Agenda 02/10/2009 Item #16E 5
Page J of 1
Item r'~o. 16E5
F3brG8rY 10, 2009
Page 1 of 99
COLLIER COUNTY
"'-".
BOAR::> OF COUNTY COMMISSIONERS
Item Number:
Item Summary:
16E5
Meeting Date:
Approval of the Collier County Employee Benefit Plan and Flexible Benefits Plan documents
effective January 1 2009
2/10/2009 9:00.0:J AM
Prepared Il}'
Jeffrey A. Walker, CPCU,
ARM
Risk Management Dl~e::tor
Date
Administrative Services
Risk Management
1/26/20092:16:47 PM
Approved 8)'
Jeffrey A. Walker, CPCU,
ARM
Risk Management Director
Date
Administrative Services
Risk Management
1/26/20092:16 PM
Approved BJ
William Mountford
Assistant County Attorney
Date
County Attorney
County Attorney Office
1127/200910:52 AM
Approved By
Len Golden Price
Administrative Services Adminis'.:rator
Date
~
Administrative Services
Administrative Services Admin.
1127/2009 1052 PI~
Appro"e-d By
Jeff Klatzkow
Assistant Counly Attorney
Date
County Attorney
County Attorney Office
1!28f2009 9:::3 AM
Approve-d By
OMS Co:xdinator
OMS Coordinator
Date
County Manager's Office
Office of Management & Budget
1/28/200910:50 AIVl
Approved By
Laura Davisson
County ManagE:'r's Office
Management & BUG get Analyst
Office of Managemei1t & 8udg-sl
Date
1/28/200911:21 AM
ApprO\'l'd By
James V. Mudd
County Manager
Date
Board of County
Commissioners
County Manager's Offi::.e
1!29/2009 3:43 PM
~
file:IIC:\Al!endaTest\ExDort\ 123-Februarv%20 1 0.0;;,202009\ 16.%20CONSENT'Yo20AC, END ".
2/4/2009
iL~iTj ;-~J, /i '3E
10, ::-00
2 'J~' ~;'
EXECUTIVE SUMMARY
Approval of the Collier County Employee Benefit Plan and Flexible Benefits Plan
documents effective January 1, 2009.
OBJECTIVE: To receive approval of the Collier County Employee Benefit Plan and Flexible
Benefits Plan documents effective January 1, 2009 to be used to administer the Health Insurance
and Flexible Reimbursement Account programs.
CONSIDERATIONS: The Board of Commissioners provides group health insurance coverage to
its employees through a partially self-insured group health program. This program utilizes two
Master Plan Documents (the Policies or Plan Documents) which governs covered benefits and
exclusions. The County's third party claims administrator, Meritain, Inc., utilizes these documents
to adjudicate claims. The Plan's reinsurers use the documents to determine reinsurance pricing
and reimbursement eligibility.
Effective January 1, 2009 a behavior based wellness incentive program was incorporated into the
design of the health plan. The purpose of the program is to engage employees to participate in
various wellness related activities or "qualifiers" to prevent illness and to manage chronic disease.
Employees are enrolled in one of three plans with progressively better benefits (Basic, Select, or
Premium) based upon their completion of these qualifiers. The qualifiers include the completion of
a personal wellness profile; the gathering of weight, height and waist measurements; a complete
blood analysis; age and gender based screenings; and participation in diabetes management and
smoking cessation programs (if applicable). A new Group Health Plan Document (The Collier
County Employee Benefit Plan) has been prepared to govern the program.
-
A revised Flexible Benefit Plan Document has also been created to govern the county's flexible
benefits program. This program permits employees to set aside payroll dollars in the form of pre-
tax contributions for the funding of eligible out of pocket medical expenses and eligible dependent
care expenses. These contributions reduce the taxable salary of these workers resulting in federal
income and FICA tax savings to those employees who participate. Further, these dollars also
reduce the county's FICA contribution. The County does not contribute to these accounts.
These documents were prepared by risk management staff in conjunction with Meritain, Inc., the
county's third party administrator; and Willis, Inc., the county's benefits actuary and plan
consultant. 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
the documents.
FISCAL IMPACT: There is no fiscal impact associated with the approval of the Plan Amendment.
GROWTH MANAGEMENT IMPACT: There is no growth management impact associated with the
approval of these documents.
LEGAL CONSIDERATIONS: There are no legal considerations associated with this item. This
item is not quasi judicial, and as such ex parte disclosure is not required. This item requires
majority vote only. William E. Mountford, ACA
.-'
:tern 'OJ]. i CE~)
Ft;Ll,U::'i;V 10. 2C!CJ9
;:::::;~:...,,,,, ~) CJ- f 00
, Cl~...- 0 ".~,
RECOMMENDATION: It is recommended that the Board of Commissioners approves the Collier
County Employee Benefit Plan and Flexible Benefits Plan documents effective January 1, 2009.
PREPARED BY:
Jeff Walker, CPCU, ARM, Director Risk Management
-
~-
~,--'P-'" ':> .oIT" ~,!rl 1h;:::::~
F ebrLi3fY 10, 2009
Page 4 oi 99
COLLIER COUNTY GOVERNMENT
Employee Benefit Plan
Effective:
Restated:
January 1, 2000
January 1, 2009
Group No.:
RB785
i;l;~ lVIERITAINsM
11II;;; .' H!= a LTH
,jj/ _'t. I I
P.O. BOX 27267
MINNEAPOLIS, MN 55427-0267
,L.~wnda Item ~~o. 16E5
~ February 10. 2009
Page 5 of 99
COLLIER COUNTY GOVERNMENT
EMPLOYEE BENEFIT PLAN
This Plan is 'Nritten, adopted and operative for the sole and exclusive purpose of providing to the Eligible Employees and
their Eligible Dependents employee welfare benefits as described herein.
The Plan agrees to provide the Benefits set forth in the Schedule of Benefits to all Covered Persons in accordance with the
provisions and conditions of the Plan.
The Plan is subject to all the conditions and provisions set forth in this document and subsequent amendments that are
made a part of this Plan.
It is understood by the Employer that once claim processing has begun, any claims needing to be reprocessed as a result
of changes or corrections to this document may result in a reprocessing fee.
Collier County Government has caused this RESTATED Plan to take effect as of 12:01 a.m., local time on January 1,2009
at Naples, Florida.
Authorized Signature
Date
Title
Witness
Date
Title
/\genda item ~.Jo. 16E5
February 10, 2009
Page 6 of 99
TABLE OF CONTENTS
GENERAL PLAN INFORMATION ...............................................................................................................................1
INVEST IN YOUR HEALTH - HOW TO QUALIFy....................................................................................................2
COUNTY SPONSORED TOBACCO CESSATION PROGRAM ONLy...................................................................... 5
COUNTY SPONSORED DIABETES MANAGEMENT PROGRAM ONLy................................................................. 7
HEALTH REIMBURSEMENT ACCOUNT ...................................................................................................................8
SCHEDULE OF BENEFITS PREMIUM OPTION ......................................................................................................10
SCHEDULE OF BENEFITS SELECT OPTION .........................................................................................................14
SCHEDULE OF BENEFITS BASIC OPTION ............................................................................................................1e
PRESCRIPTION DRUG CARD BENEFITS ............................................................................................................... 21
ELIGIBILITY, ENROLLMENT & EFFECTIVE DATE OF COVERAGE ..................................................................... 29
ELIGIBLE EXPENSES ......................................................................... ......................................................................32
SMARTCHOICE PROGRAM .....................................................................................................................................40
MEDICAL EXPENSE AUDIT BONUS .......................................................................................................................40
ALTERNATIVE BENEFITS ........................................................................................................................................41
PRE-EXISTING CONDITION LIMIT A TION................................................................................................................ 41
NOTIFICATION PROVISIONS ...................................................................................................................................42
EXCLUSIONS AND LIMIT A TIONS............................................................................................................................ 44
DEFIN ITIONS ............................................................................................................................................................. 49
TERMINATION OF BENEFITS .................................................................................................................................. 56
CONTINUATION OF BENEFITS (COBRA) ......................... ........................................_............................................. 58
COORDINATION OF BENEFITS ............................................................................................................................... 62
EFFECT OF MEDiCARE............................................................................................................................... ............. 64
SUBROGATION ......................................................................................................................................................... 65
REIMBURSEMENT RIGHTS ..................................................................................................................................... 66
RIGHTS OF RECOVERY ........................................................................................................................................... 66
RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION ..................................................................... 66
NOTICE TO PLAN PARTICIPANTS .......................................................................................................................... 67
GENERAL PROVISIONS .......................................................................................... .............................. ................... 68
INSTRUCTIONS FOR SUBMISSION OF CLAIMS.................................................................................................... 72
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION.................................................................... 74
Name of Plan:
Type of Plan:
Plan Number:
Plan Administrator:
Group Number:
Employer Tax ID Number:
Plan Effective Date:
Plan Restated Date:
Plan Renewal Date:
Plan Year Ends:
Agent for Legal Service:
(Process may be serviced upon
the Plan Administrator)
Contract Administrator:
Named Fiduciary:
Effective Date of Coverage:
Termination Date of Coverage:
RB785 - Restated 1/1/09
GENERAL PLAN INFORMATION
,';r-""n'"'3 Ij':';'1T1 ~~o ~P.f=5
:1~' _'-'_'-~,~'~_.._ '",' ~.___;:
reu; UcL Y I J, .<:Ou9
P;::~ge 7 of 99
Collier County Government
Employee Benefit Plan
Self-funded welfare plan providing medical and prescription drug
coverage.
501
Jeff Walker, Director Risk Management
Collier County Government
3301 East Tamiami Trail, Building 0
Nap!es, FL 34112
(239) 252-8461
RB 785
59-6000558
January 1, 2000
January 1, 2009
January 1
December 31
Collier County Government
3301 East Tamiami Trail, Building 0
Naples, FL 34112
(239) 252-8461
Meritain Health,m
P.O. Box 27267
Minneapolis, MN 55427-0267
(952) 546-0062
(800) 925-2272
Collier County Government
3301 East Tamiami Trail, Building 0
Naples, FL 34112
(239) 252-8461
See Eligibility, Enrollment & Effective Date of Coverage section.
The last day of the month in which the employee terminated.
Aaenda Item No. 16E5
~ February 10, 2009
Page 8 of 99
INVEST IN YOUR HEALTH - HOW TO QUALIFY ONLY
CURRENT EMPLOYEES /RETIREES/COBRA PARTICIPANTS
PLAN YEAR 2009
Employees/Retirees/COBRA participants covered under the group health plan will automatically be placed in the
Select plan effective 1/1/09 through 12/31/09. Expenses will be payable as shown in the Schedule of Benefits.
PLAN YEAR 2010
Qualifying Events Period
Qualifying Events are specific actions to be completed by an Employee/Retiree/COBRA participant to determine which
health plan the participant qualifies for in next the plan year.
Qualifying Guidelines
o The Qualifying Event Period is between January 1,2009 and September 30,2009
o Paperwork is due to the on-site contracted Health Advocate's office by 9/30/09 (no exceptions)
o Tobacco Users must complete qualifying criteria each year
o Diabetics must complete qualifying criteria each year
o Next qualifying period 10/1/09 - 9/30/10 for plan year 2011
Qualifiers for each of the health plans (Qualifiers were determined using Evidence Based Medical Guidelines and
may be adjusted annually)
Premium Plan - Hiqhest Level of Reimbursement
Qualifying Events for all eligible employees, Retirees, COBRA Participants, VSIP (Voluntary Separation
Incentive Program) Participants
Health History Questionnaire
Lab work
Meet with Health Advocate
If applicable -
Age/Gender Screenings (For ages 20, 25, 30, 35, 40, 43, 46, 50 & over)
Tobacco Cessation Program
Diabetes Management Program
How to Qualify
Complete Health History Questionnaire -This can be done online, at home, or your desk, or by paper at your
scheduled lab draw.
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.
Retirees/COBRA participants who do not reside in Collier County will contact Quest Diagnostics for a remote iab
kit to be used at a Quest Diagnostics center in their area.
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. An
appointment with your Primary Care Physician or Vocatus can be scheduled for age/gender screenings or other
conditions that need follow up, if applicable. Specific forms supplied by the Health Advocate will need to be
completed at your physician's appointment. A copy of the Personal Wellness Profile should be given to the
physician at the appointment.
RB785 - Restated 1/1/09
2
,A.o6nda ite-m hJo. 16E5
- February 10. 2009
Page 9 of 99
Retirees/COBRA participants who do not reside in Collier County will contact the Advocates by phone.
Age/Gender Screening - (For ages 20, 25, 30, 35, 40, 43, 46, 50 & over) Can be completed at The
MedCenter, Vocatus Medical Management or by your primary care physician. The completed form(s) must be
provided to the on-site contracted Health Advocate.
Tobacco Cessation Program - Administered through The MedCenter. A certificate of completion must be
provided to the on-site contracted Health Advocate. This is an annual requirement if still a tobacco user.
Retirees/COBRA participants who do not reside in Collier County will work with the Health Advocate who will
monitor the tobacco cessation program they are engaged in.
Diabetes Management Program - Administered through The MedCenter. Completed Diabetes form must be
given to on-site contracted Health Advocate.
Retirees/COBRA participants who do not reside in Collier County will continue to work with their own provider and
submit a completed diabetes form to the Health Advocate.
Diabetes Management Program Requirements:
Annual Physical Exam by the physician managing your Diabetes
Annual Foot Exam by a health care professional
Annual Eye Exam by an ophthalmologist/Optometrist
Quarterly Lab Work; Hemoglobin A 1 C, Micro albumin, Lipid profile'
'If Hemoglobin A1C lab result is 8 or above additional events apply
Maintaining Diabetic - (2) One Hour Educational classes"
Newly Diagnosed Diabetic - (5) One Hour Educational classes"
"Diabetes educational classes available in a variety of formats
Select Plan - Middle Level of Reimbursement
Qualifying Events for all eligible employees, Retirees, COBRA Participants, VSIP (Voluntary Separation
Incentive Program) Participants
Health History Questionnaire
Lab work
Meet with Health Advocate
How to Qualify
Complete Health History Questionnaire - This can be done online, at home, or your desk, or by paper at your
scheduled lab draw.
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.
Retirees/COBRA participant who do not reside in Collier County will contact Quest Diagnostics for a remote lab kit
to be used at a Quest Diagnostics center in their area.
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. An
appointment with your Primary Care Physician or Vocatus can be scheduled for age/gender screenings or other
conditions that need follow up, if applicable. Specific forms supplied by the Health Advocate will need to be
completed at your physician's appointment. A copy of the Personal Wellness Profile should be given to the
physician at the appointment.
Retirees/COBRA participants who do not reside in Collier County will contact the Advocates by phone.
RB785 - Restated 1/1/09
3
Agenda Item No. 16E5
February 10. 2009
Page 10 of 99
Basic Plan - Lowest Level of Reimbursement
No Qualifying Events to participate - Participants automatically qualify for the Basic Plan in the plan year 2010,
if qualifying requirements for the Select Plan or the Premium Plan are not completed by 9/30/09.
Subsequent Plan Years
. Next qualifying period 10/1/09 - 9/30/10 for plan year 2011 with the same qualifying period each year
after.
. Enrollment in your plan of choice is effective January 1 of each plan year.
Plan Qualifiers Paid 100% bv Plan Qualifier Guidelines
Health History Must be completed by all Plan year 2009, all employees
Questionnaire employees to qualify for plans Plan year 2010 and forward - Age 20, 25, 30,
Select or Premium 35, 40, 43, 46, 50 & over
Lab Draw Must be completed by all Plan year 2009, all employees
employees to qualify for plans : Plan year 2010 and forward - Age 20, 25, 30,
. Select or Premium 35, 40, 43, 46, 50 & over
Adult Routine Exam Must be completed by all Age 20, 25, 30, 35, 40, 43, 46, 50 & over as
employees to qualify for the of 1/1/2009
Premium alan
I
I Pap Smear, Must be completed according to age Age 20, 25, 30, 35, 40, 43, 46, 50 & over as
I Mammogram guidelines to qualify for the of 1/1/2009
I Premium plan
Skin Screening Must be completed according to age Age 20, 25, 30, 35, 40, 43, 46, 50 & over as
guideiines to qualify for the of 1/1/2009
Premium plan
Testicular Exam Must be completed according to age Age 20, 25, 30, 35, 40, 43, 46, 50 & over as
I guidelines to qualify for the of 1/1/2009
i Premium plan
Colonoscopy Must be completed according to age I Age 50 and every 10 years thereafter as
guidelines to qualify for the 1/1/2009
Premium plan
I ,
i Tobacco Use 1- Lab test must be completed to Annually as of 1/1/2009
qualifv for the Premium plan
I
i
Tobacco Cessation Must be completed according to Annually if still using tobacco products as of
Program program guidelines to qualify for the 1/1/2009
Premium plan
Diabetes Management Must be completed according to Annually as of 1/1/2009 I
I Program program guidelines to qualify for the i
Premium plan
RB785 - Restated 1/1109
4
.~,qs'nda I~s:n r~o. :,SE5
- :=e:::lI"uary "10, 20D9
Page 11 of 99
COUNTY SPONSORED TOBACCO CESSATION PROGRAM ONLY
Who is eligible to participate?
. Employees enrolled in the BCC (Board of County Commissioners) health plan
. Spouses of employees enrolled in the BCC health plan
. Dependent chiidren over the age of 18 enrolled in the BCC health plan (dependent children between the age
of 15 and 18 can participate but without the issuance of tobacco cessation products)
Where will the Tobacco Cessation Program be available?
. Only through the County's in-house clinic
...".,
~ . ::::.
T\ ... '- "' r f 1.,. -", ~ ,"'- #..._~
.L't ','Ut'- '-.fll....e- ~
What is the cost to the participant?
. The $5.00 clinic co-pay will be waived if the visit is for the Tobacco Cessation Program. If the patient is being
seen for other issues the $5.00 clinic co-pay will be imposed.
. Reimbursement of all approved cessation products will be made to the participant. Keep your receipts.
What happens if appointments are not kept?
. Participant must notify the clinic 24 hours in advance if an appointment can not be kept otherwise the missed
appointment will be counted as a "no show".
. Three "no shows" and the participant will be disqualified from the program.
. A participant can re-enroll in the program 6 months from the date of the first appointment.
. A participant that has been disqualified from the program can continue to use the clinic for tobacco cessation
but will be charged the $5.00 clinic co-pay for each visit. The patient will be responsible for purchasing their
own cessation products.
How does completing the program affect group health insurance rates?
. Upon completion the participant will be given a certificate which enables Risk Management to change the
group health rates from smoker to non-smoker if all the criteria are met. Contact Risk Management at 252-
8417 or 252~8966 for more information.
12 Week Tobacco Cessation Action Plan
Week 1 - Visit 1 " 30 min.
. Complete "Trigger Detector"
. Exam and Bloodwork
. Educational Materials
1. Think about it money motivation
2. Time line of positive effects
. Quit Assist Booklet
. ,lI,ssignments
1. My List of Rewards
Week 2 - Visit 2 - 20 min.
. Complete "Health Risk Assessor" and
"How ready are you to quit?"
. Assessment
. Review test results
. Review assignments
. Sign Contract
RB785 - Restated 1/1/09
5
. Receive cessation product script
. Educational Materials
1. Helping a tobacco user quit
2. Reasons to quit using tobacco products
. Assignments
1. Five keys for quitting; Quit plan
2. My reasons to the use of tobacco products
Week 4 - Visit 3 -15 min.
. Assessment
. Review Assignments
. Receive cessation product script
I; Educational material
1 . What to do when the craving comes
2. Relapse prevention
3. To get back on track
. Assignments
1. Plan Ahead
2. Personal tobacco profile
Week 8 -Visit 4 - 15 min
. Assessment
. Review Assignments
. Educational materials
1 . Hunger helps
2. Walking program
3. 52 proven stress reducers
Week 12 - Visit 5 -15 min
. Assessment
. Assignment
1. Program Evaluation
. Completion certificate
RB785 - Restated 1/1/09
,n.oenda Item [\JO. ICeS
J February 10. 2009
Page 12 of 99
6
Agenda !te:n No. '] GES
i=sbr:Jarv "10. 20G9
i'.:J3ge 13 of 99
COUNTY SPONSORED DIABETES MANAGEMENT PROGRAM ONLY
Who is eligible to participate?
Employees enrolled in the BCC (Board of County Commissioners) health plan
. Spouses of employees enrolled in the BCC health plan
Dependent children age 15 and older
What is the cost to the participant?
The $5.00 clinic co-pay will be waived if the visit is for Diabetes Management Program. All visits to personal
providers will be paid according to the Schedule of Benefits.
How to get started?
. Call The MedCenter - 252-4257
How will The MedCenter assist me to manage my Diabetes?
Hemoglobin A1c test every 3 months: It checks your average blood sugar over the past two to three
months.
Blood pressure taken every 3 months: Get your blood pressure checked at every medical appointment.
. Foot exam every 3 months: At every medical appointment, your feet's nerves and blood circulation will be
checked.
Dental Exam every 6 months: See a dentist twice a year to check for gum disease and possible mouth
infections.
Blood lipid (fats) test annually: A blood test of cholesterol and triglycerides.
. Kidney function tests annually: Get a urine test that checks for protein in urine (microalbumin) at least once
a year. Get a blood test for creatinine, a waste product, at least once a year. These tests screen for kidney
problems.
. Dilated eye exam annually: See an eye care professional once a year for a complete eye exam.
Flu Shot & Pneumonia Shot: Get an annual flu shot and ask your medical provider about a pneumonia shot.
. Free Glucometer: (The MedCenter preference) plus control solution, strips, and lancets
Other Available Resources To Assist In Managing Your Diabetes
We/lness Program - 252-6092
'Group Educational Programs
'One-on-One Counseling
Monthly Healthy Lifestyle Support Group
'E-Learning Videos (internet diabetic Videos)
'Diabetic DVDs offered through the Collier Public Library System (w/library card)
Grocery Shopping Tours
Cooking Demonstrations
'Offered in English & Spanish
RB785 - Restated 1/1/09
7
~';genda ltem No. 16E5
February 10, 2009
Page 14 of 99
HEALTH REIMBURSEMENT ACCOUNT
PREMIUM OPTION ONLY
Health Reimbursement Account (HRA) as noted in IRS 2002-45.
ELIGIBILITY: Any individuals who are covered under the Premium Plan will be eligible for benefits under the HRA account.
HRA FUND AMOUNT (Annually):
Indivual/Famiiy $300
REIMBURSEMENT PROVISIONS:
1. The HRA account wiil be appiied to:
(a) Co-pays
(b) Deductibles
(c) Co-insurance amounts
(d) Out-of-Pocket Limits
(e) Medical expenses as defined in Section 213(d) of the Code
(I) Retiree premiums
(g) COBRA premiums
(h) Other insurance premiums
2. The HRA account will not be applied to any penalty amounts. Only those expenses considered eligible under the
major medical plan and also Section 213(d) of the IRS Codes may be applied to the HRA account. Any limitations
or exclusions under the Plan will also be excluded under the HRA account, unless eligible for reimbursement under
Section 213(d). A medical expense is incurred at the time the medical care or service is furnished, and not when
the expense is billed for, is charged for, or pays for the medical care.
3. A medical expense is eligible provided that the expense was incurred after the start of this Plan and while the
participant was covered under the Plan during the Calendar Year. Medical expenses can only be reimbursed to
the extent that the participant or other person incurring the expense is not reimbursed for the expense (nor is the
expense reimbursable) through other insurance, or any other accident or health plan. If only a portion of a medical
expense has been reimbursed elsewhere, the HRA Account can reimburse the remaining portion of such expense
if it meets the HRA requirements.
4. The Employer funds the full amount of the HRA Accounts. There are no participant contributions for benefits under
the Plan.
5. A participant's HRA account will be credited upon the first day of the Calendar Year after earning from prior
Calendar Year.
6. The maximum dollar amount which may be credited to the HRA account is $300 per employee or family per
Calendar Year.
7. Rollover. If any balance remains in the participant's HRA account after all reimbursements have been made for the
Calendar Year, such balance shall rollover to reimburse the participant for eligible expenses incurred during
subsequent Calendar Year as follows:
100% of the HRA balance will rollover.
8. Only those medical expenses which are incurred during the same Calendar Year of the HRA account will be
debited from the account balance. Except retirees may spend their HRA credit balance on eligible expenses until
the fund is depleted.
9. Written notice of a claim and all information needed to process the claim must be given to the Contract
Administrator as soon as reasonably possible and in no event, later than one year from the date such claim is
incurred.
RB785 - Restated 1/1/09
8
,D.genaa Item No.1 SE5
F ebru8ry 10, 2009
Page i5 of 99
10, Coordination of Benefits with Health FSA. Benefits under this Plan will be paid solely for medical care
expenses not previously reimbursed or reimbursable elsewhere, To the extent that an otherwise eligible medical
care expense is payable or reimbursable from another source, that other source shall payor reimburse prior to
payment or reimbursement from thiS Plan, Without iimiting the foregoing, if the participant's medical care
expenses are covered both by this Plan and by a Health FSA, then the stacking order of payment is set by the
Employer. In no event may a participant receive reimbursement for the same expense under a Health FSA and
under the HRA
TERMINATION:
1, If a participant loses coverage during the Calendar Year, any fund balance that is remaining at termination may be
used for any employee portion of claims while covered under the Plan or health premiums, until the fund is
depleted.
2. Retirees may spend their HRA credit balance on eligible expenses until the fund is depleted.
3. If the Covered Person chooses coverage under COBRA, the fund balance will remain active until the participant is
no longer eligible for coverage under COBRA, or until the fund is depleted.
4. Should the Employer choose to terminate this Plan, any fund balances which remain will become property of the
Employer,
COBRA AND HRA FUNDS:
When electing COBRA your HRA fund amounts will be determined based upon the COBRA continuation coverage election
as indicated:
HRA Amount for Termination of Individual Coverage and Election of Individual COBRA Continuation. If an
employee terminated with individual coverage and elected individual COBRA continuation, the HRA fund amount will
continue at the existing individual HRA fund level amount at the time of termination, including any applicable annual carry-
over amounts, less any priorreimbursements for the current Calendar Year. Upon plan renewal, the HRA fund amount will
continue at the individual HRA fund level amount, including any applicable annual carry-over amounts.
HRA Amount for Termination of Family Coverage and Election of Individual COBRA Continuation. If an employee
terminates with family coverage and elects individual COBRA continuation, the HRA fund amount will accrue at the existing
individual HRA fund level amount Upon plan renewal, the HRA fund amount will continue at the individual HRA fund level
amount, including any applicable annual carry-over amounts,
HRA Amount for Termination of Family Coverage and Election of Family COBRA Continuation. If an employee
terminates with family coverage and elects family COBRA continuation, the HRA fund amount will continue at the same
coverage level in effect before the qualifying COBRA event, including annual carry-over amounts at the family HRA fund
level amounts, less any prior HRA reimbursements for the current Calendar Year. Upon plan renewal, the HRA fund
amount will remain at the family HRA fund level amounts, including any applicable annual carry-over amounts.
RB785 - Restated 1/1/09
9
I~cenda Item No. 16E5
c' February 10. 2009
Page 16 of 99
IMPORTANT: This Plan contains a notification provision which requires that CHP must be notified in advance of Inpatient
Hospital admissions and MRI and CT Scans. See the Notification Provision section of the Plan for details. If these
procedures are not followed, eligible expenses will be reduced by $300 per incident.
SCHEDULE OF BENEFITS
PREMIUM OPTION
PPO PROVIDERS NON-PPO PROVIDERS
(Subject to Usual &
Customarv Charoes)
OVERALL LIFETIME MAXIMUM BENEFIT $2,000,000
CALENDAR YEAR DEDUCTIBLE
Individual $200 $400
Familv $400 $800
CALENDAR YEAR OUT-OF-POCKET I
LIMIT (does not include Deductibles)
Individual $1,300 $3,000
Familv $2,600 $6,000
The Deductibles, Out-of-Pocket t.imits, and all maximum amounts (Calendar Year or t.ifetime) are combined for both PPO
Providers and Non-PPO Providers,
Expenses incurred for the following cannot be applied toward the Out-of-Pocket t.imit. (1) Co-pays; (2) Deductibles; (3)
any penalty amounts; (4) any charges as defined in the Exclusions and Limitations section; (5) a Covered Person's Co-
insurance for: Chiropractic Care; Acupuncture; or Dental Care expenses due to Illness.
The Plan does have a Pre-Existing Condition t.imitation. Please refer to the Pre-Existing Condition Limitation section
for further detaiis renardino coveraoe limitations and provisions for Creditable Covera e.
MEDICAL BENEFITS
Acupuncture 90% after Deductible 70% after Deductible
Calendar Year Maximum Benefit $1,000
I Air Ambulance Services
Due to Medical Emergency 90% after Deductible 70% after Deductible
Non-Medical Emeroencv I
No Coveraoe No Coveraoe
Ground Ambulance Services
Due to Medical Emergency 90% after Deductible 70% after Deductible
I Non-Medical Emeroency No Coveraoe
No Coveraoe
Chemical Dependency Treatment
Inpatient' 90% after Deductible 70% after Deductible
Outpatient $15 Co-pay, then 100%; Deductible 70% after Deductible
waived
I Calendar Year Maximum Benefit 20 visits
Inpatient and Outpatient
Combined Lifetime Maximum Benefit $15,000
, Discontinuance of an Inpatient treatment program by the Covered Person prior to completion of the program will result in I
no Inpatient benefits being paid under the Plan.
NOTE: A Partial Hosoitalization (minimum 6 hours to a maximum of 12 hours) will be considered as Inpatient benefits.
I Chiropractic Care!Spinal Manipulation! $15 Co-pay, then 100%; Deductible No Coverage
Massage Therapy waived
Combined Calendar Year Maximum Benefit 20 visits
Colonoscopies (see Eligible Expenses) 90%; Deductible waived No Coverage
,
RB785 - Restated 1/1/09
10
,A,genca ! ler.1 r,~o. ~ 61:.5
February 10, 2009
Pa;]e 'i 7 of '~9
PPO PROVIDERS
NON-PPO PROVIDERS
(Subject to Usual &
Customa Char es
, Dental Care (due to Illness - see Eligible
Expenses)
After benefits are exhausted under
an Dental Plan
Durable Medical E ui ment
Emergency Room Services
Due to Medical Emerqencv
90%; Deductible waived
70% after Deductible
90% after Deductible
70% after Deductible
$50 Co-pay per visit, then
Deductibie, then 90%
$100 Co-pay, then
Deductib!e, then 90%
NOTE: The Emer enc Room Co- a will be waived if the erson is admitted direct!
I Hearing Aids (due to Accident or Illness 90% after Deductible
only)
, Lifetime Maximum Benefit $2,000
Home Health Care
Hospice Care
Inpatient
Non-Medical Emerqencv
$50 Co-pay per visit, then
Deductible, then 70%
$100 Co-pay, then
Deductible, then 70%
as an In atient to the Hos ita!.
