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Agenda 01/27/2015 Item #16E 3 1/27/2015 16.E.3. EXECUTIVE SUMMARY Recommendation to approve the Collier County Government Employee Benefit Plan Document, Dental Plan Document, Flexible Benefits Plan Document and Health Reimbursement Arrangement Document effective January 1, 2015. OBJECTIVE: To receive approval of the Group Health, Group Dental, Flexible Benefits and Health Reimbursement Account Plan Documents for the purpose of administering these programs effective January 1, 2015. CONSIDERATIONS: The Board of Commissioners provides group health insurance, group dental insurance, a flexible reimbursement program and a health reimbursement account program to its employees and participating agencies through a partially self-insured group benefits program. Federal and state law requires that the Board adopt Master Plan Documents (the Policy or Plan Documents) to govern covered benefits and exclusions provided by these Plans. The County's third party claims administrator, Allegiance, Inc., utilizes the Plan Documents to adjudicate claims. The Plan's reinsurance carriers use the Plan Documents to determine reinsurance pricing and reimbursement eligibility. The County's actuarial and benefit consulting firm utilizes the Documents to determine Plan rates and to comply with Florida Department of Insurance rate filings pursuant to Florida Statutes Chapter 112.08. Finally, the Risk Management staff utilizes the Plan Documents to administer the overall program. The current Plan Documents were approved by the Board effective January 1, 2014. The proposed Plan Documents will take effect January 1, 2015. The significant changes to the Plan Documents are as follows: 1. Pursuant to the requirements of the Affordable Care Act, the out of pocket maximums for medical expenses (including co-pays and deductibles) under the Basic Plan are decreased as follows: Basic Plan Out of Pocket Max PPO Network Single From $6,350 to $5,200 Family From $12,700 to$10,400 2. Pursuant to IRS Publication 502, the "use it or lose it" rule for Flexible Spending Accounts has been changed. Up to $500 of unused 2014 health flexible spending account (FSA) elections can be carried forward for use in the 2015 plan year. This feature replaces the current 2 1, month grace period extension. 3. Pursuant to the Board's approval on September 23, 2014 of item 16E3, the Dental Insurance program will change from a fully insured plan sponsored by CIGNA to a self insured plan administered by Allegiance, the County's Health Plan Administrator. The Plan will continue to utilize the CIGNA provider network. The Dental Plan Document has been amended to reflect this change. 4. Any Hospital Observation that extends beyond 24 hours will require precertification for medical necessity. Packet Page-530- 1/27/2015 16.E.3. 5. Under the Envision pharmacy program, members may request a 90 day supply of medications (subject to limitations) at any network retail pharmacy. All deductibles, co-payments and out of pocket maximums for the Select and Premium Plans will remain unchanged. The Plan Documents were prepared by the staff attorneys at Allegiance, Inc., the county's third party administrator in conjunction with risk management staff. The Documents have also been reviewed for legality by the County Attorney's Office. The Plan Documents are attached as part of the agenda item. Once approved by the Board, each employee will be provided a copy of both a Summary Plan Description and Plan Documents as required by PPACA and as recommended by Allegiance, Inc. FISCAL IMPACT: There is no fiscal impact associated with the approval of the Plan Documents. The Fund 517, Group Health and Life Insurance budget for FY 15 has been approved by the Board and the adoption of these Plan Documents will not change the adopted budget. GROWTH MANAGEMENT IMPACT: There is no growth management impact associated with the approval of these Documents. LEGAL CONSIDERATIONS: This item is approved as to form and legality, and requires majority vote for Board approval.—SRT RECOMMENDATION: It is recommended that the Board approves the Collier County Government Employee Benefit Plan Document, Flexible Benefits Plan Document and Health Reimbursement Arrangement Document effective January 1, 2015. PREPARED BY: Jeff Walker, CPCU, ARM, Director Risk Management Attachments: • Collier County Government Health Plan Document • Health Plan Amendments (5) • Health Reimbursement Arrangement Document • Flexible Benefits Plan Document • Dental Plan Document Packet Page-531- 1/27/2015 16.E.3. COLLIER COUNTY Board of County Commissioners Item Number: 16.16.E.16.E.3. Item Summary: Recommendation to approve the Collier County Government Employee Benefit Plan Document, Dental Plan Document, Flexible Benefits Plan Document and Health Reimbursement Arrangement Document effective January 1, 2015. Meeting Date: 1/27/2015 Prepared By Name: WalkerJeff Title:Director-Risk Management, Risk Management 12/15/2014 1:14:54 PM Submitted by Title: Director-Risk Management,Risk Management Name: WalkerJeff 12/15/2014 1:14:55 PM Approved By Name: TeachScott Title: Deputy County Attorney, County Attorney Date: 12/24/2014 4:07:05 PM Name: PriceLen Title: Administrator-Administrative Services,Administrative Services Division Date: 12/30/2014 10:25:13 AM Name: TeachScott Title: Deputy County Attorney, County Attorney Date: 1/5/2015 1:46:33 PM Name: KimbleSherry Title: Management/Budget Analyst, Senior, Office of Management&Budget Date: 1/6/2015 9:18:38 AM Packet Page-532- 1/27/2015 16.E.3. Name: KlatzkowJeff Title: County Attorney, Date: 1/14/2015 11:11:59 AM Name: OchsLeo Title: County Manager, County Managers Office Date: 1/19/2015 6:48:22 PM Packet Page -533- 1/27/2015 16.E.3. PLAN DOCUMENT SUMMARY PLAN DESCRIPTION for the COLLIER COUNTY GOVERNMENT EMPLOYEE BENEFIT PLAN This booklet describes the Plan Benefits in effect as of January 1, 2014 The Plan has been established for the benefit of Eligible employees and their dependents of: COLLIER COUNTY GOVERNMENT Claims Processed By: ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. 2806 South Garfield Street PO Box 3018 Missoula,MT 59806-3018 Phone Number:(855)333-1004 Collier County Government-SPD Group#2003021-Eff Date 1/1/2014 Packet Page-534- 1/27/2015 16.E.3. Packet Page-535- 1/27/2015 16.E.3. TABLE OF CONTENTS INTRODUCTION 1 HEALTH PLAN QUALIFIERS 2 QUALIFYING PERIODS 2 QUALIFYING GUIDELINES 2 PLAN QUALIFIERS 2 NEW HIRES AND NEW SPOUSES 3 EMPLOYEES WHO BECOME TOTALLY DISABLED DURING THE QUALIFYING PERIOD 3 EMPLOYEES WHO LEAVE AND RETURN TO EMPLOYMENT WITHIN THE CURRENT BENEFIT PERIOD 3 IN-NETWORK BENEFIT 4 SCHEDULE OF BENEFITS -PREMIUM OPTION 5 SCHEDULE OF BENEFITS -SELECT OPTION 9 SCHEDULE OF BENEFITS -BASIC OPTION 13 PHARMACY BENEFIT 17 PREMIUM OPTION -COST SHARING PROVISIONS 17 SELECT OPTION -COST SHARING PROVISIONS 18 BASIC OPTION -COST SHARING PROVISIONS 18 COVERAGE 19 SERVICE OPTIONS 20 DRUG OPTIONS 20 COINSURANCE 20 SUPPLY LIMITS 21 STEP THERAPY PROGRAM 21 PRIOR AUTHORIZATION 21 EXCLUSIONS 21 MEDICAL BENEFIT DETERMINATION REQUIREMENTS 23 ELIGIBLE SERVICES, TREATMENTS AND SUPPLIES 23 DEDUCTIBLE 23 BENEFIT PERCENTAGE 23 OUT-OF-POCKET MAXIMUM 23 'COPAYMENT 23 MAXIMUM BENEFIT 24 APPLICATION OF DEDUCTIBLE AND ORDER OF BENEFIT PAYMENT 24 CHANGES IN COVERAGE CLASSIFICATION 24 NEW YORK STATE EXPENSES 24 MEDICAL BENEFITS 25 SMARTCHOICE PROGRAM 39 MEDICAL EXPENSE AUDIT BONUS 40 NOTIFICATION PROVISIONS 41 MANDATORY CASE MANAGEMENT 43 GENERAL EXCLUSIONS AND LIMITATIONS 44 Collier County Government-SPD i Group#2003021 -Eff Date 1/1/2014 Packet Page-536- 1/27/2015 16.E.3. COORDINATION OF BENEFITS 49 DEFINITIONS 49 ORDER OF BENEFIT DETERMINATION 50 Non-Dependent/Dependent 50 Child Covered Under More Than One Plan 50 Active or Inactive Employee 51 Longer or Shorter Length of Coverage 51 No Rules Apply 51 COORDINATION WITH MEDICARE 51 For Working Aged 51 For Retired Persons 52 For Covered Persons who are Disabled 52 For Covered Persons with End Stage Renal Disease 52 COORDINATION WITH MEDICAID 52 COORDINATION WITH TRICARE/CHAMPVA 52 PROCEDURES FOR CLAIMING BENEFITS 53 CLAIM DECISIONS ON CLAIMS AND ELIGIBILITY 53 Urgent Care Claims 54 Pre-Service Claims 54 Post-Service Claims 54 Concurrent Care Review 54 APPEALING AN UN-REIMBURSED PRE-SERVICE CLAIM 54 First Level of Benefit Determination Review 55 Second Level of Benefit Determination Review 55 INDEPENDENT EXTERNAL REVIEW FOR A PRE-SERVICE CLAIM 56 APPEALING AN UN-REIMBURSED POST-SERVICE CLAIM 56 First Level of Benefit Determination Review 57 Second Level of Benefit Determination Review 57 INDEPENDENT EXTERNAL REVIEW FOR A POST-SERVICE CLAIM 57 ELIGIBILITY PROVISIONS 59 EMPLOYEE ELIGIBILITY 59 WAITING PERIOD 59 DEPENDENT ELIGIBILITY 59 EXTENDED COVERAGE FOR DEPENDENTS 60 PARTICIPANT ELIGIBILITY FOR DEPENDENT COVERAGE 60 DECLINING COVERAGE 60 RETIREE ELIGIBILITY 60 EFFECTIVE DATE OF COVERAGE 61 PARTICIPANT COVERAGE 61 DEPENDENT COVERAGE 61 AUTOMATIC NEWBORN COVERAGE 61 RETIREE COVERAGE 61 OPEN ENROLLMENT PERIOD 62 SPECIAL ENROLLMENT PERIOD 62 CHANGE IN STATUS 63 QUALIFIED MEDICAL CHILD SUPPORT ORDER PROVISION 64 PURPOSE 64 DEFINITIONS 64 CRITERIA FOR A QUALIFIED MEDICAL CHILD SUPPORT ORDER 64 PROCEDURES FOR NOTIFICATIONS AND DETERMINATIONS 65 NATIONAL MEDICAL SUPPORT NOTICE 65 Collier County Government-SPD ii Group#2003021 -Eff Date 1/1/2014 Packet Page-537- 1/27/2015 16.E.3. FAMILY AND MEDICAL LEAVE 66 DEFINITIONS 66 EMPLOYERS SUBJECT TO FMLA 66 ELIGIBLE EMPLOYEES 67 REASONS FOR TAKING LEAVE 67 ADVANCE NOTICE AND MEDICAL CERTIFICATION 67 PROTECTION OF JOB BENEFITS 67 UNLAWFUL ACTS BY EMPLOYERS 67 ENFORCEMENT 67 TERMINATION OF COVERAGE 68 PARTICIPANT TERMINATION 68 RETIREE TERMINATION 68 DEPENDENT TERMINATION 69 REINSTATEMENT OF COVERAGE 69 VOLUNTARY SEPARATION INCENTIVE PROGRAM 69 RESCISSION OF COVERAGE 70 CONTINUATION COVERAGE AFTER TERMINATION 71 NOTIFICATION RESPONSIBILITIES 71 ELECTION OF COVERAGE 72 MONTHLY PREMIUM PAYMENTS 72 DISABILITY EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE 73 SECOND QUALIFYING EVENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE 73 MEDICARE ENROLLMENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE 73 WHEN COBRA CONTINUATION COVERAGE ENDS 73 QUESTIONS 74 INFORM THE PLAN OF ADDRESS CHANGES 74 COVERAGE FOR A MILITARY RESERVIST 75 FRAUD AND ABUSE 76 MISSTATEMENT OF AGE 76 MISREPRESENTATION OF ELIGIBILITY 76 MISUSE OF IDENTIFICATION CARD 76 REIMBURSEMENT TO PLAN 76 RESCISSION OF COVERAGE 76 RECOVERY/REIMBURSEMENT/SUBROGATION 77 RIGHT TO RECOVER BENEFITS PAID IN ERROR 77 REIMBURSEMENT 77 SUBROGATION 77 RIGHT OF OFF-SET 79 PLAN ADMINISTRATION 80 PURPOSE 80 EFFECTIVE DATE 80 PLAN YEAR 80 PLAN SPONSOR 80 PLAN SUPERVISOR 80 NAMED FIDUCIARY AND PLAN ADMINISTRATOR 80 PLAN INTERPRETATION 80 CONTRIBUTIONS TO THE PLAN 81 PLAN AMENDMENTS/MODIFICATION/TERMINATION 81 TERMINATION OF PLAN 81 Collier County Government-SPD iii Group#2003021-Eff Date 1/1/2014 Packet Page-538- 1/27/2015 16.E.3. SUMMARY PLAN DESCRIPTIONS 81 CREDITABLE COVERAGE PROCEDURES 82 CERTIFICATE OF CREDITABLE COVERAGE 82 GENERAL PROVISIONS 83 EXAMINATION 83 PAYMENT OF CLAIMS 83 LEGAL PROCEEDINGS 83 NO WAIVER OR ESTOPPEL 83 VERBAL STATEMENTS 83 FREE CHOICE OF PHYSICIAN 83 WORKERS' COMPENSATION NOT AFFECTED 84 CONFORMITY WITH LAW 84 MISCELLANEOUS 84 FACILITY OF PAYMENT 84 PROTECTION AGAINST CREDITORS 84 PLAN IS NOT A CONTRACT 84 GENERAL DEFINITIONS 85 NOTICES 99 HIPAA PRIVACY AND SECURITY STANDARDS 100 DEFINITIONS 100 PRIVACY CERTIFICATION 100 SECURITY CERTIFICATION 101 PLAN SUMMARY 102 Collier County Government-SPD iv Group#2003021 -Eff Date 1/1/2014 Packet Page-539- 1/27/2015 16.E.3. INTRODUCTION Effective January 1,2014,Collier County Government, hereinafter referred to as the"County"or"Employer", restates the benefits, rights and privileges which will pertain to participating Employees, referred to as "Participants,"qualifying Retirees and the eligible Dependents of such Participants or Retirees, as defined, and which benefits are provided through a fund established by the County and referred to as the"Plan. This Summary Plan Description includes changes reflected by Amendments #1, #2 and #3 to the Plan Document dated January 1,2014. "This booklet describes the Plan in effect as of January 1, 2014. Coverage provided under this Plan for Employees and their Dependents will be in accordance with the Eligibility, Effective Date,Qualified Medical Child Support Order,Termination, Family and Medical Leave Act and other applicable provisions as stated in this Plan. Collier County Government(the Plan Sponsor)has retained the services of an independent Plan Supervisor, experienced in claims processing, to handle health claims. The Plan Supervisor for the Plan is: Allegiance Benefit Plan Management, Inc. P.O. Box 3018 Missoula, MT 59806-3018 We recommend that you read this booklet carefully before incurring any medical expenses. If you have specific questions regarding coverage or benefits, you are urged to refer to the Plan Document which is available for your review in the Personnel Office or at the office of the Plan Supervisor. If you wish, you may call or write to Allegiance Benefit Plan Management, Inc. regarding any detailed questions you may have concerning the Plan. This Plan is not intended to,and cannot be used as workers compensation coverage for any employee or any covered dependent of an employee. Therefore,this plan generally excludes claims related to any activity engaged in for wage or profit including,but not limited to,farming,ranching,part-time and seasonal activities. See Plan Exclusions for specific information. The information contained in this Plan Document/Summary Plan Description is only a general statement regarding FMLA,COBRA,USERRA,and QMCSO's. It is not intended to be and should not be relied upon as complete legal information about those subjects. Covered Persons and Employers should consult their own legal counsel regarding these matters. Collier County Government-SPD 1 Group#2003021-Eff Date 1/1/2014 Packet Page-540- 1/27/2015 16.E.3. HEALTH PLAN QUALIFIERS Employees and their spouse may qualify under any of the three Plan Options made available under this Plan: Premium, Select and Basic. Plan Options for Employees may be different than their spouses depending on the results of the Plan Qualifiers. Qualifying Periods for Retirees and COBRA Participants will be the same as they were prior to retirement or continuing coverage under COBRA. Plan Qualifiers are specific actions to be completed by an Employee or Retiree and their spouse to determine which health Plan Option they would qualify for the next Benefit Period. QUALIFYING PERIODS 1. For spouses a Qualifying Period will be October 1 ending September 30 of every odd year. 2. For Employees a Qualifying Period will be October 1 ending September 30 of every even year. QUALIFYING GUIDELINES The following are qualifying guidelines: 1. Paperwork is due to the on-site contracted Health Advocate's office by September 30 (*no exceptions); 2. Tobacco Users must complete qualifying criteria by September 30; 3. Risk Factors criteria must be completed by September 30.. PLAN QUALIFIERS The following are Plan Qualifiers for the Premium and Select Options(Plan Qualifiers were determined using Evidence Based Medical Guidelines and may be adjusted annually): 1. Complete Health history questionnaire - This can be done online, at home, or at your desk. A Kiosk is available in the Health Advocate"s office for Employees who do not have access to a computer workstation. 2. Lab work - Lab draws will be scheduled during regular work hours on the main campus and at various worksites by the contracted Lab provider. Calendars will be posted at all work sites. All qualifying lab draws must be completed by Quest Diagnostics. Eligible Employees/Spouses/Retirees/COBRA need to make an appointment with Quest through the Advocate website at www.chipha.com. 3. Meet with On-site Health Advocate-Schedule your appointment with the Health Advocate through www.chpha.com to review the results of your Personal Wellness Profile,which includes the lab draw, Health History Questionnaire and baseline measurements. Eligible Retirees/COBRA who do not reside in Collier County will contact the Advocates by phone. The following are additional Plan Qualifiers for the Premium Option: 1. Age/Gender Screening-(For ages 20,25,30,35,40,43,46,50 and over)-Screenings, including, pap smear, mammogram, skin screening, testicular exam and colonoscopy, must be completed at the MedCenter, the MedCenter North or by your Primary Care Physician. A copy of the lab results from Personal Wellness Profile should be given to the Physician at the appointment. Collier County Government-SPD 2 Group#2003021 -Eff Date 1/1/2014 Packet Page-541- 1/27/2015 16.E.3. Health Plan Qualifiers 2. Tobacco Cessation Program-This Program is only administered through The MedCenter or The MedCenter North. A certificate of completion will be issued after a follow-up lab test has been completed at either of the MedCenters. The certificate of completion must be provided to the on-site contracted Health Advocate by September 30. Covered Persons who do not reside in Collier County will work with the Health Advocate who will monitor the tobacco cessation program they are engaged in. A certificate of completion must be provided to the on-site contracted Health Advocate by September 30. There are no Plan Qualifiers to participate in the Basic Option. Participants, Retirees and their spouses automatically qualify for the Basic Option if qualifying requirements for the Select or Premium Options are not completed by September 30. NEW HIRES AND NEW SPOUSES All newly hired Employees,newly eligible Employees and newly covered spouses will be placed in the Select Option and will be required to complete Plan Qualifiers by September 30. Employees whose effective date of coverage is on or after October 1 will remain in the Select Plan Option and will have until September 30 of the following Benefit Period to complete Plan Qualifiers. EMPLOYEES WHO BECOME TOTALLY DISABLED DURING THE QUALIFYING PERIOD Employees who become Totally Disabled for six (6) months or more during the Qualifying Period and are unable to complete the Plan Qualifiers,will remain in the Plan Option they are currently in until such time Plan Qualifiers can be completed. Verification of the disability should be submitted to the Health Advocates Office. "Total Disability"or"Totally Disabled"means that a person is prevented from performing the principal functions of the person's occupation,and as a result,the person has a loss of 20%or more of their pre-disability weekly earnings due to an Accidental Injury, Illness, Mental Illness, Substance Abuse or Pregnancy. EMPLOYEES WHO LEAVE AND RETURN TO EMPLOYMENT WITHIN THE CURRENT BENEFIT PERIOD Employees who leave employment and return within the current Benefit Period will be enrolled in the plan they were in as of the date of termination. If the Employee returns after the current Benefit Period,the Employee will be placed in the Select Plan Option. Collier County Government-SPD 3 Group#2003021 -Eff Date 1/1/2014 Packet Page-542- 1/27/2015 16.E.3. IN-NETWORK BENEFIT This Plan provides benefits through a group of contracted providers (In-Network Providers). An In-Network Provider means using a Physician who is part of the group of contracted providers. Using In-Network Physicians offers cost-savings advantages because a Covered Person pays only a percentage of the scheduled fee for services provided. Out-of-Network Provider means a provider who is not an In-Network Provider. A Covered Person who uses an Out-of-Network Provider will pay more and his or her share of the cost may not apply to the Out-of-Pocket Maximum. To determine if a Physician or health care provider qualifies as an eligible In-Network Provider under this Plan, please consult Allegiance's website at www.abpmtpa.com/ccq to access links for directories of participating providers. The following benefit provisions apply when a covered service is rendered by a Out-of-Network provider: 1. Charges for an Emergency as defined by this Plan, limited to only those emergency medical procedures necessary to treat and stabilize an eligible injury or illness and then only to the extent that the same are necessary in order for the Covered Person to be transported, at the earliest medically appropriate time to an In-Network Hospital,clinic or other facility,or discharged will be paid at the In- Network level of benefits. 2. Charges which are incurred as a result of and related to confinement in or use of an In-Network Hospital, clinic or other facility only for Out-of-Network services and providers over whom or which the Covered Person does not have any choice in or ability to select will be paid at the In-Network Provider level of benefits. The Plan UCR limitations will not apply to this exception. 3. If the provider rendering service is located in Collier County and is not part of the CHP Network but is part of the CIGNA Network, benefits will be paid at the Out-of-Network Provider level of benefits. 