illness or disorder, a
functional nervous disorder, Alcoholism or drug addiction by a licensed psychiatrist, psychologist, Licensed
Social Worker or licensed professional counselor acting within the scope and limitations of his /her respective
license, provided that such treatment is Medically Necessary as defined by the Plan, and within recognized
and accepted professional psychiatric and psychological standards and practices.
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PSYCHIATRIC FACILITY
"Psychiatric Facility" means a licensed institution that provides Mental Illness treatment and which provides
for a psychiatrist who has regularly scheduled hours in the facility, and who assumes the overall responsibility
for coordinating the care of all patients.
PSYCHOLOGIST
"Psychologist" means a person currently licensed in the state in which services are rendered as a psychologist
and acting within the scope of his /her license.
QMCSO
" QMCSO" means Qualified Medical Child Support Order as defined by Section 609(a) of ERISA, as amended.
QUALIFIED BENEFICIARY
"Qualified Beneficiary" means an Employee, former Employee or Dependent of an Employee or former
Employee who is eligible to continue coverage under the Plan in accordance with applicable provisions of Title
X of COBRA or Section 609(a) of ERISA in relation to QMCSO's.
"Qualified Beneficiary" will also include a child born to, adopted by or Placed for Adoption with an Employee
or former Employee at any time during COBRA Continuation Coverage.
REGISTERED NURSE
"Registered Nurse" means an individual who has received specialized nursing training and is authorized to
use the designation of "R.N." and who is licensed by the state or regulatory agency in the state in which the
individual performs such nursing services.
REHABILITATION FACILITY
"Rehabilitation Facility" means a facility that meets all of the following requirements:
1. Care must be for the treatment of acute Injury or Illness;
2. Is licensed as an acute rehabilitation facility;
3. The care is under the direct supervision of a Physician;
4. Services are Medically Necessary;
5. Services are specific to an active written treatment plan;
6. The patient's condition requires skilled nursing care and interventions which cannot be achieved or
managed at a lower level of care;
7. Twenty -four (24) hour nursing services are available; and
8. The confinement is not for Custodial or maintenance care.
RETIREE
"Retiree" means an Employee who retires under a retirement program authorized by law and eligible to
continue coverage with the Employer pursuant to the terms of Florida statute 112.0801, as amended.
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ROOM AND BOARD
"Room and Board" refers to all charges which are made by a Hospital, Hospice, or Skilled Nursing Facility as
a condition of occupancy. Such charges do not include the professional services of Physicians or intensive
nursing care by whatever name called.
SEMI - PRIVATE
"Semi- Private" refers to the class of accommodations in a Hospital or Skilled Nursing Facility in which at least
two patient beds are available per room.
SKILLED NURSING FACILITY
"Skilled Nursing Facility" means an institution, or distinct part thereof, which meets all of the following
conditions:
It is currently licensed as a long -term care facility or skilled nursing facility in the state in which the
facility is located;
2. It is not, other than incidentally, a place for rest, the aged, drug addicts, alcoholics, mentally disabled
persons, custodial or educational care, or care of mental disorders; and
3. It is certified by Medicare.
This term also applies to Incurred Expenses in an institution known as a Convalescent Nursing Facility,
Extended Care Facility, Convalescent Nursing Home, or any such other similar nomenclature.
SPEECH THERAPY
"Speech Therapy" means a course of treatment, ordered by a Physician, to treat speech deficiencies or
impediments.
SUBSTANCE ABUSE /CHEMICAL DEPENDENCY
"Substance Abuse" or "Chemical Dependency' means the physiological and psychological addiction to a
controlled drug or substance, or to alcohol. Dependence upon tobacco, nicotine, caffeine or eating disorders
are not included in this definition.
URGENT CARE FACILITY
"Urgent Care Facility" means a free - standing facility which is engaged primarily in diagnosing and treating
Illness or Injury for unscheduled, ambulatory Covered Persons seeking immediate medical attention. A clinic
or office located in or in conjunction with or in any way made a part of a Hospital will be excluded from the
terms of this definition.
USERRA
" USERRA" means the Uniformed Services Employment and Reemployment Rights Act, as amended.
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USUAL, CUSTOMARY AND REASONABLE (UCR)"
"Usual, Customary and Reasonable (UCR)" means the maximum amount considered for payment by this Plan
for any covered treatment, service, or supply, subject however, to all Plan annual and lifetime maximum
benefit limitations. The following will apply in the order below to determination of the Usual, Customary, and
Reasonable amount:
A contracted amount as established by a preferred provider or other discounting contract; or,
An amount established through a nationally recognized, published Usual, Customary and Reasonable
(UCR) data base utilized by the Plan Supervisor and adopted by the Plan Administrator using the 90th
percentile of said database; or
The billed charge if less than A or B above.