70% after Deductible
90% after Deductible
70% after Deductible
90% after Deductible
70% after Deductible
Home Hos ice Care
Hospital Expenses or Long-Term Acute
Care Facility/Hospital (facility charges) I
Inpatient 90% after Deductible 70% after Deductible
Room & Board Allowance Semi-private room rate*' Semi-private room rate*'
Intensive Care Unit I 90% of actual charge after 70% of actual charge after
I Deductible I Deductible
Miscellaneous Services & Supplies : 90% after Deductible I 70% after Deductible
I OutDatlent I 90% after Deductible , 70% after Deductible l
, .. A private room will be considered eligible when Medically Necessary Charges made by a Hospital haVing only single
or rivate rooms will be considered at the least ex ensive rate for a sin Ie or rivate room.
Mental/Nervous Disorders
Inpatient
90% after Deductible
70% after Deductible
Outpatient
I
r
I
90% after Deductible
70% after Deductible
Calendar Year Maximum Benefit 20 visits
NOTE: A Partial Hos italization minimum 6 hours to a maximum of 12 hours will be considered as In atient benefits,
On-Site Clinic Services 'I' $5 Co-pay, then 100%; Deductible N/A
waived
--,-.
The on-site clinic services are available to all eligible participants covered under the Collier County Government
Employee Benefit Plan. All services performed in the clinic are covered under the $5 Co-pay. A referral from the clinic to
a network rovider will be rocessed as a network claim throu h Meritain Health'm.
I Outpatient Therapies I $25 Co-pay, then 100% of the first
(i.e, physical, speech, occupational, aquatic) $500 per visit (Deductible waived),
then Deductible, then 90%
I Calendar Year Maximum Benefit i 60 visits each therapy
t:J:::Iin Manage~ont I np;d' ,..""Ie:- f-:>I'''''t hl"I'vS I qnvo,/i} aftprncductib!ol 7AO/ ......Her Ded""'~;b'e
~~d"n'erve sti~'~l~to~~) , ...,...,~, '....Vv '-"vv,~ ~ --=---.~-=-- _-1' v /u al~ u\.<u I J'
Calendar Year Maximum Benefit I 6 procedures
$15 Co-pay, then 100%;
Deductible waived
70% after Deductible
70% after Deductible
RB785 - Restated 1/1/09
11
ACJenda Item No. 16E5
- February 10, 2009
Paga ~8 of 99
PPO PROVIDERS NON-PPO PROVIDERS
(Subject to Usual &
Customarv Charaes)
Physician's Services
InpatienVOutpatient Services 90% after Deductible 70% after Deductible
Primarv Care Phvsician Office Visit Charoe $15 Co-pay, then 100% of the first 70% after Deductible
$500 per visit (Deductible waived),
then Deductible, then 90%
$25 Co-pay, then 100% of the first 70% after Deductible
I Specialist Office Visit Charoe $500 per visit (Deductible waived),
then Deductible, then 90%
I
All Other Services/Supplies Performed in a 100% of the first $500 per visit 70% after Deductible
Phvsician's Office (Deductible waived), then
Deductibie, then 90%
Radiation Therapy/Chemotherapy and 90% after Deductibie 70% after Deductible
Infusion Theranv
Routine Care (age 16 and over - See 100%; Deductible waived No Coverage
Eligible Expenses)
Calendar Year Maximum Benefit $350
Routine Mammograms (see Eligible 100%; Deductible waived No Coverage
Exoenses for aae limitations)
Scalp Hair Prosthesis (wigs/hair pieces) 90% after Deductible 70% after Deductible
Lifetime Maximum Benefit One wig or hair piece
Skilled Nursing Facility and I
Rehabilitation Facilitv 90% after Deductible 70% after Deductible I
Tobacco Cessation (through The Med 100%; Deductible and Co-pay N/A
Center on Iv) waived
Uraent Care Facilitv 90% after Deductible 70% after Deductible
Well Child Care (up to age 16) 100%; Deductible waived No Coverage
Calendar Year Maximum Benefit $700
1 All Other Eligible Expenses 90% after Deductible 70% after Deductible
BENEFIT PROVISIONS
A separate listing may be obtained from the Plan Administrator showing the providers available within the Preferred
Provider Network at no cost to the Covered Person.
PPO Providers are not subject to Usual and Customary Charges. Non-PPO Physician's services are subject to Usual and
Customary Charges and any charges in excess of Usual and Customary will not be considered eligible for payment.
Expenses which are incurred due to a Medical Emergency by a Non-PPO Provider will be paid at the PPO Provider level of
benefits. This includes expenses incurred outside an individual's state of residence.
Emergency room professional services and any anesthesia services which are provided by a Non-PPO Provider but
rendered at a PPO facility will be paid at the PPO Provider level of benefits.
If the providerrendering service is located in Collier County and is not part of the CHP network but is part of the First Health
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
First Health network, benefits will be paid at the PPO Provider level of benefits.
Subject to Contract Administrator prior approval, professional services which are not available within the PPO Network will
be paid at the PPO Provider level of benefits.
RB785 - Restated 1/1/09
12
A~enda item No. 16E5
~ February 10, 2009
Page 19 of 99
Expenses for obtaining medical records will be paid in full to a maximum benefit of $100 per provider.
The iocal Community Health Partners network established via the Messenger Model letter dated June 2000 will be used to
establish participating vs. non-participating benefits for claims with dates of service on or after August 2,2001. Any and all
Collier County providers who do not participate in the local CHP network established via the Messenger Model letter dated
June 2000 for this program will be reimbursed the contracted fee for service amount(s) negotiated or the fee schedule as
established in the Messenger Model letter. The participant will be responsible for any applicable out-of-pocket expenses
and differences between the billed and allowed which exceed the local contracted amount. First Health will be used as the
national overlay network for any non-Collier County services provided.
If a provider did not accept the new fee schedule for Collier County Government through the local PPO network, CHP,
then those provider's claims will be paid as out-of-network at the new CHP fee scheduied rate.
Claims receiving a discount for First Health providers outside of Collier County will be considered as in-network.
If a PPO Physician or PPO facility refers x-ray and laboratory services to a Non-PPO Provider, those services will be paid
at the PPO Provider level of benefits.
Professional services that are provided by a Non-PPO Provider but rendered at a PPO facility will be paid at the PPO
Provider level of benefits.
RB785 - Restated 1/1/09
13
,t..genda !';lem No. i 6~5
February 10,2009
Page 20 of 99
IMPORT ANT: This Plan contains a notification provision which requires that CHP must be notified in advance of Inpatient
Hospital admissions and MRI and CT Scans. See the Notification Provision section of the Plan for details. If these
procedures are not followed, eligible expenses will be reduced by $300 per incident.
SCHEDULE OF BENEFITS
SELECT OPTION
PPO PROVIDERS NON-PPO PROVIDERS
(Subject to Usual &
Customary CharQes)
OVERALL LIFETIME MAXIMUM BENEFIT $2.000,000
CALENDAR YEAR DEDUCTIBLE
individual $500 $1,000
Familv , $1,000 $2,000
CALENDAR YEAR OUT-OF-POCKET !
LIMIT (does not include Deductibles)
Individual $2,500 $5,000
Familv $5,000 $10,000
The Deductibles, Out-of-Pocket Limits, and all maximum amounts (Calendar Year or Lifetime) are combined for both PPO
Providers and Non-PPO Providers.
Expenses incurred for the following cannot be applied toward the Out-of-Pocket Limit: (1) Co-pays; (2) Deductibles; (3)
any penalty amounts; (4) any charges as defined in the Exclusions and Limitations section; (5) a Covered Person's Co-
insurance for: Chiropractic Care; Acupuncture; or Dental Care expenses due to Illness.
The Plan does have a Pre-Existing Condition Limitation, Please refer to the Pre-Existing Condition Limitation section
for further details reoardinn coveraoe limitations and provisions for Creditable Coveraoe.
MEDICAL BENEFITS
Acupuncture 80% after Deductible 50% after Deductible
Calendar Year Maximum Benefit $1,000
Air Ambulance Services I
Due to Medical Emergency 80% after Deductible 80% after Deductible
Non-Medical Emeroencv No Coveraoe No Coveraoe
Ground Ambulance Services I I
Due to Medical Emergency I 80% after Deductible 80% after Deductible I
I
Non-Medical Emeraencv No Coveraoe No CoveraQe
Chemical Dependency Treatment
Inpatient' 80% after Deductible 60% after Deductible
Outpatient $30 Co-pay, then 100%; 60% after Deductible
Deductible waived
Caiendar Year Maximum Benefit 20 visits
Inpatient and Outpatient
Combined Lifetime Maximum Benefit $15,000
. Discontinuance of an Inpatient treatment program by the Covered Person prior to completion of the program will result in
no Inpatient benefits being paid under the Plan.
NOTE: A Partial Hosoitalization (minimum 6 hours to a maximum of 12 hours) will be considered as Inpatient benefits.
I Chiropractic Care/Spinal Manipulation/ $30 Co-pay, then 100%: No Coverage
Massage Therapy Deductible waived
Combined Calendar Year Maximum Benefit 20 visits
I Colonoscopies (see Eligible Expenses) 80%; Deductibie waived I No Coverage
RB785 - Restated 1/1/09
14
!t~m hlo. 16E5
Fcbruary 10. 2009
Page 21 :>f 99
PPO PROVIDERS NON-PPO PROVIDERS I
(Subject to Usual &
Customarv Charges)
Dental Care (due to Illness - see Eligible
Expenses)
After benefits are exhausted under
any Dental Plan 80%; Deductible waived 60% after Deductible
Durable Medical Eauioment 80% after Deductible 60% after Deductible
Emergency Room Services
Due to Medical Emeraencv $100 Co-pay per visit, then $100 Co-pay per visit, then
Deductible, then 80% Deductible, then 80%
Non-Medical Emeraencv [ $100 Co-pay, then $100 Co-pay, then I
Deductible, then 80% i Deductible, then 60%
NOTE: The Emeroencv Room Co-pay wiil be waived if the person is admitted directly as an Inpatient to the Hospital.
I Hearing Aids (subject to technical review 80% after Deductible i 60% after Deductible
for Medical Necessity) I
i Lifetime Maximum Benefit $2,000
Home Health Care 80% after Deductible 60% after Deductible
I Hospice Care -
Inpatient 80% after Deductible 60% after Deductible
i Home Hospice Care 80% after Deductible 60% after Deductible
! Hospital Expenses or Long-Term Acute I
I Care Facility/Hospital (facility charges)
Inpatient 80% after Deductible 60% after Deductible
. Room & Board Allowance Semi-private room rate" Semi-private room rate**
Intensive Care Unit 80% of actual charge after 60% of actual charge after
Deductible I Deductible
,
Miscellaneous Services & Supplies 80% after Deductible I 60% after Deductible
Outpatient 80% after Deductible , 60% after Deductible
J
i
.. A private room will be considered eligible when Medically Necessary. Charges made by a Hospital having only single
or rivate rooms will be considered at the least ex ensive rate for a sin Ie or rivate room.
[' Mental/Nervous Disorders
Inpatient 80% after Deductible .__~60%_"fter Deductible
i
I Outpatient
Calendar Year Maximum Benefit 20 visits
NOTE: A Partial Hospitalization (minimum 6 hours to a maximum of 12 hours) will be considered as Inpatient
benefits.
IOn-Site Clinic Services $5 Co-pay, then 100%; Deductible
____ I waived
I The on-site cliniC services are available to all eligible participants covered under the Collier County Government
I Employee Benefit Plan. All services performed in the clinic are covered under the $5 Co-pay. A referral from the clinic to
a network provider will be rocessed as a network claim throu h Meritain Health'm.
Outpatient Therapies $30 Co-pay, then 100% of the first 60% after Deductible
(i.e. physical, speech, occupational, 'I $500 per visit (Deductible waived),
aquatic) then Deductible, then 80% I
I '60 visits each therapy
Calendar Year Maximum Benefit -1-
Pain Management (epidurals, facet blocks I 80% after Deductible 60% after Deductible
and nerve stimulators) :--
i Calendar Year Maximum Benefit
$30 Co-pay, then 100%; Deductible
waived
60% after Deductible
N/A
-~
6 pro~ecJures
RB785 - Restated 1/1/09
15
Agenda item [\lo. ! 5E5
Fsbruary 10, 20D9
Page 22 of ~}9
PPO PROVIDERS NON.PPO PROVIDERS
(Subject to Usual &
Customarv Charqes)
Physician's Services
InoatienUOutpatient Services 80% after Deductible 60% after Deductible
Primarv Care Phvslcian Office Visit $30 Co-pay, then 100% of the first 60% after Deductible
Charqe $500 per visit (Deductible waived),
then Deductible, then 80%
Specialist Office Visit Charqe $50 Co-pay, then 100% of the first 60% after Deductible
I $500 per visit (Deductible waived),
,
, then Deductible, then 80% I
,
All Other Services/Supplies Performed in 100% of the first $500 per visit 60% after Deductible
iL Phvsician's Office (Deductible waived), then Deductible,
then 80%
Radiation Therapy/Chemotherapy and 80% after Deductible 60% after Deductible
Infusion Theraov I
Routine Care (age 16 and over - See 100%; Deductible waived No Coverage
Eligible Expenses)
Calendar Year Maximum Benefit $350
Routine Mammograms (see Eligible 100%; Deductible waived No Coverage
Expenses for aGe limitations)
Scalp Hair Prosthesis (wigs/hair pieces) i 80% after Deductible 60% after Deductible
Lifetime Maximum Benefit , One wig or hair piece
1
Skilled Nursing Facility and !
Rehabilitation Facilitv 80% after Deductible 60% after Deductible
Tobacco Cessation (through The Med 100%; Deductible and Co-pay N/A
Center onlv) waived
Uraent Care Facilitv , 80% after Deductible 60% after Deductible
I
Well Child Care (up to age 16) 100%; Deductible waived No Coverage
Calendar Year Maximum Benefit i $350' 1
I . increased to $500 for a child under age 1 I I
I - I
I All Other Eligible Expenses
80% after Deductible
60% after Deductible
BENEFIT PROVISIONS
A separate listing may be obtained from the Plan Administrator showing the providers available within the Preferred
Provider Network at no cost to the Covered Person.
PPO Providers are not subject to Usual and Customary Charges. Non-PPO Physician's services are subject to Usual and
Customary Charges and any charges in excess of Usual and Customary will not be considered eligible for payment.
Expenses which are incurred due to a Medical Emergency by a Non-PPO Provider will be paid at the PPO Provider level of
benefits. This includes expenses incurred outside an individual's state of residence.
Emergency room professional services and any anesthesia services which are provided by a Non-PPO Provider but
rendered at a PPO facility 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 First Health
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
First Health network, benefits will be paid at the PPO Provider level of benefits.
RB785 - Restated 1/1/09
16
~,genda ![2m ~~o. i SE5
~;:;.h"'IJ~-Y 1'J 'J-nl"9
' _....JI~ d, ~-' _.J#:
rage L3 Of:;;lg
Subject to Contract Administrator prior approval, professional services which are not available within the PPO Network will
be paid at the PPO Provider level of benefits.
Expenses for obtaining medical records will be paid in full to a maximum benefit of $100 per provider.
The local Community Health Partners network established via the Messenger Model letter dated June 2000 will be used to
establish participating vs. non-participating benefits for claims with dates of service on or after August 2, 2001. Any and all
Collier County providers who do not participate in the local CHP network established via the Messenger Model letter dated
June 2000 for this program will be reimbursed the contracted fee for service amount(s) negotiated or the fee schedule as
established in the Messenger Model letter. The participant will be responsible for any applicable out-of-pocket expenses
and differences between the billed and allowed which exceed the local contracted amount. First Health will be used as the
national overlay network for any non-Collier County services provided.
!f a provider did not accept the new fee schedule for Collier County Government through the local PPO network, CHP,
then those provider's claims will be paid as out-of-network at the new CHP fee scheduled rate.
Claims receiving a discount for First Health providers outside of Collier County will be considered as in-network.
If a PPO Physician or PPO facility refers x-ray and laboratory services to a Non-PPO Provider, those services will be paid
at the PPO Provider level of benefits.
Professional services that are provided by a Non-PPO Provider but rendered at a PPO facility will be paid at the PPO
Provider level of benefits.
RB785 - Restated 1/1109
17
/...cenca item No. 16E5
. February 10, 2009
Page 24 of 99
IMPORTANT: This Plan contains a notification provision which requires that CHP must be notified in advance of Inpatient
Hospital admissions and MRI and CT Scans. See the Notification Provision section of the Plan for details. If these
procedures are not followed, eligible expenses will be reduced by $300 per incident
SCHEDULE OF BENEFITS
BASIC OPTION
PPO PROVIDERS NON-PPO PROVIDERS
(Subject to Usual &
Customarv Charqes)
OVERALL LIFETIME MAXIMUM BENEFIT $2,000,000
CALENDAR YEAR DEDUCTIBLE i I
Individual I $2,000 $4,000
Famiiv I $4,000 $8,000
CALENDAR YEAR OUT-OF-POCKET i
LIMIT (does not include Deductibles)
Individual $8,000 $10,000
Familv $16,000 $20,000
The Deductibles, Out-of-Pocket Limits, and all maximum amounts (Calendar Year or Lifetime) are combined for both PPO
Providers and Non-PPO Providers,
Expenses incurred for the following cannot be applied toward the Out-of-Pocket Limit: (1) Co-pays; (2) Deductibles; (3)
any penalty amounts; (4) any charges as defined in the Exclusions and Limitations section; (5) a Covered Person's Co-
insurance for: Chiropractic Care; Acupuncture; or Dental Care expenses due to Illness.
The Plan does have a Pre-Existing Condition Limitation. Please refer to the Pre-Existing Condition Limitation section
for further details reqardinq coveraoe limitations and provisions for Creditable Coveraoe.
MEDICAL BENEFITS
Air Ambulance Services
Due to Medical Emergency 80% after Deductible 60% after Deductible
Non-Medical Emerqencv No Coveraqe No Coveraqe
Ground Ambulance Services
I Due to Medical Emergency 80% after Deductible 60% after Deductible
Non-Medical Emeraencv No Coveraoe No CoveraGe
Chemical Dependency Treatment
Inpatient' 80% after Deductible 60% after Deductible
Outpatient 80% after Deductible I 60% after Deductible
Inpatient and Outpatient
Combined Lifetime Maximum Benefit $15,000
, Discontinuance of an Inpatient treatment program by the Covered Person prior to completion of the program will result in
no Inpatient benefits being paid under the Plan.
NOTE: A Partial Hospitalization (minimum 6 hours to a maximum of 12 hours) will be considered as Inoatient benefits.
Chiropractic Care!Spinal Manipulation! 80% after Deductible No Coverage
Massage Therapy
Combined Calendar Year Maximum Benefit
20 visits
Co/onoscopies (see Eligible Expenses) I 80% after Deductible 60%; Deductible waived
I Durable Medical Eouioment 80% after Deductible 60% after Deductible
Emergency Room Services
Due to Medical Emerqencv 80% after Deductible 80% after Deductible
Non-Medical Emerqencv I 80% after Deductible I 60% after Deductible
! Home Health Care f 80% after Deductible I 60% after Deductible
I -
RB785 - Restated 1/1/09
18
!~\jerHja Item ~~o. .16~5
:=eb~uary 10, 2009
Page 25 of 99
~
PPO PROVIDERS NON-PPO PROVIDERS ,
(Subject to Usual &
Customary Charqes)
Hospice Care
Inpatient 80% after Deductible 60% after Deductible
Home Hosoice Care 80% after Deductible 60% after Deductible
Hospital Expenses or Long- Term Acute
Care Facility/Hospital (facility charges)
Inpatient 80% after Deductible 60% after Deductible
Room & Board Allowance Semi-private room rate** Semi-private room rate**
Intensive Care Unit 80% of actual charge after 60% of actual charge after I
I Deductible Deductible
I Miscellaneous Services & Supplies I 80% after Deductible 60% after Deductible
Ou.!lliltient I 80% after Deductible 60% after Deductible
.. A private room will be considered eligible when Medically Necessary. Charges made by a Hospital having only single
or,Qrivate rooms will be considered at the least expensive rate for a sinqle or private room.
Mental/Nervous Disorders
Inpatient 80% after Deductible 60% after Deductible
Outpatient 80% after Deductible 60% after Deductible
On-Site Clinic Services i $5 Co-pay, then 100%; N/A
Deductible waived
The on-site clinic services are available to all eligible participants covered under the Collier County Government
Employee Benefit Plan. All services performed in the clinic are covered under the $5 CD-pay. A referral from the clinic to
a network orovider will be processed as a network claim throuqh Meritain Health'm.
Outpatient Therapies ! 80% after Deductible I 60% after Deductible
(i,e. physical, speech, occupational, aquatic) i
Calendar Year Maximum Benefit 60 visits each therapv
I Pain Management (epidurals, facet blocks 80% after Deductible i 60% after Deductibie
and nerve stimulators) I-
I Calendar Year Maximum Benefit 6 procedures
Physician's Services I
InpatienVOutpatient Services i 80% after Deductible 60% after Deductible
I Primarv Care Phvsician Office Visit Charqe ! 80% after Deductible 60% after Deductible
Specialist Office Visit Charqe I 80% after Deductible 60% after Deductible
All Other Services/Supplies Performed in a I 80% after Deductible 60% after Deductible
,
I Phvslclan s Office . L
I Radiation Therapy/Chemotherapy and I 80% after Deductible =i 60% after Deductible
I Infusion Thera I
Routine Care (age 16 and over - See 80% after Deductible No Coverage
Eligible Expenses) '_
Rout/ne Mammograms (see Eli9ib",Ie, I 100%, Deductible waived I No Coverage
I Expenses for aqe limitations) _----1._ __
I Sc~/p.Hair Pr~sthesis (wj~s/ha[r p=-t='eces) '_ 80% after Deductibie i 60% after Deductibie
Lifetime MaXimum Benefit ___.._One wiq Dr hair pie~
Skilled Nursing Facility and 'I
Rehabilitation Facilit , 80% after Deductible 60% after Deductible
i Tobacco Cessation (through The Med . I 100%; Deductible waived I N/A
I Centeronly)______~._____~
j
I
-i
,
RB785 - Restated 1/1/09
19
PPO PROVIDERS
p..gsnda 1~2iTl r"-lo. "j 6E5
February 10, 2009
Page 26 of 99
NON-PPO PROVIDERS
(Subject to Usual &
Customa Char es
60% after Deductible
No Covera e
60% after Deductible
80% after Deductible
80% after Deductible
80% after Deductible
BENEFIT PROVISIONS
A separate listing may be obtained from the Plan Administrator showing the providers available within the Preferred
Provider Network at no cost to the Covered Person.
PPO Providers are not subject to Usual and Customary Charges. Non-PPO Physician's services are subject to Usual and
Customary Charges and any charges in excess of Usual and Customary wiii not be considered eiigible for payment.
Expenses which are incurred due to a Medical Emergency by a Non-PPO Provider will be paid at the PPO Provider level of
benefits. This includes expenses incurred outside an individual's state of residence.
Emergency room professional services and any anesthesia services which are provided by a Non-PPO Provider but
rendered at a PPO facility 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 First Health
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
First Health network, benefits will be paid at the PPO Provider level of benefits.
Subject to Contract Administrator prior approval, professional services which are not available within the PPO Network will
be paid at the PPO Provider level of benefits.
Expenses for obtaining medical records will be paid in full to a maximum benefit of $100 per provider,
The local Community Health Partners network established via the Messenger ModelleUer dated June 2000 will be used to
establish participating vs. non-participating benefits for claims with dates of service on or after August 2, 2001. Any and all
Collier County providers who do not participate in the local CHP network established via the Messenger ModelleUer dated
June 2000 for this program will be reimbursed the contracted fee for service amount(s) negotiated or the fee schedule as
established in the Messenger ModelleUer. The participant will be responsible for any applicable out-of-pocket expenses
and differences between the billed and allowed which exceed the local contracted amount. First Health will be used as the
national overlay network for any non-Collier County services provided.
If a provider did not accept the new fee schedule for Collier County Government through the local PPO network, CHP,
then those provider's claims will be paid as out-of-network at the new CHP fee scheduled rate.
Claims receiving a discount for First Health providers outside of Collier County will be considered as in-network.
If a PPO Physician or PPO facility refers x-ray and laboratory services to a Non-PPO Provider, those services will be paid
at the PPO Provider level of benefits.
Professional services that are provided by a Non-PPO Provider but rendered at a PPO facility will be paid at the PPO
Provider level of benefits.
RB785 - Restated 1/1109
20
/~~Je;lda item ~J:J. 1 GE5
February 10, 2009
Page 27 of 99
PRESCRIPTION DRUG CARD BENEFITS
Express Scripts is the company chosen by Collier County Government to administer your prescription benefit plan.
We're here to help you save money and get the best service on prescriptions for you and your family. Your Express
Scripts plan includes:
. 24-hour, 365-day-a-year Customer Service Call Center
. a national network of over 53,000 retail pharmacies
· convenient shipment of your medications through our Home Delivery Pharmacy program
. a Web site offering valuable claim and plan cost information
, Copayments for your prescription program
Prescriptions from a Retail Prescriptions from Express
Pharmacy In-Network Scripts Home Delivery Pharmacy
(Uo to a 30-day supply) . (Up to a 90-dav supolv)
BASIC PLAN
Generic Drug 30% 30%
(Listed on Formulary in lower
case)
Preferred Drug 30% 30%
(Listed on Formularv in all Caps)
Non-Preferred Drug 50% 50%
_(Not Listed on Formularv)
Annual Deductible - Combined
Retail and Mail Order
Single $400
Familv $800
Annual Out-of-Pocket Limit
Single $1,000
Family $2,000
SELECT PLAN
Generic Drug 20% 20%
(Listed on Formulary in lower
case)
Preferred Drug 20% 20%
(Listed on Formularv in all Caps)
Non-Preferred Drug 40% 40%
(Not listed on Formulary)
Annual Deductible - Combined
Retail and Mail Order
Single $100
Familv $200
Annual Out-of-Pocket Limit
Single I $ 600 I
Family $1 ,200 ,
RB785 - Restated 1/1/09
21
Agenda Item No. 16E5
February 10, 2009
Page 28 of 99
Co payments for your prescription program
Prescriptions from a Retail Prescriptions from Express Scripts
Pharmacy In-Network Home Delivery Pharmacy
(Up to a 30-dav suoolv) IUo to a 90-dav supply)-
PREMIUM PLAN
Generic Drug 20% 20%
(Listed on Formulary in lower
case)
Preferred Drug 20% 20%
(Listed on Formulary in all Caps)
Non-Preferred Drug 40% 40%
(Not iisted on Formulary)
Annual Deductible - Combined
Retail and Mail Order
Single None None
Familv None None
Annual Out-of-Pocket Limit
Single $450
Family $900
. Refills- The plan will allow refills at a retail pharmacy after 75% of your medication has been utilized (for a
typical 30 day supply, this means you can refill when there is about one week of medication remaining). For
mail order, you may refill your medication when there is a 34 days supply remaining.
How to get prescriptions from a local, retail pharmacy
You will receive a combined medical and prescription 10 card showing the Express Scripts logo. You'll need to show
this 10 card to your pharmacist each time you get a prescription filled. When making your purchase, you will need to
pay the required copayment charge at the point of sale. There are numerous chain retail pharmacies in the Express
Scripts network. To locate pharmacies near you that are in the Express Scripts network, visit the web site at
www.express-scriots.com.
Examples of Local and National Retail Pharmacy Chains in the Express Scripts Network
. Albertsons (Sav-On) . Publix . Sweet Bay
. Wal-Mart . CostCo . CVS
. Golden Gate . Winn Dixie . Sam's Club
. Lakeview . Apothocary . Rite-Aid
. Walgreens . K-Mart
. Sunshine . Wooley's
. Target . Island Drug
I How to use the Home Delivery Pharmacy
The Express Scripts Home Delivery Pharmacy is best suited to individuals who use medication on a long-term basis,
Maintenance medications can be obtained at a better value through the Home Delivery option if you have a long-term
condition for which you are stabilized on a medicine, Ask your doctor to write a new prescription for a 90-day
supply, plus appropriate refills for up to one year. If you need to begin the medicine immediately, ask your doctor
for a second prescription for a 3D-day supply and take that to your local participating retail pharmacy. This supply will
last you until your new order arrives in the mail.
To begin mail service, complete the member profile on the form (available at www.express-scripts.com. call the toll-
free number on the back of your 10 card, call Risk Management to request one.) Be sure to include your 10 number
and your prescription in the envelope, The Express Scripts Mail Service Pharmacy will process your first time order
within a 2-week time period and ship it directly to your home. Once your Mail Service account is established, refills will
process and ship within 48 hours of order receipt.
RB785 - Restated 1/1/09
22
,L\qenda !Iem f\Jo. 16:=5
- February 10, 2009
?age 29 of 99
Along with your medication, you will receive a form to remind you when to order your refill. Once your Home Delivery
prescription account is established, refills are available by mail, by phone or online at www.express-scripts.com.
The Express Scripts Home Delivery plan will offer a courtesy call to let you know that your order has been received.
Another courtesy call is made when your order has been shipped, Overnight or second-day delivery may be available
for your area for an additional charge,
I 24-Hour Customer Service ,
To answer your questions and ensure your prescription drug plan runs smoothly, the Express Scripts customer service
center is always open-24-hours-a-day, seven days a week. Call us any time at 1 -866-349-6602.
I Prescription Services Online
Please visit the Express Scripts member web site at www.express-scripts.com to view personalized claim and copay
Information as well as savings opportunities.
This Web site will allow you to;
. Locate pharmacies in your neighborhood or vacation destination
. Review your claims profile
. Look up drugs by name and read about them
. Read about drug-to-drug interactions
. Sign up for Home Delivery
. Order refills for the Home Delivery Program and check the status of your order
. Send e-mail questions to a pharmacist
. Use Price Check to view an estimate of your copayment before making a purchase
I Benefits
PROTON PUMP INHIBITORS (PPI'S) BENEFIT
PPI's are medications to treat acid reflux disease and certain other stomach problems, The drug names are; Prilosec
Over-the-Counter, omeprazole, Proton ix, Aciphex, Nexium, Prevacid and prescription strength Prilosec.
Your prescription drug plan will cover the "over the counter" form of Prilosec (Prilosec OTC) as if it were a generic
prescription drug, You pay only the copayment your plan requires for a generic prescription drug.
Simply ask your doctor to write you a prescription for Prilosec OTC and take it to a pharmacy that participates in your
Express Scripts' network, Find Prilosec OTC on the store's shelves and take it to the pharmacist, who will accordingly
charge you the amount of your plan's generic prescription drug copayment. Your plan pays the rest.
You and your doctor are free to choose a medication other than Prilosec OTC-however, you will pay more. The plan
will pay only the amount it would have paid for Prilosec OTC. You will pay the difference between that and the other
drug's higher cost. If you look at the table, you'll see this means another $100 or so out of your pOCket.