4. If the provider rendering service is located outside of Collier County and is not part of the CHP Network but is part of the CIGNA Network, benefits will be paid at the In-Network Provider level of benefits. Collier County Government-SPD 4 Group#2003021 -Eff Date 1/1/2014 Packet Page-543- 1/27/2015 16.E.3. SCHEDULE OF BENEFITS- PREMIUM OPTION FOR ELIGIBLE PARTICIPANTS AND DEPENDENTS ALL BENEFITS PAYABLE UNDER THIS PLAN ARE SUBJECT TO THE APPLICABLE PLAN EXCLUSIONS AND THE USUAL, CUSTOMARY AND REASONABLE LIMITS OF THE PLAN THE BENEFIT PERIOD IS A CALENDAR YEAR MEDICAL BENEFIT COST SHARING PROVISIONS IN-NETWORK OUT-OF-NETWORK DEDUCTIBLE Per Covered Person per Benefit Period $400 $800 Per Family per Benefit Period $800 $1,600 The Deductible applies to all Eligible Expenses, unless specifically stated otherwise. An individual Covered Person cannot receive credit toward the Family Deductible for more than the individual Annual Deductible. The Deductible is combined for both In-Network Providers and Out-of-Network Providers. OUT-OF-POCKET MAXIMUM Per Covered Person per Benefit Period $1,800" $3,800* Per Family per Benefit Period $3,600* $7,600* *Includes the Deductible and any Medical Benefit Copayments The Out-of-Pocket Maximum applies to all Eligible Expenses,unless specifically stated otherwise. The Out- of-Pocket Maximum is combined for both In-Network Provider and Out-of-Network Providers. Expenses incurred for the following do not apply toward the Out-of-Pocket Maximum:1)any penalty amounts; 2)any charges defined in the General Exclusions and Limitations Section; 3)Dental Care expenses due to Illness or injury. BENEFIT PERCENTAGE Before satisfaction of Out-of-Pocket Maximum 80% 70% After satisfaction of Out-of-Pocket Maximum 100% 100% The Benefit Percentage applies to all Eligible Expenses, unless specifically stated otherwise. Eligible Expenses will be paid by the Plan according to the applicable Benefit Percentage. NON-COMPLIANCE PENALTY See Mandatory Case Management Non Participation in Case Management Penalty $1,000 Non Participation in Notification Provisions $300 PHYSICIAN REGIONAL HOSPITAL COPAYMENT Copayment applies to any non-emergent or scheduled $1,000 Inpatient admission or Outpatient service. MAXIMUM LIFETIME BENEFIT FOR ALL CAUSES Unlimited Collier County Government-SPD 5 Group#2003021 -Eff Date 1/1/2014 Packet Page-544- 1/27/2015 16.E.3. Schedule of Benefits-Premium Option BENEFIT MAXIMUMS ARE FOR SERVICES RECEIVED FROM IN-NETWORK AND OUT-OF- NETWORK PROVIDERS BENEFIT PERCENTAGE/LIMITATIONS MEDICAL BENEFITS IN-NETWORK I OUT-OF-NETWORK Acupuncture 80%after Deductible I 70%after Deductible 20 Visits Ambulance Services 80%after Deductible 80%after Deductible Bariatric Surgery(only if pre- 80%after Deductible 70% after Deductible approved by SmartChoice) Chiropractor Care/Spinal 100% after$25 Copayment per No Coverage Manipulation/Massage Therapy Visit, Deductible Waived Combined Maximum of 20 Visits* per Benefit period *Visit includes all services performed during a calendar day, including x-rays Diagnostic Colonoscopies(See 80%, Deductible Waived No Coverage Medical Benefits) See Preventive Care for Screening Colonoscopies Dental Care(due to an Illness 80%, Deductible Waived 70%after Deductible or Injury. See Medical Benefits) After benefits are exhausted under any Dental Plan. Durable Medical Equipment 80%after Deductible 70% after Deductible Emergency Room Services (Facility charges only) Due to Medical Emergency $50 Copayment per visit, $50 Copayment per visit, then 80%after Deductible then 70%after Deductible Non-Medical Emergency $100 Copayment per visit, $100 Copayment per visit, then 80% after Deductible then 70%after Deductible Note: The Emergency Room Copayment will be waived if the person is admitted directly as an Inpatient to the Hospital. Hearing Aids 80%after Deductible I 70% after Deductible Maximum Benefit of$5,000 every 5 Benefit Periods Home Health Care 80% after Deductible 70% after Deductible Hospice Care, including 80%after Deductible 70% after Deductible Bereavement Counseling Bereavement Counseling 15 visits per Family per Lifetime Hospital Services or Long- 80% after Deductible 70% after Deductible Term Acute Care Facility/Hosp (facility charges) Inpatient Room& Board Allowance Semi-private room rate* Semi-private room rate* Intensive Care Unit 80% of actual charge after Ded 70% of actual charge after Ded Outpatient 80%after Deductible 70% after Deductible *Room and board limited to Semi-private room rate. A private room will be considered eligible when Medically Necessary. Charges made by a Hospital having only single or private rooms will be considered at the least expensive rate for a single or private Collier County Government-SPD 6 Group#2003021 -Eff Date 1/1/2014 Packet Page-545- 1/27/2015 16.E.3. Schedule of Benefits-Premium Option BENEFIT PERCENTAGE/LIMITATIONS MEDICAL BENEFITS IN-NETWORK I OUT-OF-NETWORK Medical Records 100%, Deductible Waived 100%, Deductible Waived up to maximum benefit of$100 up to maximum benefit of$100 per provider per provider Mental Illness Inpatient 80%after Deductible 70%after Deductible Outpatient 100% after$25 Copayment of 70%after Deductible the first$500 per visit, Deductible Waived, then 80%after Deductible On-Site Clinic Services 100%, Deductible Waived N/A The on-site clinic services are available to all eligible Participants and Dependents 15 years or older who are covered under the Collier County Government Employee Benefit Plan. A referral from the clinic to an In-Network Provider will be processed as an In-Network claim. Outpatient Lab Services 100% of the first$500 per visit, 70%after Deductible Deductible Waived, then 80% after Deductible Outpatient Renal Dialysis 80%after Deductible 100% after Deductible Benefit For Out-of-Network Medical Services/Supplies: Maximum Benefit 125%of Medicare Allowable ESRD Related Drugs: Maximum Benefit of 125%of the Average Sales Price(ASP) Outpatient Therapies(physical, 100% after$35 Copayment of 70% after Deductible speech, occupational, aquatic) the first$500 per visit, Deductible Waived, then 80% after Deductible Pain Management 80%after Deductible 70% after Deductible Epidurals,facet blocks and nerve stimulators are limited to a combined Maximum Benefit of 6 procedures per Benefit Period. Other procedures are not limited. Physician Services Inpatient/Outpatient Services, 80%after Deductible 70%after Deductible except for office visits Primary Care Physician Office 100%after$25 Copayment of 70% after Deductible Visit Charge the first$500 per visit, Deductible Waived, then 80% after Deductible Specialist Physician Office 100% after$35 Copayment of 70% after Deductible Visit Charge the first$500 per visit, Deductible Waived, then 80%after Deductible All Other Services/Supplies 100%of the first$500 per visit, 70% after Deductible other than evaluation and Deductible Waived, management charges then 80%after Deductible performed in a Physician's office. If more than one Physician is seen in the same clinic on the same day, only one Copayment will apply. "Primary Care Physician" includes a general practitioner, family practitioner, Internist, OB/GYN (obstetrics/gynecology), Pediatrician, Psychiatrist, licensed nurse practitioner or Physician Assistant. "Specialist Physician"includes any Physician practicing any branch of medicine or medical specialty who is not otherwise a Primary Care Physician. Collier County Government-SPD 7 Group#2003021 -Eff Date 1/1/2014 Packet Page-546- 1/27/2015 16.E.3. Schedule of Benefits-Premium Option BENEFIT PERCENTAGE/LIMITATIONS MEDICAL BENEFITS IN-NETWORK I OUT-OF-NETWORK Preventive Care(See Medical 100%, Deductible Waived No Coverage Benefits Section) Radiation Therapy/ 80%after Deductible 70% after Deductible Chemotherapy/Home Infusion Therapy Routine Qualifier Services(See 100%, Deductible Waived No Coverage Medical Benefits Section) Scalp Hair Prosthesis' 80%after Deductible 80% after Deductible (wigs/hair pieces) Maximum Lifetime Benefit one wig or hair piece Skilled Nursing Facility and 80%after Deductible 70%after Deductible Rehabilitation Facility Substance Abuse/Chemical Dependency Disorders 80% after Deductible 70%after Deductible Inpatient Outpatient 100% after$25 Copayment of 70%after Deductible the first$500 per visit, Deductible Waived, then 80% after Deductible Emergency Care (ambulance 80%after Deductible 80% after In-Network and emergency room) Deductible In-Network Out-of-Pocket Maximum applies Tobacco Cessation (Referral 100%, Deductible and N/A from the MedCenter is required) Copayment Waived Urgent Care Facility 80% after Deductible 70% after Deductible 1"Scalp Hair Prosthesis"(Schedule)replaced by Amendment#1 effective 1/1/2014 Collier County Government-SPD 8 Group#2003021 -Eff Date 1/1/2014 Packet Page-547- 1/27/2015 16.E.3. SCHEDULE OF BENEFITS-SELECT OPTION FOR ELIGIBLE PARTICIPANTS AND DEPENDENTS ALL BENEFITS PAYABLE UNDER THIS PLAN ARE SUBJECT TO THE APPLICABLE PLAN EXCLUSIONS AND THE USUAL, CUSTOMARY AND REASONABLE LIMITS OF THE PLAN THE BENEFIT PERIOD IS A CALENDAR YEAR MEDICAL BENEFIT COST SHARING PROVISIONS IN-NETWORK OUT-OF-NETWORK DEDUCTIBLE Per Covered Person per Benefit Period $700 $1,400 Per Family per Benefit Period $1,400 $2,800 The Deductible applies to all Eligible Expenses, unless specifically stated otherwise. An individual Covered Person cannot receive credit toward the Family Deductible for more than the individual Annual Deductible. The Deductible is combined for both In-Network Providers and Out-of-Network Providers. OUT-OF-POCKET MAXIMUM Per Covered Person per Benefit Period $3,400* $6,400* Per Family per Benefit Period $6,800* $12,800* *Includes the Deductible and any Medical Benefit Copayments The Out-of-Pocket Maximum applies to all Eligible Expenses,unless specifically stated otherwise. The Out- of-Pocket Maximum is combined for both In-Network Provider and Out-of-Network Providers. Expenses incurred for the following do not apply toward the Out-of-Pocket Maximum:1)any penalty amounts; 2)any charges defined in the General Exclusions and Limitations Section;3)Dental Care expenses due to Illness or injury. BENEFIT PERCENTAGE Before satisfaction of Out-of-Pocket Maximum 80% 60% After satisfaction of Out-of-Pocket Maximum 100% 100% The Benefit Percentage applies to all Eligible Expenses, unless specifically stated otherwise. Eligible Expenses will be paid by the Plan according to the applicable Benefit Percentage. NON-COMPLIANCE PENALTY See Mandatory Case Management Non Participation in Case Management Penalty $1,000 Non Participation in Notification Provisions $300 PHYSICIAN REGIONAL HOSPITAL COPAYMENT Copayment applies to any non-emergent or scheduled Inpatient $1,000 admission or Outpatient service. MAXIMUM LIFETIME BENEFIT FOR ALL CAUSES Unlimited Collier County Government-SPD 9 Group#2003021 -Eff Date 1/1/2014 Packet Page-548- 1/27/2015 16.E.3. Schedule of Benefits-Select Option BENEFIT MAXIMUMS ARE FOR SERVICES RECEIVED FROM IN-NETWORK AND OUT-OF- NETWORK PROVIDERS BENEFIT PERCENTAGE/LIMITATIONS MEDICAL BENEFITS ' IN-NETWORK I OUT-OF-NETWORK Acupuncture 80%after Deductible ( 60%after Deductible 20 Visits Ambulance Services 80% after Deductible 80% after Deductible Bariatric Surgery(only if pre- 80% after Deductible 60% after Deductible approved by SmartChoice) Chiropractor Care/Spinal 100% after$40 Copayment per No Coverage Manipulation/Massage Therapy Visit, Deductible Waived Combined Maximum of 20 Visits* per Benefit period *Visit includes all services performed during a calendar day, including x-rays Diagnostic Colonoscopies(See 80%, Deductible Waived No Coverage Medical Benefits) See Preventive Care for Screening Colonoscopies Dental Care(due to an Illness 80%, Deductible Waived 60% after Deductible or Injury. See Medical Benefits) After benefits are exhausted under any Dental Plan. Durable Medical Equipment 80% after Deductible 60% after Deductible Emergency Room Services (Facility charges only) Due to Medical Emergency $100 Copayment per visit, $100 Copayment per visit, then 80% after Deductible then 80% after Deductible Non-Medical Emergency $100 Copayment per visit, $100 Copayment per visit, then 80%after Deductible then 60% after Deductible Note:The Emergency Room Copayment will be waived if the person is admitted directly as an Inpatient to the Hospital. Hearing Aids 80%after Deductible I 60% after Deductible Maximum Benefit of$5.000 every 5 Benefit Periods Home Health Care 80%after Deductible 60% after Deductible Hospice Care, including 80% after Deductible 60% after Deductible Bereavement Counseling Bereavement Counseling 15 visits per Family per Lifetime Hospital Services or Long- 80%after Deductible 60% after Deductible Term Acute Care Facility/Hosp (facility charges) Inpatient Room & Board Allowance Semi-private room rate* Semi-private room rate* Intensive Care Unit 80%of actual charge after Ded 60%of actual charge after Ded Outpatient 80%after Deductible 60% after Deductible *Room and board limited to Semi-private room rate. A private room will be considered eligible when Medically Necessary. Charges made by a Hospital having only single or private rooms will be considered at the least expensive rate for a single or private Collier County Government-SPD 10 Group#2003021 -Eff Date 1/1/2014 Packet Page-549- 1/27/2015 16.E.3. Schedule of Benefits-Select Option BENEFIT PERCENTAGE/LIMITATIONS MEDICAL BENEFITS IN-NETWORK I OUT-OF-NETWORK Medical Records 100%, Deductible Waived 100%, Deductible Waived up to maximum benefit of$100 up to maximum benefit of$100 per provider per provider Mental Illness Inpatient 80% after Deductible 60% after Deductible Outpatient 100% after$40 Copayment of 60%after Deductible the first$500 per visit, Deductible Waived, then 80% after Deductible On-Site Clinic Services 100%, Deductible Waived N/A The on-site clinic services are available to all eligible Participants and Dependents 15 years or older who are covered under the Collier County Government Employee Benefit Plan. A referral from the clinic to an In-Network Provider will be processed as an In-Network claim. Outpatient Lab Services 100% of the first$500 per visit, 60% after Deductible Deductible Waived, then 80%after Deductible Outpatient Renal Dialysis 80% after Deductible 100% after Deductible Benefit For Out-of-Network Medical Services/Supplies: Maximum Benefit 125% of Medicare Allowable ESRD Related Drugs: Maximum Benefit of 125% of the Average Sales Price(ASP) Outpatient Therapies(physical, 100% after$40 Copayment of 60%after Deductible speech, occupational, aquatic) the first$500 per visit, Deductible Waived, then 80% after Deductible Pain Management 80%after Deductible 60%after Deductible Epidurals,facet blocks and nerve stimulators are limited to a combined Maximum Benefit of 6 procedures per Benefit Period. Other procedures are not limited. Physician Services Inpatient/Outpatient Services, 80%after Deductible 60% after Deductible except for office visits Primary Care Physician Office 100% after$40 Copayment of 60%after Deductible Visit Charge the first$500 per visit, Deductible Waived, then 80% after Deductible Specialist Physician Office 100%after$60 Copayment of 60%after Deductible Visit Charge the first$500 per visit, Deductible Waived, then 80%after Deductible All Other Services/Supplies 100% of the first$500 per visit, 60% after Deductible other than evaluation and Deductible Waived, management charges then 80% after Deductible performed in a Physician's office. If more than one Physician is seen in the same clinic on the same day, only one Copayment will apply. "Primary Care Physician" includes a general practitioner, family practitioner, Internist, OB/GYN (obstetrics/gynecology), Pediatrician, Psychiatrist, licensed nurse practitioner or Physician Assistant. "Specialist Physician"includes any Physician practicing any branch of medicine or medical specialty who is not otherwise a Primary Care Physician. Collier County Government-SPD 11 Group#2003021 -Eff Date 1/1/2014 Packet Page-550- 1/27/2015 16.E.3. Schedule of Benefits-Select Option BENEFIT PERCENTAGE/LIMITATIONS MEDICAL BENEFITS IN-NETWORK I OUT-OF-NETWORK Preventive Care(See Medical 100%, Deductible Waived No Coverage Benefits Section) Radiation Therapy/ 80%after Deductible 60% after Deductible Chemotherapy/Home Infusion Therapy Routine Qualifier Services(See 100%, Deductible Waived No Coverage Medical Benefits Section) Scalp Hair Prosthesis2 80%after Deductible 80% after Deductible (wigs/hair pieces) Maximum Lifetime Benefit one wig or hair piece Skilled Nursing Facility and 80%after Deductible 60% after Deductible Rehabilitation Facility Substance Abuse/Chemical Dependency Disorders 80%after Deductible 60% after Deductible Inpatient Outpatient 100% after$40 Copayment of 60%after Deductible the first$500 per visit, Deductible Waived, then 80% after Deductible Emergency Care (ambulance 80%after Deductible 80% after In-Network and emergency room) Deductible In-Network Out-of-Pocket Maximum applies Tobacco Cessation (Referral 100%, Deductible and N/A from the MedCenter is required) Copayment Waived Urgent Care Facility 80%after Deductible 60%after Deductible 2"Scalp Hair Prosthesis"(Schedule)replaced by Amendment#1 effective 1/1/2014 Collier County Government-SPD 12 Group#2003021 -Eff Date 1/1/2014 Packet Page-551- 1/27/2015 16.E.3. SCHEDULE OF BENEFITS-BASIC OPTION FOR ELIGIBLE PARTICIPANTS AND DEPENDENTS ALL BENEFITS PAYABLE UNDER THIS PLAN ARE SUBJECT TO THE APPLICABLE PLAN EXCLUSIONS AND THE USUAL, CUSTOMARY AND REASONABLE LIMITS OF THE PLAN THE BENEFIT PERIOD IS A CALENDAR YEAR MEDICAL BENEFIT COST SHARING PROVISIONS IN-NETWORK OUT-OF-NETWORK DEDUCTIBLE Per Covered Person per Benefit Period $2,000 $4,000 Per Family per Benefit Period $4,000 $8,000 The Deductible applies to all Eligible Expenses, unless specifically stated otherwise. An individual Covered Person cannot receive credit toward the Family Deductible for more than the individual Annual Deductible. The Deductible is combined for both In-Network Providers and Out-of-Network Providers. OUT-OF-POCKET MAXIMUM Per Covered Person per Benefit Period $6,350* $14,000* Per Family per Benefit Period $12,700* $28,000* *Includes the Deductible and any Medical Benefit Copayments The Out-of-Pocket Maximum applies to all Eligible Expenses,unless specifically stated otherwise. The Out- of-Pocket Maximum is combined for both In-Network Provider and Out-of-Network Providers. Expenses incurred for the following do not apply toward the Out-of-Pocket Maximum:1)any penalty amounts; 2)any charges defined in the General Exclusions and Limitations Section; 3)Dental Care expenses due to Illness or injury. BENEFIT PERCENTAGE Before satisfaction of Out-of-Pocket Maximum 80% 60% After satisfaction of Out-of-Pocket Maximum 100% 100% The Benefit Percentage applies to all Eligible Expenses, unless specifically stated otherwise. Eligible Expenses will be paid by the Plan according to the applicable Benefit Percentage. NON-COMPLIANCE PENALTY See Mandatory Case Management Non Participation in Case Management Penalty $1,000 Non Participation in Notification Provisions $300 PHYSICIAN REGIONAL HOSPITAL COPAYMENT Copayment applies to any non-emergent or scheduled Inpatient $1,000 admission or Outpatient service. MAXIMUM LIFETIME BENEFIT FOR ALL CAUSES Unlimited Collier County Government-SPD 13 Group#2003021 -Eff Date 1/1/2014 Packet Page-552- 1/27/2015 16.E.3. Schedule of Benefits-Basic Option BENEFIT MAXIMUMS ARE FOR SERVICES RECEIVED FROM IN-NETWORK AND OUT-OF- NETWORK PROVIDERS BENEFIT PERCENTAGE/LIMITATIONS MEDICAL BENEFITS IN-NETWORK I OUT-OF-NETWORK Acupuncture 80% after Deductible I 60% after Deductible 20 visits Ambulance Services 80% after Deductible 80%after Deductible Bariatric Surgery(only if pre- 80% after Deductible 60%after Deductible approved by SmartChoice) Chiropractor Care/Spinal 80%after Deductible No Coverage Manipulation/Massage Therapy Combined Maximum of 20 Visits*per Benefit period *Visit includes all services performed during a calendar day, including x-rays Diagnostic Colonoscopies 80%, Deductible Waived No Coverage (See Medical Benefits) See Preventive Care for Screening Colonoscopies Dental Care(due to an Illness 80%, Deductible Waived 60% after Deductible or Injury. See Medical Benefits) After benefits are exhausted under any Dental Plan. Durable Medical Equipment 80% after Deductible 60% after Deductible Emergency Room Services (Facility charges only) Due to Medical Emergency 80% after Deductible 80%after Deductible Non-Medical Emergency 80% after Deductible 60% after Deductible Hearing Aids 80%after Deductible 60% after Deductible Maximum Benefit of$5,000 every 5 Benefit Periods Home Health Care 80%after Deductible 60% after Deductible Hospice Care,including 80% after Deductible 60%after Deductible Bereavement Counseling Bereavement Counseling 15 visits per Family per Lifetime Hospital Services or Long- 80%after Deductible 60% after Deductible Term Acute Care Facility/Hosp (facility charges) Inpatient Room& Board Allowance Semi-private room rate* Semi-private room rate* Intensive Care Unit 80% of actual charge after Ded 60%of actual charge after Ded Outpatient 80% after Deductible 60% after Deductible *Room and board limited to Semi-private room rate. A private room will be considered eligible when Medically Necessary. Charges made by a Hospital having only single or private rooms will be considered at the least expensive rate for a single or private Collier County Government-SPD 14 Group#2003021 -Eff Date 1/1/2014 Packet Page-553- 1/27/2015 16.E.3. Schedule of Benefits-Basic Option BENEFIT PERCENTAGE/LIMITATIONS MEDICAL BENEFITS IN-NETWORK I OUT-OF-NETWORK Medical Records 100%, Deductible Waived 100%, Deductible Waived up to maximum benefit of$100 up to maximum benefit of$100 per provider per provider Mental Illness Inpatient 80% after Deductible 60% after Deductible Outpatient 80%after Deductible 60% after Deductible On-Site Clinic Services 100%, Deductible Waived