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12/13/2011 Item 16.E.4.
NOTICES
NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT: Group health insurance issuers offering group
health insurance coverage generally may not, under Federal law, restrict benefits for any hospital length of
stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal
vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does
not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging
the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers
may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for
prescribing a length of stay not in excess of 48 hours (or 96 hours).
IDENTIFICATION OF FUNDING: Your benefits under this plan will be paid from employee or employer
contributions up to the limits defined in the Plan Document and Summary Plan Description (SPD). Benefits
in excess of the amount stated in the stop loss policy are reimbursable to the employer by stop loss insurance,
pursuant to the stop loss insurance contract or policy, subject, however, to the terms of this Plan and the stop
loss insurance contract.
WOMEN'S HEALTH AND CANCER RIGHTS ACT: Did you know that your plan, as required by the Women's
Health and Cancer Rights Act of 1998, provides benefits for mastectomy - related services including all states
of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications
resulting from a mastectomy, including lymphedema? Call your Plan Administrator for more information.
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12/13/2011 Item 16.E.4.
HIPAA PRIVACY AND SECURITY STANDARDS
These standards are intended to comply with all requirements of the Privacy and Security Rules of the
Administrative Simplification Rules of HIPAA as stated in 45 CFR Parts 160,162 and 164, as amended from
time to time.
DEFINITIONS
"Protected Health Information" (PHI) means information, including demographic information, that identifies an
individual 'and is created or received by a health care provider, health plan, employer, or health care
clearinghouse; and relates to the physical or mental health of an individual; health care that individual has
received; or the payment for health care provided to that individual. PHI does not include employment records
held by the Plan Sponsor in its role as an employer.
"Summary Health Information" means information summarizing claims history, expenses, or types of claims
by individuals enrolled in a group health plan and has had the following identifiers removed: names;
addresses, except for the first three digits of the zipcode; dates related to the individual (ex: birth date); phone
numbers; email addresses and related identifiers; social security numbers; medical record numbers; account
or plan participant numbers; vehicle identifiers; and any photo or biometric identifier.
PRIVACY CERTIFICATION
The Plan Sponsor hereby certifies that the Plan Documents have been amended to comply with the privacy
regulations by incorporation of the following provisions. The Plan Sponsor agrees to:
Not use or further disclose the information other than as permitted or required by the Plan Documents
or as required by law. Such uses or disclosures may be for the purposes of plan administration,
including but not limited to, the following:
A. Operational activities such as quality assurance and utilization management, credentialing,
and certification or licensing activities; underwriting, premium rating or other activities related
to creating, renewing or replacing health benefit contracts (including reinsurance or stop
loss); compliance programs; business planning; responding to appeals, external reviews,
arranging for medical reviews and auditing, and customer service activities. Plan
administration can include management of carve -out plans, such as dental or vision
coverage.
B. Payment activities such as determining eligibility or coverage, coordination of benefits,
determination of cost - sharing amounts, adjudicating or subrogating claims, claims
management and collection activities, obtaining payment under a contract for reinsurance or
stop -loss coverage, and related data - processing activities; reviewing health care services for
medical necessity, coverage or appropriateness of care, or justification of charges; or
utilization review activities.
C. For purposes of this certification, plan administration does not include disclosing Summary
Health Information to help the plan sponsor obtain premium bids; or to modify, amend or
terminate group health plan coverage. Plan administration does not include disclosure of
information to the Plan Sponsor as to whether the individual is a participant in; is an enrollee
of or has disenrolled from the group health plan.
2. Ensure that any agents, including a subcontractor, to whom it provides PHI received from the Plan
agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such
information;
3. Not use or disclose the PHI for employment - related actions and decisions or in connection with any
other benefit or employee benefit plan of the Plan Sponsor;
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12/13/2011 Item 16.E.4.