Also in some cases, for people with certain conditions. not all PPls are equally effective. There is a procedure for
obtaining Prevacid instead of Prilosec OTC if you are tested and found to have gastric ulcer, peptic ulcer disease, and
grade three or four esophagitis, In this case, you will pay your plan's normal copayment for Prevacid if your doctor
prescribes it-you won't be required to also pay the difference in cost between Prevacid and Prilosec OTC, For the
plan to make this exception, you must have approval in advance from Community Health Partners (CHP), your medical
plan's preferred provider network, If you use a CHP doctor, he or she will take care of obtaining this approval for you. If
you use a doctor who is not a member of the CHP network, you must contact CHP to obtain the approval at 239-659-
7700.
RB785 - Restated 1/1/09
23
,L'..genda :tem No. 16E5
Fsbruacy 10, 2009
Page 30 of 99
GENERICS PREFERRED PROGRAM
What are Qeneric druQs?
Generic drugs are copies of brand-name drugs whose patents have run out. That is, a generic drug has the same
chemical makeup as the original brand-name drug. Generics account for more than 45% of all medications prescribed
in the U.S. More peopie are choosing them because they're:
. safe - they have the same active ingredients and are used in the body the same way as their original brand-
name drugs. They're also approved by the US. Food and Drug Administration (FDA), just like brand-name
drugs.
. effective - they're just as strong and deliver the same medical benefits as the brand-name drugs.
. less expensive - they aren't advertised like brand names, and they cost less to produce, so the savings are
passed along to you in the form of a lower copayment.
How do you use the Qenerics preferred proQram?
. If you choose the generic, your co payment will be less than for a brand-name drug.
. If you or your physician chooses the brand-name, you'll pay your copayment plus the difference in cost
between the generic and the brand-name drug. This difference in cost will not apply to the maximum
Calendar Year Co-pay limit.
DRUG QUANTITY MANAGEMENT
Quantitv limits promote safety and savinQs
This change makes sure you receive the medication you need in the quantity considered safe, That is, you get the
right amount to take the daily dose recommended by the U,S. Food & Drug Administration (FDA) and medical studies.
Quantity limits also help you save money, For instance, if your medicine is available in different strengths, you might
take one dose of a higher strength instead of two or more of a lower strength. This saves money, since you pay for
fewer doses. The program also controls the cost of "extra" supplies of medication that could go to waste in your
medicine cabinet.
How the new prOQram works
At the pharmacy, you might be toid that you're asking for a refill too soon; that is, you should still have some of your
medication on hand. In this case, simply ask your pharmacist when you can get your next refill. But if your prescription
is written for a larger amount than your plan covers:
. You can ask your pharmacist to give you the amount that your plan covers. You'll pay the appropriate
copayment each time.
. Or, your pharmacist can ask your doctor to change your prescription to a higher strength, when one is
available. For instance, you might take one 40 mg pill instead of two 20 mg pills. This way, you meet your
plan's quantity limit, you get the daily dose you need and you have fewer copayments.
. Or, if your doctor doesn't agree with the limit, he or she can call Express Scripts to request a "prior
authorization," which may let you get a greater quantity.
Quantity limits can hetp you get the prescription drugs you need safely and affordably.
RB785 - Restated 1/1/09
24
L,=!,;mda iteiTl ~~o. 1 (3E5
~ i="sbruary 10, 20C)9
Page 31 of 99
PRIOR AUTHORIZATION
How Prior Authorization works
The program monitors certain prescription drugs and their costs so that you can get the right drug at the right cost.
That is, you receive an effective drug which is also covered by your benefits. It works much like a health plan that
approves some medical procedures beforehand, to make sure you're getting tests you need: Some prescriptions are
pre-approved for coverage,
What vou can do
. Show your doctor the enclosed list. If a drug you use is on the list, your doctor should contact Express Scripts.
An Express Scripts representative will see if your plan can cover the drug.
. Your pharmacist might also tell you that a drug needs a prior authorization, If this occurs, the pharmacist can
call your doctor and ask him or her to contact Express Scripts to see if your plan can cover the drug.
When a prescription drug is approved for coverage, you'll pay the applicable copayment(s), If a drug you're taking
cannot be covered and you still want to take it, you must pay the full cost.
Prior Authorization helps you get a prescript/on drug that works well for you and that /s covered by your plan.
I PRIOR AUTHORIZATION LIST
Brand Name
Aranespcs injection Amevivecs injection
Raptivacs iniection
Avita and Retin-A creams and eels Diflucantablets (exclude 150me)
MyobiocCS iniection Lamisil tablets
EpogenCS and ProcritCS injections Pen lac solution
Genotropincs, HumatropeCs, Norditropincs, Nutropincs, Actiq, Fentanyl Patch
Nutropin AQcs, Protropincs, Nutropin Depocs, Saizencs,
SerostimCs injections
I
CS,
I ProlastinLD, AralastLD, ZemairaLD injections Enbrelcs , Humiracs,
KineretCS, Orenciacs,
Remicadecs, RituxanCs iniections
Regranex Del Exubera inhaled insulin I
RevatioCs tablets ForteoCs injection I
Tazorac cream and eel Provieil tablets
Xolaircs injection Topamax tablets
I Zonegran caDsules
~ranox capsules - ---.- ----...
Brand Name
Ilncrelex Injection
CS _ CuraScript specialty medication
LD _ Limited distribution specialty; not available at CuraScript
* List is subject to change,
RB785 - Restated 1/1/09
25
Aaenda ltem ~~CL 16E5
~ r=ebruary 10, 2009
Page 32 of 99
SPECIALTY MEDICATIONS
Express Scripts is the company your health plan uses to help manage your prescription-drug benefit. Your health plan
recently selected the Express Scripts specialty pharmacy program, CareLogicSM This means you can now order your
specialty medications exclusively through CuraScript specialty pharmacy, and receive additional care and services.
New, Dependable Services - and More
Now your specialty medications can be delivered to your home, your doctor's office or any approved location. In
addition, you'll have other benefits through CareLogic, including:
. Access to specialty experts dedicated to serving you with a higher level of personal care
. Care management programs to help ensure you're taking medications correctly and to provide the support you
need to manage your condition
. A patient care coordinator who will provide comprehensive clinical management services
. Supplies for administering your medications - such as syringes, needles and sharps containers
To receive your next supply of the specialty medication(s) on the patient medication profile form through our
specialty pharmacy, call toll free. 866.848.9870.
. Monday through Friday, 8 a.m. to 9 p.m. EST and Saturday, 9 a.m. to 1 p.m, EST
. Closed Sunday and Holidays (New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving,
Christmas)
A patient care coordinator will contact your doctor and work with you to schedule a delivery time for your medication.
Please Note: Your health pian will no longer cover specialty medications through other pharmacies. So to receive
coverage, be sure to order this medication through the CareLogic program. We've also let your doctor know about your
benefit change. To learn more, please refer to the enclosed brochure or call toll free, 866.848.9870. We believe you'll
be satisfied with this enhancement to your health plan, and we look forward to serving your specialty medication
needs.
RB 785 - Restated 1/1/09
26
L.cenca item ~'JCJ. 'i :3E5
~ February 10, 2009
Page 23 of 99
STEP THERAPY
Your pharmacy benefit plan will use a program called Step Therapy.
What is Step Therapv?
Step Therapy is a program especially for people who take prescription drugs regularly for ongoing conditions like
arthritis and high blood pressure. It helps you get an effective medication to treat your condition while keeping
your costs as low as possible.
In Step Therapy, drugs are grouped in categories based on cost:
. Front-line drugs-the first step-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.
. 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.
How does Step Therapv work?
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've already 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) listed is
appropriate. Remember, you can always get a higher-cost brand-name drug at a higher copayment if the front-iine 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.
RB785 - Restated 1/1109
27
~ . "
Your prescription is for Pa~e 34 at ~9
Program Indication one of these targeted Your program points you to one of hese first step
step druRs drugs
Accupril, Accuretic, Aceen,
Altace, Capoten, Capozide,
Lexxel, Lotensin Her, benazepril, benazeprH/HCTZ, captopril, captopril/HCTZ, enalapril,
Angiotensin Converting High Blood Lotensin, Lotre!, Mavik, enalapril/HCTZ, fosinopril, fosinopril/HCTZ, lisinopril, lisinopril/HCTZ,
Enzyme (ACE) Inhibitors. Pressure Monopril Her, Monopril, quinapril, quinaretic
Prinivi!, Prinzide, Tarka,
Uniretic, Univasc, Vaseretic,
Vasotec, Zestoretic, Zestril
Atacand Her, Atacand,
Avalide, Avapro, Benicar, benazepril, benazeprillHCTZ, captopril, captopril/HCTZ, enalapril,
Angiotensin II Receptor High Blood Benicar Her, Cozaar, Diovan enalapril/HCTZ, fosinopril, fosinopril/HCTZ, lisinopril, lisinopril/HCTZ,
Antagonists* Pressure HCT, Diovan, Hyzaar, quinapril, quinaretic
Micardis, Micardis HCT,
Teveten, Teveten HCT
Celexa, Lexapro, Luvox, Paxil
Antidepressants. (SSRI)* Depression CR, Paxil, Pexeva, Prozac, f1uoxetine, f1uvoxamine, paroxetine, citalopram, sertraline
Prozac Weekly, Sarafem,
Zoloft
Cymbalta, Effexor. Effexor XR, f1uoxetine, f1uvoxamine. paroxetine. citalopram, sertraline, venlafaxine
Other Antidepressants* Depression
Weltbutrin XL bupropion SR
acebutolol, atenolol, betaxolol, bisoprolol, labetalol, metoprolol tartrate,
High Blood Toprol XL, Coreg, Gartrol , nadolo!, pindolol, propranolol, sotalol, timolol, atenolollchlorthaHdone,
Beta Blockers Pressure Levatol, Inderal LA, InnoPran bi soprol ol/hyd ro chlorothi azide, meto p rolol/hydroch lorothia zide ,
XL nado lol/bend rof! umethiazide, pro pra nolo I/hyd roch lorothlazid e ,
timolollhydrochlorothiazide
Pain and diclofenae, etodolac, fenoprofen, f1urbiprofen, ibuprofen, indomethacin,
Branded NSAID* Inflammation Arthrotee, Mobie, Ponstel ketoprofen, ketorolac, meclofenamate, nabumetone, naproxen,
oxaprozin, piroxicam, sulindae. tolmetin
CeB - Dihydropyridine* Adalat, Gardene SR, Dynacirc nifedipine SR, nifedipine IR, nicardipine IR, felodipine ER, isradipine
CR, Norvasc, Plendil,
High Blood Procardia,-XL Sular
Pressure
Verapamil* GALAN -SR Covera-HS, Isoptin-
SR ,Verelan Verelan PM verapamil SR, verapamillR
Pain and diclofenae, etodolac, fenoprofen, f1urbiprofen, ibuprofen, indomethacin,
COX-2 Inhibitors* Inflammation Celebrex ketoprofen, ketorolac, meclofenamate, nabumetone, naproxen,
oxaprozin, piroxicam, sulindac, tolmetin
Advicor, Altoprev, Caduet, Step-One: lovastatin, pravastatin, simvastatin
HMG - Enhanced* High Cholesterol Lescol, Lescol XL, Lipitor,
Pravaehot. Zocor Step-Two: Crestor, Vytorin
Hypnotics Insomnia Ambien CR, Lunesta, Ambien
Rozerem, Sonata
Leukotriene Pathway Asthma and Category 1:BeconaseAQ, f1uticasone, Flunisolide, Nasacort, Nasarel,
Inhibitors* Allergies Accolate, Singulair, Zytlo Nasonex, Rhinocort AQ
Category 2: Fexofenadine, Allegra-D, Clarinex. Zyrtec, Zyrtec 0
Non-sedating Allergies Clarinex, Clarinex-D, Zyrtec, fexofenadine,
Antihistamines Zyrtec-D, Allegra, Allegra-D,
Aciphex, Nexium, Prevacid,
Proton Pump Inhibitors- Heartburn and Prevacid SoluTab, Prevacid omeprazole
generic* Ulcers Suspension, Prilosec, Protonix
, Zeoerid
Adavate, Aristocart, Capex, Clobex, Cloderm, Cor-dr-an, Culivale,
T apical Cyclocort, Derma-Smoothe, Diprolene, Diprolene AF, Dlprosone,
Skin Conditions Elidel, Protopic Elocon, Florone, Florone E, Halog, Halog E, Kenalog, Lidex, Locoid,
Immunomodulators Luxiq, Olux, Pandel, Psoreon E, Synalar, Temovate, Topicort,
Ultravate, Vanos
Agenda Ite;n t'~o. 16E5
Fcbruarv 10 2009
RB785 - Restated 1/1/09
28
;",oe,-ida It2,ll r'~o. i 6E5
~ February 10, 2009
Page 3.5 of 99
ELIGIBILITY, ENROLLMENT &
EFFECTIVE DATE OF COVERAGE
A - Eligible Employees
An employee is eligible to participate in this Plan if they are a regular, full-time or part-time employee of Collier County
Government and are regularly scheduled to work a minimum of twenty (20) hours per week. An employee is also eligible to
participate in this Plan if they are a qualifying retiree of Collier County Government. Qualifying retirees must meet the
requirement of Florida Statute 112.0801. Eligibility for Medicaid or the recipient of Medicaid benefits will not be taken into
account in determining eligibility. Other employees such as temporary or seasonal will not be eligible to enroll for coverage
under this Plan.
If you are a qualifying retiree you have thirty-one (31) days from the last day of the month you retired to elect coverage.
Your coverage begins on the first day of the month following your retirement.
An employee's Eligibility Date will be as follows: if you are a full-time or regular part-time employee and your hire date is the
first of the month, your coverage begins on that day. If your hire date is after the first of the month, your coverage begins
on the first day of the following month.
B - Eligible Dependents
Eligible Dependents will be a Covered Employee's legally married spouse and each unmarried child until the end of the
month they attain age thirty (30), provided such dependent is not eligible for coverage under another group health plan.
The term "married" means only a iegal union between one man and one woman as husband and wife, and the term
"spouse" refers only to a person of the opposite sex who is a husband or wife.
The term "child", as used herein, shall be defined as: (a) a natural born child; (b) a stepchild; (c) a foster child; (d) an
adopted child (from the date of placement with the employee for the purpose of legal adoption); (e) a child for whom the
employee is the legal guardian; (f) a grandchild from birth up to eighteen (18) months of age if the mother or father of the
newborn is an Eligible Dependent; or (g) A child for whom the employee is required to provide health coverage due to a
Qualified Medical Child Support Order (QMCSO), Procedures for determining a Qualified Medical Child Support Order
(QMCSO) may be obtained from the Contract Administrator at no cost.
Where both the employee and spouse are employed by the Employer, each will elect single (employee only) coverage if
there are no eligible dependent children. An employee shall not elect single coverage while the spouse elects dependent
coverage if there are eligible dependent children. One of the employees shall choose to elect dependent coverage which
would cover the spouse, who is also employed by the Employer, and all eligible dependent children.
The Plan Administrator shall have the right to require documentation necessary, in its sole discretion, to establish an
individual's status as an Eligible Dependent.
Mentally or Physically Handicapped Child: If an unmarried dependent child, upon the end of the month they reach age
thirty (3) and is incapacitated, unable to be self-supporting, and resides with the employee, then such child will continue to
be an Eligible Dependent.
C - Plan Enrollment (Timely, Special and Late Enrollment)
Timely Enrollment: An Eligible Employee who elects to participate in the Plan must complete, sign, and return the
provided "enrollment form" to the Employer within thirty-one (31) days of the Eligibility Date. Failure to enroll within this
time limit will be deemed waiver of participation and the employee or dependents will be considered Late Enrollees or
Special Enrollees.
An Eligible Dependent is able to participate in the Plan when the Covered Employee completes, signs and returns an
enrollment form indicating dependent coverage to the Employer. The employee must enroll the dependent(s) within thirty-
one (31) days of whichever of the following occurs first:
1. The employee's Eligibility Date if the employee has any Eligible Dependents at that time; or
2. The date the employee acquires an Eligible Dependent.
RB785 - Restated 1/1/09
29
,l\genda Itern 1\10. 16E5
February 10, 2009
Page 36 of 99
The Pre-Existing Condition Limitation and Creditable Coverage provisions will apply.
Children covered by Qualified Medical Child Support Orders (QMCSO) may be enrolled in this Plan if the employee would
otherwise be eligible for coverage, regardless of whether the employee is currently enrolled. The Plan must enroll the
child(ren) and the employee covered by the notice without any enrollment restrictions (i.e. they will not be considered Late
Enrollees).
If dependent coverage is already in force, the employee does not have to enroll additional dependent children acquired
after dependent coverage is in force.
If dependent coverage is not already in force, newborn children and adopted children will be covered on the date of birth or
adoption (or placement for adoption) if enrolled within thirty-one (31) days of the birth, adoption or placement for adoption.
Special Enrollment: If an employee is declining enrollment for single or family coverage because of other health coverage
under a Qualified Health Plan, the employee may in the future be able to enroll for single or family coverage, provided the
request for enrollment is received within thirty-one (31) days after coverage under the Qualified Health Plan terminates due
to one or more of the following:
1. Loss of eligibility, which includes, but is not limited to:
(a) Legal separation, divorce, cessation of dependent status (such as attaining the maximum age to be
considered an Eligible Dependent under the plan), death of an employee, termination of employment,
reduction in the number of hours of employment;
(b) Coverage is offered through an HMO or other arrangement, in the individual market that does not provide
benefits to individuals who no longer reside, live or work in a service area (whether or not within the choice
of the individual);
(c) Coverage is offered through an HMO or other arrangement, in the group market that does not provide
benefits to individuals who no longer reside, live or work in a service area (whether or not within the choice
of the individual), and no other benefit package is available to the individual;
(d) When a Covered Person incurs a claim that would meet or exceed a lifetime limit on all benefits (this right
continues until at least 31 days after the earliest date that a claim is denied due to the operation of the
lifetime limit);
(e) When a plan no longer offers any benefits to a class of similarly situated individuals, i.e. terminated
coverage for part-time employees, etc.
2. Termination of employer contributions toward the cost of coverage; or
3. COBRA continuation coverage is exhausted.
If an employee has a new dependent as a result of marriage, birth, adoption, or placement for adoption, the employee may
be able to enroll for coverage, provided the employee requests enrollment within thirty-one (31) days after the marriage,
birth, adoption or placement for adoption of a new dependent child.
A written waiver of coverage stating the existence of coverage under another Qualified Health Plan must have been
completed by the employee in order for the employee to be considered a Special Enrollee at a later date.
The Pre-Existing Condition Limitation and Creditable Coverage provisions will apply.
Late EnrollmenUOpen Enrollment: A Late Enrollee may enroll for single or family coverage under the Plan any time
during the year; however, coverage will not become effective until the following January 1 st The waiting period will be
waived; however, the eighteen (18) month Pre-Existing Condition Limitation will apply.
Also during this Open Enrollment, Covered Employees and their covered dependents will be able to a make a change in
coverage under this Plan. Plan choices made during Open Enrollment will become effective January 1 st and remain in
effect until the next January 1 st, unless there is a special enrollment period. A Covered Employee who fails to make an
election during Open Enrollment will automatically retain their present coverage.
RB785 - Restated 1/1/09
30
D - Return to Work - USERRA
,';Qt::;llda i~8m f~O. 16E5
- February 10,2009
Page 37 of 99
Employees who are covered under the Uniformed Services Employment and Reemployment Rights Act (USERRA) will be
eligible for coverage on the date they return to work, provided the employee returns to work with the Employer within the
specified time period in the Uniformed Services Employment and Reemployment Rights Act (USERRA). Coverage for a
reservist will be on the same basis it is for active employees and dependents. Eligibility waiting periods and the Pre-
Existing Condition Limitation will be imposed only to the extent they were applicable prior to the period of uniformed
services. See the Termination of Benefits section for more information regarding USERRA.
F - Effective Date of Coverage
Timely Enrollees:
1. Employees: The employee's Eligibility Date if the employee enrolls within thirty-one (31) days thereafter.
2. Dependents: The employee's effective date of coverage.
Special Enrollees:
1. The day following the date the employee or dependent's coverage terminated due to loss of eligibility under a
Qualified Health Plan, provided enrollment is received within thirty-one (31) days of losing coverage.
2. The day following the date the employee or dependent's coverage terminated due to termination of em pi oyer
contributions toward the cost of coverage, provided enrollment is received within thirty-one (31) days of losing
coverage.
3. The date of marriage, provided the new dependent(s) is enrolled within thirty-one (31) days of the marriage and
dependent coverage is already in force; or the first of the followin9 month if changing from single to dependent
coverage.
4. The date of birth or adoption (or placement for adoption) of a new dependent, provided the employee enrolls for
single or family coverage within thirty-one (31) days of the birth, adoption or placement for adoption.
5. The day following the date in which COBRA coverage is exhausted if the employee or dependent had elected
COBRA coverage under a Qualified Health Plan, provided enrollment is received within thirty-one (31) days of
exhausting benefits.
Late Enrollees:
1. January 1 st following the date the Late Enrollee enrolls. The Pre-Existing Condition Limitation and Creditable
Coverage provisions will apply.
RB785 - Restated 1/1/09
31
,1\..o8nda item No. 16E5
, February 10. 2009
Page 38 of 99
ELIGIBLE EXPENSES
Eligible expenses shall be the charges actually made 10 the Covered Person and, unless otherwise shown, will be
considered eligible only if the expenses are:
1. Due to Illness or Injury (except as specified);
2. Ordered or performed by a Physician;
3. Medically Necessary;
4. Usual and Customary Charges; and
5. Not otl',elwise excluded under the Plan.
Reimbursementfor eligible expenses will be made directly to the provider of the service, unless a receipt showing payment
is submitted. All eligible expenses incurred at a Preferred Provider will be reimbursed to Ihe provider.
1. Acupuncture (Premium and Select Options Only): Acupuncture performed by a licensed provided will be
payable as shown in the Schedule of Benefits.
2. Allergy Services: Allergy testing, treatment and serum. Allergy injections will be payable under the Physician
office visit benefit.
3. Ambulance Service: Commercial ground or air ambulance service will be payable as shown in the Schedule of
Benefits to transport the patient:
(a) To the nearest Hospital equipped to treat the specific Illness or injury in an emergency situation; or
(b) To another Hospital in the area when the first Hospital did not have services required and/or facilities to
treat the patient; or
(c) To and from a Hospital during a period of Hospital confinement to another facility for special services
which are not available at the first Hospital;
(d) From the Hospital to the individual's home, or to a convalescent facility when there is documentation the
patient required ambulance transportation; or
(e) Transportation of a newborn to and from the nearest available facility appropriately staffed and equipped
to treat the newborn's condition, when such transportation is certified by the attending Physician as
necessary to protect the health and safety of the newborn child.
4. Ambulatory Surgical Facility: Services and supplies provided by an Ambulatory Surgical Faciiity.
5. Anesthetics: Anesthetics and their professional administration.
6. Aquatic Therapy: Medically Necessary aquatic or pool therapies.
7. Blood and Blood Derivatives: Blood, blood plasma, or blood components not donated or replaced.
8. 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 vertebral abnormalities; (c) are
receiving long term glucocorticoid (steroid) therapy; (d) have primary hyperparathyroidism; or (e) have a family
history of osteoporosis.
RB785 - Restated 1/1/09
32
!'--\oenda Item No. i 6E5
, February 10, 2009
Page 39 of 99
9. Cardiac Rehabilitation: Cardiac rehabilitation services which are rendered: (a) under the 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 forthe 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.
10. 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.
11, Chemical Dependency; Inpatient and outpatient treatment of Chemical Dependency will be payable as shown in
the Schedule of Benefits. Discontinuance of an Inpatient treatment program by the Covered Person prior to
completion of the program will result in no Inpatient benefits being paid under the Plan.
Expenses for detoxification or Chemical Dependency evaluations will not be considered eligible, unless followed by
an Inpatient stay in a Hospital or a residential Chemical Dependency treatment facility or an outpatient treatment
program within fourteen (14) days of the evaluation or receipt of the detoxification services.
12. 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.
13. Circumcision; Services and supplies related to circumcision.
14. 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.
15. Colonoscopies: Colonoscopies for Covered Persons age fifty (50) and over; or for a Covered Person of any age
with a strong family history of colon cancer or medical symptoms will be paid as shown in the Schedule of
Benefits and will not be subject to the Routine Care benefit maximum.
16. Contraceptives: Contraceptive procedures and medications, including, but not limited to: injections, diaphragms,
intrauterine devices (IUD), implants, Depo Provera and any related office visit. Some contraceptives may be
available under the Prescription Drug Card Benefits program, The Plan does not cover contraceptive supplies or
devices available without a Physician's prescription or contraceptives provided over-the-counter,
17. Cosmetic Procedures/Reconstructive Surgery: Cosmetic procedures or Reconstructive Surgery will be
considered eligible only under the following circumstances: (a) for the correction of a Congenital Anomaly for a
dependent child; (b) any other Medically Necessary surgery related to an Illness or Injury.
18, Dental Care (Premium and Select Options Only); Dental services and x-rays rendered by Dentist or Dental
Surgeon for: (a) the treatment of a fractured jaw, or (b) accidental Injuries 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.
General anesthesia and hospitalization services in assuring the safe delivery of necessary dental care provided to
a Covered Person of any age who (a) 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 (b) 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 ambuiatory surgical center.
RB785 - Restated 1/1/09
33
,A,gsnda item No. 16E5
i'ebruary 10,2009
Page 40 of 99
Dental services due to Illness will be payable as shDwn in the Schedule of Benefits, subject to prior authDrizatiDn
by the Plan. A letter of Medical Necessity from the attending Physician and the Dentist's treatment plan must be
submitted to the Contract Administrator before charges will be cDnsidered.
19. Diabetic Supplies: Diabetic supplies fDr the treatment of gestational, Type I or Type II diabetes.
20. Diagnostic Testing, X-ray and Laboratory Services: DiagnDstic testing, x-ray, and labDratory services,
including services Df a professional radiologist Dr patholDgist. Dental x-rays are not eligible expenses, except as
specified under Dental Care.
21. Durable Medical Equipment: The rental of Dxygen, wheelchairs, walkers, special Hospital beds, iron lungs, and
other Durable Medical Equipment will be payable as shown in the Schedule of Benefits, subject to the fDIIDwing:
(a) The equipment must be piesciibed by a Physician and needed in the treatrnent of an illness or Injury; and
(b) The equipment will be provided on a rental basis, however such equipment may be purchased at the
Plan's optiDn. Any amount paid to rent the equipment will be applied towards the purchase price. In no
case will the rental cost of Durable Medical Equipment exceed the purchase price Df the item (oxygen
equipment is not limited to the purchase price); and
(c) Benefits will be limited to standard models, as determined by the Plan; and
(d) The Plan will pay benefits fDr only ONE of the fDllowing: a manual wheelchair, motDrized wheelchair or
motorized scooter, unless Medical Necessary due to growth Df the persDn or changes ID the persDn'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 cannDt be restDred to a
serviceable condition, replacement will be considered eligible, subject tD 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 conditiDner, air purifier, or any Dther device or
appliance will nDt be considered eligible.
22. Emergency Room Services: Treatment in a Hospital emergency room, including professional services will be
payable as shDwn in the Schedule of Benefits. The Co-pay will be waived if the person is admitted directly as an
Inpatient to the Hospital.
23. Hearing Aids (Premium and Select Options Only): Hearing aids and their fittings when due to an Accident or
Illness will be payable as shDwn in the Schedule of Benefits.
24. Hemodialysis/Peritoneal Dialysis: Treatment of a kidney disorder by hemodialysis or peritDneal dialysis as an
Inpatient in a Hospital or other facility, or for expenses in an Dutpatient facility or in the Covered Person's home,
including the training of one attendant to perfDrm kidney dialysis at home. The attendant may be a family member.
When home care replaced Inpatient or Dutpatient dialysis treatments, the Plan will pay for rental Df dialysis
equipment and expendable medical supplies for use in the Covered Person's home as shown under the Durable
Medicai Equipment benefit.
25. Home Health Care: Services provided by a HDme Health Care Agency to a Covered Person in the home will be
payable as shown in the Schedule of Benefits. The fDllowing are cDnsidered eligible home health care services:
(a) Home nursing care;
(b) Services of a hDme health aide or licensed practical nurse (L.P.N.), under the supervision of a registered
nurse (R. N.);
(c) Physical, occupatiDnal or speech therapy if provided by the Home Health Care Agency;
(d) Medical supplies, drugs and medications prescribed by a Physician;
(e) LabDratory services; and
(f) Nutritional cDunseling by a licensed dietician.
In nD event will the services of a Close Relative, sDcial worker, transpDrtation services, housekeeping services,
and meals, etc. be cDnsidered an eligible expense.
RB785 - Restated 1/1/09
34
26. Hospice Care: Hospice care on either an Inpatient or outpatient basis for a terminally ill person rendered under a
Hospice treatment plan will be payable as shown in the Schedule of Benefits. The Hospice treatment plan must
certify that the person is terminally ill with a life expectancy of six (6) months or less.
L,genca :iern t~o. 16E5
Febccary 10, 2009
?age ..:j 1 of ~J9
Covered services include:
(a) Room and board charges by the Hospice;
(b) Other Medically Necessary services and supplies;
(c) Nursing care by or under the supervision of a registered nurse (R.N.);
(d) Home health care services furnished in the patient's home by a Home Health Care Agency for the
following: (i) health aide services consisting primarily of caring for the patient (excluding housekeeping,
meals, etc.); and (ii) physical and speech therapy;
(e) Counseling services by a licensed social worker or a licensed pastoral counselor for the patient's
immediate family;
(f) 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 coverage is limited to 50% of the charges for the services and not more than a total of
fifteen [15] visits per family.)
Counseling services received In connection with a terminal Illness as described above will not be considered to
have been received due to a Mental/Nervous Disorder.
The term "Patient's immediate Famiiy" as used herein means the patient's spouse, parents, and/or dependent
children who are covered under the Plan.
27. Hospital Services or Long-Term Acute Care Facility/Hospital:
Inpatient
Room and board, including all regular daily services in a Hospital or Long-Term Acute Care Facility/Hospital will be
payable as shown in the Schedule of Benefits. Charges made by a facility having only single or private rooms will
be considered at the least expensive rate for a single or private room.
Care provided in an Intensive Care Unit will be payable as shown in the Schedule of Benefits.
Miscellaneous services and supplies, including any additional Medically Necessary nursing services furnished
while being treated on an Inpatient basis.
Outpatient
Services and supplies furnished whiie being treated on an outpatient basis will be payable as shown in the
Schedule of Benefits.
28. 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.
29. Maternity: Expenses incurred by an employee or a dependent spouse for:
(a) Pregnancy;
(b) Services provided by a Birthing Center;
(c) Amniocentesis testing;
(d) Ultrasounds;
(e) Elective induced abortions 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.
Hospital stays in connection with childbirth for either the mother or newborn may not be limited to 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 precertify the maternity admission, unless the stay extends past the applicable forty-
RB785 - Restated 1/1/09
35
Agenda Item ~,Jo. 16E5
cebruary 10, 2009
Pag,e 42 of 99
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.