N/A The on-site clinic services are available to all eligible Participants and Dependents 15 years or older who are covered under the Collier County Government Employee Benefit Plan. A referral from the clinic to an In-Network Provider will be processed as an In-Network claim. Outpatient Lab Services 80% after Deductible 60%after Deductible Outpatient Renal Dialysis 80% after Deductible 100% after Deductible Benefit For Out-of-Network Medical Services/Supplies: Maximum Benefit 125%of Medicare Allowable ESRD Related Drugs: Maximum Benefit of 125%of the Average Sales Price (ASP) Outpatient Therapies(physical, 80%after Deductible 60%after Deductible speech, occupational, aquatic) Pain Management 80%after Deductible 60% after Deductible Epidurals,facet blocks and nerve stimulators are limited to a combined Maximum Benefit of 6 procedures per Benefit Period. Other procedures are not limited. Physician Services Inpatient/Outpatient Services, 80%after Deductible 60%after Deductible except for office visits Primary Care Physician Office 60% after Deductible Visit Charge 80% after Deductible Specialist Physician Office 60%after Deductible Visit Charge 80% after Deductible All Other Services/Supplies 60% after Deductible other than evaluation and 80% after Deductible management charges performed in a Physician's office. "Primary Care Physician" includes a general practitioner, family practitioner, Internist, OB/GYN (obstetrics/gynecology), Pediatrician, Psychiatrist, licensed nurse practitioner or Physician Assistant. "Specialist Physician"includes any Physician practicing any branch of medicine or medical specialty who is not otherwise a Primary Care Physician. Preventive Care(See Medical 100%, Deductible Waived No Coverage Benefits Section) Radiation Therapy/ 80%after Deductible 60% after Deductible Chemotherapy/Home Infusion Therapy Collier County Government-SPD 15 Group#2003021 -Eff Date 1/1/2014 Packet Page-554- 1/27/2015 16.E.3. Schedule of Benefits-Basic Option BENEFIT PERCENTAGE/LIMITATIONS MEDICAL BENEFITS IN-NETWORK I OUT-OF-NETWORK Routine Qualifier Services(See 100%, Deductible Waived No Coverage Medical Benefits Section) Scalp Hair Prosthesis3 80%after Deductible 80% after Deductible (wigs/hair pieces) Maximum Lifetime Benefit one wig or hair piece Skilled Nursing Facility and 80%after Deductible 60% after Deductible Rehabilitation Facility Substance Abuse/Chemical Dependency Disorders 80% after Deductible 60% after Deductible Inpatient Outpatient 80% after Deductible 60%after Deductible Emergency Care (ambulance 80% after Deductible 80% after In-Network and emergency room) Deductible In-Network Out-of-Pocket Maximum applies Tobacco Cessation (Referral 100%, Deductible and N/A from the MedCenter is required) Copayment Waived Urgent Care Facility 80%after Deductible 60% after Deductible 3"Scalp Hair Prosthesis"(Schedule)replaced by Amendment#1 effective 1/1/2014 Collier County Government-SPD 16 Group#2003021 -Eff Date 1/1/2014 Packet Page-555- 1/27/2015 16.E.3. PHARMACY BENEFIT Prescription drug charges are payable only through the Plan's Pharmacy Benefit Manager(PBM) program, which program is sponsored in conjunction with and is an integral part of this Plan. Coinsurance does not serve to satisfy the Medical Benefits Annual Deductible or Out-of-Pocket Maximum. However, Pharmacy Coinsurance does apply toward the applicable Pharmacy Benefit Out-of-Pocket Maximum. The Pharmacy Benefit Manager(PBM)will provide separate information for details regarding Network pharmacies, Preferred Brand prescriptions and Specialty Drugs upon enrollment for coverage under this Plan. Mandatory Generic - If there is a generic alternative for the prescription drug, and the Covered Person chooses a brand name instead, regardless of how the prescription is written,the Covered Person must pay the difference in cost between the generic and brand name medication plus the applicable brand Coinsurance amount. Proton Pump Inhibitors (PPI's) Benefit -The "over-the-counter" form of Prilosec (Prilosec OTC) will be covered the same as if it were a generic prescription drug. There is no coordination of benefits for Pharmacy Benefits. PREMIUM OPTION -COST SHARING PROVISIONS Pharmacy Deductible (combined Retail and Mail Order) per Benefit Period Per Covered Person $50 Per Family $100 Pharmacy Benefit Out-of-Pocket Maximum per Benefit Period (Includes the Pharmacy Deductible and applicable Coinsurance) Per Covered Person $500 Per Family $1,000 Pharmacy Coinsurance is waived after satisfaction of the Pharmacy Out-of-Pocket Maximum. The following are payable at 100% and are not subject to any Deductible or Coinsurance: 1. Prescribed generic contraceptives or brand if generic is unavailable; 2. Smoking cessation products prescribed by a Physician or Licensed Health Care Provider; and 3. Over-the-counter (OTC) medications only when prescribed by a Physician or Licensed Health Care Provider, and only if listed as an A or B recommendation as a Preventive Service covered under the Affordable Care Act which can be viewed at http://www.hhs.gov/healthcare/prevention/index.html. Premium Option-Coinsurance per Prescription Drug Type Retail- PBM Network Member Submit* Mail Order Generic 20% 20% 20% Preferred Brand 20% 20% 20% Non-Preferred Brand 40% 40% 40% *For Member Submit prescriptions,the PBM will reimburse the contract cost of the prescription drug, less the applicable Coinsurance per Prescription. Contract cost is the PBM's discounted cost of the prescription drug. Reimbursement will not exceed what the PBM would have reimbursed for a Network Prescription. Collier County Government-SPD 17 Group#2003021 -Eff Date 1/1/2014 Packet Page -556- 1/27/2015 16.E.3. Pharmacy Benefit SELECT OPTION -COST SHARING PROVISIONS Pharmacy Deductible (combined Retail and Mail Order)per Benefit Period Per Covered Person $200 Per Family $400 Pharmacy Benefit Out-of-Pocket Maximum per Benefit Period (Includes the Pharmacy Deductible and applicable Coinsurance) Per Covered Person $800 Per Family $1,600 Pharmacy Coinsurance is waived after satisfaction of the Pharmacy Out-of-Pocket Maximum. The following are payable at 100%and are not subject to any Deductible or Coinsurance: 1. Prescribed generic contraceptives or brand if generic is unavailable; 2. Smoking cessation products prescribed by a Physician or Licensed Health Care Provider; and 3. Over-the-counter (OTC) medications only when prescribed by a Physician or Licensed Health Care Provider, and only if listed as an A or B recommendation as a Preventive Service covered under the Affordable Care Act which can be viewed at http://www.hhs.gov/healthcare/prevention/index.html. Select Option-Coinsurance per Prescription '';" Drug Type Retail - PBM Network Member Submit* Mail Order Generic 20% 20% 20% Preferred Brand 20% 20% 20% Non-Preferred Brand 40% 40% 40% *For Member Submit prescriptions,the PBM will reimburse the contract cost of the prescription drug, less the applicable Coinsurance per Prescription. Contract cost is the PBM's discounted cost of the prescription drug. Reimbursement will not exceed what the PBM would have reimbursed for a Network Prescription. BASIC OPTION -COST SHARING PROVISIONS Pharmacy Deductible (combined Retail and Mail Order) per Benefit Period Per Covered Person $400 Per Family $800 Pharmacy Benefit Out-of-Pocket Maximum per Benefit Period (Includes the Pharmacy Deductible and applicable Coinsurance) Per Covered Person $1,400 Per Family $2,800 Pharmacy Coinsurance is waived after satisfaction of the Pharmacy Out-of-Pocket Maximum. The following are payable at 100% and are not subject to any Deductible or Coinsurance: 1. Prescribed generic contraceptives or brand if generic is unavailable; 2. Smoking cessation products prescribed by a Physician or Licensed Health Care Provider; and 3. Over-the-counter (OTC) medications only when prescribed by a Physician or Licensed Health Care Provider, and only if listed as an A or B recommendation as a Preventive Service covered under the Affordable Care Act which can be viewed at http://www.hhs.gov/healthcare/prevention/index.html. Collier County Government-SPD 18 Group#2003021 -Eff Date 1/1/2014 Packet Page-557- 1/27/2015 16.E.3. Pharmacy Benefit Basic Option-Coinsurance per Prescription Drug Type Retail - PBM Network Member Submit* Mail Order Generic 30% 30% 30% Preferred Brand 30% 30% 30% Non-Preferred Brand 50% 50% 50% *For Member Submit prescriptions,the PBM will reimburse the contract cost of the prescription drug, less the applicable Coinsurance per Prescription. Contract cost is the PBM's discounted cost of the prescription drug. Reimbursement will not exceed what the PBM would have reimbursed for a Network Prescription. COVERAGE Coverage for prescription drugs will include only those drugs requiring a written prescription of a Physician or Licensed Health Care Provider, if within the scope of practice of the Licensed Health Care Provider, and that are Medically Necessary for the treatment of an Illness or Injury. Coverage also includes prescription drugs or supplies that require a written prescription of a Physician or Licensed Health Care Provider,if within the scope of practice of the Licensed Health Care Provider,as follows: 1. Self-administered contraceptives and over-the-counter FDA approved female contraceptives with a written prescription by a Physician or Licensed Health Care Provider. Contraceptive Management,injectable contraceptives and contraceptive devices are covered under the Medical Benefits of this Plan. 2. Tretinoin agents used in the treatment of acne and/or for cosmetic purposes (Retin A) subject to medical review. 3. Erectile Dysfunction non-injectables subject to medical review. 4. Weight management subject to medical review. 5. Serums,toxoids and vaccines subject to medical review. 6. Legend vitamins (oral only). 7. Legend fluoride products (oral only). 8. Diabetic supplies, including syringes, needles, swabs, blood test strips (glucose or ketone), blood glucose calibration solutions, urine tests, lancets and lancet devices. 9. Smoking cessation products prescribed by a Physician. 10. Over-the-counter(OTC)medications only when prescribed by a Physician or Licensed Health Care Provider, and only if listed as an A or B recommendation as a Preventive Service covered under the Affordable Care Act which can be viewed at http://www.hhs.dov/healthcare/prevention/index.html. Collier County Government-SPD 19 Group#2003021 -Eff Date 1/1/2014 Packet Page-558- 1/27/2015 16.E.3. Pharmacy Benefit SERVICE OPTIONS The Program includes the following Service Options for obtaining prescriptions under the Pharmacy Benefit: PBM Network Prescriptions: Available only through a retail pharmacy that is part of the PBM Network. The pharmacy will bill the Plan directly for that part of the prescription cost that exceeds the Coinsurance (Coinsurance amount must be paid to pharmacy at time of purchase). The prescription identification card is required for this option. Member Submit Prescriptions:Available only if the prescription identification card cannot be used because a pharmacy is not part of the PBM Network, or the prescription identification card is not used at a PBM pharmacy. Prescriptions must be paid for at the point of purchase and the prescription drug receipt must be submitted to the Pharmacy Benefit Manager(PBM),along with a reimbursement form(Direct Reimbursement). The PBM will reimburse the contract cost of the prescription drug, less the applicable Coinsurance per Prescription. Contract cost is the PBM's discounted cost of the prescription drug. Reimbursement will not exceed what the PBM would have reimbursed for a Network Prescription. Mail Order Prescriptions:Available only through a licensed pharmacy that is part of the PBM Network which fills prescriptions and delivers them to Covered Persons through the United States Postal Service, United Parcel Service or other delivery service. The pharmacy will bill the Plan directly for prescription costs that exceed the Coinsurance. Specialty Drug(s):These medications are generic or non-generic drugs classified by the Plan and listed by the PBM as Specialty Drugs and require special handling (e.g., most injectable drugs other than insulin). Specialty drugs must be obtained from a preferred specialty pharmacy. Only your first prescription can be obtained at a network retail pharmacy. All subsequent refills must be obtained through a preferred specialty pharmacy. A list of specialty drugs and preferred specialty pharmacies may be obtained from the PBM or Plan Supervisor. DRUG OPTIONS The drug options available are: Generic:Those drugs and supplies listed in the most current edition of the Physicians Desk Reference or by the PBM Program as generic drugs. Preferred Brand:Non-generic drugs and supplies listed as"Preferred Brand"by the PBM Program as stated in a written list provided to Covered Persons and updated from time to time. Non-Preferred Brand: Copyrighted or patented brand name drugs(Non-Generic)which are not recognized or listed as Preferred Brand drugs or supplies by the PBM Program. COINSURANCE "Coinsurance"means a dollar amount fixed percentage per prescription payable to the pharmacy at the time of service. Coinsurance amounts are specifically stated in this section. Coinsurance is not payable by the Plan and does not serve to satisfy the Medical Benefits Annual Deductible or Out-of-Pocket Maximum. However, Pharmacy Coinsurance does apply toward the applicable Pharmacy Benefit Out-of-Pocket Maximum. Collier County Government-SPD 20 Group#2003021 -Eff Date 1/1/2014 Packet Page-559- 1/27/2015 16.E.3. Pharmacy Benefit SUPPLY LIMITS Supply is limited to 30 days for PBM Network or Member Submit Prescriptions and 90-days for Mail Order Prescriptions. Prescription drug refills are not allowed until 75% of the prescribed day supply is used. The amount of certain medications are limited to promote safe,clinically appropriate drug usage. If you have exceeded a limit and your physician believes you need an additional supply of a medication,it will be reviewed for medical necessity. A current list of applicable quantity limits can be obtained by contacting the PBM at the number listed on your identification card. STEP THERAPY PROGRAM Step Therapy is a program especially for people who take prescription drugs regularly for ongoing conditions like arthritis and high blood pressure.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: 1. Front-line drugs-Step 1 drugs are generic drugs proven to be safe,effective and affordable. These drugs should be tried first because they can provide the same health benefit as more expensive drugs, at a lower cost. 2. Back-up drugs-Step 2 and Step 3 drugs are brand-name drugs like those that you see advertised on TV. There are lower-cost brand drugs (Step 2) and higher-cost brand drugs (Step 3). Back-up drugs typically cost more than front-line drugs. The next time your doctor writes you a prescription, ask your doctor if a generic medication listed below as a front-line drug is right for you. It makes good sense to ask for these drugs first because,for most everyone, they work as well as brand-name drugs, and they almost always cost less. And, because these drugs have been on the market for a long time, they have a more established safety record than newer drugs. If you have tried a front-line drug,or your doctor decides one of these drugs isn't appropriate for you,then your doctor can prescribe a back-up drug. Ask your doctor if one of the lower-cost brands (Step 2 drugs) is appropriate. Remember, you can always get a higher-cost brand-name drug at a higher coinsurance if the front-line or Step 2 back-up drugs aren't right for you. Your doctor can call 800-417-8164 to request a prior authorization for the medication. Step Therapy helps you get the most out of your prescription drug benefit. For more information on the how Step Therapy works and how it benefits you,watch this short video at: www.StepTherapvFacts.com. PRIOR AUTHORIZATION Certain drugs require approval before the drug can be dispensed. A current list of drugs that require prior authorization can be obtained by contacting the PBM at the number listed on your identification card. EXCLUSIONS Prescription drugs or supplies in the following categories are specifically excluded: 1. Cosmetic only indications including, but not limited to, photo-aged skin products (Renova); Hair Growth Agents (Propecia, Vaniqa); Injectable cosmetics (botox cosmetic); and depigmentation products used for skin conditions requiring a bleaching agent. Collier County Government-SPD 21 Group#2003021 -Eff Date 1/1/2014 Packet Page-560- 1/27/2015 16.E.3. Pharmacy Benefit 2. Legend homeopathic drugs. 3. Fertility agents, oral, vaginal and injectable. 4. Erectile dysfunction injectables. 5. Allergen injectables. 6. Over-the-counter equivalents and non-legend medications(OTC), except when approved for Proton Pump Inhibitors or when specifically covered as a Recommended Preventive Services. 7. Blood monitors and kits(glucose or ketone).* 8. Durable Medical Equipment.* 9. Experimental or Investigational drugs. 10. Abortifacient drugs. `Eligible for coverage under the Medical Benefits, subject to all provisions and limitations of this Plan. Collier County Government-SPD 22 Group#2003021 -Eff Date 1/1/2014 Packet Page-561- 1/27/2015 16.E.3. MEDICAL BENEFIT DETERMINATION REQUIREMENTS ELIGIBLE SERVICES, TREATMENTS AND SUPPLIES Services, treatments or supplies are eligible for coverage if they meet all of the following requirements: 1. They are administered, ordered or provided by a Physician or other eligible Licensed Health Care Provider; and 2. They are Medically Necessary for the diagnosis and treatment of an Illness or Injury or they are specifically included as a benefit if not Medically Necessary; and 3. Charges do not exceed the Usual, Customary and Reasonable limits of the Plan; and 4. They are not excluded under any provision or section of this Plan. Treatments, services or supplies excluded by this Plan may be reimbursable if such charges are approved by the Plan Administrator prior to beginning such treatment. Prior approval is limited to medically accepted non-experimental or investigational treatments, services,or supplies,which, in the opinion of the Plan Administrator, are more cost effective than a covered treatment, service or supply for the same Illness or Injury, and which benefit the Covered Person. DEDUCTIBLE The Deductible is stated in the Schedule of Medical Benefits according to the Plan Option selected. The Deductible applies to Expenses Incurred during each Benefit Period,unless specifically waived,but it applies only once for each Covered Person within a Benefit Period. Also, if members of a Family have satisfied individual Deductible amounts that collectively equal the Deductible per Family, as stated in the Schedule of Medical Benefits, during the same Benefit Period, no further Deductible will apply to any member of that Family during that Benefit Period. An individual Covered Person cannot receive credit toward the Family Deductible for more than the Individual Annual Deductible as stated in the Schedule of Medical Benefits. BENEFIT PERCENTAGE The Benefit Percentage is stated in the Schedule of Medical Benefits according to the Plan Option selected. The Plan will pay the Benefit Percentage of the Eligible Expense indicated. OUT-OF-POCKET MAXIMUM The Out-of-Pocket Maximum, per Covered Person or Family, whichever is applicable, is stated in the Schedule of Medical Benefits and includes the Annual Deductible, amounts in excess of the Benefit Percentage paid by the Plan and any applicable Medical Benefit Copayments. Expenses Incurred in a single Benefit Period after satisfaction of the Out-of-Pocket Maximum per Covered Person or per Family,whichever is applicable, will be paid at 100% of the Eligible Expense for the remainder of the Benefit Period. An individual Covered Person cannot receive credit toward the Family Out-of-Pocket Maximum for more than the Individual Out-of-Pocket Maximum as stated in the Schedule of Medical Benefits. COPAYMENT Copayments are stated in the Schedule of Medical Benefits according to the Plan Option selected. A Copayment is the portion of the medical expense that is the responsibility of the Covered Person. A Copayment is applied for each occurrence of such covered medical service and is not applied toward satisfaction of the Deductible but will apply toward the Out-of-Pocket Maximum and after the Out-of-Pocket Maximum is satisfied, Copayments will no longer apply for the remainder of the Benefit Period. Collier County Government-SPD 23 Group#2003021 -Eff Date 1/1/2014 Packet Page-562- 1/27/2015 16.E.3. Medical Benefit Determination Requirements MAXIMUM BENEFIT The amount payable by the Plan will not exceed any Maximum Benefit or Maximum Lifetime Benefit as stated in the Schedule of Medical Benefits, for any reason. APPLICATION OF DEDUCTIBLE AND ORDER OF BENEFIT PAYMENT Deductibles will be applied to Expenses Incurred in the chronological order in which they are adjudicated by the Plan. Expenses Incurred will be paid by the Plan in the chronological order in which they are adjudicated by the Plan. The manner in which the Deductible is applied and Expenses Incurred are paid by the Plan will be conclusive and binding on all Covered Persons and their assignees. CHANGES IN COVERAGE CLASSIFICATION A change in coverage that decreases a benefit of this Plan will become effective on the stated effective date of such change with regard to all Covered Persons to whom it applies. NEW YORK STATE EXPENSES This Plan has voluntarily elected to make public goods payments directly to the Office of Pool Administration in conformance with HCRA provisions and New York State Department of Health(Department)requirements. Collier County Government-SPD 24 Group#2003021 -Eff Date 1/1/2014 Packet Page-563- 1/27/2015 16.E.3. MEDICAL BENEFITS Charges for the following Medical Benefits are payable as stated in the Schedule of Medical Benefits and subject to all terms and conditions of this Plan. Medical Benefits include: 1. Acupuncture:Acupuncture performed by a licensed Health Care Provider will be payable as stated and limited in the Schedule of Benefits. 