HIPAA Privacy and Security Standards
4. Report to the Plan any use or disclosure of the information that is inconsistent with-the uses or
disclosures provided for of which it becomes aware;
5. Make available PHI as required to allow the Covered Person a right of access to his or her PHI as
required and permitted by the regulations;
6. Make available PHI for amendment and incorporate any amendments into PHI as required and
permitted by the regulations;
7. Make available the PHI required to provide an accounting of disclosures as required by the
regulations;
8. Make its internal practices, books, and records relating to the use and disclosure of PHI received from
the Plan available to any applicable regulatory authority for purposes of determining the Plan's
compliance with the law's requirements;
9. If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any
form and retain no copies of such information when no longer needed for the purpose for which
disclosure was made, except that, if such return or destruction is not feasible, limit further uses and
disclosures to those purposes that make the return or destruction of the information infeasible; and
10. Ensure that the adequate separation required between the Plan and the Plan Sponsor is established.
To fulfill this requirement, the Plan Sponsor will restrict access to nonpublic personal information to
the Plan Administrator(s) designated in this Plan Document or employees designated by the Plan
Administrator(s) who need to know that information to perform plan administration and healthcare
operations functions or assist eligible persons enrolling and disenrolling from the Plan. The Plan
Sponsor will maintain physical, electronic, and procedural safeguards that comply with applicable
federal and state regulations to guard such information and to provide the minimum PHI necessary
for performance of healthcare operations duties. The Plan Administrator(s) and any employee so
designated will be required to maintain the confidentiality of nonpublic personal information and to
follow policies the Plan Sponsor establishes to secure such information.
When information is disclosed to entities that perform services or functions on the Plan's behalf, such entities
are required to adhere to procedures and practices that maintain the confidentiality of the Covered Person's
nonpublic personal information, to use the information only for the limited purpose for which it was shared, and
to abide by all applicable privacy laws.
SECURITY CERTIFICATION
The Plan Sponsor hereby certifies that its Plan Documents have been amended to comply with the security
regulations by incorporation of the following provisions. The Plan Sponsor agrees to:
1. Implement and follow all administrative, physical, and technical safeguards of the HIPAA Security
Rules, as required by 45 CFR § §164.308, 310 and 312.
2. Implement and install adequate electronic firewalls and other electronic and physical safeguards and
security measures to ensure that electronic PHI is used and disclosed only as stated in the Privacy
Certification section above.
3. Ensure that when any electronic PHI is disclosed to any entity that performs services or functions on
the Plan's behalf, that any such entity shall be required to adhere to and follow all of the requirements
for security of electronic PHI found in 45 CFR § §164.308, 310, 312, 314 and 316.
4. Report to the Plan Administrator or the Named Fiduciary of the Plan any attempted breach, or breach
of security measures described in this certification, and any disclosure or attempted disclosure of
electronic PHI of which the Plan Sponsor becomes aware.
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12/13/2011 Item 16.E.4.
COLLIER COUNTY GOVERNMENT
EMPLOYEE BENEFIT PLAN
PLAN SUMMARY
The following information, together with the information contained in this booklet, form the Summary Plan
Description.
1. PLAN
The name ofthe Plan is the COLLIER COUNTY GOVERNMENT EMPLOYEE BENEFIT PLAN, which
Plan describes the benefits, terms, limitations and provisions for payment of benefits to or on behalf
of eligible Participants.
2. PLAN BENEFITS
This Plan provides benefits for covered expenses incurred by eligible participants for:
Hospital, Surgical, Medical, Maternity, Pharmacy other eligible medically related,
necessary expenses.
3. PLAN EFFECTIVE DATE
This Plan was established effective January 1, 2000, and restated January 1, 2012.
4. PLAN SPONSOR
Name: Collier County Government
Phone (239) 252 -8461
Address: 3311 East Tamiami Trail, Building D
Naples, FL 34112
5. PLAN ADMINISTRATOR
The Plan Administrator is the Plan Sponsor.
6. NAMED FIDUCIARY
Name: Collier County Government
Phone (239) 252 -8461
Address: 3311 East Tamiami Trail, Building D
Naples, FL 34112
7. PLAN FISCAL YEAR
The Plan fiscal year ends December 31
8. PLAN TERMINATION
The right is reserved by the Sponsor to terminate, suspend, withdraw, amend or modify the Plan in
whole or in part at any time.
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12/13/2011 Item 16.E.4.
Plan Summary
9. IDENTIFICATION NUMBER
Plan Number: 501
Group Number: 2003021
Employer Identification Number: 59- 6000558
10. PLAN SUPERVISOR
Name: Allegiance Benefit Plan Management, Inc.
Address: P.O. Box 3018
Missoula, MT 59806
11. ELIGIBILITY
Employees and dependents of employees of the Plan Sponsor may participate in the Plan based
upon the eligibility requirements set forth by the Plan.
12. PLAN FUNDING
The Plan is funded by contributions from the employer and employees.
13. AGENT FOR SERVICE OF LEGAL PROCESS
The Plan Administrator is the agent for service of legal process.
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