30. Medical and Surgical Supplies: Casts, splints, trusses, braces, crutches, orthotics, dressings, and other
Medically Necessary supplies ordered by a Physician. Foot orthotics are covered under the Podiatry benefit.
31. Medical Records: Charges for obtaining medical records will be payable as shown in the Schedule of Benefits.
32. Mental/Nervous Disorders: Inpatient and outpatient treatment of Mental/Nervous Disorders will be payable as
shown in the Schedule of Benefits. This benefit also includes family therapy provided to the patient and the
patient's family when the patient is present at the session.
33. Morbid Obesity: Medically Necessary surgical and non-surgical treatment of Morbid Obesity.
34. Non-Emergency Transportation. Non-emergency ambulance transportation to an individuals home or facility to
facility when there is documentation the patient needed the non-emergency transport.
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 under the recommendation
of a Physician. Outpatient occupational therapy will be payable as shown in the Schedule of Benefits.
Occupational therapy is covered under the Plan only if it follows 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. Outpatient Pre-Admission Testing: Outpatient pre-admission testing performed within seven (7) days of a
scheduled Inpatient hospitalization or Surgery,
39. Physical Therapy: Physical therapy rendered by a physical therapist under the recommendation of a Physician.
Outpatient physical therapy will be payable as shown in the Schedule of Benefits. Maintenance Therapy will not
be considered eligible.
40. Physician's Services: Services of a Physician for medical care or Surgery will be payable as shown in the
Schedule of Benefits.
Services performed in a Physician's office regardless if a Physician is seen or not will be payable as shown in the
Schedule of Benefits. Services include, but are not limited to: examinations, x-ray and laboratory tests (including
the reading or processing of the tests), supplies, injections, allergy shots, cast application, and minor surgery. If
more than one Physician is seen in the same clinic on the same day, only one Co-pay will apply.
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.
For multiple or bilateral surgeries performed during the same operative session which are not incidental, or not part
of some other procedure, and which add significant time or complexity (all as determined by the Plan) to the
complete procedure, the charge considered will be: (a) 100% for the primary procedure; (b) 50% for the secondary
procedure, inciuding any bilateral procedure; and (c) 50% for each additional covered procedure. This applies to all
surgical procedures. except as determined by the Plan.
For surgical assistance by an Assistant Surgeon, the charge will be 20% of the Usual and Customary Charge for
the corresponding surgery'.
RB785 - Restated 1/1/09
36
/-\:Js:lda :i8:l1 r'~o. f 6E5
-' )::"w'--)~, '?ry 10 00r,0
~ll .....,-' I, L-\.. ....~
?age -13 of 99
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 diagosis (i.e. PVD); (e) any Medically Necessary surgical
procedure required for a foot condition; or (f) orthotics, including orthopedic shoes when an integral part of a leg
brace.
42. Private Duty Nursing: Service of a registered nurse (R.N.) or a licensed practical nurse (L.P.N.) for private duty
nursing as follows:
(a) Inpatient private duty nursing is covered only when care is Medically Necessary and not for Custodial
Care, and the Hospital's Intensive Care Unit is filled or the Hospital has no Intensive Care Unit.
(b) Outpatient private duty nursing is covered only vv'hen Medically Necessary' and will be payable under the
Home Health Care benefit.
43. Prosthetics: Artificial iimbs, eyes, or other prosthetic devices for replacement when necessary due to an Illness
or Injury. Charges for the 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, and does not include
charges for repair or maintenance. Replacement due to normal wear and tear and deterioration is not considered
eligible.
44. Radiation Therapy/Chemotherapy: Radium and radioactive isotope therapy, and chemotherapy treatment will be
payable as shown in the Schedule of Benefits.
45. Reconstructive Surgery/Cosmetic Procedures: Reconstructive Surgery or Cosmetic procedures will be
considered eligible only under the following circumstances: (a) for the correction of a Congenital Anomaly for a
dependent child; (b) any other Medically Necessary surgery related to an Illness or Injury.
Charges for reconstructive breast surgery following a mastectomy will be eligible as follows: (a) reconstruction of
the breast on which the mastectomy has been performed; (b) surgery and reconstruction of the other breast to
produce symmetrical appearance; and (c) coverage for prostheses and physical complications of all stages of
mastectomy, including Iymphedemas.
The manner in which breast reconstruction is performed will be determined in consultation with the attending
Physician and the patient.
46. 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 within fourteen (14) days after discharge from a required Hospital or Skilled Nursing Facility
confinement of at least three (3) days in length for which room and board benefits are paid; (c) is for the 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 Care Facility.
47. Routine Care: Routine care age sixteen (16) and over will be payable as shown in the Schedule of Benefits and
will include the office visit and the following performed during an annual screening exam, including, but not limited
to:
(a) Annual physical screening exams;
(b) Gynecological exams;
(c) Digital rectal exams for men starting at age forty (40);
(d) Lab work to include CBCD, HDLD (includes cholesterol), urinalysis, and comprehensive metabolic panel;
(e) Pap smears;
(f) EKG baseline at age forty (40) and repeated every ten (10) years after age fifty (50);
(g) SMA 15, PSA for men annually, occult blood stool, repeated one year after screening, then every five (5)
years:
(11) Vaccinations or inoculations;
(i) Bone density testing.
RB785 - Restated 1/1/09
37
,L\genja item ~~o. 16E5
February 10, 2009
Page 44 of 99
If a diagnosis is indicated after a routine exam, the exam will still be payable under the routine care benefit,
however, all charges related to the diagnosis (except the initial exam) will be payable as any other Illness.
48. Routine Mammograms: Expenses for routine mammograms, including the office visit charge and all other related
services, will be payable as shown in the Schedule of Benefits according to the following schedule:
(a) Age thirty-five (35) through age thirty-nine (39), one baseline mammogram;
(b) Age forty (40) through age forty-nine (49), one mammogram every two (2) years, or more frequently if
recommended by a Physician;
(c) Age fifty (50) and over, one mammogram every year; and
(d) One or more mammograms a year, based upon a Physician's recommendation, for any woman who is at
risk for breast cancer because: (i) of a personal or family history of breast cancer; (ii) of having a history of
a biopsy-proven benign breast disease; (iii) of having a mother, sister, or daughter ........ho has or has had
breast cancer; or (iv) a woman has not given birth before the age of thirty (30).
49. Routine Newborn Care: Routine 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.
50. 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.
51. Second Surgical Opinions: Voluntary second surgical opinions for elective, non-emergency Surgery when
recommended for a Covered Person.
Benefits for the second opinion will be payable only if the opinion is given by a specialist who: (a) is certified in the
field related to the proposed Surgery; and (b) is not affiliated in any way with the Physician recommending the
Surgery.
52. Skilled Nursing Care/Facility: Skilled Nursing Care provided in a Skilled Nursing Facility will be payable as
shown in the Schedule of Benefits, provided such confinement: (a) is under the recommendation and generai
supervision of a Physician; (b) begins within fourteen (14) days after discharge from a required Hospital or
Rehabilitation Facility confinement of at least three (3) days in length for which room and board benefits are paid;
(c) is for the purpose of receiving medical care necessary for convalescence from the conditions causing or
contributing to the precedent Hospital or Rehabilitation Facility confinement; and (d) is not for Custodial Care.
See the Rehabilitation Facility benefit for services and supplies provided for confinements in a Rehabilitation
Facility.
53. Sleep Disorders: Treatment of or related to sleep disorders.
54. Speech Therapy: Restorative or rehabilitative speech therapy necessary because of loss or impairment due to an
Illness, Injury or Surgery, or therapy to correct a Congenital Anomaly. Speech therapy for developmental delay
or to change voice sound will not be considered eligible. Outpatient speech therapy will be payable as shown
in the Schedule of Benefits. Maintenance Therapy will not be considered eligible.
55. Sterilization: Elective sterilization procedures.
56. Temporomandibular Joint Dysfunction (TMJ): Surgical and non-surgical treatment ofTemporomandibular 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 shall include, but is
not limited to: orthodontics; physical therapy; and any appliance that is attached to or rests on the teeth.
RB785 - Restated 1/1/09
38
/-\G8ilCa ltem No. 16E5
~ F8bruary 10,2009
Page 45 01 99
57. Tobacco Cessation: Tobacco cessation programs offered through The Med Center only. 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 (prescriptions and over-the-counter gums, patches, etc.).
58. Transplants: Services and supplies in connection with Medically Necessary non-Experimental transplant
procedures, subject to the following conditions:
(a) A concurring opinion must be obtained prior to undergoing any transplant procedure. This mandatory
opinion must concur with the attending Physician's findings regarding the Medical Necessity of such
procedure. The Physician rendering this concurring opinion must be qualified to render such a service
either through experience, specialist training, 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, eligible expenses incurred by the donor will be considered eiigible.
!f the donor is not covered under this Plan, reference provision (e).
(c) If the recipient is covered under this Plan, eligible expenses incurred by the recipient will be considered
eligible.
(d) If both the donor and the recipient are covered under this Plan, eligible expenses incurred by each person
will be treated separately for each person.
(e) The Usual and Customary fee 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.
Exclusions
(a) Non-human and artificial organ transplants;
(b) Lodging expenses, including meals;
(c) Expenses related to the Covered Person's transportation;
(d) The purchase price of any of bone marrow, organ, tissue, or any similar items which are sold rather than
donated; and
(e) Transplants which are not medically recognized and are Experimental/Investigational in nature,
59. Urgent Care Facility: Services and supplies provided by an Urgent Care Facility will be payable as shown in the
Schedule of Benefits,
60. Well Child Care: Well child care up to age sixteen (16), including, but not limited to, vaccinations and
immunizations, routine office visits, developmental assessments, and related laboratory tests and x-rays will be
payable as shown in the Schedule of Benefits.
RB785 - Restated 1/1/09
39
AGarlda Item ~,b. .16E5
, February 10, 2009
Page 46 of 99
SMARTCHOICE PROGRAM
Smartchoice is a health management program for specific members covered under this Plan. Those members would be
identified as diagnosed with Morbid Obesity and interested in surgical-weight loss procedures that are considered Medically
Necessary for Morbid Obesity.
The 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.
Members must enroll and actively participate for twelve consecutive months in the Smartchoice program prior to
consideration for pre-certification of any gastric by-pass surgery. Recommendation regarding request for gastric
procedures inclusive of but not limited to: Bariatric Surgery, Gastric Stapling, Laparoscopic Gastric Bypass, Roux-en-Y
Gastric Bypass (RYGB), Vertical Banded Gastroplasty (VBG).
Please contact Smartchoice for further information. (239) 659-7740.
DIABETES SUPPLY AND EDUCATION PROGRAM
The Plan offers a diabetes supply program through Certified Diabetic Services, Inc. (CDS), This Diabetic Supply Program
allows a Covered Person to, from the comfort of the Covered Person's home:
1. Get all diabetic supplies from one source (no extra trips to the pharmacy)
2. Get a ninety (90) day supply
3. Receive valuable educational material
Diabetic supplies provided through Certified Diabetic Services, Inc. will be payable at a $14 Co-pay. Please call (239)430-
5000 or (800) 441-8643 to order supplies fast and simple. Each shipment will be shipped directly to your home and will
contain a ninety (90) day supply. CDS will automatically ship supplies every three (3) months based on the Covered
Person's eligibility verification at time of shipment.
MEDICAL EXPENSE AUDIT BONUS
The Plan offers an incentive to all Covered Persons to encourage examination and self-auditing of eiigible 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 eiimination or reduction of benefits paid, 50% of the amount saved will be reimbursed
directly to the employee (subject to a $10 minimum payment and a $500 maximum payment per Calendar Year), provided
the savings are accurately documented, and satisfactory evidence is submitted to the Contract Administrator (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 wiil not be payable for expenses in excess of the Usual and Customary Charges or expenses which are not
covered under the Plan, regardless of whether benefits paid are reduced.
RB785 - Restated 1/1/09
40
r\Gen::Ja 118m No. i6E5
~ F'3bruary 10 2009
Page 47 of 99
ALTERNATIVE BENEFITS
In addition to the benefits specified, the Plan may elect to offer benefits for services furnished by any provider pursuant to a
Plan-approved alternative treatment plan, in which case those charges incurred for services provided to a Covered Person
under an alternate treatment plan to its end, will be more cost effective than those charges to be incurred for services to be
provided under the current treatment plan to its end, and will be subject to Medical Review.
The Plan shall provide such alternative benefits at its sole discretion and only when and for so long as it determines that
alternative care services are Medically Necessary and cost effective, If the Plan elects to provide alternative benefits for a
Covered Person in one instance, it shall not be obligated to provide the same or similar benefits for other Covered Persons
under this Plan in any other instance, nor shall it be construed as a waiver of the Plan Administrator's rights to administer
this Plan thereafter in strict accordance with its express terrns.
PRE-EXISTING CONDITION LIMITATION
Expenses incurred in connection with a Pre-Existing Condition will not be considered eligible. A Pre-Existing Condition is
defined as an Illness or Injury (whether physical or mental), regardless of cause, for which medical advice, diagnosis, care,
or treatment was recornmended or received during the six (6) consecutive month period prior to the individual's Enrollment
Date of coverage under this Plan. Pre-Existing Conditions will be covered after the end of twelve (12) consecutive months
(18 consecutive rnonths for Late Enrollees) after the individual's Enrollment Date. The Pre-Existing Condition Limitation
does not apply to:
1. Maternity benefits.
2. A newborn child or newly adopted child if enrolled within thirty-one (31) days of the birth, adoption or placement
with the ernployee for the purpose of adoption.
3. Genetic Information provided there has been no diagnosis of a condition related to the Genetic Information.
4. Prescription drugs purchased through the Prescription Drug Card program.
5. An ernployee and/or dependent who was covered under a Qualified Health Plan which is replaced by this Plan,
unless they have not satisfied the Pre-Existing Condition Limitation of the Qualified Health Plan in effect prior to the
effective date of this Plan.
The length of the Pre-existing Condition Limitation may be reduced or eliminated if a Covered Person has
Creditable Coverage from another Qualified Health Plan, provided there was not a break in coverage of sixty-three
(63) or more days, A Covered Person rnay request a Certificate of Creditable Coverage from their prior plan within
twenty-four (24) months of losing coverage. Certificates of Creditable Coverage should be submitted to Meritain
Health, and appropriate credit for tirne covered will be applied to the pre-existing condition limitation. A HIPAA
Determination letter will then be sent to the Covered Person, advising them of the credit applied to their pre-
existing condition limitation,
The Plan must establish a procedure for Covered Persons to request and receive a certificate of Creditable Coverage, Any
questions regarding obtaining a Certificate of Creditable Coverage or obtaining credit for additional past periods of
coverage, please contact Meritain Health's Service Center at (800) 925-2272, or fax the Certificate(s) of Creditable
Coverage from the prior plan(s) to: (952) 593-3779.
If all necessary information is not received by the Plan for determination of a pre-existing condition, or the Plan requests a
Certificate of Creditable Coverage and that information is not received as requested, all additional claims related to that
condition will receive an Adverse Benefit Determination and will be denied until the necessary inforrnation is received.
Please refer to the General Provisions. Right of Review and Appeal section for further details.
RB785 - Restated 1/1/09
41
,1\o8:1da ilem No. 16E5
" February 10, 2009
Page 48 of 99
NOTIFICATION PROVISIONS
Community Health Partners
(239) 659.7700
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 the following tests or procedures are done on an outpatient basis:
MRI and CT Scans
If anyone of the procedures listed above is performed in the emergency room, no pre-certification 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, Ihe 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 forty-eight (48) 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 Person, 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) 659-7700. If the call is made after hours, the following
information must be left on CHP's confidential voice mail:
Employee's name
Employee 10 number
Patient's name and relationship to the employee
The name of the Hospital where the procedure will take place (if appiicable)
The procedure to be performed
The name and telephone number of the Physician
It is vital the call occurs within the time frames listed above. If notification is not made, eligible expenses will be
reduced by $300 per incident. This penalty for faiiure to call CHP is a part of this Plan. Determinations regarding the
penalty rest with the Plan Administrator, not with CHP.
If notification is not provided 'vvithin the times outlined, CHP vvill 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.
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 attendjng 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
RB785 - Restated 1/1/09
42
.A.gt;;nC8 item hio. 16E5
February 10, 2009
Page 49 of 99
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.
RB785 - Restated 1/1109
43
A,genda item No. 16E5
February 10, 2009
Page 50 of 99
EXCLUSIONS AND LIMITATIONS
No payment will be eligible under any portion of this Plan for expenses incurred by a Covered Person for the expenses or
circumstances iisted below. If an expense is paid that is found to be excluded or limited as shown beiow, the Plan has the
right to collect that amount from the payee, the Covered Person, or from future benefits, and any such payment does not
waive the written exclusions, limitations or other terms of the Plan.
1. Abortions: Expenses related to elective abortions will not be considered eligible, except as specified under the
Maternity benefit under Eligible Expenses.
2, Acupuncture: Expenses for acupuncture will not be considered eligible, except as specified under Eligible
Expenses.
3. Adoption: Expenses for adoption will not be considered eligible.
4. Artificial Heart: Expenses for insertion or maintenance of an artificial heart will not be considered eligible.
5. Biofeedback: Expenses for biofeedback will not be considered eligible.
6. Cardiac Rehabilitation: Expenses in connection with Phase III cardiac rehabilitalion, 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.
7. 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.
8. Chemical Dependency Evaluations: Expenses for Chemical Dependency evaluations will not be considered
eligible, unless followed by an Inpatient stay in a Hospital or a residential Chemical Dependency treatment facility,
or an outpatient treatment program within fourteen (14) days of the receipt of the evaluation.
9. Close Relative: Expenses for services, care or supplies provided by a Close Relative will not be considered
eligible.
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 IIiness.
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, except complications from abortions as specified under
Eligible Expenses.
12. Convenience Items: Expenses for personal hygiene and convenience items will not be considered eligible.
13. Cosmetic Procedures: Expenses for Cosmetic and reconstructive procedures will not be considered eligible,
except as specified under Eligible Expenses.
14. Counseling: Expenses for religious, marital, family or relationship counseling will not be considered eligible,
except as specified under Eligible Expenses.
15. Coverage Under Other Plans: Expenses for treatment for which the Covered Person is also eligible for benefits
under any other group insurance or service plan through any employer (see Coordination of Benefits section); or
the medical payment or personal Injury sections of automobile, casualty or liability insurance regardless of whether
such policy is owned by the Covered Person or some other party (see Subrogation section) will not be considered
eligible.
RB785 - Restated 1/1/09
44
.-'\C8~lda !lsm No. I !,t::::l
-, February 10, 2009
Page 51 of ~9
16. Custodial Care: Expenses for Custodial Care will not be considered eligible, except as specified under the Home
Health Care and Hospice Care benefits.
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 Eligible Expenses.
18. Detoxification: Expenses for detoxification will not be considered eiigible, unless followed by an Inpatient stay in a
Hospital or a residential Chemical Dependency treatment facility or an outpatient treatment program within
fourteen (14) days of the receipt of the detoxification services.
19. 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.
20. Durable Medical Equipment: 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, except as specified under Eligible Expenses.
21. Experimental/Investigational: Expenses for services or supplies which are not medically recognized or are
Experimental/Investigational in nature will not be considered eligible.
22. Foot Care: Expenses for routine foot care will not be considered eligible.
23. Gambling Addiction: 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 as specified under Eligible Expenses.
25. Governmental Agency: Expenses for services and supplies which are provided by any governmental agency for
which the Covered Person is not liable for payment will not be considered eligible. In the case of a state-sponsored
medical assistance program, benefits payable under this Plan will be primary. Benefits payable under this Plan will
also be primary for any Covered Person eligible under TRICARE (the government sponsored program for military
dependents ).
26. Hair Loss: Expenses for hair loss, hair transplants, wigs or scalp hair prostheses will not be considered eligible,
except as specified under Eligible Expenses.
27. Hearing Exams/Aids: Expenses for routine hearing examinations and hearing aids, including the fitting thereof,
will not be considered eligible, except newborn hearing screenings and those hearing aids as specified under
Eligible Expenses.
28. Homeopathic Treatment: Expenses for naturopathic and homeopathic treatments, services and supplies will not
be considered 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 Occupation/Felony: Expenses for or in connection with an Injury or Illness arising out of the commission of
an illegal occupation or felony will not be considered eligible. This exclusion will not apply to Injuries and/or
Illnesses sustained due to a medical condition (physical or mental) or domestic violence.
32. Infertility: Expenses for confinement, treatment. testing or service related to infertility (the inability to conceive) or
the prornotion of conception \lvill not be considered eligible.
33. Mailing: Expenses for mailing and/or shipping and handling expenses will not be considered eligible.
RB785 - Restated 111109
45
L.,gsnda itsin t-Jo. 1 EE5
Febn.;ary 10.2009
Page 52 of 99
34, Maintenance Therapy: Expenses for Maintenance Therapy of any type when the individual has reached the
maximum level of improvement will not be considered eligible.
35, Maternity: Expenses for maternity expenses incurred by a dependent other than an employee's spouse will not be
considered eiigible.
36, Medically Necessary: Expenses which are determined not to be Medically Necessary will not be considered
eligible.
37. Missed Appointments: Expenses for completion of claim forms, missed appointments, telephone consultations,
expedited processing fees, shipping and handling fees will not be considered eligible.
38. No Legal Obligation: Expenses for services which are furnished under conditions which the Covered Person has
no legal obligation to pay will not be considered eligible. This exclusion will not apply to eligible expenses which
may be covered by state Medicaid coverage where federal law requires this Employer's plan to be primary.
39. 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.
40. Not Recommended by a Physician: Expenses by a Hospital or covered residential treatment center if
hospitalization is not recommended or approved by a legally qualified Physician will not be considered eligible.
41. Nutritional Supplements: Expenses for nutritional supplements or other enteral supplementation will not be
considered eligible, except as specified under Eligible Expenses. Over-the-counter nutritional supplements or
infant formulas will not be considered eligible even if prescribed by a Physician.
42. Obesity: Expenses for weight loss programs or treatment of obesity will not be considered eligible, except for
Morbid Obesity as specified under Eligible Expenses.
43. Occupational Therapy: Expenses for occupational therapy primarily for recreational or social interaction will not
be considered eligible.
44. Operated by the Government: Expenses for treatment at a facility owned or operated by the government will not
be considered eligible, unless the Covered Person is legally obligated to pay. This does not apply to covered
expenses rendered by a Hospital owned or operated by the United States Veteran's Administration when services
are provided to a Covered Person for a non-service related Illness or Injury.
45. Outside the United States: Expenses for services or supplies if the Covered Person leaves the United States,
the U.S. Territories, or Canada for the express purpose of receiving medical treatment will not be considered
eligible.
Expenses for a patient who becomes sick or injured while out of the United States, the U.S. Territories, or Canada
will not be considered eligible after one hundred twenty (120) consecutive days. This time limit will not be applied
if the Covered Person is out of the country for business or as a Full-Time Student.
46. Over-the-Counter Medication: Expenses for any over-the-counter medication will not be considered eligible.
Expenses for drugs and medicines not requiring a prescription by a licensed Physician and not dispensed by a
licensed pharmacist will not be considered eligible.
47. Overdose: Expenses for treatment of or related to an overdose of drugs or medications will not be considered
eligible. This exclusion will not apply if self-infiicted Injuries result from a medical condition such as depression and
the benefits for such Injuries are normally covered under the Plan.
48. Penile Prosthetic Implants: Expenses for peniie prosthetic implants will not be considered eligible.
49. Prior to Effective Date: Expenses which are incurred prior to the effective date of coverage, or after the
termination date of coverage will not be considered eligible.
RB785 - Restated 1/1/09
46
L,::;81Ica Item !\io. i3E5
ret:l:L;ary 10. 20D9
Page 53 of ~;9
50. Radioactive Contamination: Expenses incurred as the result of radioactive contamination or the hazardous
properties of nuclear material will not be considered eligible.
51. Recreational and Educational Therapy: Expenses for recreational and educational services; learning
disabilities; behavior modification services; any form of non-medical self-care or self-help training, including any
related diagnostic testing; music therapy; health club memberships; or non-Medically Necessary aquatic or pool
therapies will not be considered eligible.
52. Refractive Errors: Expenses for radial keratotomy, lasik surgery or any surgical procedure to correct refractive
errors of the eye will not be considered eligible.
53. RioURevolt: Expenses resulting from a Covered Person's participation in a riot or revolt will not be considered
eligible. This exclusion will not apply to Injuries and/or Illnesses sustained due to a medical condition (physical or
mental) or domestic violence.
54. Routine Care: Expenses for well child care and routine care, including x-ray and laboratory tests, vaccinations and
immunizations will not be considered eligible, except as specified under Eligible Expenses.
55. Sales Tax: Expenses for sales tax will not be considered eligible.
56. Self-Inflicted Injury: Expenses for Injury or Illness arising out of attempted suicide or an intentional self-inflicted
Injury, will not be considered eligible. This exclusion will not apply if self-inflicted injuries result from a medical
condition such as depression and the benefits for such injuries are normally covered under the Plan.
57. Sex Transformation: Expenses in connection with sex transformation will not be considered eligible.
58. Sexual Dysfunction: Expenses for services, supplies or drugs related to sexual dysfunction not related to organic
disease will not be considered eligible. Expenses for sex therapy will not be considered eligible.
59. Stand-By Physician: Expenses for technical medical assistance or stand-by Physician services will not be
considered eligible.
60. Sterilization: Expenses for the reversal of elective sterilization will not be considered eligible.
61. Surrogate: Expenses related to surrogate services will not be considered eligible.
62, Tobacco Cessation: Expenses for tobacco cessation programs, including tobacco deterrents not incurred thru
MedCenter will not be considered eligible, See Eligible Expenses.
63. Travel: Expenses for travel of a Physician or Covered Person will not be considered eligible, except ambulance
services as specified under Eligible Expenses.
64. Usual and Customary Charge: Expenses in excess of the Usual or Customary Charge will not be considered
eligible.
65. Vision Care: Expenses for vision care, including routine eye exams, professional services for the fitting and/or
supply of lenses, frames, contact lenses and other fabricated optical devices will not be considered eligible.
However, benefits will be provided for the necessary initial placement of a pair of eyeglasses, contact lenses or an
intraocular lens following a Medically Necessary surgical procedure to the eye. This exclusion does not apply to
aphakic patient and soft lenses or sclera shells intended for use as corneal bandages.
66. Wage or Profit: Expenses for or in connection with any Injury or Illness which arises out of or in the course of any
occupation for wage or profit (including self-employment) will not be considered eligible.
67. War: Expenses for the treatment of Illness or Injury resulting from a war or any act of war or terrorism, whether
declared or undeclared, or while in the armed forces of any country or international organization will not be
considered eligible.
RB785 - Restated 1/1/09
47
,'~genda Item No. 16E5
February 10, 2009
Page 54 of 99
68. 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.
69. Worker's Compensation: Expenses for or in connection with any Injury or Illness which arises out of or in the
course of any occupation for which the Covered Person would be entitled to compensation under any Worker's
Compensation Law (even if the coverage was not purchased), or occupational disease law or similar legislation will
not be considered eligible.
Expenses for Injuries or Illness which were eligible for payment under Worker's Compensation or similar law and
have reached the maximum reimbursement paid under Worker's Compensation or similar law will not be eligible
for payment under this Plan.
RB785 - Restated 111/09
48
ii:?;nll'~o. 16E5
:=-ebruary 10 2009
?a'JG 55 of 99
DEFINITIONS
The following defined terms are capitalized and used throughout the document:
Accident/Accidental: An unforeseen or unexplained sudden occurrence by chance without intent or violation.
Adverse Benefit Determination: Means any of the following:
1. A denial in benefits;
2. A reduction in benefits;
3. A termination of benefits; or
4. A failure to provide or make payment (in whole or in part) for a benefit, including any such denial, reduction,
termination, or faiiure to provide or make payment that is based on a determination of a Claimant's eligibility to
participate in the Pian.
Ambulatory Surgical Facility: An ambulatory surgical center, free-standing surgical center, or outpatient surgical center,
which is not part of a Hospital and which: (1) has an organized medical staff of Physicians; (2) has permanentfaciljties that
are equipped and operated primarily for the purpose of performing surgical procedures; (3) has continuous Physician's
services and registered graduate nursing (R.N.) services whenever a patient is in the facility; (4) is licensed by the
jurisdiction in which it is located; and (5) does not provide for overnight accommodations.
Assistant Surgeon: A Physician who actively assists the Physician in charge of a case in performing a surgical procedure.
Depending on the type of surgery to be performed, an operating surgeon may have one or two (2) Assistant Surgeons. The
technical aspects of the surgery involved dictate the need for an Assistant Surgeon.
Authorized Representative: A Claimant may authorize a representative 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 wriUen
authorization must be provided to the Plan. The Plan will recognize this Authorized Representative when the Plan receives
the wriUen authorization. In the case of a claim involving urgent care, a Health Care Professional with knowledge of the
Claimant's medical condition IS also permiUed to act as the Claimant's Authorized Representative.
Birthing Center: A place licensed as such by an agency of the state. If the state does not have any licensing
requirements, it must meet all of the following tests: (1) is primarily engaged in providing birthing services for low risk
pregnancies; (2) is operated under the supervision of a Physician; (3) has at least one registered nurse (R.N.) certified as a
nurse midwife in attendance at all times; (4) has a written agreement with a licensed ambulance for that service to provide
immediate transportation of the Covered Person to a Hospital as defined herein if an emergency arises; and (5) has a
written agreement with a Hospital located in the immediate geographical area of the Birthing Center to provide emergency
admission of the Covered Person.
Calendar Year: January 1 through December 31 each year.
Chemical Dependency: A condition characterized by physiological or psychological dependence, or both, on alcohol or a
controlled substance. It is further characterized by a frequent or intense pattern of pathological use, to the point that the
user: (1) loses self-control over the amount and circumstances of use; or (2) develops symptoms of tolerance, or
psychological and/or physiological withdrawal if use is reduced or stopped; or (3) substantially impairs or endangers their
health or substantially disrupts their social or economic function. Chemical Dependency includes alcohol or drug
psychoses and alcohol or drug dependence syndromes.
Claim for Benefits: A request for a plan benefit or benefits made by a claimant in accordance with a Plan's reasonable
procedure for filing benefit claims. A claim for benefits includes any Pre-Service and Post-Service Claims. A request for
benefits includes a request for coverage determination, for pre-authorization or approval of a plan benefit, orfor a utilization
review determination in accordance with the terms of the Plan.
Claimant: A person requesting benefits under the Plan. A Claimant mayor may not be a Covered Person under the Plan.
Close Relative: A Covered Person's spouse, parent (inc!uding step-parents), sibling, child, grandparent, or in-Ial."/.
RB785 - Restated 1/1/09
49
,0,aenda item No. 16E5
, F"bruary 1 0, 2009
Pag~ S6 of 99
Co-Insurance: The percentage of eligible expenses the Plan and the Covered Person are required to pay, The amount of
Co-insurance a Covered Person is required to pay is the difference from what the Plan pays as shown in the Schedule of
Benefits.