2. Allergy Services:Allergy testing,treatment and serum. Allergy injections will be payable under the Physician's Office Visit benefit. 3. Ambulance Service: Commercial or ground or air ambulance service to the nearest facility where Emergency care or treatment can be rendered; or from one facility to another for care; or from a facility to the patient's home when Medically Necessary. 4. Ambulatory Surgical Center: Services and supplies provided by an Ambulatory Surgical Center. 5. Anesthetics/Oxygen: The cost and administration of an anesthetic or for oxygen and other gases and their administration. 6. Aquatic Therapy: Medically Necessary aquatic or pool therapies. 7. Autism Spectrum Disorder: Testing and treatment for Autism Spectrum Disorder is covered the same as any other Illness or Injury,including treatment for ABA(Applied Behavioral Analysis)therapy. 8. Bariatric Surgery: Medically Necessary surgical treatment and follow-up care for Morbid Obesity/Clinically Severe Obesity, including complications, only if approved by SmartChoice. See SmartChoice Program for further details. 9. Birthing Center: Services and supplies furnished by a Birthing Center. 10. Blood and Blood Derivatives: Blood transfusions, blood processing, blood transporting, blood handling, administration, and the cost of blood, plasma and blood derivatives. Any credit allowable for replacement of blood plasma by donor or blood insurance will be deducted from the total Eligible Expense. 11. Bone Density Testing: Medically Necessary diagnosis and treatment of osteoporosis for high-risk individuals who: a) are estrogen deficient and at clinical risk for osteoporosis, b) have vetebral abnormalities; c) are receiving long term glucocorticoid (steroid) therapy; d) have primary hyperparathyroidism; or e)have a family history of osteoporosis. 12. Cardiac Rehabilitation:Cardiac Rehabilitation services which are rendered:a)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 for the medical condition ends; and d) in a medical care facility. Expenses in connection with Phase III cardiac rehabilitation including, but not limited to, Occupational Therapy or work hardening programs will not be considered eligible. Phase III is defined as the general maintenance level of treatment, with no further medical improvements being made, and exercise therapy that no longer requires the supervision of medical professionals. 13. Cataract Surgery: Initial pair of eyeglasses, contact lenses or an intraocular lens following a Medically Necessary surgical procedure to the eye, aphakic patients, or soft lenses or sclera shells intended for use as corneal bandages. Collier County Government-SPD 25 Group#2003021 -Eff Date 1/1/2014 Packet Page-564- 1/27/2015 16.E.3. Medical Benefits 14. Chiropractic Care/Spinal Manipulation: Skeletal adjustments, manipulation, or other treatment in connection with the correction by manual or mechanical means of structural imbalance or subluxation in the human body, including x-rays will be payable as shown in the Schedule of Benefits. 15. Circumcision: Services and supplies related to circumcision. 16. Cleft Lip and/or Cleft Palate:Cleft lip and cleft palate treatment for a child under age eighteen (18), including medical, dental, Speech Therapy, audiology and nutrition services, but only if they are prescribed by the treating Physician or surgeon and the Physician or surgeon certifies that the services are Medically Necessary. 17. Contraceptive Management: Contraceptive Management, regardless of Medical Necessity. "Contraceptive Management" means Physician fees related to a prescriptive contraceptive device, obtaining a prescription for contraceptives,purchasing,fitting,injecting,implantation or placement of any contraceptive device or removal of IUD regardless of Medical Necessity. Contraceptive supplies or devices available without a Physician's prescription or contraceptives provided over-the-counter are only covered as outlined in the Pharmacy Benefit section. 18. Dental Care: A. Dental services and x-rays rendered by a Dentist or Dental Surgeon for the treatment of a fractured jaw or Accidental Injury to sound natural teeth. Dental Services will be eligible if treatment begins within ninety(90)days of the accident and will continue to be eligible until the treatment is completed. B. General anesthesia and hospitalization services in assuring the safe delivery of necessary dental care provided to a Covered Person of any age who: 1) Is determined by a licensed Dentist and the attending Physician to require necessary dental treatment in a Hospital or Ambulatory Surgical Center because of a significantly complex dental condition or a developmental disability in which patient management has proved ineffective; or 2) Has one or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental treatment or surgery if not rendered in a Hospital or Ambulatory Surgical Center. Dental services due to Illness or injury will be payable as shown in the Schedule of Benefits, subject to review by the Plan. A letter of Medical Necessity from the attending Physician and the Dentist's treatment plan must be submitted to the Plan Supervisor before charges will be considered. 19. Diabetic Supplies: Diabetic supplies, other than those that are specifically covered under the Pharmacy Benefit,for the treatment of gestational,Type I or Type I I diabetes. Custom made diabetic shoes when Medically Necessary and prescribed by a physician. 20. Diagnostic Testing,X-ray and Laboratory Services:Diagnostic testing,x-ray and laboratory tests, including electrocardiograms, electroencephalograms, pneumoencephalograms, basal metabolism tests, CAT scans, MRIs, microscopic tests, or similar well-established diagnostic tests generally accepted by Physicians throughout the United States. 21. Durable Medical Equipment: The rental of a wheelchair, Hospital bed, respirator or other Durable Medical Equipment required for therapeutic use will be payable as shown in the Schedule of Benefits, subject to the following: A. The equipment must be prescribed by a Physician and needed in the treatment of an Illness or Injury; Collier County Government-SPD 26 Group#2003021 -Eff Date 1/1/2014 Packet Page -565- 1/27/2015 16.E.3. Medical Benefits B. The equipment will be provided on a rental basis, or the purchase of this equipment if economically justified, whichever is less. If the purchase is not medically feasible, rental charges will be paid without limitation based upon purchase price. Any amount paid to rent the equipment will be applied towards the purchase price. In no event will the rental cost of Durable Medical Equipment exceed the purchase price of the item; C. Benefits will be limited to standard models, as determined by the Plan; D. The Plan will pay for only ONE of the following: a manual wheelchair, motorized wheelchair or motorized scooter, unless Medically Necessary due to growth of the person or changes to the person's medical condition require a different product, as determined by the Plan; E. If the equipment is purchased, benefits will be payable for subsequent repairs, excluding batteries, necessary to restore the equipment to a serviceable condition. If such equipment cannot be restored to a serviceable condition,replacement will be considered eligible,subject to prior approval by the Plan. In all cases, repairs or replacement due to abuse or misuse, as determined by the Plan, are not covered; and F. Expenses for the rental or purchase of any type of air conditioner, air purifier, or any other device or appliance will not be considered eligible. • In-Network providers are recommended for Durable Medical Equipment (DME) purchases. Some DME can be purchased via the Internet. Internet sales of DME will be reimbursed at the In-Network rate provided the DME is ordered by a physician and is qualified under Plan provisions as a benefit. Purchases of DME via the Internet will be limited to the normal expected service life of the DME or once every five (5) years, whichever is less. Failure of equipment or dissatisfaction with the equipment purchased via the Internet will not be considered sufficient basis to allow another purchase from a local provider in any time frame less than the normal expected service life of the equipment. Service and calibration expenses may be reimbursable if otherwise eligible for benefits. 22. Emergency Room Services: Treatment in a Hospital emergency room, including professional services will be payable as shown in the Schedule of Benefits. 23. Genetic Testing: Expenses limited to the following genetic testing procedures: A. Flow Cytometry; B. FISH: Manual,Automated and UroVysion; C. Cytogenetics; D. Molecular: B&T cell gene rearrangement; E. Molecular: JAK2 MPN Reflex Panel; F. Molecular: BCR/ABL; G. Molecular: PML/RARA; H. Molecular: NPM1. I. Molecular: EGFR J. EER2; K. KRAS; L. CCR5 M. HCV 24.4 Hearing Aids: Hearing aids and their fittings will be payable as shown in the Schedule of Benefits, regardless of Medical Necessity. 4 Item 24"Hearing Aids"(Medical Benefits)replaced by Amendment#2 effective 1/1/2014 Collier County Government-SPD 27 Group#2003021-Eff Date 1/1/2014 Packet Page-566- 1/27/2015 16.E.3. Medical Benefits 25. Hemodialysis/Peritoneal Dialysis: Treatment of a kidney disorder by hemodialysis or peritoneal dialysis as an Inpatient in a Hospital or other facility, or for expense in an Outpatient facility or in the Covered Person's home, including the training of one attendant to perform kidney dialysis at home. The attendant may be a family member. When home care replaced Inpatient or Outpatient dialysis treatments,the Plan will pay for rental of dialysis equipment and expendable medical supplies for use in the Covered Person's home as shown under the Durable Medical Equipment benefit. 26. Home Health Care: Services provided by a Home Health Care Agency to a Covered Person in the home will be payable as shown in the Schedule of Benefits. The following are considered eligible home health care services in accordance with a Home Health Care Plan for the following services: A. Part-time or intermittent nursing care by a Registered Nurse(R.N.)or by a Licensed Practical Nurse(L.P.N.),a vocational nurse,or public health nurse who is under the direct supervision of a Registered Nurse; B. Home health aides; C. Medical supplies, drugs and medicines prescribed by a Physician, and laboratory services provided by or on behalf of a Hospital. Home Health Care specifically excludes the following: A. Services and supplies not included in the approved Home Health Care Plan. B. Services of a person who ordinarily resides in the home of the Covered Person, or who is a Close Relative of the Covered Person who does not regularly charge the Covered Person for services. C. Services of any social worker. D. Transportation services. E. Housekeeping services. F. Custodial Care. 27. Home Infusion Services: Home infusion services ordered by a Physician and provided by a home infusion therapy organization licensed and approved within the state in which the services are provided. A home infusion therapy organization is a health care facility that provides home infusion therapy services and skilled nursing services. Home infusion therapy services include the preparation,administration,or furnishing of parenteral medications,or parenteral or enteral nutritional services to a Covered Person by a home infusion therapy organization. Services also include education for the Covered Person, the Covered Person's caregiver, or a family member. Home infusion therapy services include pharmacy, supplies, equipment and skilled nursing services when billed by a home infusion therapy organization. Skilled nursing services billed by a home health agency are covered under the Home Health Care Benefit. 28. Hospice Care:Services provided by a Hospice within any one Hospice Benefit Period will be payable as shown in the Schedule of Benefits. The following are considered eligible Hospice services: A. Room and Board, including any charges made by the facility as a condition of occupancy,or on a regular daily or weekly basis such as general nursing services. If private room accommodations are used, the daily Room and Board charge allowed will not exceed the facility's average Semi-Private charges or an average Semi-Private rate made by a representative cross section of similar institutions in the area. Collier County Government-SPD 28 Group#2003021 -Eff Date 1/1/2014 Packet Page-567- 1/27/2015 16.E.3. Medical Benefits B. Nursing care by a Registered Nurse (R.N.), a Licensed Practical Nurse (L.P.N.), a public health nurse who is under the direct supervision of a Registered Nurse. C. Medical supplies, including drugs and biologicals and the use of medical appliances. D. Physician's services. E. Services,supplies,and treatments deemed Medically Necessary and ordered by a licensed Physician. F. Counseling services by a licensed social worker or a licensed pastoral counselor for the patient's immediate family. G. Bereavement counseling services by a licensed social worker or a licensed pastoral counselor for the patient's immediate family. (The bereavement services must be furnished within six(6)months after the patient's death and payable up to limits shown in Schedule of Benefits. The term"Patient's Immediate Family"as used herein means the patient's spouse, parents, and/or dependent children who are covered under the Plan. "Hospice Benefit Period" means a specified amount of time during which the Covered Person undergoes treatment by a Hospice. Such time period begins on the date the attending Physician of a Covered Person certifies a diagnosis of terminal Illness, and the Covered Person is accepted into a Hospice program. The period will end the earliest of six months from this date or at the death of the Covered Person. A new Hospice Benefit Period may begin if the attending Physician certifies that the patient is still terminally ill; however, additional proof will be required by the Plan Administrator before a new Hospice Benefit Period can begin. 29. Hospital Services or Long-Term Acute Care Facility/Hospital: The following are considered eligible charges payable as shown in the Schedule of Benefits: A. Daily Room and Board in a Semi-Private Room (or private room if no Semi-Private room is available or when confinement in a private room is Medically Necessary)and general nursing services,or confinement in an Intensive Care Unit,not to exceed the applicable limits shown in the Schedule of Medical Benefits. B. Medically Necessary Hospital Miscellaneous Expenses other than Room and Board furnished by the Hospital, including Inpatient miscellaneous service and supplies,Outpatient Hospital treatments for chronic conditions and emergency room use, Physical Therapy treatments, hemodialysis, and x-ray. C. Nursery neonatal units,general nursing services,including Hospital Miscellaneous Expenses for services and supplies, Physical Therapy, hemodialysis and x-ray, care or treatment of Injury or Illness, congenital defects, birth abnormalities or premature delivery incurred by a Newborn Dependent. 30. 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. Collier County Government-SPD 29 Group#2003021 -Eff Date 1/1/2014 Packet Page-568- 1/27/2015 16.E.3. Medical Benefits 30. Maternity/Pregnancy: Expenses incurred by the covered Employee or a Dependent Spouse for Pregnancy,including charges for prenatal care,childbirth,miscarriage,and any medical complications arising out of or resulting from Pregnancy. Expenses for Amniocentesis testing and Cystic fibrosis testing will also be eligible. Elective induced abortions are eligible only when carrying the fetus to full term would seriously endanger the life of the mother. If complications arise after the performance of any abortion,any expenses incurred to treat those complications will be eligible,whether the abortion was eligible or not. Coverage for well woman prenatal visits as a required recommended preventive service are covered under the Preventive Care benefit. 32. Medical and Surgical Supplies: Dressings, sutures, casts, splints, trusses, crutches, braces, custom-made orthotics, and other Medically Necessary supplies ordered by a Physician. Foot orthotics are covered under the Podiatry benefit. 33. Medical Records:Charges for producing medical records will be payable as shown in the Schedule of Benefits. 34. Mental Illness: The following are considered eligible Mental Illness services and are payable as shown in the Schedule of Benefits: A. Physician or Licensed Health Care Provider charges for diagnosis and Medically Necessary Psychiatric Care and treatment. B. Charges for well-established medically accepted diagnostic testing generally accepted by Physicians in the United States. C. Charges for Inpatient and partial hospitalization,for Medically Necessary treatment, for the same services as are covered for hospitalization for physical Illness or Injury by this Plan. D. Charges for Medically Necessary treatment, including involuntary or court ordered admissions, at a Psychiatric Facility or Residential Treatment Facility for Mental Illness and licensed as such by the State in which the facility operates that is primarily for the treatment of Mental Illness if it meets these requirements: 1) Has a Physician in regular attendance; 2) Continuously provides twenty-four(24)hour a day nursing service on site or on call by a Registered Nurse (RN)or Licensed Practical Nurse(LPN); 3) Has a full-time Psychiatrist or Psychologist on staff; and 4) Is primarily engaged in providing diagnostic and therapeutic services and facilities for treatment of Mental Illness. Medically Necessary will not include Maintenance Therapy which means medical and non-medical health-related services that does 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. Notification is required for admission to a Residential Treatment Facility. Please refer to the Notification Provisions of this Plan for further details. Collier County Government-SPD 30 Group#2003021 -Eff Date 1/1/2014 Packet Page -569- 1/27/2015 16.E.3. Medical Benefits 35. Midwife Services: Services by a Certified Nurse Midwife (CNM) who is a registered nurse and enrolled in either the certification maintenance program or the continuing competency assessment program through the American College of Nurse Midwives (ACNM). "Certified Nurse Midwife" means an individual who has received advanced nursing training and is authorized to use the designation of"CNM"and who is licensed by the state or regulatory agency in the state in which the individual performs such nursing services. Services of a direct-entry midwife or lay midwife or the practice of direct-entry midwifery will not be considered eligible. A Direct-entry midwife is one practicing midwifery and licensed pursuant to the state in which services are performed and who is not a licensed Certified Nurse Midwife. 36. Newborn Care: Newborn care,including Hospital nursery expenses and routine pediatric care while confined following birth will be considered as part of the newborn's expense. If the Newborn is ill, suffers an Injury, or requires care other than routine care, benefits will be provided on the same basis as any other eligible expense. 37. 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. 38. Occupational Therapy: Occupational Therapy rendered by an occupational therapist on an Outpatient basis under the recommendation of a Physician whose primary purpose is to provide medical care for an Illness or Injury. Expenses for Maintenance Therapy, or therapy primarily for recreational or social interaction will not be considered eligible. 39. Organ or Tissue Transplant Procedures: Services and supplies in connection with non- Experimental or non-Investigational organ or tissue transplant procedures, subject to the following conditions: A. A second opinion is recommended prior to undergoing any transplant procedure. This second opinion should concur with the attending Physician's findings regarding the Medical Necessity of such procedure. The Physician rendering this second opinion must be qualified to render such a service either through experience, specialist training or education, or such similar criteria,and must not be affiliated in any way with the Physician who will be performing the actual surgery. B. If the donor is covered under this Plan, expenses Incurred by the donor will be considered for benefits to the extent that such expenses are not payable by the recipient's plan. C. If the recipient is covered under this Plan, expenses Incurred by the recipient will be considered for benefits. If the donor is not covered under this Plan, reference provision E. D. If both the donor and the recipient are covered under this Plan, Expenses Incurred by each person will be treated separately for each person. E. The Eligible Expense of securing an organ from the designated live donor, a cadaver or tissue bank, including the surgeon's fees, anesthesiology, radiology, and pathology fees for the removal of the organ, and a Hospital's charge for storage or transportation of the organ, will be considered eligible. In no event will benefits be payable in excess of the applicable benefit limits still available to the recipient. Collier County Government-SPD 31 Group#2003021 -Eff Date 1/1/2014 Packet Page-570- 1/27/2015 16.E.3. Medical Benefits 40. Orthognathic Surgery:Orthognathic surgery and related charges. Any orthodontic expenses related to orthognathic surgery will not be considered eligible. 41. Orthopedic Appliance: Purchase of Orthopedic Appliances or replacement or repair of Orthopedic Appliances. 42. Outpatient Renal Dialysis: Charges for Outpatient renal dialysis will be payable up to the limits stated in the Schedule of Medical Benefits. In order to avoid or reduce liability for amounts not covered by the Plan, a Covered Person who is diagnosed with End Stage Renal Disease (ESRD) should immediately follow these steps: A. Notify Plan Administrator when you are diagnosed with ESRD by your doctor; B. Notify Plan Administrator if or when you begin to receive dialysis treatments; and C. Enroll in Parts A and B of Medicare. The Plan Sponsor may assist you with payment of medicare premiums up to a lifetime total of$5,500; and D. Contact Specialty Care Management at (765)320-0118. 43. Physical Therapy:Physical Therapy rendered by an physical therapist on an Outpatient basis under the recommendation of a Physician whose primary purpose is to provide medical care for an Illness or Injury. Expenses for Maintenance Therapy,or therapy primarily for recreational or social interaction will not be considered eligible. 44. Physician Services:Services of a licensed Physician or Licensed Health Care Provider for medical care and/or treatments, including office, home visits, Hospital Inpatient care, Hospital Outpatient visits/exams,clinic care,and surgical opinion consultations will be payable as shown in the Schedule of Benefits. Diagnostic x-ray and laboratory services which are ordered on the same day as the office visit, but performed or read at a later date and/or at another facility will be considered as part of the office visit. Charges are eligible for drugs intended for use in a physicians'office or settings other than home use that are billed during the course of an evaluation or management encounter. When two or more Surgical Procedures occur during the same operative session, charges will be considered as follows: A. When multiple or bilateral Surgical Procedures are performed that increase the time and amount of patient care, 100% of the Eligible Expense will be considered for the Major Procedure; and 50% of the Eligible Expense will be considered for each of the lesser procedures,except for contracted or negotiated services. Contracted or negotiated services will be reimbursed at the contracted or negotiated rate. B. When an incidental procedure is performed through the same incision, only the Eligible Expense for the Major Procedure will be considered. Examples of incidental procedures are: excision of a scar,appendectomy at the time of other abdominal surgery,lysis of adhesions, etc. When an assisting Physician or non-physician is required to render technical assistance during a Surgical Procedure, the charges for such services will be limited to 20% of the primary surgeon's Eligible Expense for the Surgical Procedure. Collier County Government-SPD 32 Group#2003021 -Eff Date 1/1/2014 Packet Page-571- 1/27/2015 16.E.3. Medical Benefits 45. Podiatry:Treatment for the following foot conditions:a)weak,unstable or flat feet;b)bunions,when an open cutting operation is performed;c)non-routine treatment of corns or calluses;d)toenails when at least part of the nail root is removed or Medically Necessary by diagnosis (i.e. PVD); e) any Medically Necessary surgical procedure required for a foot condition; or f) custom-made orthotics, including orthopedic shoes when an integral part of a leg brace. 46. Pre-admission Testing: Outpatient pre-admission testing performed within seven (7)days prior to a scheduled Inpatient Hospitalization or surgery. 47. Prescription Drugs: Drugs requiring the written prescription of a Physician or a Licensed Health Care Provider and Medically Necessary for the treatment of an Illness or Injury. Coverage also includes prescription contraceptive drugs not available through the Pharmacy Benefit regardless of Medical Necessity and FDA approved over-the-counter female contraceptives prescribed by a Physician or Licensed Health Care Provider. Conditions of coverage for outpatient prescription drugs and supplies available through the Pharmacy Benefit are as stated in the Pharmacy Benefit section of the Plan. 48. Preventive Care: The following are eligible Preventive Care Services: A. Routine Wellness care for children and adults for the following: 1) Routine physical examinations by a Physician or Licensed Health Care Provider, which will include a medical history, physical examination, developmental assessment, and anticipatory guidance as directed by a Physician or Licensed Health Care Provider and associated routine testing provided or ordered at the time of the examination; and 2) Routine immunizations according to the schedule of immunizations which is recommended by the Advisory Committee on Immunization Practices (ACIP)that have been adopted by the Director of the Centers for Disease Control and Prevention. B. Prostate Specific Antigen (PSA)test for men or digital rectal exams for men starting at age forty(40). C. Recommended preventive services as set forth in the recommendations of the United States Preventive Services Task Force (Grade A and B rating), the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and the guidelines supported by the Health Resources and Services Administration. The complete list of recommendations and guidelines can be viewed at: http://www.hhs.gov/healthcare/prevention/index.html. D. Office visit charges only if the primary purpose of the office visit is to obtain a recommended Preventive Care service identified above. E. Women's Preventive Care for the following: 1) Well-women annual visits for women 18 years of age and older to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care, and additional visits as medically appropriate. 2) Screening for gestational diabetes for pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes. 3) Human papillomavirus (HPV) DNA testing beginning at thirty (30) years of age, limited to once every three (3)years. Collier County Government-SPD 33 Group#2003021 -Eff Date 1/1/2014 Packet Page-572- 1/27/2015 16.E.3. Medical Benefits 4) Annual counseling on sexually transmitted infections (STI's) and human immune- deficiency virus (HIV) screening for all sexually active women. 5) All Food and Drug Administration approved prescription contraceptives and female over-the-counter contraceptives when prescribed by a Physician or Licensed Health Care Provider,sterilization procedures,and patient education and counseling for all women with reproductive capacity. This does not include abortifacient drugs. Self- administered contraceptives are available only through the Pharmacy Benefit as outlined in the Pharmacy Benefit section of this Plan. 6) Breast feeding support,supplies,and counseling,including comprehensive lactation support and counseling by a trained provider during pregnancy and/or in the postpartum period, and costs for breast feeding equipment and related supplies. 7) Annual screening and counseling for interpersonal and domestic violence. "Preventive Care" means routine treatment or examination provided when there is no objective indication or outward manifestation of impairment of normal health or normal bodily function, which is not provided as a result of any Injury or Illness. Charges will be payable as shown in the Schedule of Benefits. Expenses payable under this Preventive Care benefit will not be subject to the Medical Necessity provisions of this Plan. "Charges for Preventive care that involve excessive, unnecessary or duplicate tests are specifically excluded." Charges for treatment of an active Illness or Injury are subject to the plan provisions, limitations and exclusions and are not eligible in any manner under Preventive Care. 49. Private Duty Nursing:Service of a Registered Nurses(R.N.'s)or Licensed Practical Nurse(L.P.N.) for private duty nursing. Special duty nursing services are excluded as follows: A. Which would ordinarily be provided by the Hospital staff or its Intensive Care Unit (the Hospital benefit of the Plan pays for general nursing services by Hospital staff); or B. When private duty nurse is employed solely for the convenience of the patient or the patient's Family or for services which would consist primarily of bathing, feeding, exercising, homemaking,moving the patient,giving medication or acting as a companion,sitter or when otherwise deemed not Medically Necessary as requiring skilled nursing care. 50. Prosthetic Appliance: Artificial limbs, eyes, larynx, or other Prosthetic Appliance for replacement when necessary due to an Illness or Injury. Charges for the repair or replacement will only be included as an eligible expense when required due to a pathological change or replacement is less expensive than repair of existing equipment. Replacement due to normal wear and tear and deterioration is not considered eligible. 51. Radiation Therapy/Chemotherapy: Radium and radioactive isotope therapy, and chemotherapy treatment will be payable as shown in the Schedule of Benefits. 52. Reconstructive Breast Surgery: Reconstructive breast surgery subsequent to any mastectomy, limited to the following: A. Reconstruction of the breast(s) upon which the mastectomy was performed, including implants; B. Surgical procedures and reconstruction of the non-affected breast to produce a symmetrical appearance, including implants; Collier County Government-SPD 34 Group#2003021-Eff Date 1/1/2014 Packet Page-573- 1/27/2015 16.E.3. Medical Benefits C. Non-surgical treatment of lymphedemas and other physical complications of mastectomy, including non-surgical prostheses and implants for producing symmetry. Specifically excluded from this benefit are expenses for the following: A. Solely Cosmetic procedures unrelated to producing a symmetrical appearance; B. Breast augmentation procedures unrelated to producing a symmetrical appearance; C. Implants for the non-affected breast unrelated to producing a symmetrical appearance; D. Non-surgical prostheses or any other procedure unrelated to producing a symmetrical appearance. 53. Rehabilitation Facility: Inpatient care provided in a Rehabilitation Facility will be payable as shown in the Schedule of Benefits, provided such confinement a)is under the recommendation and general supervision of a Physician; b) begins after discharge from a required Hospital or Skilled Nursing Facility confinement;c)is 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 Facility. 54. Routine Patient Costs: "Routine Patient Costs"for a Phase I"Approved Clinical Trial"for"Qualified Individuals". "Routine Patient Costs" include but are limited to Medically Necessary services which a Covered Person with the identical diagnosis and current condition would receive even in the absence of participating in an Approved Clinical Trial. "Routine Patient Costs"do not include any investigational item, device, or service that is part of the Approved Clinical Trial;an item or service provided solely to satisfy data collection and analysis needs for the trial if the item or service is not used in the direct clinical management of the patient;a service that is clearly inconsistent with widely accepted and established standards of care for the individual's diagnosis; or an item or service customarily provided and paid for by the sponsor of an Approved Clinical Trial. "Approved Clinical Trial"means a Phase I clinical trial that is conducted in relation to the prevention, detection,or treatment of an acutely life-threatening disease state and is not designed exclusively to test toxicity or disease pathophysiology. The Approved Clinical Trial must be: A. Conducted under an investigational new drug application reviewed by the United States Food and Drug Administration; B. Exempt from obtaining an investigational new drug application; or Collier County Government-SPD 35 Group#2003021-Eff Date 1/1/2014 Packet Page-574- 1/27/2015 16.E.3. Medical Benefits C. Approved or funded by: 1) The National Institutes of Health,the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality,Centers for Medicare and Medicaid Services, or a cooperative group or center of any of the entities described above; 2) A cooperative group or center of the United States Department of Defense or the United States Department of Veterans Affairs; 3) A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support groups; or 4) The United States Departments of Veterans Affairs, Defense,or Energy if the study or investigation has been reviewed and approved through a system of peer review determined by the United States Secretary of Health and Human Services to: a) Be comparable to the system of peer review of studies and investigations used by the national institutes of health; and b) Provide unbiased scientific review by individuals who have no interest in the outcome of the review. A"Qualified Individual"is a Covered Person who is eligible to participate in an Approved Clinical Trial according to the trial protocol with respect to the treatment of an acutely life-threatening disease state and either (i)the referring health care professional is a participating health care provider and has concluded that the individual's participation in such trial would be appropriate, or (ii) the Covered Person provides medical and scientific information establishing that the individual's participation in such trial would be appropriate. 55. Routine Qualifier Services: The following qualifier services will be payable as shown in the Schedule of Benefits and as shown below for Covered Employees and spouses only: Plan Qualifiers Paid 100%by Plan Qualifier Guidelines Lab Draw Must be completed by all Odd year-spouses Employees/Spouses to qualify Even year-employees for Select or Premium Options Pap Smear, Must be completed according to Age 20, 25, 30, 35, 40,43, 46, 50 & Mammogram age guidelines to qualify for the over Premium Option Skin Screening Must be completed according to Age 20, 25, 30, 35,40, 43, 46, 50 & age guidelines to qualify for the over Premium Option Testicular Exam Must be completed according to Age 20, 25, 30, 35, 40,43, 46, 50 & age guidelines to qualify for the over Premium Option Colonoscopy Must be completed according to Age 50 and every 10 years thereafter age guidelines to qualify for the **Note that if newly covered Premium Option employees and spouse age 50 and older, first colonoscopy is covered under the qualifiers regardless of age. After initial then will follow above age requirements. Collier County Government-SPD 36 Group#2003021 -Eff Date 1/1/2014 Packet Page-575- 1/27/2015 16.E.3. Medical Benefits 56. 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. 57. Skilled Nursing Facility: Charges made by a Skilled Nursing Facility for the following services and supplies furnished by the facility during convalescent confinement. Only charges in connection with convalescence from the Illness or Injury for which the Covered Person was Hospital-confined will be eligible for benefits. These expenses include: A. Room and Board,including any charges made by the facility as a condition of occupancy,or on a regular daily or weekly basis such as general nursing services. If private room accommodations are used, the daily Room and Board charge allowed will not exceed the facility's average Semi-Private charges or an average Semi-Private rate made by a representative cross section of similar institutions in the area. B. Medical services customarily provided by the Skilled Nursing Facility, with the exception of private duty or special nursing services and Physicians'fees. C. Drugs,biologicals,solutions,dressings and casts,furnished for use during the Convalescent Period, but no other supplies. 58. Sleep Disorders: Treatment of or related to sleep disorders. 59. Speech Therapy:Services provided by a licensed speech therapist for Speech Therapy,also called speech pathology, and audio diagnostic testing services for diagnosis and treatment of speech and language disorders. Outpatient Speech Therapy will be payable as shown in the Schedule of Benefits when all of the following criteria are met: A. There is a documented condition or delay in development that can be expected to improve with therapy within a reasonable time. B. Improvement would not normally be expected to occur without intervention. C. Treatment is not rendered for stuttering. D. Treatment is not rendered for behavioral or learning disorders. E. Treatment is rendered for a condition that is the direct result of a diagnosed neurological, muscular, or structural abnormality affecting the organs of speech. F. Therapy has been prescribed by the speech language pathologist or Physician and includes a written treatment plan with estimated length of time for therapy, along with a statement certifying all above conditions are met. 60. Sterilization: Vasectomies. Sterilization procedures for women are covered under the Preventive Care Benefit. 61. Substance Abuse/Chemical Dependency: Coverage under this benefit includes the following services: A. Physician or Licensed Health Care Provider charges for diagnosis and Medically Necessary treatment including, but not limited to, group therapy. B. Charges for well-established medically accepted diagnostic testing generally accepted by Physicians in the United States. Collier County Government-SPD 37 Group#2003021 -Eff Date 1/1/2014 Packet Page-576- 1/27/2015 16.E.3. Medical Benefits C. Charges for in-patient or partial hospitalization, for Medically Necessary treatment, for the same services as are covered for hospitalization for physical Illness or Injury by this Plan. D. Charges for Medically Necessary treatment, including aftercare, at an Alcoholism and/or Chemical Dependency Treatment Facility or Residential Treatment Facility for Substance Abuse/Chemical Dependency and licensed as such by the State in which the facility operates that is primarily for the treatment of Substance Abuse/Chemical Dependency if it meets these requirements: 1) Has a Physician in regular attendance; 2) Continuously provides twenty-four(24)hour a day nursing service on site or on call by a Registered Nurse(RN)or Licensed Practical Nurse (LPN); 3) Has a full-time Psychiatrist or Psychologist on staff; and 4) Is primarily engaged in providing diagnostic and therapeutic services and facilities for treatment of Substance Abuse/Chemical Dependency. Medically Necessary will not include Maintenance Therapy which means medical and non-medical health-related services that does 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. Notification is required for admission to a Residential Treatment Facility. Please refer to the Notification Provisions of this Plan for further details. 62. Temporomandibular Joint Dysfunction (TMJ): Surgical and non-surgical treatment of Temporomandibular Joint Dysfunction (TMJ). The treatment of jaw joint disorders(TMJ)includes conditions of structures linking the jawbone and skull and complex muscles, nerves, and other tissues related to the temporomandibular joint. Treatment includes, but is not limited to: orthodontics; physical therapy; and any appliance that is attached to or rests on the teeth. 63. Testosterone Injections:Medically Necessary expenses for testosterone injections and related office visit. 64. Tobacco Cessation:Tobacco cessation programs only when referred by the Med Center are payable as shown in the Schedule of Benefits. This includes but is not limited to the following:a)one-on-one visits with clinician, include electrical simulation on the ears; b) one-on-one visit with a certified dietician;c)educational materials;and d)cessation products(prescription and over-the-counter gums, patches, etc. 65. Urgent Care Facility: Services and supplies provided by an Urgent Care Facility will be payable as shown in the Schedule of Benefits. 66. Weight Loss Program:The program must be under the supervision of a licensed Physician. Patient must have a diagnosis of Morbid Obesity or Clinically Severe Obesity. Eligible expenses include physician office visits and services provided by the weight loss clinics, such as medications, supplements, injections, blood-pressure monitoring and dietary counseling. Collier County Government-SPD 38 Group#2003021 -Eff Date 1/1/2014 Packet Page-577- 1/27/2015 16.E.3. SMARTCHOICE PROGRAM Smart Choice is a health management program for specific members covered under this Plan. Those members would be identified as diagnosed with Morbid Obesity or Clinically Severe Obesity and interested in surgical-weight loss procedures that are considered Medically Necessary for Morbid Obesity or Clinically Severe Obesity. Smart Choice does not apply to any other approved medically supervised programs. The Smart Choice Lifestyle management program focuses on long-term weight loss and improved health. It includes assessment, education, and monitoring of a treatment plan agreed upon by your physician. A care plan will be developed with goals outlined.A registered nurse(R.N.) manages all aspects of the program. A Covered Person must enroll in the Smart Choice Program and actively participate for twelve(12)consecutive months in the SmartChoice program prior to consideration for pre-certification of any gastric by-pass surgery and six (6) consecutive months following the surgery. Surgery must be performed immediately after completing the twelve(12)month program. Recommendation regarding request for gastric procedures limited to: Bariatric Surgery, Gastric Stapling, Laparoscopic Gastric Bypass, Roux-en-Y Gastric Bypass (RYGB), Vertical Banded Gastroplasty(VBG). The following criteria will be used for pre-certifying benefits for the above procedures: 1. A clinical history of unsuccessful diet and other weight management programs. 