Co-pay: The portion of the medical expense that is the responsibility of the Covered Person as shown in the Schedule of
Benefits. A Co-pay is applied for each occurrence of such covered medical service and is not applied toward satisfaction of
the Deductible, Co-insurance or Out-of-Pocket Limit.
COBRA: Consolidated Omnibus Reconciliation Act of 1985, as amended.
Concurrent Care: Ongoing care or course of treatment.
Congenital Anomaly: A physical developmental defect that is present at birth.
Contract Administrator: The organization providing services to the Employer in connection with the operation ofthis Plan
and performing such other functions, including processing of claims, as may be delegated to it.
Cosmetic: Any procedure which is primarily directed at improving an individual's appearance and does not meaningfully
promote the proper function of the body or prevent or treat Illness or disease.
Covered Employee: An Eligible Employee whose coverage has become effective and has not terminated.
Covered Person: An Eligible Employee or Eligible Dependent whose coverage has become effective and has not
terminated.
Creditable Coverage: Coverage provided under any Qualified Health Plan,
Custodial Care: Care or service which is designed primarily to assist a Covered Person, whether or not disabled, 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: The total amount of eligible expenses, as shown in the Schedule of Benefits, which must be incurred by a
Covered Person during any Calendar Year before covered expenses are payable under the Plan. The Family Deductible
maximum, as shown in the Schedule of Benefits, is the maximum amount or maximum number of Deductibles (depending
on Plan Option selected) which must be incurred by the covered family members during a Calendar Year, However, each
individual in a family is not required to contribute more than one individual Deductible amount to the family Deductible,
Carry-Over: If the medical Deductible is satisfied in whole or in part by eligible expenses incurred during October,
November, or December, those expenses will apply to the Deductible applicable in the next Calendar Year.
Dentist: An individual who is duly licensed to practice dentistry or to perform oral surgery in the state where the service is
performed and is operating within the scope of such license, A physician will be considered a Dentist when performing any
covered dental services allowed within such license,
Durable Medical Equipment: Equipment prescribed by the attending Physician which meets all of the following
requirements: (1) is Medically Necessary; (2) can withstand repeated use; (3) is not disposable; (4) is not useful in the
absence of an Illness or Injury; (5) it would have been covered if provided in a Hospital; and (6) is appropriate for use in the
home.
Eligibility Date: The first date of coverage after the Eligible Employee has satisfied any applicable waiting period. See
Eligibility & Enrollment section.
Employer: Collier County Government, or any successor thereto,
Enrollment Date: The earlier of: (1) the first date of coverage; or (2) the first day of any applicable waiting period. The
Enrollment Date with regards to a Late Enrollee will be the first date of coverage,
RB785 - Restated 1/1/09
50
Experimental/lnvestigational: A drug, device, medical treatment or procedure is Experimental or Investigational: (1) if the
drug or device 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; (2) if Reliable Evidence shows that the drug,
device, medical treatment or procedure is the subject of ongoing Phase I, II or III clinical trials, or is under study to
determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means
of treatment or diagnosis; (3) if Reliable Evidence shows that the prevailing opinion among experts regarding the drug,
device, medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum
tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or
diagnosis.
i~0,n !'~:J. i SE5
cebiuary I iJ 2CU9
P2ge 57 :)) 99
"Reliable Evidence" shall mean only published reports and articles in the authoritative medical and scientific literature; the
written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same
drug, device, medical treatment or procedure; or the written informed consent used by the treating facility or another facility
studying substantially the same drug, device, medical treatment or procedure.
Genetic Information: Information about genes, gene products, and inherited characteristics that may derive from the
individual or a family member. This includes information regarding carrier status and information derived from laboratory
tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories, and direct
analysis of genes or chromosomes.
Health Care Professional: A Physician or other Health Care Professional licensed, accredited, or certified to perform
specified health services consistent with State law.
Home Health Care Agency: A public or private agency or organization that specializes in providing medical care and
treatment in the home. Such a provider must meet all of the following conditions, it: (1) is duly licensed, if such licensing is
required, by the appropriate licensing authority to provide skilled nursing services and other therapeutic services; (2)
qualifies as a Home Health Care Agency under Medicare; (3) meets the standards of the area-wide health care planning
agency; (4) provides skilled nursing services and other services on a visiting basis in the patient's home; (5) is responsible
for administering a home health care program; and (6) supervises the delivery of a home health care program where the
services are prescribed and approved in writing by the patient's attending Physician.
Hospice: An agency that provides counseling and incidental medical services and may provide room and board to
terminally ill individuals and which meets all of the foilowing requirements: (1) has obtained any required state or
governmental Certificate of Need approval; (2) provides twenty-four (24) hour-a-day, seven (7) days-a-week service; (3) is
under the direct supervision of a duly qualified PhYSician; (4) has a nurse coordinator who is a registered nurse (R.N.) with
four (4) years of full-time clinical experience, at least two (2) of which involved caring for terminally ill patients; (5) has a
social-service coordinator who is licensed In the jurisdiction in which it is located; (6) is an agency that has as its primary
purpose the provision of hospice services; (7) has a full-time administrator; (8) maintains written records of services
provided to the patient; (9) the employees are bonded, and it provides malpractice and malplacement insurance; (10) IS
established and operated in accordance with the applicable laws in the jurisdiction In which it is located and, where
licensing is required, has been licensed and approved by the regulatory authority having responsibility for licensing under
the law; (11) provides nursing care by a registered nurse (R.N.), a licensed practical nurse (L.P.N.), a licensed physical
therapist, certified occupational therapist, American Speech Language and Hearing Association certified speech therapist,
or a certified respiratory therapist; and (12) provides a home health aide acting under the direct supervision of one of the
above persons while performing services specifically ordered by a Physician.
Hospital: A facility which: (1) is licensed as a Hospital where licenSing is required; (2) is open at all times; (3) is operated
mainly to diagnose and treat Illnesses or Injuries on an Inpatient basis; (4) has a staff of one or more Physicians on call at
all times; (5) has twenty-four (24) hour a day nursing services by registered nurses (R.N.'s); and (6) has organized facilities
for major Surgery,
However, an institution specializing in the care and treatment of Mental/Nervous Disorders or Chemical Dependency which
would qualify as a Hospital, except that it lacks organized facilities on its premises for major Surgery, shall be deemed a
Hospital.
In no event shall "Hospital" include an institution which is primarily a rest home, a nursing home, a clinic, a Skilled Nursing
Facility, a convalescent home or a similar institution.
Illness: .4.. disease, sickness, Pregnancy or a condition involving bodily or mental disorder of any kind. AI! disorders which
RB785 - Restated 1/1/09
51
A';Je.-lda aern No. -i 6E5
February 10, 2009
Page 58 of 99
exist simultaneously and are due to the same or related causes shall be considered one Illness.
Injury: A bodily Injury which results independently of Illness and is caused by Accidental means. All bodily Injuries
sustained in anyone Accident and all related conditions and recurrent symptoms will be considered one Injury.
Inpatient: Admission as a bed patient to an eligible institution.
Intensive Care Unit: A separate, clearly designated service area, which is maintained within a Hospital solely for the care
and treatment of patients who are critically ill. This also includes what is referred to as a "coronary care unit", or an "acute
care unit." It has: (1) facilities for special nursing care not available in regularrooms and wards of the Hospitai; (2) special
life saving equipment which is immediately available at all times; (3) at least two (2) beds for the accommodation of the
critically ill; and (4) at least one registered nurse (R.N.) in continuous and constant attendance twenty-four (24) hours a day.
Late Enrollee: An Eligible Employee or Eligible Dependent who does not elect coverage under this Plan within thirty-one
(31) days of their Eiigibility Date and who is not otherwise considered a Special Enrollee. An employee not enrolled or not
eligible for coverage under the Employer's previous Employer-sponsored plan will be considered a Late Enrollee.
Legal Guardian: A person recognized by a court of law as having the duty of taking care of the person and managing the
property and rights of a minor child.
Lifetime Maximum: The maximum benefit payable during an individual's lifetime while covered under this Plan. Benefits
are available only when an individual is eligible for coverage under this Plan. The Plan provides for a Lifetime Maximum
Benefit for specific types of medical treatment, as well as for the total benefits provided by the Plan as shown in the medical
and prescription drug Schedule of Benefits.
Long-term Acute Care Facility/Hospital: Facilities that provide specialized acute care for medically complex patients who
are critically ill; have mulli-system complications and/or failures and require hospitalization in a facility offering specialized
treatment programs and aggressive clinical and therapeutic intervention on a twenty-four (24) hour a day, seven (7) days a
week basis. The severity of the L TACH patient's condition requires a Hospital stay that provides: (1) interactive Physician
direction with daily on-site assessment; (2) significant ancillary services as dictated by complex, acute medical needs -
such as full service and laboratory, radiology, respiratory care ser,ices, etc; (3) a patient-centered outcome-focused,
interdisciplinary approach requiring a Physician-directed professional team that includes intensive case management to
move the patient efficiently through the continuum of care; (4) clinically competent care providers with advanced
assessment and intervention skills; (5) education for the patient and family to manage their present and future healthcare
needs.
Maintenance Therapy: 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.
Medical Emergency: Medical services and supplies provided after the sudden onset of a medical condition (Injury or
Illness) manifesting itself by acute symptoms, including intense pain, which are severe enough that the lack of immediate
medical attention could reasonably be expected to result in any of the following: (1) the patient's health would be placed in
serious jeopardy; (2) bodily function would be seriously impaired; or (3) there would be serious dysfunction of a bodily
organ or part,
Medically Necessary/Medical Necessity: The medical service a patient receives which is recommended by a Physician
and is required to treat the medical symptoms of a certain Illness or Injury. Although the service may be prescribed by a
Physician, that does not mean the service is Medically Necessary. The medical care or treatment must: (1) be consistent
with the medical diagnosis and prescribed course of medical treatment for the Covered Person's medical condition; (2) be
required for reasons other than the convenience of the Covered Person or the attending Physician; (3) generally be
accepted as an appropriate form of care for the medical condition being treated; and (4) be likely to result in physical
improvement of the patient's medical condition which is unlikely to ever occur if the medical treatment is not administered.
Mental/Nervous Disorders: Any condition classified as a mental disorder, except for mental retardation and Chemical
Dependency, in the current edition of the International Classification of Diseases published by the U.S. Department of
Health and Human Services. This includes, but is not limited to, eating disorders, bipolar disorders, psychotic disorders,
neurotic disorders, adjustment disorders and personality disorders.
RB785 - Restated 1/1/09
52
Item ["J:J. '15E5
"ebruary 1 O. 2009
Page 59 of 99
Morbid Obesity: A condition of morbid or clinically severe obesity in which the body weight is in excess of the norm for a
person of the same age, sex and height by the lesser of one hundred (100) pounds or 50% of the persons ideal weight,
provided treatment is under the recommendation and supervision of a Physician. Any treatment for the condition of Morbid
Obesity must be determined to be Medically Necessary by the Plan.
Out-Of-Pocket Limit: An Out-of-Pocket Limit is the maximum amount of Co-insurance a Covered Person and/or all family
members will pay for eligible expenses incurred during a Calendar Year before the covered percentage increases to 100%.
Expenses incurred for the following cannot be applied toward the Out-of-Pocket Limit: (1) Co-pays; (2) Deductibles; (3) any
penalty amounts; (4) any charges as defined in the Exclusions and Limitations section: and (5) a Covered Person's Co-
insurance for: chiropractic care; acupuncture; dental care expenses due to Illness.
Partial Hospitalization; Treatment received in a residential setting for Mental/Nervous Disorder or Chemical Dependency
treatment that is provided in a less restrictive manner than are Inpatient services. but in a more intensive manner than are
outpatient services, Acceptable residential settings include: halfway houses, three-quarter-way houses, and participation in
an independent living center program.
Physician: A legally licensed Physician who is acting within the scope of their license, and any other licensed practitioner
required to be recognized for benefit payment purposes under the laws of the state in which they practice and who is acting
within the scope of their license. The definition of Physician includes, but is not limited to: Doctor of Medicine (MD.),
Doctor of Osteopathy (D.O.), Chiropractor, Licensed Consulting Psychologist, Licensed Psychologist, Licensed Clinical
Social Worker, Occupational Therapist, Optometrist, Ophthalmologist, Physical Therapist, Podiatrist, Registered Nurse
(R.N.), Licensed Practical Nurse (L.P.N.), Speech Therapist, Speech Pathologist, Licensed Midwife. An employee of a
Physician who provides services under the direction and supervision of such Physician will also be deemed to be an
eligible provider under the Plan.
Plan: The Collier County Government Employee Benefit Plan, and any amendments attached thereto.
Plan Administrator: The Employer, which is sponsoring this Plan for its employees. The Plan Administrator may hire
persons or firms to process claims and perform other Plan connected services.
Post-Service Claim: Post-Service Claims are all claims that are not Pre-Service Claims.
Pre-Service Claim: Pre-Service Ciaim is any request for approval of a benefit with respect to which the terms of the Plan
condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care,
Preferred Provider Network: All participating providers, health professionals, Hospitals, or other organizations having an
agreement with the Preferred Provider Organization (PPO).
Pregnancy: Childbirth and conditions associated with Pregnancy, including complications of Pregnancy.
Primary Care Physician: A Physician responsible for managing and coordinating the full scope of a Covered Person's
medical care, including but not limited to performing routine evaluations and treatment, arranging for all necessary referrals
to specialists, ordering laboratory tests and x-ray examinations, prescribing necessary medications and arranging for a
Covered Person's hospitalization or other services when appropriate (ie. General Practitioner Including Internist, OB\GYN,
Pediatrician, family practice, etc.).
Qualified Health Plan: The following will be considered Qualified Health Plans: (1) a group health plan; (2) health
insurance coverage; (3) Medicare; (4) Medicaid; (5) TRI-CARE; (6) an Indian Health Service plan or tribal organization
plan; (7) a state risk pool coverage; (8) a federal employees health insurance coverage; (9) a public health plan (this
includes plans established or maintained by a state, the U.S. government, a foreign country, a state or federal penitentiary,
U.S. Veterans Administration, or any political subdivision of a state, the U.S, government, or a foreign country that provides
health coverage to individuals who are enrolled in the Plan); (10) a Peace Corps plan; (11) the State Chiidren's Health
insurance Program.
Qualified Medical Child Support Order (QMCSO): A judgment or decree by a court of competent jurisdiction or order
issued through an administrative process established under state law that has the force and effect of state law that requires
the Plan to provide coverage to the children of an employee pursuant to a state domestic relations law.
RB785 - Restated 1/1/09
53
Aqenda Item f'h. 16E5
" February 10,2009
Page 60 of 99
Reconstructive Surgery: Surgery that is incidental to an Injury, Illness, or Congenital Anomaly when the primary purpose
is to improve physiological functioning of the involved part of the body. The fact that physical appearance may change or
improve as a result of Reconstructive Surgery does not classify such surgery as cosmetic when a physical impairment
exists, and the surgery restores or improves function, The fact that a Covered Person may suffer psychological
consequences, or socially avoidant behavior as a result of an Injury, Illness, or Congenital Anomaly does not classify
surgery done to reiieve such consequences or behavior as Reconstructive Surgery.
Rehabilitation Facility: The faciiity must meet all of the following requirements: (1) 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 Care or maintenance care.
Semi~private Room: A hospital room shared by two (2) or more patients.
Skilled Nursing Facility: An institution or that part of any institution which operates to provide convalescent or nursing
care which: (1) is primarily engaged in providing to Inpatients skilled nursing care and related services for patients who
require medical or nursing care; or sub-acute rehabilitation services for the rehabilitation of injured, disabled, or sick
persons; (2) has policies which are developed with the advice of (and with provision for review of such policies from time to
time by) a group of professional personnel, including one or more Physicians and one or more registered nurses (R.N,) to
govern the skilled nursing care and related medical or other services it provides; (3) has a Physician, a registered nurse
(R.N,), or a medical staff responsible for the execution of such policies; (4) has a requirement that the health care of every
patient be under the supervision of a Physician, and provides for having a Physician available to furnish necessary medical
care in case of emergency; (5) maintains clinical records on all patients; (6) provides twenty-four (24) hour nursing service
which is sufficient to meet nursing needs in accordance with the policies developed above, and has at least one registered
nurse (R.N.) employed full-time; (7) provides appropriate rnethods and procedures for the dispensing and administering of
drugs and injections; (8) in the case of an institution in any state in which state or applicable local law provides for the
licensing of institutions of this nature, is licensed pursuant to such law, or is approved by the agency of the state or locality
responsible for licensing institutions of this nature as meeting the standards established for such licensing; and (9) rneets
any other conditions relating to the health and safety of individuals who are furnished services in such institutions or relating
to the physical facilities thereof.
Special Enrollee: See Eligibility, Enrollment & Effective Date of Coverage section.
Specialist Physician: A Physician who provides services to a Covered Person within the range of his or her specialty
when referred by the primary care Physician (ie. cardiologist, neurologist, etc.),
Successive Periods of Confinement: With respect to an employee, Successive Periods of Confinement for the sarne or
related causes shall be considered one period of confinement unless the subsequent confinement commences after a
return to active work on a full-time basis for a period of two (2) weeks. Successive Periods of Confinement due to entirely
unrelated causes shall be considered one period of confinement unless the subsequent confinement commences after a
return to active work on a full-tirne basis for one day.
With respect to a dependent, Successive Periods of Confinement will be considered one period of confinement uniess the
subsequent confinement commences after three (3) months following the prior confinement.
Surgery: Any operative or diagnostic procedure performed in the treatment of an IIiness or Injury by an instrument or
cutting procedure through any natural body opening or incision, The reduction of a fracture or dislocation will also be
considered Surgery.
Urgent Care Claim: Any Pre-Service Claim for medical care or treatment with respect to which the application of the time
periods for making non-urgent care determinations could seriously jeopardize the life or health of the Claimant or the ability
of the Claimant to regain maximum function, or in the opinion of a Physician with knowledge of the Claimant's medical
condition, would subject the Clairnant to severe pain that cannot be adequately managed without the care or treatment that
is the subject of the claim, A Post-Service Claim is never an Urgent Care Claim.
RB785 - Restated 1/1/09
54
!~'.J8nda item No. 1-3E5
" February 10, 2009
Page 61 of ~)9
Urgent Care Facility: A facility which is engaged primarily in providing minor emergency and episodic medical care to a
Covered Person. A board-certified Physician, a registered nurse, and a registered x-ray technician must be in attendance at
all times that the facility is open. The facility must include x-ray and laboratory equipment and a life support system. For
the purpose of this Plan, a facility meeting these requirements will be considered to be an Urgent Care Facility, by whatever
actual name it may be called; however, an after-hours clinic shall be excluded from the terms of this definition.
Usual and Customary Charge: Charges made for medical services or supplies essential to the care of the individual will
be subject to a Usual and Customary determination. Usual and Customary allowances are based on what is usually and
customarily accepted as payment for the same service within a geographical area. In determining whether charges are
Usual and Customary, consideration will be given to the nature and severity of the condition and any medical complications
or unusual circumstances which require additional time, skill or experience.
RB785 - Restated 1/1/09
55
l\genda item NT i6E5
February 10, 2009
Page 52 of '39
TERMINATION OF BENEFITS
An employee or dependent's coverage shall terminate at the earliest time indicated below:
1. In the event the employee fails to make any required contributions when due, benefits shall automatically terminate
at the end of the period for which the contribution was made.
2. Upon termination of employment or retirement, benefits will cease on the last day of the month in which the
employee terminated. Cessation of active work by an employee shall be deemed termination of employment,
except as follows:
(a) In the event an employee is absent on account of Illness or Injury, employment shall be deemed to
continue for the purpose of benefits hereunder until the earlier of: (i) the date contributions received from
the Employer for such employee's benefits are discontinued; or (il) a period of tweive (12) months; or
(b) An employee who retires and qualifies as a retiree of Collier County Government (qualifying retirees must
meet the requirement of Florida Statute 112.0801). Eligibility for Medicaid or the recipient of Medicaid
benefits will not be taken into account in determining eiigibility, This extension also applies to the retiree's
dependents. Once the retiree becomes eligible for Medicare, this Plan will pay secondary to Medicare.
Should the retiree become deceased or cancel the County's coverage once eligible for Medicare, the
spouse may remain on the Plan until the date the spouse becomes eligible for Medicare; or
(c) The benefits of an employee who is temporarily laid-off or granted leave of absence may be continued, but
not beyond the end of the leave of absence or lay-off. The leave of absence or lay-off may not exceed six
(6) months.
3. The end of the month the employee ceases to be eligible for coverage or ceases to be in a class eligible for
coverage.
4. The end of the month the dependent ceases to be eligible for coverage or ceases to be in a class eligible for
coverage.
5. When maximum benefits of this Plan have been exhausted.
6. The date the dependent becomes an Eligible Employee.
7. When the employee or dependent enters the military service on a full-time active duty basis other than scheduled
drills or other training not exceeding one month in any Calendar Year.
8. The date the Plan is terminated.
VOLUNTARY SEPARATION INCENTIVE PROGRAM
Medical coverage provided by the County with Meritain Health,m 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 and dental benefits for a period of three (3) years, or will provide a
financial incentive in lieu of benefits if the employee so chooses.
Medical Coveraqe
1. Eligible employees may elect to continue coverage at their current participation level (single or family
medical/single, single +1 or family dental).
2. Employees will not pay any medical or dental premiums - the County will pay the premium costs for up to three (3)
years.
3. Eligible employees may select a blended option of medical and dental coverage, together with a partial cash
payment.
RB785 - Restated 1/1/09
56
Enrollment
t>,g~;nca :iSill No. 1'3ES
February 10. 2009
Page 63 of 99
1. Eligible employees will have a period of sixty (60) days to enroll.
2. The plan enrollment period begins and ends as determined by the Employer.
3. Employees who meet the 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 FRS guidelines.
4. Employees who 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.
Family and Medical Leave Act (FMLA)
1. An eligible employee that qualifies for FMLA is entitled to a maximum of twelve (12) weeks of unpaid leave in any
twelve (12) month period forreasons that qualify under FMLA. The employee must have worked for the Employer
for at least twelve (12) months, and have worked at least 1 ,250 hours during the twelve (12) months preceding the
start of the leave.
2. The National Defense Authorization Act (NOAA) expands FMLA to include leaves for military families. A spouse,
son, daughter, parent, or next of "kin" will be allowed up to twenty-six (26) weeks during a twelve (12) month period
to care for a member of the Armed Forces, including a member of the National Guard or Reserves, who is
undergoing medical treatment, recuperation, or therapy, otherwise in outpatient status, or is otherwise on the
temporary disability retired list, for a serious Injury or Illness.
3. During the single twelve (12) month period described in number (2) above, an eligible employee shall be entitled to
a total of twenty-six (26) weeks of leave under numbers (1) and (2) combined.
An employee may choose not to retain health coverage during the FMLA leave, However, when an employee returns from
leave, the employee is entitled to have coverage reinstated on the same basis as it would have been if the leave had not
been taken. Coverage will be reinstated without any additional qualification requirements imposed by the Plan. (The Plan's
provisions with respect to Pre-Existing Conditions, Deductibles and Coinsurance amounts will apply on the same basis as
they did prior to the FMLA leave.)
Uniformed Services Employment And Reemployment Rights Act (USERRA)
If an individual was covered under this Plan immediately prior to being called to active duty by any of the uniformed
services of the United States of America, coverage may continue for up to twenty-four (24) months or the period of
uniformed service leave, whichever is shortest, if the individual pays any required contributions toward the cost of coverage
during the leave. If the leave is less than thirty (30) days, the contribution rate will be the same as for active employees. If
the leave is longer than thirty (30) days, the required contribution will not exceed 102% of the cost of coverage.
Whether or not the individual elects continuation coverage under the Uniformed Services Employment and Reemployment
Rights Act (USERRA), coverage will be reinstated on the first day the individual returns to active employment with the
Employer if released under honorable conditions and the individual returns to employment: (a) on the firstfull business day
following completion of the military service for a leave of thirty (30) days or less; or (b) within fourteen (14) days of
completing military service for a leave of thirty-one (31) to one hundred eighty (180) days; or (c) within ninety (90) days of
completing military service for a leave of more than one hundred eighty (180) days (a reasonable amount of travel time or
recovery time for an Illness or Injury determined by the VA to be service connected will be allowed).
When coverage under this Plan is reinstated, all provisions and limitations in this Plan will apply to the extent that they
would have appiied if the military leave had not been taken and coverage had been continuous under this Plan, The
eligibility waiting period will be waived and the Pre-Existing Condition Limitation will be credited as if you had been
continuously covered under this Plan from the original effective date, unless the waiting period or Pre-Existing Condition
Limitation would have applied to the employee if the employee had remained continuousiy employed during the period of
military leave. (This waiver of limitations does not provide coverage for any Illness or Injury caused or aggravated by the
military service, as determined by the VA. For complete information regarding the rights under USERRA contact the
Employer,)
RB785 - Restated 1/1/09
57
,!>,lsnda 11em ~~'J. 16c5
.. Fsbruary 10, 2009
Page 64 of 99
CONTINUATION OF BENEFITS (COBRA)
COBRA continuation coverage is temporary continuation of Plan coverage that can become available to individuals who
are covered under the Plan when a "Qualifying Event" occurs which results in a loss of coverage under the Plan,
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Reconciliation Act of
1985 (COBRA).
COBRA continuation coverage must be offered to each person who is a "Qualified Beneficiary". A Qualified Beneficiary is
an individual who is covered under the Plan the dav before a Qualifying Event takes place which results in a loss of
coverage under the Plan. A Qualified Beneficiary can be the Covered Employee (or covered retired employee), the covered
spouse of the employee, or the covered dependent child(ren) of the employee, Any child born to or placed for adoption with
the covered employee during a period of continuation coverage is also considered a Qualified Beneficiary.
If COBRA continuation coverage is elected, coverage will continue as though the Qualifying Event had not occurred. Any
Deductible or Co-insurance amounts satisfied, or amounts credited toward any maximum benefits of this Plan, will be
retained. Similarly, no new or additional waiting periods or pre-existing limitation requirements will apply.
If any changes are made to the coverage for employees actively-at-work, the coverage provided to individuals under this
continuation provision will be similarly changed.
COBRA may not be denied to an individual who had coverage under another group health plan or Medicare prior to a
Qualifying Event
Specific Qualifying Events and the corresponding time period for which continuation coverage is available are listed below.
In some instances, Qualified Beneficiaries may be covered under multiple Qualifying Events (see "Extension of
Continuation Coverage" below),
Qualifying Events
An eighteen (18) month continuation is available to employees and/or dependents in the event of anyone or both of the
following Qualifying Events:
1. An employee's termination of employment for any reason except gross misconduct;
2, An employee's loss of eligibility to participate due to reduced work hours.
In the event that both Qualifying Events happen, the total length of the continuation will not exceed eighteen (18) months.
A thirty-six (36) month continuation shall be available to a covered dependent spouse and/or child of an empioyee in the
event of anyone of the following Qualifying Events:
1. An employee's death;
2. Divorce or legal separation from the employee;
3. A child ceasing to meet the eligibility requirements described in the Eligibility & Enrollment section;
4, A dependent's loss of eligibility to participate in this Plan due to the employee becoming entitled to Medicare
benefits (under Part A, Part B, or both), either as the result of disability or choosing Medicare in the place of this
plan at age sixty-five (65).
Notification of some Qualifying Events is required. In the case of divorce or legal separation from the employee, or a
child ceasing to meet the eligibility requirements, the employee or Qualified Beneficiary must send written notice of the
event to the Plan Administrator within sixty (60) days after the later of: (a) the date of the Qualifying Event; (b) the date on
which coverage would have been lost as a result of the Qualifying Event; or (c) the date on which the Qualified Beneficiary
is informed, through the furnishing of this summary plan description or the initial general COBRA notice, of the
responsibility and procedures for providing such notice to the Plan Administrator. This written notice must include
supporting legal documentation when applicable (e,g. divorce decree or legal separation agreement), Failure to notify the
Plan Administrator as described will cause any Qualified Beneficiary to lose eligibility for COBRA continuation coverage.
RB785 - Restated 1/1/09
58
A';Jej--;da it~n-l No. iDE5
February 10,2009
Page C5 of 99
If a Qualified Beneficiary has a new dependent eligible for coverage as the result of a marriage or birth, adoption, or
placement for adoption of a child, the Qualified Beneficiary must notify the Plan Administrator as described under the
Eligibility & Enrollment section.
Extension of Continuation Coverage
In certain circumstances, a Quaiified Beneficiary may be able to continue coverage beyond the initial eighteen (18) monlh
continuation period.
Due to Disability: An eleven (11) month extension of the eighteen (18) month continuation period (resulting in a total of 29
months of continuation coverage) may be available to all covered family members in the event a Qualified Beneficiary is
determined to be disabled by the Social Security Administration, In order to be eligible for this extension, the following
requirements must !ill be satisfied:
1. The initial Qualifying Event must have been either termination of employment or reduction in hours; and
2. The Qualified Beneficiary must be declared disabled by the Social Security Administration on or before the date of
the Qualified Beneficiary's initial Qualifying Event, or during the first sixty (60) days of COBRA continuation
coverage; and
3. The Qualified Beneficiary must send written notice of a disability determination to the Plan Administrator before the
end of the original eighteen (18) monlhs of COBRA continuation coverage and within sixty (60) days of the later of:
(a) the date of the disability determination; (b) the date of the initial Qualifying Event; (c) the date coverage would
have been lost as a result of the Qualifying Event; or (d) the date on which the Qualified Beneficiary is informed,
through the furnishing of this summary plan description or the initial general COBRA notice. of the responsibility
and procedures for providing such notice to the Plan Administrator. A copy of the Social Security Administration's
determination letter must be included in this written notice.
Failure to meet any of the above requirements will cause the Qualified Beneficiary to lose eligibility for the eleven (11)
month extension,
If the Qualified Beneficiary is later determined by the Social Security Administration to no longer be disabled, the Qualified
Beneficiary must notify the Plan Administrator in writing of that fact within thirty (30) days of the Social Security
Administration's determination,
Multiple Qualifying Events: An eighteen (18) month extension of the initial eighteen (18) month continuation period
(resulting in a total of 36 months of continuation coverage) may be available to a Qualified Beneficiary of a former
employee who experiences a second Qualifying Event during the first eighteen (18) months of continuation coverage. This
extension is not available to the former employee. A second Qualifying Event must be one of the events listed under the
thirty-six (36) month continuation section and must occur during the initial eighteen (18) month continuation period.