2. Must receive a positive assessment of surgery risk-benefit from all evaluating staff members of the pre-surgery program. 3. Must be at least 18 years of age and less than 70 years of age. The following is specifically excluded: 1. Surgical procedures except for Roux-En-Y Divided Bypass Surgery or laparoscopic adjustable gastric banding)surgery. 2. Any expenses incurred for which all of the conditions of the SmartChoice Program have not been met. 3. Any redo or revision of a prior bariatric surgical procedure. 4. A second bariatric surgical procedure,whether or not the first procedure was performed while covered under this plan or not. Please contact SmartChoice for further information. (239)659-7740. Collier County Government-SPD 39 Group#2003021 -Eff Date 1/1/2014 Packet Page-578- 1/27/2015 16.E.3. MEDICAL EXPENSE AUDIT BONUS The Plan offers an incentive to all Covered Persons to encourage examination and self-auditing of eligible medical bills to ensure the amounts billed by any provider accurately reflect the services and supplies received by the Covered Person. The Covered Person is asked to review all medical charges and verify that each itemized service has been received and that the bill does not represent either an overcharge or a charge for services never received. This self-auditing procedure is strictly voluntary; however, it is to the advantage of the Plan as well as the Covered Person to avoid unnecessary payment of health care costs. In the event a self-audit results in elimination or reduction of benefits paid, 50% of the amount saved will be reimbursed directly to the Participant(subject to$10 minimum payment and a $500 maximum payment per Calendar Year), provided the savings are accurately documented,and satisfactory evidence is submitted to the Plan Supervisor(e.g. a copy of the incorrect bill and a copy of the corrected billing). This self-audit credit is in addition to the payment of all other applicable plan benefits for legitimate medical expenses. This credit will not be payable for expenses in excess of the Usual,Customary and Reasonable charges which are not covered under the Plan, regardless of whether benefits paid are reduced. Collier County Government-SPD 40 Group#2003021 -Eff Date 1/1/2014 Packet Page-579- 1/27/2015 16.E.3. NOTIFICATION PROVISIONS5 Community Health Partners (239)659-7770 or(888)-594-9008 To ensure the most appropriate care is provided, and to control the costs of this Plan, the Plan contains a notification provision. The notification provision requires that a Covered Person call Community Health Partners (CHP) at least twenty-four (24) hours before all elective (non-urgent, pre-arranged, non- emergency) Inpatient admissions in a Hospital, Hospice, Skilled Nursing, Rehabilitation or Chemical Dependency/Mental Illness Treatment Facilities . It also requires notification twenty-four(24) hours before any of the following that are done on an Outpatient basis: CAT Scans, MRI, MRA, CT Guided procedures, transplants(all), including initial consultation,evaluation,and actual transplant,rental or purchase of Durable Medical Equipment(DME)with cost anticipated in excess of$500.00. Pre-notification is not required for virtual colonoscopies or if any one of these procedures is performed in the emergency room. For a non-emergency hospitalization,CHP will evaluate the proposed admission plan and length of stay. CHP will certify the number of days appropriate. In making these determinations,the diagnosis,physical status and any other complicating conditions of the patient will be taken into account. CHP will review any x-ray and laboratory results and confer with the attending Physician if necessary. The decision to be admitted will always rest with the patient and the Physician. The notification process will let the patient know, before expenses are incurred,whether or not the admission would be certified. Benefits will only be available for the number of days that have been certified. If the confinement will last longer than the number of days certified, CHP must be notified. At this point,CHP will conduct a Continued Stay Review. The Continued Stay Review will be conducted in much the same way as the initial notification. The case will be reviewed with the attending Physician to determine any additional Inpatient days. Benefits will not be available for any days beyond those certified. In a Covered Person is admitted to the Hospital or other facility 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, the Hospital, or the Physician. However,the Covered Person is ultimately responsible for the notification. It is strongly recommended,therefore,that the Covered Person makes the call. Notification requires only a brief phone call to CHP at(239)659-7770 or toll free at(888)594-9008. If the call is made after hours, the following information must be left on CHP's confidential voice mail: 1. Employee's name. 2. Employee ID number. 3. Patient's name and relationship to the Employee. 4. The name of the Hospital where the procedure will take place (if applicable). 5. The procedure to be performed. 6. The name and telephone number of the Physician. It is vital the call occurs within the time frames list above. If notification is not made,eligible expenses will be reduced by $300 per procedure or confinement except for Urgent Care claims as stated in the Procedures for Claiming Benefits section. , If notification is not provided within the times outlined, CHP will review the claim to determine whether the admission,test, or procedure was Medically Necessary. Irrespective of the eventual determination by CHP, the penalty will still be applied and cannot be rescinded. 5"Notification Provisions"section replaced by Amendment#3 effective 1/1/2014 Collier County Government-SPD 41 Group#2003021 -Eff Date 1/1/2014 Packet Page-580- 1/27/2015 16.E.3. Notification Provisions Hospital stays in connection with childbirth for either the mother or Newborn may not be less than forty-eight (48) hours following a vaginal delivery or ninety-six (96) hours following a cesarean section. These requirements can only be waived by the attending Physician in consultation with the mother. The Covered Person or provider is not required to notify CHP of the maternity admission, unless the stay extends past the applicable forty-eight (48) or ninety-six (96) hour stay. A Hospital stay begins at the time of delivery or for deliveries outside the Hospital, the time the Newborn or mother is admitted to a Hospital following birth, in connection with childbirth. If the patient is unconscious, in a coma or unable to contact CHP due to Illness or Injury rendering the patient physically or mentally incapable,the notification requirement will be waived until the patient is able to contact CHP. Certification will be retroactive to the date of admission. Collier County Government-SPD 42 Group#2003021 -Eff Date 1/1/2014 Packet Page -581- 1/27/2015 16.E.3. MANDATORY CASE MANAGEMENT Community Health Partners(CHP)will monitor a Covered Person's emerging risk, a condition or diagnosis that may be potentially significant by utilizing several different methods such as Verisk Medical Intelligence, Notification request, Pharmacy and TPA reports. When a Covered Person has been identified with emerging risk they will be encouraged to enroll in Case Management and actively participate in their care plan. Active participation is described as, communicating with their Case Manager on a weekly basis until less intensity is needed determined by the Case Manager or the Covered Person is disenrolled from program.Communication may be in the form of letters,phone calls, face to face meetings or encrypted emails. If a Covered Person cancels an appointment with the case manager,it is the Covered Person's responsibility to reschedule with 48 business hours. If a Covered Person refuses to participate and their level of medical and pharmacy spend combined exceeds$100,000 in a six(6) month period, they will receive a monetary benefit adjustment for failure to participate. First Contact:Covered Persons will be contacted by a Case Manager as soon as a trend is identified to enroll the Covered Person into Case Management. Initially a letter will be sent from Community Health Partners advising the Covered Person they have been identified to participate in Case Management and will be contacted within one week. The letter will provide the Case Manager's contact information and ask the Covered Person to be pro-active and reach out to the case manager and communicate the best time to schedule a call with the Covered Person. Second Contact: If no-response,the Case Manager will confirm with the Human Resource Department that they have the most current contact information.A second call will be place within 48 business hours. Third Contact:Third call will be place to the Covered Person within another 48 business hour cycle.This call will be placed after normal business hours between 5 and 7pm. Fourth contact: Certified letter requiring a signature will be sent to the Covered Person's current home address. This letter will outline the attempts made to contact the Covered Person as well as the potential benefit adjustment due to failure to participate. While participation in case management is voluntary, declining to participate or declining to continue to participate in case management services when requested by the Plan will result in an additional Copayment of$1,000 for non-participation of the condition for which case management was declined. The additional Copayment imposed by this provision will not accrue towards the Out-of-Pocket Maximum or change after satisfaction of the annual Out-of-Pocket Maximum. Collier County Government-SPD 43 Group#2003021 -Eff Date 1/1/2014 Packet Page-582- 1/27/2015 16.E.3. GENERAL EXCLUSIONS AND LIMITATIONS Expenses Incurred for the following are not considered eligible under this Plan: 1. Abortions: Expenses related to elective abortions, except as specified under the Maternity benefit under Medical Benefits. 2. Acupuncture: Acupuncture except as specified under Medical Benefits. 3. Adoption: Expenses for adoption will not be considered eligible. 4. Against Medical Advice:Complications that directly result from acting against medical advice,non- compliance with specific physician's orders or leaving an inpatient facility against medical advice will not be considered eligible. 5. Artificial Organ: Expenses for insertion or maintenance of artificial organ implant procedures. 6. Biofeedback: Expenses for biofeedback will not be considered eligible, unless pre-determined for Medical Necessity. 7. Cardiac Rehabilitation: Expenses in connection with Phase 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. 8. Chelation Therapy: Expenses for chelation therapy will not be considered eligible, unless due to heavy metal poisoning. Chelation therapy reduces the plaque deposits in the arteries and other parts of the body. 9. Close Relative: Services rendered by a Physician or Licensed Health Care Provider who is a Close Relative of the Covered Person, or resides in the same household of the Covered Person and who does not regularly charge the Covered Person for services. 10. Cognitive and Kinetic Therapy: Expenses for cognitive therapy and kinetic therapy will not be considered eligible. Cognitive therapy is defined as therapy which embraces mental activities associated with thinking, learning, and memory. Kinetic therapy is defined as therapy related to motion or movement(i.e.the study of motion,acceleration or rate of change). This exclusion will not apply to expenses related to a neurological brain impairment resulting from an acute major Illness. 11. Complications: Expenses for care,services or treatment required as a result of complications from a treatment not covered under the Plan will not be considered eligible or that are the result of any medical complication resulting from a treatment, service or supply which is, or was at the time the charge was incurred, excluded from coverage under this Plan will not be considered eligible. This exclusion does not apply to complications from abortions as specified under Medical Benefits. 12. Convalescent Care: Expenses for hospitalization when such confinement occurs primarily for physiotherapy, hydrotherapy, convalescent or rest care, or any routine physical examinations,tests or treatments not connected with the actual Illness or Injury will not be considered eligible. 13. Convenience/Personal Comfort:Services or supplies used primarily for cosmetic,personal comfort, convenience, hygiene, beautification items, television or telephone use that are not related to treatment of a medical condition. Collier County Government-SPD 44 Group#2003021 -Eff Date 1/1/2014 Packet Page -583- 1/27/2015 16.E.3. General Exclusions and Limitations 14. Cosmetic: Expenses in connection with the care or treatment of, surgery performed for, or as the result of,a Cosmetic procedure. This exclusion will not apply when such treatment is rendered to correct a condition resulting from an Accidental Injury or an Illness, or when rendered to correct a congenital anomaly for a covered Dependent child. 15. Counseling: Expenses for recreational counseling or milieu therapy. 16. Custodial Care: Expenses related to Custodial Care will not be considered eligible. 17. Dental Care:Expenses Incurred in connection with dental care,treatment,x-rays,general anesthesia or Hospital expenses will not be considered eligible, except as specified under Medical Benefits. 18. Developmental Delays: Expenses in connection with the treatment of developmental delays including, but not limited to, Speech Therapy, Occupational Therapy, Physical Therapy, and any related diagnostic testing will not be considered eligible. This exclusion does not apply to any Autism Spectrum Disorder. 19. Education or Training:Expenses for professional services on an Outpatient basis in connection with disorders of any type or cause,that can be credited towards earning a degree or furtherance of the education or training of a Covered Person regardless of the diagnosis will not be considered eligible. 20. Charges for any services or supplies to the extent that benefits are otherwise provided under this Plan, or under any other plan of group benefits that the Participant's Employer contributes to or sponsors. 21. Experimental/Investigational:Expenses for services,supplies or treatments or procedures,surgical or otherwise which are Experimental or Investigational, except for treatment for ABA (Applied Behavioral Analysis)therapy. 22. Foot Care: Expenses for routine foot care will not be considered eligible for the following services: A. Cutting or removal of corns and calluses; B. Trimming, cutting, clipping, or debriding of nails; C. Other hygienic and preventive maintenance care,such as cleaning and soaking the feet,the use of skin creams to maintain skin tone of either ambulatory or bedfast patients; and D. Any other service performed in the absence of localized Illness, Injury or symptoms involving the foot. 23. Gambling 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 as specified under Medical Benefits and as specifically covered under the Preventive Care Benefit. 25. Governmental Agency: Expenses for services or supplies which are obtained from any governmental agency without cost by compliance with laws or regulations enacted by any governmental body. Also, charges to the extent that the Covered Person could have obtained payment, in whole or in part, if he or she had applied for coverage or obtained treatment under any federal,state or other governmental program or in a treatment facility operated by a government agency, except where required by law, such as for cases of medical emergencies or for coverage provided by Medicaid are not considered eligible. Collier County Government-SPD 45 Group#2003021 -Eff Date 1/1/2014 Packet Page-584- 1/27/2015 16.E.3. General Exclusions and Limitations 26. Hair Loss: Expenses for hair transplant procedures,wigs and artificial hairpieces or drugs which are 6 prescribed to promote hair growth, except as specified under Medical Benefits. 27. Homeopathic Treatment: Expenses for homeopathic,naturopathic and holistic medical procedures will not be eligible. 28. 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. 29. Hypnotherapy: Expenses for hypnotherapy will not be considered eligible. 30. Illegal Charges: Expenses for services, treatment or supplies not considered legal in the United States. 31. Incurred by a Non-Covered Person:Expenses Incurred by persons other than the Covered Person receiving treatment or Expenses for treatment, services or supplies not actually rendered to or received and used by the Covered Person will not be considered eligible. 32. Infertility: Expenses related to or in connection with fertility studies, sterility studies, procedures to restore or enhance fertility, artificial insemination, or in-vitro fertilization, or any other assisted reproductive technique. 33. Mailing: Expenses for mailing and/or shipping and handling expenses will not be considered eligible. 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/Pregnancy: Expenses for maternity expenses incurred by a Dependent other than an Employee's spouse will not be considered eligible. This exclusion does not include well woman prenatal visits as a required recommended preventive service as specifically covered under the Preventive Care benefit. 36. Medically Necessary: Expenses for services, supplies or treatments or procedures, surgical or otherwise, not recognized as generally accepted and Medically Necessary for the diagnosis and/or treatment of an active Illness or Injury. 37. Missed Appointments/Not Rendered In Physical Presence: Expenses for completion of claim forms, missed appointments, telephone consultations, or for treatment which is not rendered by or in the physical presence of a Physician or Licensed Health Care Provider,expedited processing fees, shipping and handling feels will not be considered eligible. 38. No Legal Obligation: Expenses for which the Covered Person is not, in the absence of this coverage, legally obligated to pay,or for which a charge would not ordinarily be made in the absence of this coverage. 39. Non-Medical Expenses: Expenses for non-medical expenses such as training, education, instructions or educational materials, even if they are performed, provided or prescribed by a Physician are not considered eligible, except as specified under Medical Benefits. 40. Non-Prescription: Charges for supplies or devices available without a Physician's prescription, except as covered under the Preventive Care Benefit.. 6 Item 27"Hearing Exams/Aids"(General Exclusions and Limitations)deleted by Amd#2 eff 1/1/2014,28-60 renumbered Collier County Government-SPD 46 Group#2003021 -Eff Date 1/1/2014 Packet Page-585- 1/27/2015 16.E.3. General Exclusions and Limitations 41. 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. 42. Nutritional Supplements:Expenses for non-prescription vitamins or nutritional supplements,except as covered under the Preventive Care Benefit. 43. Obesity: Expenses in connection with services or supplies provided for the treatment of obesity and weight reduction, including bariatric surgery or any other related bariatric procedure, except as specified for Bariatric Surgery under Medical Benefits or as specified under the Weight Loss Program. 44. Prior to Effective Date:Expenses for services rendered or started,or supplies furnished prior to the effective date of coverage under the Plan, or after coverage is terminated under the Plan, except as specifically provided for in the Plan provisions. 45. Refractive Errors:Expenses for any surgical,medical or Hospital services and/or supplies rendered in connection with radial keratotomy, LASIK or any other procedure designed to correct farsightedness, nearsightedness or astigmatism. 46. Routine Care: Expenses for routine medical examinations, routine health check-ups or preventive immunizations not necessary for the treatment of an Injury or Illness, except as specified under Medical Benefits. 47. Sales Tax: Expenses for sales tax will not be considered eligible. 48. Sexual dysfunction: Expenses for any services, care or treatment for sexual dysfunction, trans- sexualism, gender dysphoria or sexual reassignment including related drugs, medications, surgery, medical or Psychiatric Care or treatment will not be considered eligible, except as specified under Medical Benefits. 49. Stand-by Physician: Expenses for technical medical assistance or stand-by Physician services will not be considered eligible. 50. Sterilization: Expenses resulting from or in connection with the reversal of an elective sterilization procedure. 