In order to be eligible for this extension, the following requirements must !ill be satisfied:
1. The initial Qualifying Event must have been either the former employee's termination of employment or reduction
in hours; and
2, The event would have to have caused the Qualified Beneficiary to lose coverage under the Plan had the first
Qualifying Event not occurred; and
3, The Qualified Beneficiary must send written notice to the Plan Administrator within sixty (60) days of the later of:
(a) the date of the second Qualifying Event; (b) the date coverage would have been lost as a result of the
Qualifying Event; or (c) the date the Qualitied BenefiCiary is informed, through the furnishing of this summary plan
description or the initial general COBRA notice, of the responsibility and procedures for providing such notice to
the Plan Administrator, This written notice must contain supporting legal documentation when applicable (e.g.
death certificate, divorce decree, or legal separation agreement),
Failure to nollfy the Plan Administrator as described will cause the Qualified Beneficiary to lose eligibility for extended
COBRA continuation coverage,
RB785 - Restated 1/1/09
59
item ~Jo. iCES
F8bcc;ary ~iO, 2009
r)age 66 of 99
In no event will coverage be continued for more than thirty-six (36) months,
Retirees Covered Under the Plan
A continuation may also be available to a retiree andlorthe dependent(s) of a retiree in the event of the Employer's filing of
a bankruptcy proceeding under Title 11 of United States Code with respect to the employer providing this health Plan
results in a loss of coverage considered a Qualifying Event),
Notice of Continuation
At the time coverage commences under the Plan, or as permitted by applicable law, the Plan Administrator will provide
written notice to each Covered Employee and spouse (if any) of the right to continuation coverage.
When a Qualifying Event occurs, COBRA continuation coverage will be offered to each affected Qualified Beneficiary,
provided any applicable notification requirements have been met. The cost of the continuation coverage will be included
with the election form. A Qualified Beneficiary eligible to elect continuation coverage shall have the right to continue the
level of coverage in effect on the day before the Qualifying Event.
The decision to elect COBRA continuation coverage is the responsibility of the Qualified Beneficiary, However, failure to
continue group health plan coverage may affect the Qualified Beneficiary's future rights under federal law, including the
portability of health coverage and special enrollment rights as provided by the Health Insurance Portability and
Accountability Act (HIPM), and the guaranteed right to purchase an individual health insurance policy. For more
information on a Covered Person's rights regarding COBRA and HIPM, the Covered Person should contact the nearest
office of the Employee Benefits Security Administration, US. Department of Labor, listed in the telephone directory, or the
Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200
Constitution Avenue NW., Washington, D.C. 20210, or visit the EBSA website at www,doLgov/ebsa. (Addresses and
phone numbers of Regional and District EBSA Offices are available through EBSA's website,)
To elect COBRA continuation coverage, the Qualified Beneficiary must complete the election form and return it to the
COBRA administrator by mail or fax within sixty (60) days of the date of the notice, or sixty (60) days of the date coverage
ends as a result of the Qualifying Event, whichever is later, The names of each Qualified Beneficiary electing COBRA
continuation coverage must be listed on the COBRA election form, the coverage being elected must be checked, and the
form must be signed by a Qualified Beneficiary. Each Qualified Beneficiary will have an independent right to elect COBRA
continuation coverage. A parent may elect to continue coverage on behalf of any dependent children. The employee or
employee's spouse can elect continuation coverage on behalf of all the Qualified Beneficiaries.
Failure to fully compiete and return the election form by the due date will result in the loss of the right to elect COBRA
continuation coverage.
If a Qualified Beneficiary initially waives coverage under COBRA, the Qualified Beneficiary may still later elect coverage,
provided the election is made within sixty (60) days of the date of the notice, or sixty (60) days after coverage ends as a
result of the Qualifying Event, whichever is later. However, coverage will not begin until the date of the election (the date
the election form is postmarked, if mailed, or the date faxed),
Paying for Continuation Coverage
Generally, each Qualified Beneficiary may be required to pay the entire cost of continuation coverage. The amount a
Qualified Beneficiary may be required to pay may not exceed 102% (or, in the case of an extension of continuation
coverage due to a disability, 150%) of the cost to the group health plan (including both employer and employee
contributions) for coverage of a similarly situated plan participant or beneficiary who is not receiving continuation coverage.
The first payment for continuation coverage must be made within forty-five (45) days after the date of the election (this is
the date the election form is postmarked, if mailed, or the date faxed), If the first payment for continuation coverage is not
made in full within that forty-five (45) days, the Qualified Beneficiary will lose all continuation coverage rights under the
Plan.
The first payment must cover the cost of continuation coverage from the time coverage under the Plan would have
otherwise terminated up to the time the first payment is made. The Qualified Beneficiary is responsible for making sure that
the amount of the first payment is correct.
RB785 - Restated 1/1/09
60
l~oenda itsm r'~o. i GES
~ February 10, 2009
Page 67 of 99
Thereafter, periodic payments can be made on a monthly basis, Each of these periodic payments for continuation coverage
is due on the first day of every coverage period, although a grace period of thirty (30) days will be allowed. Continuation
coverage will be provided for each coverage period as long as payment for that period is made before the end of the grace
period. If a periodic payment is made later than its due date, but during the grace period, coverage under the Plan will be
suspended as of the first day of the coverage period and then retroactively reinstated (going back to the first day of the
coverage period) when the periodic payment is made. Any claims submitted while coverage is suspended may be denied,
and will have to be resubmitted when coverage is reinstated.
If a Qualified Beneficiary fails to make a periodic payment before the end of the grace period for that payment, all rights to
continuation coverage under the Plan will be lost. The plan will not send periodic notices of payments due.
Trade Act of 2002
The Trade Act of 2002 created a new tax credit for certain individuals who become eligible for trade adjustment assistance
and for certain retired employees who are receiving pension payments from the Pension Benefit Guaranty Corporation
(PBGC) (eligible individuals). Under the new tax provisions, eligible individuals can either take a tax credit or get advance
payment of 65% of premiums paid for qualified health insurance, including continuation coverage. If an individual has
questions about these new tax provisions, the Health Coverage Tax Credit Customer Contact Cenler may be contacted toll-
free at 1-866-628-4282. TTDmy callers may call toll-free at 1-866-626-4282. More information about the Trade Act is also
available at: www.doleta.gov/tradeacU2002acUndex.asp.
Termination of Continuation Coverage
Continuation of coverage under this Plan shall not be provided beyond whichever of the following dates is first to occur:
1. The date the maximum continuation period expires for the corresponding Qualifying Event;
2. The date the individual fails to pay any required contributions in full on time;
3. The date a Qualified Beneficiary becomes covered, after electing continuation coverage, under another group
health plan that does not impose any pre-existing condition exclusion for a pre-existing condition of the Qualified
Beneficiary;
4. The date a Qualified Beneficiary becomes entitied to Medicare benefits (under Part A, Part B, or both) after
electing continuation coverage;
5. The date this Plan is terminated, though a Qualified Beneficiary may have the right to continue COBRA under
another group health plan provided by the Employer to similarly situated employees;
6. The date the employer ceases to provide any group health plan for its employees; or
7. in the month that begins more than thirty (30) days after a final determination has been made that an individual is
no longer disabled.
Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a participant or
beneficiary not receiving continuation coverage (such as fraud).
Keep Plan Informed of Address Changes
In order to protect an individual's rights under COBRA, it is important that the Plan Administrator be informed of any
address changes. Individuals should keep a copy of any notices sent to the Plan Administrator for their records.
RB785 - Restated 1/1/09
61
/\08iida item ~-Jo. 1 GE5
- csbrLary 10, 2009
Page 68 of 99
COORDINATION OF BENEFITS
If a Covered Person is covered under more than one group plan as defined below, including this Plan, benefits will be
coordinated. The benefits payable under this Plan for any Claim Determination Period, will be either its regular benefits or
reduced benefits which, when added to the benefits of the other plan, may equal 1 00% of the Allowable Expenses defined
below.
DEFINITIONS
Allowable Expenses: Any Medically Necessary, Usual and Customary item of expense incurred by a Covered Person
which is covered at least in part under this Plan.
Claim Determination Period: A Calendar or Plan Year or that portion of a Calendar or Plan Year during which the
Covered Person for whom claim is made has been covered under this Plan.
Plan: Any plan under which benefits or services are provided by:
1. Group, blanket or franchise insurance coverage;
2. Any group Hospital service prepayment, group medical service prepayment, group practice or other group
prepayment coverage;
3. Group coverage under labor-management trusteed plans, union welfare plans, Employer organization plans or
employee benefits plans;
4. Coverage under Medicare and any other governmental program that the Covered Person is liable for payment,
except state-sponsored medical assistance programs and TRICARE, in which case this Plan pays primary;
5. Coverage provided through a school or other educational institution;
6. Coverage under any Heaith Maintenance Organization (HMO); or
7. Coverage provided by no-fault auto insurance, by whatever names it is called, when not prohibited by law.
When medical payments are available under vehicle insurance, the Plan shall pay excess benefits only, without
reimbursement for vehicle plan deductibles. This Plan shall always be considered the secondary carrier regardless of the
individual's election under PiP (personal injury protection) coverage with the auto carrier.
Order of Benefit Determination
When a claim is made, the primary plan pays its benefits without regard to any other plans. The secondary plan adjusts its
benefits so that the total benefits paid by both plans will not exceed 100% of the Allowable Expenses. Neither plan pays
more than it would without the Coordination of Benefits provision.
A plan without a Coordination of Benefits provision is always the primary plan. The FIRST rule that applies determines
primary carrier and supersedes the following rules. If all plans have a Coordination of Benefits provision:
1. The plan covering the person directly, rather than as an employee's dependent, is primary and the other plans are
secondary.
2. Dependent children of parents not separated or divorced, or unmarried parents living together: the plan covering
the parent whose birthday falls earlier in the year pays first. The plan covering the parent whose birthday falls later
in the year pays second.
However, if the other plan does not have this rule but instead has a rule based upon the gender of the parent, and
if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of
benefits.
RB785 - Restated 1/1/09
62
Auenca Ilsm hi8. 1':~E5
-' February 10, 2009
Page 69 of 99
3, Dependent children of separated or divorced parents, or unmarried parents not living together: When parents are
separated or divorced or unmarried and not living together, neither the male/female nor the birthday rules apply.
Instead:
(a) The plan of the parent with custody pays first;
(b) The plan of the spouse of the parent with custody (the step-parent) pays next;
(c) The plan of the parent without custody pays next; and
(d) The plan of the spouse of the non-custodial parent pays last.
However, if specific terms of a court decree state that one of the parents is responsible for the child's health care
expenses, and the insurer or other entity obliged to payor provide the benefits of that parent's plan has actual
knowledge of those terms, that plan pays first.
4. Active/Laid-Off or Retired Employees: The plan which covers that person as an active employee (or as that
employee's dependent) determines its benefits before the Plan which covers that person as a laid-off or retired
employee (or as that employee's dependent). If the Plan which covers that person has not adopted this rule, and if,
as a result, the Plans do not agree on the order of benefits, this rule (4) will not apply.
5. If a person whose coverage is provided under a right of continuation pursuant to state or federal law (i.e. COBRA)
is also covered under another plan, the plan covering the person as an employee, member, subscriber, or retiree
(or as that person's dependent) is primary and the continuation coverage is secondary. 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 (5) is ignored.
6. If none of the above rules determines the order of benefits, the plan covering a person longer pays first. The plan
covering that person for the shorter time pays second.
Coordination of Benefits may operate to reduce the total amount of benefits otherwise payable during any Claim
Determination Period with respect to a Covered Person under this Plan. When the benefits of this Plan are reduced, each
benefit is reduced proportionately. The reduced amount is then charged against any applicable benefit limit of this Plan.
When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each
service rendered will be considered to be both an Allowable Expense and a benefit paid.
Recovery
If the amount of the payment made by this Plan is more than it should have been, the Contract Administrator on behalf of
the Plan, has the right to recover the excess from one or more of the following:
1. The person this Plan has paid or for whom it has paid;
2. Providers of care;
3. Insurance companies; or
4. Other organizations.
Payment to Other Carriers
Whenever payments, which should have been made under this Plan in accordance with the above provisions, have been
made, this Plan will have the right to pay any organization making those payments any amounts it determines to be
warranted in order to satisfy the intent of the above provisions. Amounts paid in this manner will be considered to be
benefits paid under this Plan and, to the extent of these payments, this Plan will be fully discharged from liability.
RB785 - Restated 1/1/09
63
.Agenda Item ~.Jo. 16E5
February 10, 2009
Page 70 of 99
EFFECT OF MEDICARE
In accordance with Federal Medicare regulations, the following is a brief explanation of the Medicare guidelines, not to be
considered all inclusive,
When an employee or spouse reaches age sixty-five (65), they may become entitled to Medicare based on their age. An
employee or dependent may also become entitled to Medicare under age sixty-five (65) due to disabiiity or End Stage
Renal Disease (ESRD).
The Plan will pay benefits before Medicare for an employee or covered dependent:
1. If the empioyee or spouse is age sixty-five (65), is actively working, and the employer has twenty (20) or more
employees;
2. For the first thirty (30) months the employee or dependent is eiigible for Medicare due to End Stage Renal Disease
(or 33 months, depending upon whether a transplant or self-dialysis is involved); or
3. For the employee or dependent who is actively working, is eligible for Medicare under sixty-five (65) due to
disability, and the employer has one hundred (100) or more employees,
The Plan will pay benefits after Medicare for an employee or covered dependent:
1. Who is age sixty-five (65) or older and are not actively working;
2. Who is age sixty-five (65) or older and the employer has fewer than twenty (20) employees;
3. After the first thirty (30) months an employee or spouse is eligible for Medicare due to End Stage Renal Disease
(or 33 months, depending upon whether a transplant or self-dialysis is involved); or
4. Who is eligible for Medicare under age sixty-five (65) due 10 disability, but are not actively working or are actively
working for an employer with fewer than one hundred (100) employees.
All Individuals Eligible for Medicare. Covered Persons should be certain to enroll in Medicare Part A & B coverage in a
timely manner to assure maximum coverage. Contact the Social Security Administration office to enroll for Medicare. If this
Plan is secondary, benefits under this Plan will be coordinated with the dollar amount that Medicare will pay, subject to the
rules and regulations specified by federal law,
Medicare and COBRA. For most COBRA beneficiaries, Medicare rules state that Medicare will be primary to COBRA
continuation coverage, and this would apply to this Plan's Continuation of Benefits (COBRA) coverage.
RB785 - Restated 1/1/09
64
,L\ge:lC13 itsrn i\Jo. 16E5
February 10. 2009
Page 71 of ~..!9
SUBROGATION
Benefits are payable only upon the Covered Person's acceptance of the terms of the Plan. As a condition to receiving
benefits under this Plan, a Covered Person agrees:
1. To serve as a constructive trustee, and to hold in constructive trust such money or property resulting from any
payments or settlement proceeds and agrees that they will not dissipate any such money or property without prior
written consent of the Plan, regardless of how such money or property Is classified or characterized, from any
person, corporation, entity, no-fault carrier, uninsured motorist carrier, underinsured motorist carrier, other
insurance policies for funds; and
2. To restore to the Plan any such benefits paid or payable to, or on behalf of, the Covered Person when said
benefits are paid or estabiished by any person, corporation, entity, no-fault carrier, uninsured motorist carrier,
underinsured motorist carrier, other insurance policies for funds; and
3. To refrain from reieasing any party, person, corporation, entity, insurance company, insurance policies or funds
that may be liable for or obligated to the Covered Person for the Injury or condition without obtaining the Plan's
written approval; and
4. Without limiting the preceding, to subrogate the Plan to any and all claims, causes of action or rights that they have
or that may arise against any person, corporation and/or other entity and to any coverage, no-fault coverage,
uninsured motorist coverage, underinsured motorist coverage, other insurance policies or funds ("Coverage") for
which the Covered Person claims an entitlement to benefits under this Plan, regardless of how classified or
characterized.
In the event a Covered Person settles, recovers, receives, or is reimbursed by any first or third party or Coverage, the
Covered Person agrees that they are a constructive trustee, and shall hold any such funds received in conslructive trust for
the benefit of the Plan, and to transfer tille to the Plan for all benefits paid or that will be paid as a result of said Injury or
condition. The Covered Person acknowiedges that the Plan has a property interest in the Covered Person's settlement,
recovery, or reimbursement, and that the Plan's subrogation rights shall be considered a first priority claim and shall be
paid before any other claims for the Covered Person as the result of the Illness or Injury, regardless of whether the Covered
Person is made whole. If the Covered Person fails to reimburse the Plan for all benefits paid or to be paid, as a result of
said Injury or condition, out of any recovery or reimbursement received, the Covered Person will be liable for any and all
expenses (whether fees or costs) associated with the Plan's attempt to recover such money from the Covered Person.
The Covered Person shall execute and return a Subrogation Agreement to the Plan Administrator and shall supply other
reasonable information and assistance as requested by the Plan Administrator regarding the claim or potential claim. If the
Subrogation Agreement is not executed and returned or if information and assistance is not provided to the Plan
Administrator upon request, no benefits will be payable under the Plan with respect to costs incurred in connection with
such Illness or Injury.
If the Covered Person (or guardian or estate) decides to pursue a first or third party or any Coverage available to them as a
result of the said Injury or condition, the Covered Person agrees to include the Plan's subrogation claim in that action and if
there is failure to do so the Plan will be legally presumed to be included in such action or recovery. In the event the
Covered Person decides not to pursue any and all first or third parties or Coverage, the Covered Person authorizes the
Plan to pursue, sue, compromise or settle any such claims in their name, to execute any and all documents necessary to
pursue said claims in their name, and agrees to fully cooperate with the Plan in the prosecution of any such claims. The
Covered Person (or guardian or estate) agrees to take no prejudicial actions against the subrogation rights of the Plan or to
in any way impede the action taken by the Plan to recover its subrogation claim. Such cooperation shall include a duty to
provide information, execute and deliver any acknowledgment and other le9al instruments documenting the Plan's
subrogation rights and lake such action as requested by the Plan to secure the subrogation rights of the Plan.
The Plan will not payor be responsible, without its written consent, for any fees or costs associated with a Covered Person
pursuing a claim against any Coverage or first or third party. The Plan Administrator retains sole and final discretion for
interpreting the terms and conditions of the Plan document. The Plan Administrator may amend the Plan in its sole
discretion at anytime without notice. This right of subrogation shall bind the Covered Person's guardian(s), estate,
executor, personal representative, and heir(s),
RB785 - Restated 1/1/09
65
,L\qenda Item No. 16E5
- February 10, 2009
Page 72 of 99
REIMBURSEMENT RIGHTS
The Covered Person, by accepting benefits under this Plan, agrees to hold in constructive trust any money or property
resulting from any recovery, insurance payments or settlement proceeds, first or third party payments, settlement proceeds
or judgment for the Plan's benefits under this provision. If a Covered Person fails to reimburse the Plan for all benefits paid
or to be paid, as a result of their Illness or Injury, out of any recovery or reimbursement received, the Covered Person will
be liable for any and all expenses (whether fees or costs) associated with the Plan's attempt to recover such money from
the Covered Person. This right of reimbursement shall bind the Covered Person's guardian(s), estate, executor, personal
representative, and heir(s).
RIGHTS OF RECOVERY
In the event of any overpayment of benefits by this Plan, the Plan will have the right to recover the overpayment. If a
Covered Person is paid a benefit greater than allowed in accordance with the provisions of this Plan, the Covered Person
will be required to refund the overpayment. If payment is made on behalf of a Covered Person to a Hospital, Physician or
other provider of health care, and the payment is found to be an overpayment, the Plan will request a refund of the
overpayment from the provider. If the refund is not received from the provider, or from the Covered Person, the amount of
the overpayment will be deducted from future benefits, if available. If future benefits are not available, the Covered Person
will be required to refund the overpayment.
RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION
For the purposes of implementing the terms of this Plan, the Contract Administrator retains the right to request any medical
information from any insurance company or provider of service it deems necessary to properly process a claim. The
Contract Administrator may, without consent of the Covered Person, release or obtain any information it deems necessary.
Any person claiming benefits under this Plan shall furnish to the Contract Administrator such information as may be
necessary to implement this provision.
RB785 - Restated 1/1/09
66
Aqenda item No. i6E5
- February 10, 2009
Page 73 of 99
NOTICE TO PLAN PARTICIPANTS
regarding
MASTECTOMY RELATED COVERAGE
The Women's Health and Cancer Rights Act of 1998
The "Women's Health and Cancer Rights Act of 1998" was signed into law as part of the Omnibus Budget Bill on October
21, 1998. This act amends ERISA and the Public Health Service Act by requiring that group health plans provide certain
coverages to plan participants in connection with mastectomies.
Effective with your plan anniversary on or after October 21, 1998 or on the effective date of any new policy issued on or
after October 21, 1998, a participant who elects breast reconstruction in connection with such covered mastectomy shall
have coverage for:
1. Reconstruction of the breast on which the mastectomy has been performed;
2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
3. Prostheses and physical complications for all stages of mastectomy, including Iymphedemas;
in a manner determined in consultation with the attending Physician and the patient. Such coverage may be subject to
annual Deductibles, Co-insurance, and provisions consistent with those established for other benefits under the Plan.
This Plan is administered in accordance with the regulations set forth in this Act or plan provisions that may be applicable.
RB785 - Restated 1/1/09
67
Ih:;iTl f'~o. 16E5
Fsbruary 10, 2009
Page 74 of 99
GENERAL PROVISIONS
Notice of Claim
Written notice of a claim and all information needed to process the claim must be given to the Contract Administrator as
soon as reasonably possible and in no event, later than one year from the date such claim is incurred.
Records
For the purposes of claims administration, each Covered Person authorizes and directs any provider that has attended,
examined, or treated them to furnish to the Contract Administrator, at any time upon its request, any and all information,
records or copies of records relating to the attendance, examination or treatment rendered to the Covered Person; and the
Contract Administrator agrees that such information and records will be considered confidential. Further, any charges
imposed relative to the acquisition of such information will be absorbed by the Covered Person, except as specified in the
Schedule of Benefits.
Claim Determination
Urgent Care Claims: Determination for any pre-service Urgent Care Claims (whether adverse or not) must take place as
soon as possible but not longer than seventy-two (72) hours, uniess the Claimant fails to provide sufficient information to
determine whether, or to what extent, benefits are covered or payable under the Plan. In the case of such failure, the
Contract Administrator shall notify the Claimant as soon as possible, but not later than twenty-four (24) hours afterreceipt
of the claim by the Plan, of the specific information necessary to complete the claim. The Claimant will be afforded a
reasonable amount of time, taking into account the circumstances, but not less than forty-eight (48) hours, to provide the
specified information. The Contract Administrator shall notify the Claimant of the Plan's benefit determination as soon as
possible, but in no case later than forty-eight (48) hours after the earlier of:
1. The Plan's receipt of the specified information; or
2. The end of the period afforded the Claimant to provide the additional information.
Urgent Care Claims must be decided within seventy-two (72) hours. There is no extension of time allowed for claims
involving urgent care.
Pre-Service Claims: Pre-Service Claims must be decided within a maximum of fifteen (15) days at the initial level and up
to thirty (30) days following an Adverse Benefit Determination. In the case of a failure by a Claimant or an Authorized
Representative of a Claimant to follow the Plan's procedures for filing a Pre-Service Claim, the Claimant or representative
shall be notified of the failure and the proper procedures to be followed in filing a Claim for Benefits. This notification shall
be provided to the Claimant or Authorized Representative, as appropriate. as soon as possible, but not later than five (5)
days following the failure. Notification may be oral, unless written notification is requested by the Claimant or Authorized
Representative.
Post-Service Claims: Post-Service Claims must be decided within thirty (30) days for the initial decision and a maximum
of sixty (60) days on review.
Filing Extensions: The Plan may extend determination on both Pre-Service and Post-Service Claims for one additional
period of fifteen (15) days after expiration of the relevant initial period, if the Contract Administrator determines that such an
extension is necessary for reasons beyond the control of the Plan. Delays caused by cyclical or seasonal fluctuations in
claims volume are not considered to be matters beyond the control of the Plan that would justify an extension.
If the reason for taking the extension is the faiiure of the Claimant to provide necessary information, the time period for
making the determination is tolled from the date on which notice of the necessary information is sent to the Claimant until
the date on which the Claimant responds to the notice. The time periods for making a decision are considered to
commence when a claim is filed in accordance with the reasonable filing procedures of the Plan, without regard to whether
all the information necessary to decide the claim accompanies the filing.
Concurrent Care Decisions: If a Plan has approved an ongoing course of treatment to be provided over a period oftime,
or number of treatments, any reduction or termination by the Plan (other than by plan amendments or termination) before
the end of such period of time or number of treatments shall be considered an Adverse Benefit Determination, The
Contract Administrator shall notify the Claimant ofthe Adverse Benefit Determination at a time sufficiently in advance of the
reduction or termination to allow the Claimant to appeal and obtain a determination on review of that Adverse Benefit
RB785 - Restated 1/1/09
68
Determination before the benefit is reduced or terminated,
.L\oe,lda item t~o. i6E5
-' :=ebruary 10,2009
Page 75 of 99
RB785 - Restated 1/1/09
69
I~cenda Its:-n No. 16E5
- February 10, 20C9
Page 76 of 99
Any request by a Claimant to extend the course of treatment beyond the period of time or number of treatments for a claim
involving urgent care, shall be decided as soon as possible, taking into account the medical exigencies, and the Contract
Administrator shall notify the Claimant of the benefit determination, whether adverse or not, within twenty-four (24) hours
after receipt of the claim by the Plan, provided that any such claim is made to the Plan at least twenty-four (24) hours prior
to the expiration of the prescribed period of time or number of treatments.
Adverse Benefit Determination: The notice of an Adverse Benefit Determination will either include the protocol in which
it was based upon or a statement that a protocol was relied upon and that a copy is available free of charge upon request
by the Claimant.
Notification of an Adverse Benefit Determination (at both the initial level and on review) based on Medical Necessity,
Experimental treatment, or other similar exclusion or limit will be explained as to the scientific or clinical judgment of the
Plan to the Claimant's medical circumstances, or an explanation will be provided free of charge to the Claimant upon
request.
Where the Plan utiiizes a specific internal rule or protocol, it must furnish the protocol to the Claimant or their Authorized
Representative upon request.
Authorized Representative: The Plan will recognize an Authorized Representative, including a health care provider,
acting on behalf of a Claimant. The Plan will recognize a Health Care Professional with knowledge of a Claimant's medical
condition as the Claimant's representative in connection with an Urgent Care Claim. Procedures will be established by the
Plan for verifying that an individual has been authorized to act on behalf of a Claimant.
Right of Review and Appeal
A Claimant has up to one hundred eighty (180) days to file an appeal of an Adverse Benefit Determination. As part of the
appeal process, a Covered Person has the right to (a) review this Plan and otherrelevant documents, (b) argue againstthe
denial in writing, and (c) have a representative act on behalf of the Covered Person in the appeal. All relevant documents
will be provided free of charge, upon request by the Claimant, after receiving an Adverse Benefit Determination. A
document, record or other information is considered relevant if it was relied upon in making the benefit determination, if it
was considered or generated in the course of making the benefit determination, if it demonstrates compliance with the
administrative processes, or if it constitutes a statement of policy or guidance with respect to the Plan concerning the
denied treatment option or benefit for the Claimant's diagnosis, without regard to whether such advice or statement was
relied upon in making the determination.
If the Claimant or an Authorized Representative appeals an Adverse Benefit Determination, the Contract Administrator will
respond to the appeal within seventy-two (72) hours for an Urgent Care Claim, thirty (30) days for a Pre-Service Claim, and
sixty (60) days for a Post-Service Claim. The notice will specify the reason for the denial or describe the additional
information required to process the claim. Written denial will include:
1. Specific reasons for denial with reference to the Plan Document section(s);
2. A description and need for any other material pertinent to the claim; and
3. An explanation of this Plan's review procedure and the names of any medical professionals consulted as part of
the claims process.
A full and fair review of an Adverse Benefit Determination will be performed by an appropriate named fiduciary, who is
neither the party who made the initial adverse determination, nor the subordinate of such person. The review will not defer
to the initial Adverse Benefit Determination. The review will take into account all comments, documents, records and other
information submitted by the Claimant, without regard to whether such information was previously submitted or considered
in the initial determination,
If the review results in another Adverse Benefit Determination, it shall include specific reasons for denial, written in a
manner understandable to the Covered Person, and will contain specific reference to the pertinent Plan provisions upon
which the decision was based.
A Covered Person must follow the Right of Review and Appeal procedures listed above before initiating any legal actions.
These are the Covered Person's administrative remedies, which must be exhausted before legal action may be pursued.
RB785 - Restated 1/1/09
70
t~c8nda 1'l2m f'.)o. 16;::5
" f=ebruary 10, 2009
Page 77 of 99
If the Plan fails to provide procedures in compliance with the regulation, or the required procedures, the Claimant is
deemed to have exhausted the administrative remedies and Is free to pursue legal action on the basis that the Plan has
failed to provide a reasonable claims procedure that would yield a decision on the merits of the claim.
No legal action involving this Plan or its administration shall be allowed or brought after the expiration of two (2) years
following the date any eligible expense is incurred, or one year following the date of the Adverse Benefit Determination,
whichever is the shorter period,
Plan Interpretation
All decisions concerning the interpretation or the application of this Plan and its terms shall be at the discretion of the Plan
Administrator.
Periodic Report
Within one month following the date of any change in the group of employees and dependents covered, the Empioyer shall
furnish the Contract Administrator the names of all employees who have become covered or cease to be covered since the
date of the previous reports.
Failure on the part of the Employer to report the name of any employees or dependents who are eligible for coverage, shall
not deprive such persons of their benefits under the Plan; nor shall faiiure on the part of the Employer to report any
termination of any employee or dependent, obligate the Plan to continue such benefits beyond the date of termination.
Choice of Physician
The Covered Person shall have the free choice of any legally qualified Physician and the Physician-patient relationship
shall be maintained.
Affiliated Companies
Any of the Employer's affiliates, subsidiaries or divisions may be deleted or added to the Plan upon written notice by the
Employer on or before the date such deletion or addition is effective.
Employee Contribution
Participation in this Plan is entirely voluntary. The Employer reserves the right to modify the amount of any employee
contributions.
No Contract of Employment
This Plan is not intended to be, and may not be construed as constituting a contract or other arrangement between the
employee and the Empioyer to the effect that the employee will be employed for any specific period of time.
Inspection of Plan Document
Upon request, Ihe Employer shall make this Plan Document available for inspection by any Covered Person at a
reasonably accessible place.
Amendment or Termination of the Plan
The Plan may be amended or terminated at any time without prior notice and, except as otherwise provided, in any
manner, by written authorization and signed by the Plan Administrator.
It is the intent of this Plan to comply with all applicable Federal and State laws. Wherever this Plan is in conflict with either
Federal or State law, the Federal or State law will prevail, unless exempt from either law.
RB785 - Restated 1/1/09
71
:~\qeilda Item No. 16E5
" February 10, 2009
Page 78 of 99
INSTRUCTIONS FOR SUBMISSION OF CLAIMS
All claims submitted should include all of the following:
1. Employee's name, identification number and home address,
2, If claim is made for a dependent, the dependent's name, Employer and age.
3. Employer's name and group number.
4. Name and address of the Physician or Hospital.
5. Physician's diagnosis,
6. Itemization of charges.
7. Date the Injury or Illness began.
8. Drug bills (not cash register receipts) showing RX number, name of drug, date prescribed, and name of person for
whom drug is prescribed.
Claims Processing Procedures:
Acceptable claims forms, bills and/or documents:
1. HCFNUB or ADA Dental Claim Forms; or
2. Superbills - any submitted claim form with ;ill of the following information:
(a) Detail of procedure performed
(b) Detailed breakdown of charges
(c) Diagnosis
(d) Date of service
(e) Federal Tax Identification Number (TIN) and address of provider
A claim submitted with all of the above information included will be processed, unless additional information is required to
complete the claim, Additional information that may be required to process a claim may include, but is not limited to the
following:
1. Coordination of Benefits - Other Insurance Coverage
2. COBRA eligibility
3. Parental custody
4, Legal responsibility for dependent child health coverage
5. Divorce decree
6. Medicare eligibility
7. Full-Time Student status
8. Certificate of Creditable Coverage
9, Medical history information
10, Injury or Accident information,
When the Contract Administrator receives a billing with the required information, the Contract Administratorwill process it in
accordance with the time frames for Post-Service Claims, Pre-Service Claims and Urgent Care Claims, and in accordance
with all other Plan provisions, and in accordance with eligibility and ciaim information on file. The Contract Administrator
will provide a notice of benefit determination or a notice of Adverse Benefit Determination to the Covered Person's
designated address.
Please direct all auestions regarding claims to:
Meritain Health,m
PO. Box 27267
Minneapolis, MN 55427-0267
(952) 546-0062
(800) 925-2272
Please direct all claims to the address shown on the 10 card.
RB785 - Restated 1/1/09
72
L\genda !t2m No_ 161::5
Fsbruary 10, 2009
Page 79 of 99
Every attempt will be made to heip Covered Persons understand their benefits; however, any statement made by an
employee of the Employer or the Contract Administratorwill be deemed a representation and not a warranty. Actual benefit
payment can only be determined at the time the claim is submitted and all facts are presented in writing.
If a definite answer to a specific question is required, please submit a written request, including all pertinent information,
and a statement from the attending Physician (if appiicable), and a written reply (which will be kept on file) will be sent.
RB785 - Restated 1/1/09
73
Agenda item IJo. 16E5
February 10, 2009
Page 80 of 99
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Section 1 - Use and Disclosure of Protected Health Information (PHI)
This Plan will use protected health information (PHI) to the extent of and in accordance with the uses and disclosures
permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Specifically, the Plan will use and
disclose PHI for purposes related to health care treatment, payment for health care and health care operations.
Payment includes activities undertaken by the Plan to obtain premiums or determine or fulfill its responsibiiity for coverage
and provision of plan benefits that relate to an individual to whom health care is provided. These activities include, but are
not limited to, the following:
1. Determination of eligibility;
2. Coverage and cost sharing amounts (for exampie, cost of a benefit, plan maximums and co-payments as
determined for an individual's claim);
3. Coordination of Benefits;
4. Adjudication of health benefit claims (including appeais and other payment disputes);
5. Establishing employee contributions;
6. Risk adjusting amounts due based on enrollee health status and demographic characteristics;
7. Billing, collection activities and related health care data processing;
8. Claims management and related health care data processing, including auditing payments, investigating and
resolving payment disputes and responding to participant inquiries about payments;
9. Obtaining payment under a contract for reinsurance (including stop-loss and excess loss insurance);
10. Medical Necessity reviews or reviews of appropriateness of care or justification of charges;
11. Utilization review, including pre-authorization, concurrent review and retrospective review;
12. Disclosure to consumer reporting agencies related to the collection of premiums or reimbursement (the following
PHI may be disclosed for payment purposes: name and address, date of birth, Social Security Number, payment
history, account number and name and address of the provider and/or health plan); and
13. Reimbursement to the Plan,
Health care operations include, but are not limited to, the following activities:
1. Quality assessment;
2. Population-based activities relating to improving health or reducing health care costs, protocol development, case
management and care coordination, disease management, contacting health care providers and patients with
information about treatment alternatives and related functions;
3. Rating provider and plan performance, including accreditation, certification, licensing or credentialing activities;
4. Underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of
health insurance or health benefits, and ceding, securing or placing a contract for reinsurance of risk relating to
health care claims (including stop-loss insurance and excess loss insurance);
5. Conducting or arranging for medical review, legal services and auditing functions, including fraud and abuse
detection and compliance programs;
6. Business planning and development, such as conducting cost-management and planning-related analyses related
to managing and operating the Plan, including formulary development and administration, development or
improvement of payment methods or coverage policies;
7. Business management and general administrative activities of the Pian, including, but not iimited to:
(a) Management activities relating to the implementation of and compliance with HIPAA's administrative
simplification requirements; or
(b) Customer service, including the provision of data analyses for policyholders, plan sponsors or other
customers;
8, Resolution of intemal grievances; and
9, Due diligence in connection with the sale or transfer of assets to a potential successor in interest, if the potential
successor in interest is a "covered entity" under HIPAA or, following completion of the sale or transfer, will become
a covered entity.
Section 2 - The Plan Will Use and Disclose PHI as Required by Law and as Permitted by Authorization of the
Participant or Beneficiary
With an authorization, the Plan will disclose PHI to the benefit plans or other separate plans of this Employer.
RB785 - Restated 1/1/09
74
Section 3 - For purposes of this section, the Employer is the Plan Sponsor
,b,genda item No. iCE5
February 10, 2009
Page 81 of 99
The Plan will disclose PHI to the Plan Sponsor only upon receipt of a certification from the Plan Sponsor that the plan
documents have been amended to incorporate the following provisions.
Section 4 - With Respect to PHI, the Plan Sponsor Agrees to Certain Conditions
The Plan Sponsor agrees to:
1. Not use or further disclose PHI other than as permitted or required by the plan document or as required by law;
2. Ensure that any agents, including a subcontractor and the Contract Administrator, to whom the Plan Sponsor
provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor
with respect to such PHI;
3. Not use or disclose PHI for employment-related actions and decisions unless authorized by an individual;
4, Not use or disclose PHI in connection with any other benefit or employee benefit plan of the Plan Sponsor unless
authorized by an individual;
5. Report to the Plan any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of which
it becomes aware;
6. Make PHI available to an individual in accordance with HIPAA's access requirements;
7. Make PHI available for amendment and incorporate any amendments to PHI in accordance with HIPAA;
8. Make available the information required to provide an account of disclosures;
9. Make internal practices, books and records relating to the use and disclosure of PHI received from Plan available
to the HHS Secretary for the purposes of determining the plan's compliance with HIPAA; and
10. 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 PHI when no longer needed for the purpose for which disclosure was made (or if return or
destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction
infeasible).
Section 5 - Adequate Separation Between the Plan and the Plan Sponsor Must Be Maintained
In accordance with HIPAA, only the following employees or classes of employees may be given access to PHI:
1. The Benefits Manager or other authorized representative of the Plan; and/or
2. Staff designated by the Benefits Manager or other authorized representative of the Plan.
Section 6 - Limitations of PHI Access and Disclosure
The persons described in Section 5 may only have access to and use and disclose PHI for plan administration functions
that the Plan Sponsor performs for the Plan.
Section 7 - Noncompliance Issues
If the persons described in Section 5 do not comply with this plan document, the Plan Sponsor shall provide a mechanism
for resolving issues of noncompliance, including disciplinary sanctions.
Section 8 - Security of Electronic PHI
To the extent required by45 C.F.R. section 164.314(b), except when the only electronic PHI disclosed to the Plan Sponsor
is disclosed pursuant to 45 C.F.R. section 164.504(f)(1 )(ii) or (iii), or as authorized under 45 C.F.R. section 164.508, the
Plan Sponsor will reasonably and appropriately safeguard electronic PHI created, received, maintained, or transmitted to or
by the Plan Sponsor on behalf of the Plan.
In accordance with the foregoing, the Plan Sponsor shall:
1. Implement administrative, physical, and technical safeguards that reasonably and appropriately protect
confidentiality, integrity, and availability of the electronic PHI that it creates, receives, maintains or transmits on
behalf of the Plan;
2. Ensure that the adequate separation required by 45 C.F.R. section 164.504(f)(2)(iii) is supported by reasonable
and appropriate security measures;
3. Ensure that any agent, including a subcontractor, to whom the Plan Sponsor provides this information agrees to
implement reasonable and appropriate security measures to protect the information; and
4. Report to the Plan any security incident of which it becomes aware.
RB785 - Restated 1/1/09
75
P.oenda item ~~o. 16E5
-' February 10, 2009
Page 82 of 99
COLLIER COUNTY GOVERNMENT
FLEXIBLE BENEFITS PLAN
SUMMARY PLAN DESCRIPTION
(Amended 1/1/2009)
,!:\.genda Item No. 16=:5
February 10, 2009
?ag8 83 of 99
SUMMARY PLAN DESCRIPTION
OF
COLLIER COUNTY GOVERNMENT
FLEXIBLE BENEFITS PLAN
Dear Participant:
Collier County Government has adopted the Flexible Benefits Plan for the exclusive benefit of you and all Participating
Employees. Its purpose is to reward you for loyal service by enabling you to select certain employee benefits that will
best fit your individual needs in a tax-effective manner. If you electto use the benefits of the Flexible Benefits Plan, you
may realize savings of income taxes and Social Security taxes. Collier County Government has established this Plan
with the intention that It will be continued Indefinitely, but Collier County Government does reserve the power to amend
or terminate this Plan at any time.
The Plan is a written document which sets forth the provisions of this fringe benefit program. In order to find out how
the program affects you and your family, you may read the actual document (copies are available to you at the offices
of Collier County Government, the Plan Administrator during regular business hours). However, in order to help you
understand this program, we have condensed your Plan into a series of questions and answers which summarize and
explain the provisions and benefits available under the program. If you want additional information about the Plan,
please contact the Risk Management Director at the address or phone number listed in the Important Information
section.
This summary is not meant to interpret, extend or change the Plan in any way. In case of a confiict between this
summary and the actual provisions of the Plan, the provisions of the Plan will govern your rights and benefits.
IMPORTANT INFORMATION
Effective Date:
Amended Date:
January 1, 1992
January1, 2009
Plan Year:
January 1 through December 31
Benefit Option(s):
Pre-tax premium payment for group insurance, Health FSA, and
DCAP,
Employer:
Collier County Government
3301 East Tamiami Trail, Building 0
Naples, FL 34112
(239) 252-8461
Employer Identification Number:
59-6000558
Plan Number:
510
Plan Administrator:
Collier County Government
Contact(s) at Plan Administrator:
Group Insurance Manager
Address:
3301 East Tamiami Trail, Building 0
Naples, FL 34112
Telephone:
(239) 252-8461
Number of Fiex Deductions:
From 24 payroil checks.
Agenda Item I-Jo. ~16E5
February 10, 2009
Page 84 of 99
Maximum Allocation:
Health FSA: $5,000
DCAP: $2,500/$5,000"
"See "DCAP" under Question #2
Changes in Status:
CBSA and Collier County Government must be notified within 30
days of the change in status event. See Question #10.
Continuation Coverage (COBRA):
If you terminate participation in the Flex Plan you will have 60 days
after the date of termination to elect continuation coverage under
COBRA if you qualify. See Question #13.
Where to Send Claims:
Flexible Benefits Department
Corporate Benefit Services of America, Inc. (CBSA)
P.O. Box 27847
Minneapolis, MN 55427-08470
Deadline to Submit Claims to CBSA:
Five business days prior to Flex Reimbursement.
End of Plan Year:
You will have 90 days after the end of the plan year to submit
claims incurred through December 31. See Question #22.
Upon Termination:
See Question #11.
Flex Checks:
Reimbursement checks will be mailed to your home each week.
Minimum Reimbursement:
$10.00
ELIGIBILITY
1. When am I eligible to join the Plan?
A part-time or full-time employee of Collier County Government (other than an Excluded Employee) who works
twenty (20) or more hours per week on a regular basis is eligible to participate in the Plan.
An Employee employed on the Effective Date, who has met the eligibility requirements, may elect to participate
on the Effective Date.
Any other Employee who elects to become a Participant will become a Participant in the Plan on the date of hire
if hired on the first day of the month. If hired after the first of the month an Employee may elect to become a
participant effective the first day of the following month provided the Employee meets the eligibility requirements.
Any Employee who does not elect to participate in the Plan on the date the Employee first becomes eligible, may
later elect to begin participating as of the first day of any subsequent Plan Year, except for a Change in Status.
A qualifying retiree of Collier County Government who meets the requirement of Florida Statute 112.0801 is
eligible to participate in the Plan and may elect to participate effective the first day of the month following
retirement. Any qualifying retiree who does not elect to participate in the Plan on the date the Retiree first
becomes eligible, may later elect to begin participating as of the first day of any subsequent Plan Year, except for
a Change in Status.
"Employee" means an individual that the Employer classifies as a common-law employee and who is on the
Employer's W-2 payroll, except that the term does not include any common-law employee who is a leased
employee, or any common-law employee classified by the Employer as a contract worker, independent
contractor, temporary employee or casual employee. "Employee" also does not include any individual who
performs services for the Employer but who is paid by a temporary or other employment or staffing agency, nor
any employer covered under a collective bargaining agreement (unless lhe collective bargaining agreement
provides otherwise).
2
r'\cenda item ~~o. 16E5
- February 10. 2,]09
Page 85Jf 99
Those Employees who actually participate in the Plan are called "Participants." An Employee continues to
participate until (a) the end of the Plan Year for which the election to participate was made, unless the Participant
elects during the Open Enrollment Period (defined in Question 7) to continue participation; (b) the termination of
the Plan; (c) the date on which the Participant ceases to be an eligible Employee (because of retirement,
termination of employment, layoff, reduction in hours, orfor any otherreason), except that eligibility may continue
beyond such date for purposes of pre-taxing COBRA coverage as may be permitted by the Administrator on a
uniform and consistent basis (but not beyond the current Plan Year); or (d) the Participant revokes his or her
election, as described in Question 10.
If your Employer is a Subchapter S-Corporation, you are excluded from participation if you own more than 2% of
the shares in Collier County Government, or if you are the spouse, lineal ascendant or lineal descendant of an
individual who owns more than 2% of the shares in Collier County Government. If Collier County Government is a
Limited Liability Corporation, and you are an Owner of or Partner in this company you are also excluded from
participation in this Pian.
If an Excluded Employee who is not a Participant becomes eligible to participate in the Plan by reason of a
change in employment classification, he will participate in the Plan immediately if he has satisfied the eligibility
conditions and would have been a Participant had he not been an Excluded Employee during his period of
service.
CONTRIBUTIONS AND BENEFITS
2. What are the benefits available to me?
Collier County Government provides you with the opportunity to use pre-tax dollars to pay for one or more of the
Benefit Options listed above in the Important Information section. By entering into a compensation reduction
arrangement you elect to pay for the benefits with pre-tax dollars instead of receiving a corresponding amount of
your regular pay. Alternatively, you may choose to pay for any of the available benefits with after-tax contributions
on a payroll reduction basis.
Health Flexible Spending Arrangement (Health FSA): Also called a medical expense reimbursement account.
The Health FSA enables you to pay expenses which are not covered by an insured or self-insured medical plan
and save taxes at the same time. The account allows reimbursement of out-of-pocket expenses incurred by you
and your dependents, which meet the criteria for deductibility as medical expenses under Code Section 213(d),
or prevailing IRS guidelines.
During the course of the Plan Year you may submit requests for reimbursement of qualified medical, dental and
vision expenses you have incurred during the Plan Year. An expense is considered incurred when the service
that gives rise to the expense is provided, not when the expense was paid. Note that if you have paid for the
expense but the service has not yet been rendered, then the expense has not been incurred for this purpose.
Collier County Government will provide you with acceptable forms for submitting these requests for
reimbursements. If the request qualifies as a benefit or expense that the Plan has agreed to pay for, you will
receive a reimbursement payment soon thereafter. Remember. these reimbursements which are made from the
Plan are not subject to Federal income tax or withholding.
Any monies left in your Health FSA at the end of the Plan Year will be forfeited, unless eligible forreimbursement
during the grace period see question #16. Obviously, qualifying expenses that you incur iate in the Plan Year for
which you seek reimbursement after the end of such Plan Year will be paid first before any amount is forfeited.
However, you must make your requests for reimbursement no later than 90 days after the end of the Plan Year,
or within the 2 '!, month grace period of the new Plan Year. Because it is possible that you might forfeit amounts
in your Health FSA if you do not fully use the contributions that have been made, it is important that you decide
how much to place in the Health FSA carefully and conservatively. Remember, you must decide how much to
place in the Health FSA before the Plan Year begins. You want to be as certain as you can that the amount you
decide to place in the Health FSA will be used up entirely.
The maximum amount of Flexible Dollars that you can allocate to your Health FSA each Plan Year for Qualified
Expenses shall be determined by the Employer prior to the beginning of each Plan Year and such amount for the
Plan Year shall not exceed $5,000.
3
Agenda Item No. 16E5
Feb'cary 10, 2009
Page 86 of 99
Dependent Care Assistance Program (DCAP): Also called a Dependent Care Expense Reimbursement
Account. The DCAP enables you to pay for out-of-pocket, work-relaled dependent daycare costs with pre-tax
Flexible Dollars. If you are married, you can use the account if you and your spouse both work or, in some
situations, if your spouse is disabled or goes to school full-time. Single Employees can also use the account.
An eligible dependent is any member of your household for whom you can claim expenses on Federal Income
Tax Form 2441 "Credit for Child and Dependent Care Expenses". If you choose to utilize the dependent care
portion of the Flex plan, you should review the IRS Tax Form 2441 for proper tax reporting. Children must
be under age thirteen (13). Other dependents must be physically or mentally unable to care for themselves.
Dependent Care arrangements which qualify include:
a. A Dependent (Day) Care Center, so long as care is provided for more than six (6) individuais. The facility
must comply with applicable state and local laws;
b. An "Individual" who provides care inside or outside your home. The "Individual" may not be a child of yours
under age nineteen (19) or anyone who you claim as a dependent for Federal tax purposes.
You should make sure that the dependent care expenses you are currently paying qualify under our Plan. The
law places limits on the amount of money that you can contribute to the DCAP. Also, Federal tax laws permit a
tax credit for certain dependent care expenses you may be paying for even if you are not a participant in this
Plan. You may save more money if you take advantage of this tax credit rather than using the DCAP under our
Plan. If you are uncertain, you should ask your tax adviser which is better for you.
During the course of the Plan Year, you may submit requests for reimbursement of qualified dependent care
expenses you have incurred during the Plan Year. An expense is considered incurred when the service that gives
rise to the expense is provided; when the expense is paid is irrelevant. Collier County Government will provide
you with acceptable forms for submitting these requests for reimbursements. If the request qualifies as a benefit
or expense that the Plan has agreed to pay and if you have sufficient Flexible Dollars in your DCAP, you will
receive a reimbursement payment soon thereafter. Remember, these reimbursements which are made from the
Plan are not subject to Federal income tax or withholding.
Any monies left in your DCAP at the end of the Plan Year will be forfeited. Obviously, qualifying expenses that
you incur late in the Plan Year for which you seek reimbursement after the end of such Plan Year will be paid first
before any amount is forfeited. However, you must make your requests for reimbursement no later than 90 days
after the end of the Plan Year. Because it is possible that you might forfeit amounts in your DCAP if you do not
fully use the contributions that have been made, it is important that you decide how much to place in the DCAP
carefully and conservatively. Remember, you must decide how much to place in the DCAP before the Plan Year
begins. You want to be as certain as you can that the amount you decide to place in the DCAP will be used up
entirely.
You may choose any amount of Dependent Care Expense reimbursement that you desire under the DCAP,
subject to the maximum reimbursement amounts described below. You will be required to pay the annual DCAP
election amount equal to the coverage level you have chosen. The amount of Dependent Care Expense
reimbursement that you choose cannot exceed the maximum amount specified in Code Section 129. The
maximum amount is currently $5,000 for a calendar year if you:
. are married and file a joint return;
. are married, but you furnish more than half the cost of maintaining those Dependents for whom you are
eligible to receive tax-free reimbursement under the DCAP, your Spouse maintains a separate residence for
the last six months of the calendar year, and you file a separate tax return; or
. are single or are the head of the household for tax purposes.
If you are married and reside with your Spouse but you file a separate federal income tax return, then the
maximum DCAP Benefit that you may elect is $2,500 for a calendar year.
The above maximum ($5,000 or $2,500 for a calendar year, as applicable) applies to the amount that you may
elect under this Plan and any pian of your Spouse. HO\NeVer, the above maximum is just the greatest amount that
is possible; the election amount that applies to you may be less than the above maximum because of other
limitations, as described below (for example, note that reimbursement cannot exceed the amount of your oryour
Spouse's earned income for the Plan Year).
4
i lern No. "IGE5
February 10, 2009
Page 87 of 99
No reimbursement will be made to the extent that such reimbursement would exceed the balance in your DCAP
Account. In addition, no reimbursement will be made to the extent that such reimbursement, when combined with
the total amount of reimbursements made for the Plan Year, would exceed the applicable statutory limit. Your
applicable statutory limit is the smallest of the following amounts:
. your earned income for the calendar year (after your Salary Reductions under the Plan);
. the earned income of your Spouse for the calendar year (your Spouse will be deemed to have earned
income of $250 ($500 if you have two or more Qualifying Individuals), for each month in which your Spouse
is (a) physically or mentally incapable of self-care; or (b) a full-time student); or
. either $5,000 or $2,500 for the calendar year, depending on your marital and tax filing status.
Premium Payment Benefit: If you elect to participate in the Premium Payment Benefit you will be able to pay
your share of premiums for qualified benefit plans with pre-tax dollars by entering into an Election Form/Salary
Reduction Agreement with Collier County Government. This means that the share of the premiums you pay will
be with pre-tax funds, which saves you Social Security and income taxes on the amount of your salary reduction.
Qualified benefit plans are the plans that your Employer maintains for Employees, their Spouses and
Dependents, providing benefits through a group policy.
The Premium Payment Benefit also allows you to use tax-free Flexible Dollars to purchase group term life
insurance coverage under the group term policies available from the Employer, if applicable. You may purchase
additional group term life insurance coverage to the point where the total of coverage purchased by you and
provided by the Employer equals $50,000.
The Premium Payment Benefit also allows you to use tax-free Flexible Dollars to purchase disability coverage
under the disability policies available from the Employer, if applicable. You should keep in mind that paying your
disability premiums on a pre-tax basis will cause the disability benefits to become taxable. The disability benefits
will also be taxable if nontaxable employer credits are used to purchase the coverage.
The right is reserved for the Plan Administrator to terminate, suspend, withdraw or modify group benefits in whole
or in part at any time, subject to the applicable prOVisions of the contracts providing benefits.
Any benefits to be provided shall be provided only after: (1) the participant has provided the Plan Administrator
the necessary information to apply for benefits; and (2) the coverage is in effect for such Participant.
3. How are my benefits paid?
Health FSA and/or DCAP Benefits. When you complete the Election Form/Salary Reduction Agreement, you
specify the amount of Health FSA and/or DCAP Benefits that you wish to pay with your salary reduction. From
then on, you must pay a premium for such coverage(s) by having an equal portion of the annual premium
deducted from each paycheck (unless otherwise agreed with, or as deemed appropriate by the Administrator). If
you pay all of your premiums, your Health FSA and/or DCAP Account will be credited with the portion of your
gross income that you have elected to give up through salary reduction, These portions will be credited as of
each pay period.
Your Employer makes no contribution to your Health FSA or DCAP Account.
Premium Payment Benefit. If you select the group plan(s) described in Question 2, you may be required to pay
a portion of the premiums for the benefits that you have selected, as described in documents furnished
separately to you. When you complete the Election Form/Salary Reduction Agreement, you specify that your
share of the premiums will be paid with that portion of gross income that you have elected to give up through pre-
tax salary reductions. From then on, you must pay a premium for such coverage by having that portion deducted
from each paycheck on a pre-tax basis (generally an equal portion from each paycheck, or an amount otherwise
agreed to or as deemed appropriate by the Administrator). The Employer will not be liable to you if a benefits
provider fails to provide any of the major medical benefits.
The Emp!oyer may contribute a!!, some, or no portion of the Benefits that you have selected, as described in
documents furnished separately to you.
5
L\genda item No. 16::5
February 10, 2009
Page 88 of 99
4. If I elect to participate in the Plan, how can this benefit me?
This can best be shown by the following example:
Employee A is married and has two (2) children. Employee A is an Employee at Example Company and earns
$20,000 a year.
Employee A decided to enroll in the Example Company Flexible Benefit Plan. Employee A elects to redirect
$1,500 ($125 per month) of current compensation into the Pian to purchase benefits which would otherwise be
purchased with after-tax dollars.
With the Plan, Employee A is able to pay for the benefits with dollars that are not taxed. Employee A's disposable
income with and without the Plan is shown below:
With Without
Flexible Benefit Flexible Benefit
Plan Plan
Gross salary $20,000 $20,000
Less: Compensation used
to purchase benefits $1,500
Taxable salary $18,500 $20,000
Federal income tax (15%) $ 2,779 $ 3,004
State income tax (6%) $1,110 $ 1,200
Social security tax (FICA) (7.65%) $ 1 ,415 $1530
Total taxes $ 5.304 $ 5,734
Salary after taxes $13,196 $14,266
Cost of benefits $_m_ $ 1.500
DISPOSABLE INCOME $13,196 $12,766
NET SAVINGS WITH PLAN $430
Employee A receives $430 ($13,196 minus $12,766) more per year in disposable income if Employee A elects to
participate in the Plan.
5. If I elect to participate in the Plan, how does this affect my Social Security benefits?
Participation in the Flexible Benefits Plan will normally result in Collier County Government and you making lower
contributions to the Federal Social Security system. This is iikely to reduce your Social Security contributions and
could reduce your benefits. However, the tax savings that you realize through Plan participation will often more
than offset any reduction in other benefits.
6. How do I elect to redirect my compensation and have it applied toward the cost of one or more of the
optional benefits?
After you complete the eligibility requirement described in Question 1, you become a Participant by signing an
individual Election Form/Salary Reduction Agreement on which you elect one or more of the benefits available
under the Plan, as well as agree to a salary reduction to pay for those benefits so elected.
7. What is the deadline to elect one or more of the optional benefits?
You must complete the Election Form/Salary Reduction agreement and turn it in to the Human Resource Office
within the time period specified by the Administrator of the Plan in the enrollment materials. Also, the Election
Form/Salary Reduction Agreement will be made available to you during the Open Enrollment Period, and you will
be given the opportunity during the Open Enrollment Period to elect your coverage for the 12 months beginning
on the next January 1, called the "Plan Year."
6
/.\g8n~3 :tem ;'10. iCE5
February 10. 2009
~age 89 of 99
8. If I am a new Participant, when can I make my Salary Reduction Election?
Collier County Government will provide you with the necessary election forms when you become eligible to
participate. These forms must be completed and returned to Collier County Government before the beginning of
the first pay period for which your agreement will apply,
9. What happens if I fail to return a completed election form to Collier County Government by the deadline?
If you do not submit an election form to Collier County Government in the year which you first become eligible to
participate, you will not have the opportunity to participate until the next Plan Year and may not enroll until the
next Open Enrollment Period, except for a Change in Status.
10. Can I change or revoke my elections during the Plan Year?
Generally, you cannot change your election to participate in the Plan or vary the salary reduction amounts you
have selected during the Plan Year (known as the irrevocability ruie), although your election will terminate if you
are no longer eligible under the Plan (see Questions 11 and 13). There are several important exceptions to the
irrevocability rule, known as Change in Election Events. "Change in Election Events" include the following events,
as more fully described below: Leaves of absence, including FMLA leave (defined in Question 14); Change in
Status; certain judgements, decrees and orders; Medicare and Medicaid; Change in Cost; and Change in
Coverage. (Changes in Status, Cost and Coverage are defined below). However, the Change in Election Events
do not apply for all Benefits - exclusions are described below for each such Event.
If a Change in Election Event (including a Change in Status) occurs, you must inform Collier County Governmenl
and complete a new Election Form/Salary Reduction Agreement within 30 days of the occurrence. However, if
the change involves a loss of your spouse's or dependent's eligibility for the Insurance Plan(s), it will be deemed
effective irnmediately even if you do not request it within the 30 days.
a. Leaves of Absence. (App/ies to Premium Payment. Health FSA and DCAP Benefits). You may change an
election under the Plan upon FMLA and non-FMLA leave only as described in Question 14.
b. Change in Status. (Applies to Premium Payment Benefits, to Health FSA Benefits as Limited Below, and
to DCAP Benefits as Limited Below) If one or more of the following Changes in Status occurs, you may
revoke your old election and make a new election, provided that both the revocation and new election are
caused by and are consistent with the Change in Status (as described below). Those occurrences that
qualify as a Change in Status include the events described below and any other events that Collier County
Government (in its sole discretion) determines to be within prevailing IRS guidance:
1. a change in your legal marital status (such as marriage, divorce, annulment, legal separation or death
of your spouse). "Spouse"means the person who is legally married to you and is treated as a spouse
under the Internal Revenue Code (Code);
2. a change in the number of your dependents (such as birth of a child, adoption or placement for
adoption of a Dependent, or the death of a dependent). "Dependent"means your tax dependent under
the Code;
3. any of the following events that change the employment status of you, your Spouse, or your
Dependent and that affects benefit eligibility under a cafeteria plan (including this Plan) or other
employee benefit plan of you, your Spouse, or your Dependents. Such events include any of the
following changes in employment status; termination or comrnencement of ernployment, a strike or
lockout, a commencement of or return from an unpaid leave of absence, a change in worksite,
switching from salaried to hourly-paid, union to non-union, or full-time to part-time (or vice versa);
incurring a reduction or increase in hours of employment; or any other similar change which makes
the individual become (or cease to be) eligible for a particular employee benefit;
4 an event that causes your dependent to satisfy or cease to satisfy an eligibility requirement for a
particular benefit (such as attaining a specified age, student status, or similar circumstance); and
7
Aaenda Item ~,Jo. 16E5
~ February 10, 2009
;:>age 90 of 99
5. a change in your, your spouse's or your dependent's place of residence. that affects benefit eligibility
under a cafeteria plan (including this Plan) or other employee benefit plan of you, your spouse, oryour
dependents
c, Change in Status - Other Requirements. (Applies to Premium Payment Benefits, to Health FSA Benefits,
and to DCAP Benefits.) If you wish to change your election based on a Change in Status, you must
estabiish that the change or revocation is on account of and corresponds with a change in status. Collier
County Government, in its sole discretion and on a uniform and consistent basis, shall determine whether a
requested change is on account of and corresponds with a Change in Status. As a general rule, a desired
election change will be found to be consistent with a Change in Status event if the event affects coverage
eligibility (for DCAP Benefits, the event may also affect eligibility of Dependent Care Expenses (see
Question 2) for the dependent care tax exclusion). But if you cancel coverage, it cannot result in your
contributions for the year being less than the amount for which you have already been reimbursed. For
example, assume that you eiected to contribute $100 per month to the Health FSA and in February you
were reimbursed for $700 of expenses. If a change in status event occurs in March that allows you to
cancel coverage, your cancellation will not take effect until you have contributed a total of $700 for the year,
d. Special Enrollment Rights. (Appiies to Premium Payment Benefits That Are Group Health Plans, but Not
to Health FSA or DCAP Benefits.) If you, your spouse or a dependent is entitled to special enrollment rights
under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) under a group health plan,
you may change your election to correspond with the special enrollment right. For example, if you declined
enrollment in your Employer's Medical Insurance Plan for yourself or for your eligible dependents because
of medical coverage under another plan, and if eligibility for such coverage is subsequently lost due to
certain reasons (i.e., due to legal separation, divorce, death, termination of employment, reduction in hours,
or exhaustion of the COBRA period), then you may be able to elect major medical coverage under the Plan
for yourself and your eligible dependents who lost such coverage, provided that you request enrollment
within 30 days after the applicable event. Furthermore, if you have a new dependent as a result of marriage,
birth, adoption, or placement for adoption, you may also be abie to enroll yourself, your spouse, and for
your newly-acquired Dependent, provided that you request enrollment within 30 days after the marriage,
birth, adoption, or placement for adoption. Piease refer to the summary plan description of the Medical
Insurance Plan for an explanation of special enrollment rights.
e. Certain Judgments and Orders. (Applies to Premium Payment Benefits That Provide Accident or Health
Coverage, and to Health FSA Benefits, but Not to DCAP Benefits.) If a judgment, decree or order from a
divorce, separation, annulment or custody change requires your Dependent child (including a foster child
who is your Dependent) to be covered under this Plan, you may change your election to provide coverage
for the Dependent child. lithe order requires that another individual (such as your former Spouse) cover the
Dependent child, then you may change your election to revoke coverage for the child.
f. Entitlement to Medicare or Medicaid. (Applies to Premium Payment Benefits, to Health FSA Benefits as
Limited Below, but Not to DCAP Benefits.) If you, your Spouse, or a Dependent becomes entitled to
Medicare or Medicaid, you may cancel that person's accident or health coverage under the Plan (for
example, the Medical insurance Plan) and change your premium benefit election accordingly and/or cancel
or reduce your Health FSA election. You may also prospectively increase your Health FSA election if you
drop your Employer's plan due to Medicare or Medicaid entitlement and the prior Employer-provided
coverage was more comprehensive.