51. Surrogate: Expenses related to surrogate services will not be considered eligible. 52. Tobacco Cessation: Expenses for tobacco cessation programs, including tobacco deterrents not incurred thru The MedCenter will not be considered eligible except as specified under the Health Plan Qualifiers section and as specifically listed as an Eligible Expense. See Medical Benefits. 53. Travel: Expenses Incurred for travel by any person for any reason will not be considered eligible. 54. Useful to Persons in Absence of Illness or Injury: Expenses for services,treatments or supplies that may be useful to persons in the absence of Illness or Injury such as air conditioners, purifiers, humidifiers, special furniture, bicycles, whirlpools, dehumidifiers, exercise equipment, health club memberships, etc.,whether or not they have been prescribed or recommended by a Physician. 55. Usual,Customary and Reasonable: Expenses in excess of the Usual,Customary and Reasonable limits of the Plan will not be considered eligible. 56. Vision Care: Expenses in connection with eye refractions, the purchase or fitting of eyeglasses or contact lenses, except as specifically listed as a covered expense following cataract surgery. Collier County Government-SPD 47 Group#2003021 -Eff Date 1/1/2014 Packet Page-586- 1/27/2015 16.E.3. General Exclusions and Limitations 57. War: Expenses which are caused by or arising out of war or act of war, (whether declared or undeclared),civil unrest,armed invasion or aggression,or caused during service in the armed forces of any country. 58. 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. 59. Work Related:Expenses Incurred by the Covered Person for all services and supplies resulting from any Illness or Injury which occurs in the course of employment for wage or profit, or in the course of any volunteer work when the organization,for whom the Covered Person is volunteering,has elected or is required by law to obtain coverage for such volunteer work under state or federal workers' compensation laws or other legislation, including Employees' compensation or liability laws of the United States (collectively called "Workers' Compensation"). This exclusion applies to all such services and supplies resulting from a work-related Illness or Injury even though: A. Coverage for the Covered Person under Workers' Compensation provides benefits for only a portion of the services Incurred; B. The Covered Person's employer/volunteer organization has failed to obtain such coverage required by law; C. The Covered Person waived his/her rights to such coverage or benefits; D. The Covered Person fails to file a claim within the filing period allowed by law for such benefits; E. The Covered Person fails to comply with any other provision of the law to obtain such coverage or benefits; or F. The Covered Person is permitted to elect not to be covered by Workers' Compensation but failed to properly make such election effective. G. The Covered Person is permitted to elect not to be covered by Workers'Compensation and has affirmatively made that election. This exclusion will not apply to household and domestic employment,employment not in the usual course of the trade, business, profession or occupation of the Covered Person or Employee, or employment of a Dependent member of an Employee's family for whom an exemption may be claimed by the Employee under the Internal Revenue Code. This exclusion also does not apply to the claims of a Covered Person whose workers' compensation coverage has ended specifically because the Covered person has reached Maximum Medical Improvement(MMI)as finally determined and certified without objection or appeal by a workers' compensation fund or insurance carrier. Collier County Government-SPD 48 Group#2003021 -Eff Date 1/1/2014 Packet Page-587- 1/27/2015 16.E.3. COORDINATION OF BENEFITS The Coordination of Benefits provision prevents the payment of benefits which exceed the Allowable Expense. It applies when the Participant or Dependent who is covered by this Plan is or may also be covered by any other plan(s). This Plan will always pay either its benefits in full or a reduced amount which,when added to the benefits payable by the other plan(s),will not exceed 100%of Allowable Expense. Only the amount paid by this Plan will be charged against the Plan maximums. In the event of a motor vehicle or premises accident;or an act of violence with the intent to disrupt electronic, communications, or any other business system, this Plan will be secondary to any auto "no fault" and traditional auto "fault" type contracts, homeowners, commercial general liability insurance and any other medical benefits coverage. The Coordination of Benefits provision applies whether or not a claim is filed under the other plan or plans. If needed,authorization is hereby given this Plan to obtain information as to benefits or services available from the other plan or plans, or to recover overpayments. All benefits contained in the Plan Document are subject to this provision. DEFIN ITIONS "Allowable Expense"as used herein means: 1. If the claim as applied to the primary plan is subject to a contracted or negotiated rate, Allowable Expense will be equal to that contracted or negotiated amount. 2. If the claim as applied to the primary plan is not subject to a contracted or negotiated rate, but the claim as applied to the secondary plan is subject to a contracted or negotiated rate, the Allowable Expense will be equal to that contracted or negotiated amount of the secondary plan. 3. If the claim as applied to the primary plan and the secondary plan is not subject to a contracted or negotiated rate,then the Allowable Expense will equal to the secondary plan's chosen limits for non- contracted providers. "Plan" as used herein means any Plan providing benefits or services for or by reason of medical, dental or vision treatment, and such benefits or services are provided by: 1. Group insurance or any other arrangement for coverage for Covered Persons in a group whether on an insured or uninsured basis including, but not limited to: A. Hospital indemnity benefits; and B. Hospital reimbursement-type plans which permit the Covered Person to elect indemnity at the time of claims; or 2. Hospital or medical service organizations on a group basis, group practice and other group pre- payment plans; or 3. Hospital or medical service organizations on an individual basis having a provision similar in effect to this provision; or 4. A licensed Health Maintenance Organization (H.M.O.); or 5. Any coverage for students which is sponsored by,or provided through a school or other educational institution; or Collier County Government-SPD 49 Group#2003021 -Eff Date 1/1/2014 Packet Page-588- 1/27/2015 16.E.3. Coordination of Benefits 6. Any coverage under a Governmental program,and any coverage required or provided by any statute; or 7. Automobile insurance; or 8. Individual automobile insurance coverage on an automobile leased or owned by the County or any responsible third-party tortfeasor; or 9. Individual automobile insurance coverage based upon the principles of"No-Fault" coverage; or 10. Homeowner or premise liability insurance, individual or commercial. "Plan"will be construed separately with respect to each policy,contract,or other arrangement for benefits or services,and separately with respect to that portion of any such policy,contract,or other arrangement which reserves the right to take the benefits or services of other Plans into consideration in determining its benefits and that portion which does not. ORDER OF BENEFIT DETERMINATION 1. Non-Dependent/Dependent The plan that covers the person as other than a dependent, (e.g., as an employee, member, subscriber, retiree) is primary and the plan that covers the person as a dependent is secondary. 2. Child Covered Under More Than One Plan A. The primary plan is the plan of the parent whose birthday is earlier in the year if: 1) The parents are married; 2) The parents are not separated (whether or not they have ever been married); or 3) A court decree awards joint custody without specifying that one parent has the responsibility to provide health care coverage. B. If both parents have the same birthday,the plan that has covered either of the parents longer is primary. C. If the specific terms of a court decree state that one of the parents is responsible for the child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms,that plan is primary. If the parent with financial responsibility has no coverage for the child's health care services or expenses, but that parent's spouse does, the spouse's plan is primary. This subparagraph will not apply with respect to any claim determination period, Benefit Period or Plan Year during which benefits are paid or provided before the entity has actual knowledge. D. If the parents are not married or are separated(whether or not they were ever married)or are divorced, and there is no court decree allocating responsibility for the child's health care services or expenses,the order of benefit determination among the plans of the parents and the parents' spouses(if any) is: 1) The plan of the custodial parent. 2) The plan of the spouse of the custodial parent. 3) The plan of the non-custodial parent. 4) The plan of the spouse of the non-custodial parent. Collier County Government-SPD 50 Group#2003021 -Eff Date 1/1/2014 Packet Page-589- 1/27/2015 16.E.3. Coordination of Benefits 3. Active or Inactive Employee The Plan that covers a person as an employee who is neither laid-off nor retired (or as that employee's dependent) is primary. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule will not be followed. 4. Longer or Shorter Length of Coverage If the preceding rules do not determine the order of benefits,the plan that has covered the person for the longer period of time is primary. A. To determine the length of time a person has been covered under a plan, two plans will be treated as one if the Covered Person was eligible under the second within 24 hours after the first ended. B. The start of a new plan does not include: 1) A change in the amount or scope of a plan's benefits; 2) A change in the entity that pays, provides, or administers the plan's benefits; or 3) A change from one type of plan to another(such as from a single employer plan to that of a multiple-employer plan). C. A person's length of time covered under a plan is measured from the person's first date of coverage under that plan. If that date is not readily available for a group plan, the date the person first became a member of the group will be used as the date from which to determine the length of time the person's coverage under the present plan has been in force. 5. No Rules Apply If none of these preceding rules determines the primary plan, the Allowable Expense will be determined equally between the plans. COORDINATION WITH MEDICARE Medicare Part A or Part B will be considered a plan for the purposes of coordination of benefits. This Plan will coordinate benefits with Medicare whether or not the Covered Person is actually receiving Medicare Benefits. This means that the plan will only pay the amount that Medicare would not have covered, even if the Covered Person does not elect to be covered under Medicare. Also, failure to enroll in Medicare Part B when a person is initially eligible may result in the person being assessed a significant surcharge by Medicare for late enrollment in Part B. 1. For Working Aged A covered Employee who is eligible for Medicare Part A or Part B as a result of age may be covered under this Plan and be covered under Medicare, in which case this Plan will pay primary. A covered Employee,eligible for Medicare Part A or Part B as a result of age,may elect not to be covered under this Plan. If such election is made, coverage under this Plan will terminate. A covered Dependent, eligible for Medicare Part A or Part B as a result of age, of a covered Employee may also be covered under this Plan and be covered under Medicare, in which case the Plan again will pay primary. A covered Dependent,eligible for Medicare Part A or Part B as a result of age, may elect not to be covered under this Plan. If such election is made, coverage under this Plan will terminate. Collier County Government-SPD 51 Group#2003021 -Eff Date 1/1/2014 Packet Page-590- 1/27/2015 16.E.3. Coordination of Benefits 2. For Retired Persons Medicare is primary and the Plan will be secondary for the covered Retiree if he/she is an individual who is enrolled in Medicare Part A or Part B as a result of age and retired. Medicare is primary and the Plan will be secondary for the covered Retiree's Dependent who is enrolled in Medicare Part A or B if both the covered Retiree and his/her covered Dependent are enrolled in Medicare Part A or Part B as a result of age and retired. Medicare is primary for the Retiree's Dependent when the Retiree is not enrolled for Medicare Part A or Part B as a result of age and the Retiree's Dependent is enrolled in Medicare Part A or Part B as a result of age. 3. For Covered Persons who are Disabled The Plan is primary and Medicare will be secondary for the covered Employee or any covered Dependent who is eligible for Medicare by reason of disability, if the Employee is actively employed by the Employer. The Plan is secondary and Medicare will be primary for the covered Employee or any covered Dependent who is eligible for Medicare by reason of disability if the Employee is retired or otherwise not actively working for the Employer. 4. For Covered Persons with End Stage Renal Disease Except as stated below*,for Employees or Retirees and their Dependents,if Medicare eligibility is due solely to End Stage Renal Disease (ESRD), this Plan will be primary only during the first thirty (30) months of Medicare coverage. Thereafter, this Plan will be secondary with respect to Medicare coverage,unless after the thirty-month period described above,the Covered Person has no dialysis for a period of twelve (12) consecutive months and: A. Then resumes dialysis,at which time the Plan will again become primary for a period of thirty (30)months; or B. The Covered Person undergoes a kidney transplant, at which time the Plan will again become primary for a period of thirty (30) months. *If a Covered Person is covered by Medicare as a result of disability,and Medicare is primary for that reason on the date the Covered Person becomes eligible for Medicare as a result of End Stage Renal Disease, Medicare will continue to be primary and the Plan will be secondary. COORDINATION WITH MEDICAID If a Covered Person is also entitled to and covered by Medicaid,the Plan will always be primary and Medicaid will always be secondary coverage. COORDINATION WITH TRICARE/CHAMPVA If a Covered Person is also entitled to and covered under TRICARE/CHAMPVA, the Plan will always be primary and TRICARE/CHAMPVA will always be secondary coverage. TRICARE coverage will include programs established under its authority, known as TRICARE Standard, TRICARE Extra and TRICARE Prime. If the Covered Person is eligible for Medicare and entitled to veterans benefits through the Department of Veterans Affairs (VA), the Plan will always be primary and the VA will always be secondary for non-service connected medical claims. For these claims,the Plan will make payment to the VA as though the Plan was making payment secondary to Medicare. Collier County Government-SPD 52 Group#2003021 -Eff Date 1/1/2014 Packet Page -591- 1/27/2015 16.E.3. PROCEDURES FOR CLAIMING BENEFITS Claims must be submitted to the Plan within twelve (12) months after the date services or treatments are received or completed. Non-electronic claims may be submitted on any approved claim form,available from the provider. The claim must be completed in full with all the requested information. A complete claim must include the following information: • Date of service; • Name of the Participant; • Name and date of birth of the patient receiving the treatment or service and his/her relationship to the Participant; • Diagnosis [code]of the condition being treated; • Treatment or service [code] performed; • Amount charged by the provider for the treatment or service; and • Sufficient documentation, in the sole determination of the Plan Administrator,to support the medical necessity of the treatment or service being provided and sufficient to enable the Plan Supervisor to adjudicate the claim pursuant to the terms and conditions of the Plan. When completed,the claim must be sent to the Plan Supervisor,Allegiance Benefit Plan Management, Inc., at P.O. Box 3018, Missoula, Montana 59806-3018, (855) 333-1004 or through any electronic claims submission system or clearinghouse to which Allegiance Benefit Plan Management, Inc. has access. A claim will not, under any circumstances, be considered for payment of benefits if initially submitted to the Plan more than twelve (12)months from the date that services were incurred. Upon termination of the Plan,final claims must be received within three(3)months of the date of termination, unless otherwise established by the Plan Administrator. CLAIMS WILL NOT BE DEEMED SUBMITTED UNTIL RECEIVED BY THE PLAN SUPERVISOR. The Plan will have the right, in its sole discretion and at its own expense, to require a claimant to undergo a medical examination, when and as often as may be reasonable, and to require the claimant to submit, or cause to be submitted, any and all medical and other relevant records it deems necessary to properly adjudicate the claim. CLAIM DECISIONS ON CLAIMS AND ELIGIBILITY Claims will be considered for payment according to the Plan's terms and conditions,industry-standard claims processing guidelines and administrative practices not inconsistent with the terms of the Plan. The Plan may, when appropriate or when required by law, consult with relevant health care professionals and access professional industry resources in making decisions about claims that involve specialized medical knowledge or judgment. Initial eligibility and claims decisions will be made within the time periods stated below. For purposes of this section, "Covered Person" will include the claimant and the claimant's Authorized Representative;"Covered Person"does not include a health care provider or other assignee,and said health care provider or assignee does not have an independent right to appeal an Adverse Benefit Determination simply by virtue of the assignment of benefits. "Authorized Representative" means a representative authorized by the claimant to act on their behalf in pursuing a benefit claim or appeal of an Adverse Benefit Determination. The claimant must authorize the representative in writing,and this written authorization must be provided to the Plan. The Plan will recognize this Authorized Representative when the Plan receives the written authorization. INFORMATION REGARDING URGENT CARE CLAIMS IS PROVIDED TO YOU UNDER THE DISCLOSURE REQUIREMENTS OF APPLICABLE LAW; THE PLAN DOES NOT MAKE TREATMENT DECISIONS. ANY DECISION TO RECEIVE TREATMENT MUST BE MADE BETWEEN THE PATIENT AND HIS OR HER HEALTHCARE PROVIDER; HOWEVER, THE PLAN WILL ONLY PAY BENEFITS ACCORDING TO THE TERMS, CONDITIONS, LIMITATIONS AND EXCLUSIONS OF THIS PLAN. Collier County Government-SPD 53 Group#2003021 -Eff Date 1/1/2014 Packet Page-592- 1/27/2015 16.E.3. Procedures for Claiming Benefits 1. Urgent Care Claims-An Urgent Care Claim is any claim for medical care or treatment with respect to which: A. In the judgment of a prudent layperson possessing an average knowledge of health and medicine could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or B. In the opinion of a Physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. There are no Urgent Care requirements under this Plan and therefore,there are no rights to appeal a pre-service Urgent Care claim denial. 2. Pre-Service Claims-Pre-Service Claims must be submitted to the Plan before the Covered Person receives medical treatment or service. A Pre-Service Claim is any claim for a medical benefit which the Plan terms condition the Covered Person's receipt of the benefit, in whole or in part,on approval of the benefit before obtaining treatment. Pre-Service Claims are procedures stated in the Plan Document which,the Plan recommends be utilized before a Covered Person obtains medical care. 3. Post-Service Claims-A Post-Service Claim is any claim for a medical benefit under the Plan with respect to which the terms of the Plan do not condition the Covered Person's receipt of the benefit, or any part thereof,on approval of the benefit prior to obtaining medical care,and for which medical treatment has been obtained prior to submission of the claim(s). In most cases, initial claims decisions on Post-Service Claims will be made within thirty(30)days of the Plan's receipt of the claim. The Plan will provide timely notice of the initial determination once sufficient information is received to make an initial determination, but no later than thirty (30) days after receiving the claim. 