Further, if you, your Spouse, or Dependent who has been entitled to Medicare or Medicaid loses eligibility
for such coverage you may prospectively change your election to add health coverage for that person
and/or commence or increase your Health FSA coverage. You may also elect to decrease or revoke your
Health FSA election if the Employer's plan elected due to a loss of eligibility for Medicare or Medicaid is
more comprehensive than Medicare or Medicaid.
g. Changes in Cost. (Applies to Premium Payment Benefits, to DCAP Benefits as Limited Below, but Not to
Health FSA Benefits.) If Collier County Government notifies you that the cost of your coverage under the
Plan significantly increases during the Plan Year, you may choose to do any of the following: (a) make a
corresponding increase in your contributions; (b) revoke your election and receive coverage under another
Plan option that provides similar coverage or elect similar coverage under the plan of your Spouse's
employer; or (c) drop your coverage, but only ifthere is no option available under the Plan that provides
8
L:.qenda item f\Jo. 16[5
, cebruary iO, 2009
Page 91 of 99
similar coverage. (Note that, for purposes of this definition, (a) a health FSA is not similar coverage to an
accident or health plan that is not a health FSA, (b) the HMO and the PPO are considered to be similar
coverage, and (c) coverage under another employer plan, such as a Spouse's or Dependent's employer, is
treated as similar coverage.) For insignificant increases or decreases in the cost of benefits, however,
Collier County Government will automatically adjust your election contributions 10 refiect the minor change
in cost.
With regard to the DCAP account you may increase or decrease your election to correspond with changes
in your dependent care provider and/or changes in your dependent care provider's fees, However, you may
not change your DCAP election when a dependent care provider who is your relative imposes a cosl
change.
h. Changes in Coverage. (Applies to Premium Payment Benefits and to DCAP Benefits, but not to Health
FSA Benefits.)
1, Significant Curtailment of Coverage. If Collier County Government notifies you that your coverage
under the Plan is significantly curtailed without a loss of coverage (for example, when there is an
increase in the deductible), then you may revoke your election and elect coverage under another Plan
option that provides similar coverage. If Collier County Government notifies you that your coverage
under the Plan is significantly curtailed with a loss of coverage (for example, the HMO ceases to be
available where you live), then you may either revoke your election and elect coverage under another
Plan option that provides similar coverage, elect similar coverage under the plan of your Spouse's
empioyer, or drop coverage but only ifthere is no option available under the plan provides similar
coverage.
Collier County Government (in its sole discretion) will decide whether a curtailment is "significant" and
whether a substitute Plan constitutes "similar coverage" based upon all the surrounding facts and
circumstances.
2, Addition or Significant Improvement of Plan Option. If during a Plan Year the Plan adds a new option
or significantly improves an existing option, Collier County Government may permit Participants who
are enrolled in an option other than the new or improved option to elect the new or improved option
on a prospective basis, subject to limitations imposed by the applicable Insurance Plan.
3. Loss of Other Group Health Coverage. You may change your election to add group health coverage
for you, your Spouse or Dependent, if any of you loses coverage under any group health coverage
sponsored by a governmental or educational institution (for example, a state children's health
insurance program or certain Indian tribal programs).
4. Change in Election Under Another Employer Plan. You may make an election change that is on
account of and corresponds with a change made under another employer plan (including a plan of the
Employer or a plan of your Spouse's or Dependent's employer), so long as (a) the other cafeteria plan
or qualified benefits plan permits its participants to make an election change permitted under the IRS
regulations; or (b) this Plan permits you to make an election for a period of coverage (for example, the
Plan Year) that is different from the period of coverage under the other cafeteria plan or qualified
benefits plan. For example, if an election is made by your Spouse during his/her employer's open
enrollment to drop coverage, you may add coverage to replace the dropped coverage,
5, DCAP Coverage Changes. You may make a prospective election change that is on account of and
corresponds with a change by your dependent care service provider. For example: (a) if you terminate
one dependent care service provider and hire a new dependent care service provider, you may
change coverage to reflect the cost of the new service provider; and (b) if you terminate a dependent
care service provider because a relative becomes available to take care of the child at no charge, you
may cancel coverage,
To make a change, you must file a written request for change with Collier County Government within 30 days of
the event permitting the change.
9
,!!.,gf!nda item No. i6ES
February 10, 2009
Page 92 of 99
Additionally, Collier County Government may modify your election(s) downward during the Plan Year if you are a
Key Employee or Highly Compensated Individual (as defined by the Internal Revenue Code), if necessary to
prevent the Plan from becoming discriminatory within the meaning of the federal income tax law and adjustments
may also be made to refiect insignificant mid-year premium increases imposed by third party insurers.
11. What if I terminate my employment during the Plan Year?
If your employment with Collier County Government is terminated during the Plan Year, your active participation
in the Plan will cease, and you will not be able to make any more contributions to the Plan. See Question and
Answer #13 of this summary and the health insurance booklets for information on your right to continued or
converted group health coverage after termination of your employment.
However, if you are rehired within the same Plan Year and are eligible to participate in the Health FSA and DCAP
Accounts, your prior elections shall remain in effect for the remainder of the Plan Year provided that you are
rehired within 30 days after you terminated employment.
If you are rehired more than 30 days after you terminated employment, you may make a new election in the
Health FSA and DCAP Accounts as a new hire.
You may reinstate your election in the pre-tax premium portion of the Plan to the extent that coverage under the
corresponding benefit plan(s) was reinstated.
Claims for Medical Expenses incurred prior to the time you cease to be a participant are covered to the extent of
Flexible Dollars available if such claims are filed within 90 days after the end of the Plan Year in which you
ceased to be a Participant. You will also have 90 days after the end of the Plan Year to submit claims for
Dependent Care Expenses.
12. Once I have enrolled, do I have to complete a new election form each year?
Pre-Tax Premium Account:
No. Only the initial completed election form is required.
Health FSA and DCAP Accounts:
Yes. An election form must be completed each year.
13. What happens to my elections if I am no longer eligible to participate in the Plan?
Elections made under this Plan will automatically terminate on the date on which you cease to be a participant in
the Plan.
However, if you were participating in the Health FSA portion of the Plan, you have the right to elect a temporary
extension of health coverage if participation by you (including your spouse and dependents) would otherwise end
due to the occurrence of a "Qualifying Event." Continuation coverage under federal law is provided under
COBRA (the Consolidated Omnibus Budget Reconciliation Act of 1985). (A similar right is provided under a
federal law called USERRA if you take a leave of absence for military service.) You should check with your
Employer to see if COBRA and USERRA apply. A Qualifying Event under COBRA is:
a. Termination of your employment for any reason except gross misconduct;
b. A reduction in your work hours that would make you ineligible to participate in the Health FSA portion of
this Plan;
c. Your death;
d. Divorce or legal separation from your spouse;
e. A dependent ceasing to be a dependent; or
f. Your becoming entitled to Medicare benefits.
10
i\genda !~em !\Jo. 16E5
February 10. 2009
Page 93 of 99
For a Qualifying Event other than a change in your employment status, it will be your responsibility to inform the
Plan Administrator of the qualifying events occurrence within 60 days of its occurrence for each medical benefit
plan you have eiected. The Plan Administrator, in turn, has a legal obligation to furnish you (or your spouse, as
the case may be) with separate, written options to continue the coverages provided at stated premium costs with
respect to each health plan in which you are participating. The notification you will receive will explain all the rest
of the terms and conditions of the continued coverage. You may pay premiums for COBRA coverage under your
Insurance Plan(s) on a pre-tax basis (unless permitted otherwise by Collier County Government on a uniform and
consistent basis) to the extent compensation is available, but not beyond the current Plan Year.
Certain Health FSA Participants will be eligible for COBRA Continuation Coverage if they have positive Health
FSA balances at the time of a Qualifying Event (taking into account all claims submitted before the date of the
qualifying event). You will be notified if you are eligible for COBRA Continuation Coverage. However, even if
COBRA is offered for the year in which the qualifying event occurs, COBRA coverage for the Health FSA
Account will cease at the end of the plan year and cannot be continued for the next plan year. You may pay
premiums for such coverage on an after-tax basis, (unless permitted otherwise by Collier County Government on
a uniform and consistent basis) to the extent compensation is available, but not beyond the current Plan Year.
14. What happens to my benefits and elections if I take a leave of absence?
If you take an unpaid leave of absence due to disability, family or medical leave, (or a paid leave where your
employer does not require your coverage to be continued) or any other reason approved by the Employer, you
shall have the option to:
a. Revoke your Salary Reduction consistent with and on account of a Change in Status, In no event may the
revocation of your election reduce the Health FSA benefit below the amount of benefit used as of the date
of the revocation. If you choose to revoke your Salary Reduction while on leave, your coverage under this
portion of the Plan terminates and you are not entitled to receive reimbursement for claims incurred while
you are out on leave.
b. Prepay all or a portion of the premium for the expected duration of the leave on a pre-tax salary reduction
basis out of pre-leave compensation. To pre-pay the premium you must make a special election to that
effect prior to the date that such compensation would normally be made available. You should note,
however, that if your leave is taken late in the plan year so that it overlaps into the next plan year, then
payments attributable to the next plan year must be made on an after-tax basis.
c. Continue to pay, on an after-tax basis, the Flexible Dollar amounts prior to taking your leave by sending
monthly payments to the Employer. If your payment is more than 30 days late, the Employer may drop your
coverage or may continue to pay for your share of the coverage at the Employer's discretion. However, the
Employer may recover from you the cost of any payments made to maintain your coverage.
If your Health FSA coverage ceases while you are on leave you will be entitled to elect to reinstate your Health
FSA Benefit at the same coverage level as in effect before the leave (with increased contributions for the
remaining period of coverage) or at a coverage level thatis reduced pro-rata for the period of leave during which
you did not pay premiums.
Regardless of the payment option selected, as long as you continue to make contributions to the Plan, the full
amount of the coverage elected under the Health FSA portion ofthe Plan, less any reduction under 13(a) or 13(b)
and less any prior reimbursements, will be available to you at all times, including during an unpaid FMLA leave
period. If you elect to reinstate coverage upon return from leave, your coverage under this portion of the Plan for
the remainder of the Plan Year will be equal to your original Salary Reduction for the twelve (12) month period of
coverage prorated for the period when coverage was terminated during leave and reduced by prior
reimbursements.
You are not eligible to claim dependent care expenses incurred while on a paid or unpaid leave of absence
because you are not gainfully employed.
11
AGenda Item l'Jo. 1 [)E5
v FetJruary 10, 2009
Page 94 of 99
15. What happens when a Medical Child Support Order is issued with respect to the medical coverage
provided through this Plan?
Upon receipt of a Medical Child Support Order, the Employer will determine, in accordance with a written and
established procedure, whether the order is qualified. If the order is found to be a Qualified Medical Child Support
Order, the Plan will provide medical coverage to your child without regard to Plan limitations which may require
that you have custody of the child or that the child be designated as your dependent for tax purposes. The child
will have medical coverage as of the date of the order, not limited or delayed for either a pre-existing condition or
a waiting period. Reimbursements of benefit payments will be made to the child or the child's custodial parent. A
Qualified Medical Child Support Order is an exception to the general rule that your benefits under Ihe Plan cannot
be assigned or aiienated.
16. What if I don't spend all Plan contributions?
Any Flexibie Dollars which are not used to pay for benefits you seiect will be forfeited back to Collier County
Government to defray administrative costs of the Plan. Because this is possible, you should be careful to
authorize only those amounts necessary to pay for the coverage you elect.
You will forfeit any amount allocated to your Health FSA and/or DCAP Account if claims for that amount have not
been submitted to the Health FSA and/or DCAP Benefits for any Plan Year within 90 days following the end of
the Plan Year for which the election was effective, or within 90 days of the current Plan Year if the Plan has a
grace period for Health FSA benefits.
If any amounts remain in the Health FSA Account at the end of the Plan Year, a 2 % month grace period may be
available to submit eligible claims incurred after the end of the previous Plan Year but within 2 % months of the
current Plan Year. Reimbursements will first be paid from any amounts remaining in the Health FSA Account in
the previous Plan Year and then from any amounts that are available for reimbursement during the current Plan
Year. Claims must be submitted within 90 days of the current Plan Year for claims incurred during the grace
period. Once paid, a claim will not be reprocessed so as to change the Plan Year from which to take funds to pay
the claim.
Amounts so forfeited shall be applied as described in the Plan (for example, used to offset reasonable
administrative expenses and future costs). Also, any Health FSA and/or DCAP Account benefit payments that are
unclaimed (for example, uncashed benefit checks) by the close of the Plan Year or the eligible grace period
following the Plan Year in which the Expenses were incurred shall be forfeited and applied as described in the
Plan.
17. Willi be taxed on the Health FSA and DCAP Benefits I Receive?
Generally, you will not be taxed on your Health FSA or DCAP Benefits, up to the limits set forth in Question 2.
However, Collier County Government cannot guarantee that specific tax consequences will flow from your
participation in the Plan. The tax benefits that you receive depend on the validity of the claims that you submit.
For example, to qualify for tax-free treatment, your Medical Care Expenses must meet the definition of "medical
care" as defined in the Code. To qualify for tax-free treatment under the DCAP Account you will be required to file
IRS Form 2441 (Child and Dependent Care Expenses) with your annual tax return (Form 1040) or a similar form.
You must list on Form 2441 the names and taxpayer identification numbers of any persons who provided you
with dependent care services during the calendar year for which you have claimed a tax-free reimbursement. If
you are reimbursed for a medical or dependent care expense that is later determined to not be for Medical
Expenses or Dependent Care Expenses, respectively, you will be required to repay the amount. Ultimately, it is
your responsibility to determine whether each payment to you under this Plan is excludable for tax purposes. You
may wish to consult a tax advisor.
18. If I elect DCAP Benefits, can I still claim the Dependent Care Credit on my federal income tax return?
You may not claim any olher tax benefit for the tax-free amounts received by you under this Plan, although the
balance of your Dependent Care Expenses may be eligible for the household and dependent care services tax
credit under Code Section 21 (Dependent Care Credit) (e.g., if you elect $3,000 of coverage under the DCAP and
are reimbursed $3,000, but you had Dependent Care Expenses totaling $5,000, you could count the excess
$2,000 when calculating the Dependent Care Credit if you have two or more dependents). Note: the amount of
any Dependent Care Credit you may have available will be offset by any DCAP Benefits received under the Plan.
12
L'.qer~C3 Item !'~o. 16E5
.. February 10, 2009
Page 95 of 99
1 g. Would it be better to include the DCAP Benefits in my income and claim the Dependent Care Credit,
instead of treating the reimbursements as tax-free?
Generally, if you are in one of the lower income tax brackets, you might come out ahead by not participating in
the DCAP and by claiming the Dependent Care Credit instead. On the other hand, generally the more income
taxes you are required to pay, the better it would be tax-wise to participate in the DCAP. Because the actual
determination of the preferable method for treating benefit payments depends on a number of factors such as a
person's tax filing status (e.g., married, single, head of household), number of Dependents, etc., each Participant
will have to determine his or her tax position individually in order to make the decision between taxable and tax-
free benefits. Use IRS Form 2441 (Child and Dependent Care Expenses) to help you. Note that in determining
the relative tax benefits of DCAP participation versus claiming the Dependent Care Tax Credit, you must also
take into account the increase or decrease in two other tax credits as well (the Earned Income Credit and the
Child Tax Credit), Your Employer may be abie to provide you with a worKsheet to heip you make the comparison.
You may also wish to consult a tax advisor.
20. What amounts will be available for reimbursement at any particular time during the Plan Year?
Health FSA. The full amount of coverage that you have elected (reduced by prior reimbursements made during
the same Plan Year) will be available to reimburse you for eligible Medical Care Expenses incurred during the
Plan Year, regardless of the amount that you have contributed when you submitted the claim (so long as you
have continued to pay the premiums.) For example, suppose that you elected $1,000 of coverage and
contributed to your Health FSA Account during January and February (assuming semi-monthly payroll
deductions) - that means that by February 24 you would have contributed $153.84 ($38.46 times 4 pay periods).
You haven't made any prior claims for reimbursement during the calendar year, but on February 26 you incur a
Medical Care Expense in the amount of $300. You submit that claim for reimbursement on February 27. So long
as the claim meets all applicable requirements, then $300 wouid be available to you for that expense, even
though you have only contributed $153.84 to your Health FSA Account at the time.
DCAP. The amount of coverage that is available for reimbursement of Dependent Care Expenses at any
particular time during the Plan Year will be equal to the amount credited to your DCAP Account at the time your
claim is paid, reduced by the amount of any prior reimbursements paid to you during the Plan Year. For example,
suppose that you elected $2,400 for Dependent Care Expenses and you incur $1 ,500 of eligible expenses by the
end of March. At that time, your DCAP Account would only have been credited with $600 ($100 times 6 semi-
monthly pay periods), so only $600 would be available for reimbursement at the end of March (assuming that you
had not received any prior reimbursements). You would have to wait to receive reimbursement of the remaining
$900 of Dependent Care Expenses until after you have contributed the appropriate credits to your DCAP
Account. Note, however that the earned income limitations described in Question 2 must also be met.
21. When are expenses incurred?
For Medical Care Expenses and Dependent Care Expenses to be reimbursed to you, they must have been
incurred during the Plan Year. An expense is incurred when the service that gives rise to the expense is provided,
not when the expense was paid, Note that if you have paid for the expense but the services have not yet been
rendered, then the expense has not been incurred for this purpose. For example, if you pay for medical or
dependent care on the first day of the month for care given on the 15th of that month, the expense has not been
incurred until the 15th of that month. You may not be reimbursed for any expenses arising before the Plan
became effective, before your Election Form/Salary Reduction Agreement became effective, for any expense
incurred after the close of the Plan Year, or after a separation from service. (For Continuation Coverage under
the Health FSA please see Question 13.)
22. How do I submit a claim under this Plan?
When you incur an expense that is eligible for payment, you must submit a claim to the Administrator on a claim
form that will be supplied to you. You must include written statements and/or bills from independent third parties
stating that the expenses have been incurred. and the amount of such expenses along with the claim form. For
the Health FSA, this generally requires including an Explanation of Benefits (EOB) Form from the medical
insurance carrier (or a bill from a doctor's office) indicating the amounts that you are obligated to pay.
13
Agenda Item I'Jo. 16E5
Ff;bruary 10, 2009
Page 96 of 99
Health FSA. If you have paid the premiums for the Health FSA coverage you have elected, then you will be
reimbursed for your eligible Medical Care Expenses within 30 days after the date you submitted the request for
reimbursement (subject to a 15-day extension for matters beyond the Pian Administrator's control- see Question
23). Remember, though that you cannot be reimbursed for any total expenses above the annual reimbursement
amount you have elected.
You will have 90 days after the end of the Plan Year in which to submit a claim for Medical Care incurred during
the previous Plan Year, or within 2'h months of the grace period for the current Plan Year. You will be notified
in writing if any claim for benefits is denied. (See Question 23.) Expenses incurred during the Plan Year or the
grace period must be submitted within ninety (90) days following the previous Plan Year to be considered
eligible for reimbursements from amounts that remain in the previous Plan Year's Health FSA Account.
DCAP. If there are enough credits to your DCAP Account, then you will be reimbursed for your eligible DCAP
Expenses within 30 days after the date you submitted the request for reimbursement (subject to a 15-day
extension for matters beyond the Administrator's control - see Question 23). If a claim is for an amount that is
more than your current DCAP Account balance, then the excess part of the claim will be carried over into the
following months, to be paid out as your balance becomes adequate. Remember, though that you cannot be
reimbursed for any total expenses above your annual credits to your DCAP Account.
You will have 90 days after the end of the Plan Year in which to submit a claim for Medical Care or Dependent
Care Expenses incurred during the previous Plan Year. Dependent Care Expenses may include expenses
incurred following termination of participation if such amounts are incurred during the current Plan Year. You will
be notified in writing if any claim for benefits is denied. (See Question 23.)
To have your claims processed as soon as possible, please read Question 23. Note that it is not necessary for
you to have actually paid the bill in an amount due for Medical Care Expenses or Dependent Care Expenses-
only for you to have incurred the expense (as outlined in Question 21), and that it is not being paid for or
reimbursed from any other source.
The administrator will, subject to the $10 minimum, pay claims weekly during the Plan Year to the extent that
Flexible Dollars are available. Any claims less than the minimum will be released for payment on the last process
of the Plan Year. After all Flexible Dollars have been exhausted, claims remaining unpaid at the Plan Year-end
will be canceled. In no event can these claims be resubmitted the next Plan Year, nor are any unpaid claims a
liability of the Employer.
If Collier County Government implements an electronic payment card program (debit card, credit card or similar
method) to pay expenses from the Health FSA, some expenses may be validated at the time the expense is
incurred (like co-pays for medical care). For other expenses, the card payment is only conditional and you will still
have to submit supporting documents. You will receive more information from your Employer about what you
must do to obtain reimbursement if such a system is implemented.
23, What can I do if my claim is denied?
Insurance Plan Coverage Claims. if your claim is for a benefit under an Insurance Plan, you will generally
proceed under the claims procedure applicable under that plan or policy, as described in the plan document or
summary plan description for the applicable Insurance Plan.
Claims under the Flex Plan. However, if (a) a claim for reimbursement under the Health FSA or DCAP is wholly
or partially denied, or (b) you are denied a benefit under the Plan (such as the ability to pay for premiums on a
pre-tax basis) due to an issue related to your coverage under the Plan (for example, a determination of: a
Change in Status; a "significant" change in premiums charged; or eligibility and participation matters under the
Flexible Benefits Plan Document), then the claims procedure described below will apply.
If your claim is denied in whole or in part, you will be notified in writing by the Administrator within 30 days of the
date the Administrator received your claim. (This time period may be extended for an additional 15 days for
matters beyond the controi of the Administrator. including in cases where a claim is incomplete. The
Administrator will provide written notice of any extension, including the reasons for the extension and the date by
which a decision by the Administrator is expected to be made. Where a claim is incompiete, the extension notice
will also specifically describe the required information, will allow you 45 days from receipt of the notice in which to
14
~qenda it8m j~jo. i (JE5
- February 10, 2009
Pa'Je 97 of 99
provide the specified information, and will have the effect of suspending the time for a decision on your claim until
the specified information is provided.) Notification of a denied claim will contain the following:
a. Specific reason or reasons for the denial;
b. Specific Plan provision on which the denial is based;
c. A description of any additional material or information necessary for you to validate such claim and an
explanation of why such material or information is necessary:
d. Information as to the steps to be taken if you wish to appeal the Administrator's decision, including your
right to submit written comments and have them considered, your right to review (upon request and at no
charge) relevant documents and other information, and your right to file suit under ERISA (where
applicable) with respect to any adverse determination after appeal of your claim.
Appeals by Participant. If your claim is denied in whole or part, you (or your authorized representative) may
request review upon written application to the Committee (the Benefits Committee that acts on behalf of the
Administrator with respect to appeals). Your appeal must be made in writing within 180 days of your receipt of the
notice that the claim was denied. If you do not appeal on time. you will lose the right to appeal the denial and the
right to file suit in court. Your written appeal should state the reasons that you feel your claim should not have
been denied. It should include any additional facts and/or documents that you feel support your claim. You will
have the opportunity to ask additional questions and make written comments, and you may review (upon request
and at no charge) documents and other information relevant to your appeal.
Decision on Review. Your appeal will be reviewed and decided by the Committee or other entity designated in the
Plan in a reasonable time not later than 60 days after the Committee receives your request for review. The
Committee may, in its discretion, hold a hearing on the denied claim. Any medical expert consulted in connection
with your appeal will be different from and not subordinate to any expert consulted in connection with the initial
claim denial. The identity of a medical expert consulted in connection with your appeal will be provided. If the
decision on review affirms the initial denial of your claim, you will be furnished with a notice of adverse benefit
determination on review containing the following:
a. Specific reason or reasons for the decision on review;
b. Specific Plan provision(s) on which the decision is based;
c. A statement of your right to review (upon request and at no charge) relevant documents and other
information );
d. If an "internal rule, guideline, protocol, or other similar criterion" is relied on in making the decision on
review, a description of the specific rule, guideline, protocol, or other similar criterion or a statement that
such a rule, guideline, protocol, or other similar Criterion was relied on and that a copy of such rule.
guideline, protocol, or other criterion will be provided free of charge to you upon request; and
e. A statement of your right to file suit under ERISA Section 502(a) (where applicable),
24. What are my rights under the law?
The Flexible Benefit Plan is not an ERISA welfare benefit plan under the Employee Retirement Income Security
Act of 1974 (ERISA). However, the Health FSA Component and the Insurance Plan(s) are governed by ERISA.
As a Participant in an ERISA-covered benefit plan, you are entitled to certain rights and protections under ERISA.
Your Rights. As a participant in the Flexible Benefits Plan, you are entitled to certain rights and protections under
the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan Participants shall
be entitled to:
a. Examine, without charge, at the Plan Administrator's office and at other specified locations, such as work
sites and union halls, all plan documents, including insurance contracts, collective bargaining agreements
and copies of all documents filed by the Plan with the U.S. Department of Labor and available at the Public
15
.".genda Item th 16E5
February 10.2009
Page 98 of 99
Disclosure Room of the Employee Benefits Security Administration. However, you may not inspect
materiais containing confidential information on other Plan participants.
b. Obtain copies of all non-confidential plan documents and other plan information upon written request to the
Plan Administrator. The Administrator may make a reasonable charge for the copies.
c. Receive a summary of the Plan's annual financial report, if any. The Administrator is required by law to
furnish each participant with a copy of this summary annual report.
COBRA and HIPAA Rights. You have a right to continue your Health Insurance Plan coverage (and, in some
cases, your Health FSA coverage) for yourself if there is a loss of coverage under the plan as a result of a
qualifying event. You may have to pay for such coverage. Review this summary plan description and the
documents 90verning the plan on the rules governing your COBRA continuation coverage rights.
You have rights regarding reduction or elimination of exclusionary periods of coverage for preexisting conditions
under your group health plan, if you have creditable coverage from another plan. You should be provided a
certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you
lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your
COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24
months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting
condition exclusion for 12 months (18 months for late enrollees) after your enrolment date in your coverage. (This
does not apply to the Health FSA, which is an "excepted benefit" under HIPM.)
HIPAA Privacy Rights. Under another provision of HIPAA, group health plans (including the Health FSA) are
required to take steps to ensure that certain "protected health information" (PHI) is kept confidential. You may
receive a separate notice from the Employer (or medical insurers) that outlines its health privacy policies. (Note:
This provision is effective as of April 14, 2004.)
Prudent Action by Plan Fiduciaries. In addition to creating rights for Plan Participants, ERISA imposes duties
upon the people who are responsible for the operation of the employee benefit plan. The people who operate
your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other plan
participants and beneficiaries. No one, including your Employer, your union, or any other person, may fire you or
otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your
rights under ERISA.
Enforce Your Rights. If your claim for a welfare benefit is denied in whole or in part you must receive a written
explanation of the reason for the denial. You have the right to have the Plan reviewed and reconsider your claim.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of
plan documents or the latest annuai report (if any) from the Plan and do not receive them within 30 days, you
may file suit in a federal court. In such case, the court may require the Plan Administrator to provide the materials
and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of
reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored,
in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plan's decision
or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you
may file suit in Federal court.
If it should happen that plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting
your rights, you may seek assistance from the U.S, Department of Labor, or you may file suit in a Federal court.
The court will decide who should pay court costs and legal fees. If you are successful, the court may order the
person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and
fees, for example, if it finds your claim is frivolous.
Assistance With Your Questions. If you have any questions about your Plan, you should contact the Plan
Administrator. If you have any questions about this statement or about your rights under ERISA or HIPM, or if
you need assistance in obtaining documents from the administrator, you should contact the nearest office of the
Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the
Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of
Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also obtain certain publications about
your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security
Administration.
16
Age!lua Itsm No. '16~5
February 10. 2009
Page 99 of 99
25. Can the Plan be terminated or amended?
Yes. Collier County Government reserves the right to terminate, suspend, withdraw or modify plan benefits in
whole or in part at any time by action of its Board of Directors, subject to the applicable provisions of any
insurance contracts providing benefits described above, However, no such change will cause you to forfeit any
funds you had contributed to the Plan prior to the change. In addition, any insurance carrier may cancel insurance
policies for under-enrollment or for nonpayment of premiums in certain circumstances. Any failure of insurance
benefits, whether due to Collier County Government's negligence, gross neglect, or otherwise, including, but not
limited to, failure to enroll a participant or to pay premiums shall not result in any liability by Collier County
Government to a Participant. Your coverage shall terminate when you leave employment if you are no longer
eligible under the terms of any of the insurance policies or benefits provided by this Plan, or when insurance
coverage terminates, whichever happens first.
Any beneiits to be provided by insurance shaii be provided oniy after: (1) you have provided the Pian
Administrator the necessary information to apply for insurance; and (2) the insurance is in effect for you.
17