4. Concurrent Care Review - For patients who face early termination or reduction of benefits for a course of treatment previously certified by the Plan, a decision by the Plan to reduce or terminate benefits for ongoing care is considered an Adverse Benefit Determination. (Note: Exhaustion of the Plan's benefit maximums is not an Adverse Benefit Determination.) The Plan will notify the Covered Person sufficiently in advance to allow an appeal for uninterrupted continuing care before the benefit is reduced or terminated. Any request to extend an Urgent Care course of treatment beyond the initially prescribed period of time must be decided within twenty-four(24)hours of the Plan's receipt of the request. The appeal for ongoing care or treatment must be made to the Plan at least twenty- four(24)hours prior to the expiration of the initially-prescribed period. APPEALING AN UN-REIMBURSED PRE-SERVICE CLAIM If a claim is denied in whole or in part, the Covered Person will receive written notification of the Adverse Benefit Determination. A claim denial will be provided by the Plan showing: 1. The reason the claim was denied; 2. Reference(s)to the specific plan provision(s) or rule(s) upon which the decision was based which resulted in the Adverse Benefit Determination; 3. Any additional information needed to perfect the claim and why such information is needed; and 4. An explanation of the Covered Person's right to appeal the Adverse Benefit Determination for a full and fair review and the right to bring a civil action following an Adverse Benefit Determination on appeal. Collier County Government-SPD 54 Group#2003021 -Eff Date 1/1/2014 Packet Page-593- 1/27/2015 16.E.3. Procedures for Claiming Benefits If a Covered Person does not understand the reason for any Adverse Benefit Determination,he or she should contact the Plan Supervisor at the address or telephone number shown on the claim denial. The Covered Person must appeal the Adverse Benefit Determination before the Covered Person may exercise his or her right to bring a civil action. This Plan provides two (2) levels of benefit determination review and the Covered Person must exercise both levels of review before bringing a civil action. To initiate the first level of benefit review,the Covered Person must submit in writing an appeal or a request for review of the Adverse Benefit Determination to the Plan within one hundred eighty (180) days after the Adverse Benefit Determination. The Covered Person should include any additional information supporting the appeal or the information required by the Plan which was not initially provided and forward it to the Plan Supervisor within the 180-day time period.Failure to appeal the Adverse Benefit Determination within the 180- day time period will render the determination final. Any appeal received after the 180-day time period has expired will receive no further consideration. Appeals or requests for review of Adverse Benefit Determinations for Pre-Service Claims must be submitted in writing to Community Health Partners, P.O. Box 9529, Naples, FL 34101. Supporting materials may be submitted via facsimile at(239)659-7799. Appeals or requests for review of Adverse Benefit Determinations for Post-Service Claims must be submitted to the Plan in writing to P.O.Box 1269,Missoula,MT 59806-1269. Supporting materials may be submitted via mail,electronic claims submission process,facsimile(fax)or electronic mail(e-mail). 1. First Level of Benefit Determination Review The first level of benefit determination review is done by Community Health Partners (CHP). CHP will research the information initially received and determine if the initial determination was appropriate based on the terms and conditions of the Plan and other relevant information. Notice of the decision on the first level of review will be sent to the Covered Person within fifteen (15) days following the date CHP receives the request for reconsideration. If, based on CHP's review, the initial Adverse Benefit Determination remains the same and the Covered Person does not agree with that benefit determination,the Covered Person must initiate the second level of benefit review. The Covered Person must request the second review in writing and send it to CHP, not later than sixty (60) days after receipt of CHP's decision from the first level of review. Failure to initiate the second level of benefit review within the 60-day time period will render the determination final. 2. Second Level of Benefit Determination Review The Plan Administrator will review the claim in question along with the additional information submitted by the Covered Person. The Plan will conduct a full and fair review of the claim by the Plan Administrator who is neither the original decisionmaker nor the decisionmaker's subordinate. The Plan Administrator cannot give deference to the initial benefit determination. The Plan Administrator may,when appropriate or if required by law,consult with relevant health care professionals in making decisions about appeals that involve specialized medical judgment. Where the appeal involves issues of medical necessity or experimental treatment,the Plan Administrator will consult with a health care professional with appropriate training who was neither the medical professional consulted in the initial determination or his or her subordinate. After a full and fair review of the Covered Person's appeal,the Plan will provide a written or electronic notice of the final benefit determination,which contains the same information as notices for the initial determination, within fifteen (15)days. Collier County Government-SPD 55 Group#2003021 -Eff Date 1/1/2014 Packet Page-594- 1/27/2015 16.E.3. Procedures for Claiming Benefits INDEPENDENT EXTERNAL REVIEW FOR A PRE-SERVICE CLAIM After exhaustion of all appeal rights stated above, a Covered Person may also request a final independent external review of any Adverse Benefit Determination involving a question of Medical Necessity,or other issue requiring medical expertise for resolution. To assert this right to independent external medical review, the Covered Person must request such review in writing within one hundred twenty (120) days after a decision is made upon the second level benefit determination above. If an independent external review is requested for a Pre-Service Claim,CHP will forward the entire record on appeal, within ten (10)days, to an independent external review organization (IRO)selected randomly. The IRO will notify the Covered Person of its procedures to submit further information. If an independent external review is requested for a Post-Service Claim,the Plan Supervisor will forward the entire record on appeal,within ten(10)days,to an independent external review organization (IRO)selected randomly. The IRO will notify the Covered Person of its procedures to submit further information. The IRO will issue a final decision within forty-five (45)days after receipt of all necessary information. The decision of the IRO will be final and binding except that the Covered Person shall have an additional right to appeal the matter to a court with jurisdiction. APPEALING AN UN-REIMBURSED POST-SERVICE CLAIM If a claim is denied in whole or in part, the Covered Person will receive written notification of the Adverse Benefit Determination. A claim Explanation of Benefits (EOB)will be provided by the Plan showing: 1. The reason the claim was denied; 2. Reference(s) to the specific plan provision(s) or rule(s) upon which the decision was based which resulted in the Adverse Benefit Determination; 3. Any additional information needed to perfect the claim and why such information is needed; and 4. An explanation of the Covered Person's right to appeal the Adverse Benefit Determination for a full and fair review and the right to bring a civil action following an Adverse Benefit Determination on appeal. If a Covered Person does not understand the reason for any Adverse Benefit Determination,he or she should contact the Plan Supervisor at the address or telephone number shown on the EOB form. The Covered Person must appeal the Adverse Benefit Determination before the Covered Person may exercise his or her right to bring a civil action. This Plan provides two (2) levels of benefit determination review and the Covered Person must exercise both levels of review before bringing a civil action. To initiate the first level of benefit review,the Covered Person must submit in writing an appeal or a request for review of the Adverse Benefit Determination to the Plan within one hundred eighty (180) days after the Adverse Benefit Determination. The Covered Person should include any additional information supporting the appeal or the information required by the Plan which was not initially provided and forward it to the Plan Supervisor within the 180-day time period.Failure to appeal the Adverse Benefit Determination within the 180- day time period will render the determination final. Any appeal received after the 180-day time period has expired will receive no further consideration. Collier County Government-SPD 56 Group#2003021 -Eff Date 1/1/2014 Packet Page-595- 1/27/2015 16.E.3. Procedures for Claiming Benefits Appeals or requests for review of Adverse Benefit Determinations must be submitted to the Plan in writing to P.O. Box 1269, Missoula,MT 59806-1269. Supporting materials may be submitted via mail, electronic claims submission process,facsimile(fax)or electronic mail (e-mail). 1. First Level of Benefit Determination Review The first level of benefit determination review is done by the Plan Supervisor. The Plan Supervisor will research the information initially received and determine if the initial determination was appropriate based on the terms and conditions of the Plan and other relevant information. Notice of the decision on the first level of review will be sent to the Covered Person within thirty (30) days following the date the Plan Supervisor receives the request for reconsideration. If,based on the Plan Supervisor's review,the initial Adverse Benefit Determination remains the same and the Covered Person does not agree with that benefit determination, the Covered Person must initiate the second level of benefit review. The Covered Person must request the second review in writing and send it to the Plan Supervisor, not later than sixty (60) days after receipt of the Plan Supervisor's decision from the first level of review.Failure to initiate the second level of benefit review within the 60-day time period will render the determination final. 2. Second Level of Benefit Determination Review The Plan Administrator will review the claim in question along with the additional information submitted by the Covered Person. The Plan will conduct a full and fair review of the claim by the Plan Administrator who is neither the original decisionmaker nor the decisionmaker's subordinate. The Plan Administrator cannot give deference to the initial benefit determination. The Plan Administrator may,when appropriate or if required by law,consult with relevant health care professionals in making decisions about appeals that involve specialized medical judgment. Where the appeal involves issues of medical necessity or experimental treatment,the Plan Administrator will consult with a health care professional with appropriate training who was neither the medical professional consulted in the initial determination or his or her subordinate. After a full and fair review of the Covered Person's appeal,the Plan will provide a written or electronic notice of the final benefit determination within a reasonable time,but no later than thirty(30)days from the date the appeal is received by the Plan at each level of review. All claim payments are based upon the terms contained in the Plan Document, on file with the Plan Administrator and the Plan Supervisor. The Covered Person may request, free of charge, more detailed information, names of any medical professionals consulted and copies of relevant documents, as defined in and required by law, which were used by the Plan to adjudicate the claim. INDEPENDENT EXTERNAL REVIEW FOR A POST-SERVICE CLAIM After exhaustion of all appeal rights stated above, a Covered Person may also request a final independent external review of any Adverse Benefit Determination involving a question of Medical Necessity,or other issue requiring medical expertise for resolution. To assert this right to independent external medical review, the Covered Person must request such review in writing within one hundred twenty (120) days after a decision is made upon the second level benefit determination above. If an independent external review is requested for a Pre-Service Claim, CHP will forward the entire record on appeal, within ten (10)days, to an independent external review organization (IRO)selected randomly. The IRO will notify the Covered Person of its procedures to submit further information. Collier County Government-SPD 57 Group#2003021-Eff Date 1/1/2014 Packet Page-596- 1/27/2015 16.E.3. Procedures for Claiming Benefits If an independent external review is requested for a Post-Service Claim,the Plan Supervisor will forward the entire record on appeal,within ten(10)days,to an independent external review organization (IRO)selected randomly. The IRO will notify the Covered Person of its procedures to submit further information. The IRO will issue a final decision within forty-five (45)days after receipt of all necessary information. The decision of the IRO will be final and binding except that the Covered Person shall have an additional right to appeal the matter to a court with jurisdiction. Collier County Government-SPD 58 Group#2003021 -Eff Date 1/1/2014 Packet Page-597- 1/27/2015 16.E.3. ELIGIBILITY PROVISIONS If both the husband and wife are employed by the County, and both are eligible for Dependent Coverage, either the husband or wife,but not both,may elect Dependent Coverage for their eligible Dependents. No one can be covered under this Plan as both an Employee and a Dependent. No one can be covered under this Plan as a Dependent by more than one Participant. EMPLOYEE ELIGIBILITY An Employee is eligible to participate in this Plan who is employed by the County and classified as regular full- time or part-time, as those terms are defined by the County, and are regularly scheduled to work a minimum of twenty (20) hours per week as a part-time Employee and a minimum of thirty (30) hours per week as a regular full-time Employee. An Employee is not eligible while on active military duty if that duty exceeds a period of thirty-one (31) consecutive days. WAITING PERIOD With respect to an eligible employee, coverage under the Plan will not start until the Employee completes a Waiting Period,which commences on the Enrollment Date(eligibility date)and will be either of the following: 1. If the Enrollment Date occurs on the first day of the month, the Waiting Period is waived; or 2. If the Enrollment Date occurs on any day other than the first day of the month,the Waiting Period will end on the first day of the month following the Enrollment Date. DEPENDENT ELIGIBILITY An eligible Dependent includes any person who is a citizen, resident alien, or is otherwise legally present in the United States or in any other jurisdiction that the related Participant has been assigned by the Employer, and who is either: 1. The Participant's legal spouse of the opposite sex,according to the marriage laws of the state where the marriage was first solemnized or established. An eligible Dependent does not include a spouse who is legally separated or divorced from the Participant and has a court order or decree stating such from a court of competent jurisdiction. 2. The Participant's Dependent child who meets all of the following"Required Eligibility Conditions": A. Is a natural child; step-child; legally adopted child; a child who has been Placed with the Participant for adoption and for whom as part of such placement the Participant has a legal obligation for the partial or full support of such child, including providing coverage under the Plan pursuant to a written agreement;a person for whom the Participant has been appointed the legal guardian by a court of competent jurisdiction prior to the person attaining nineteen (19)years of age; and B. Is less than twenty-six (26)years of age. A Dependent child is eligible until the end of the Calendar Year in which twenty-six(26)years of age is attained. This requirement is waived if the Participant's child is mentally handicapped/challenged or physically handicapped/challenged, provided that the child was incapable of self-supporting employment and was chiefly dependent upon the Participant for support and maintenance prior to end of the Calendar month in which he/she attained twenty-six (26) years of age. Proof of incapacity must be furnished to the Plan Administrator upon request,and additional proof may be required from time to time. Collier County Government-SPD 59 Group#2003021 -Eff Date 1/1/2014 Packet Page-598- 1/27/2015 16.E.3. Eligibility Provisions EXTENDED COVERAGE FOR DEPENDENTS An Extended-Coverage Child as defined by Florida Statute 627.6562 who is twenty-six(26)years of age but less than thirty(30)years of age may continue to be an eligible Dependent if the Dependent child was covered under this Plan on the last day of the Calendar Year after the Dependent child attains twenty-six(26)years of age and meets all of the following criteria required by Florida Statute: 1. Unmarried without Dependents of their own; and 2. A Florida resident or a full or part-time student; and 3. Not provided coverage under any other health plan or policy; and 4. Not entitled to coverage under Medicare. The eligible Employee must make an election to continue coverage for the Extended-Coverage Child,and file an Affidavit of Dependent Eligibility,within thirty-one(31)days following the date such child ceases to satisfy the eligibility requirements for eligible Dependent coverage under the Plan. Such Extended-Coverage Child may continue coverage until the last day of the Calendar Year in which the Extended-Coverage Child attains the age of thirty(30)years of age. If an eligible Employee fails to make an election to continue coverage under this provision within the time frame or if coverage under this provision terminates,the child will be eligible to make an election to continue coverage in accordance with the COBRA Continuation Coverage section of this Plan. The eligible Employee or Extended-Coverage Child is required to pay the entire amount of the cost of coverage for the Extended-Coverage Child under this provision in accordance with the same procedures established under the COBRA Continuation of Coverage section of this Plan. PARTICIPANT ELIGIBILITY FOR DEPENDENT COVERAGE Each Employee will become eligible for Dependent Coverage on the latest of: 1) the date the Employee becomes eligible for Participant coverage;or 2)the date on which the Employee first acquires a Dependent. DECLINING COVERAGE If an eligible person declines coverage under this Plan, he/she will state his/her reason(s)for declining, in writing. Failure to provide those reasons in writing may result in the Plan refusing enrollment at a later date. RETIREE ELIGIBILITY An Employee is eligible to continue coverage under this Plan as a Retiree if they are a Qualifying Retiree of Collier County Government. Eligible Dependents of a Qualifying Retiree may also continue coverage under this Plan. Qualifying Retirees must meet the requirements of Florida Statute 112.0801. Collier County Government-SPD 60 Group#2003021-Eff Date 1/1/2014 Packet Page -599- 1/27/2015 16.E.3. EFFECTIVE DATE OF COVERAGE All coverage under the Plan will commence at 12:01 A.M. in the time zone in which the Covered Person permanently resides, on the date such coverage becomes effective. PARTICIPANT COVERAGE Participant coverage under the Plan will become effective on the first day immediately after the Employee satisfies the applicable eligibility requirements and Waiting Period,provided that application for such coverage is made on the Plan's enrollment form within thirty-one(31)days immediately following the Enrollment Date. An eligible Employee who declines Participant coverage under the Plan during the Initial Enrollment Period will be able to become covered later in only two situations, Open Enrollment and Special Enrollment. If an eligible Employee chooses not to enroll or fails to enroll for coverage under the Plan during the Initial Enrollment Period, coverage for the Employee and Dependents will be deemed waived. If a Participant chooses not to re-enroll or fails to re-enroll during any Open Enrollment Period, coverage for the Participant and any Dependents covered at the time will remain the same as that elected prior to the Open Enrollment Period. DEPENDENT COVERAGE Each Participant who requests Dependent Coverage on the Plan's enrollment form will become covered for Dependent Coverage as follows: 1. On the Participant's effective date of coverage,if application for Dependent Coverage is made on the Plan's enrollment form within thirty-one(31)days immediately following the Participant's Enrollment Date. This subsection applies only to Dependents who are eligible on the Participant's effective date of coverage. 2. In the event a Dependent is acquired after the Participant's effective date of coverage as a result of a legal guardianship or in the event that a Participant is required to provide coverage as a result of a valid court order, or if the Dependent is acquired as a result of operation of law, Dependent Coverage will begin on the first day of the month following the Plan's receipt of an enrollment form and copy of said court order, if applicable. AUTOMATIC NEWBORN COVERAGE A child born to a covered Employee or covered Dependent spouse is automatically covered for a period of thirty(30)days whether the child is enrolled or not from the moment of birth. The child must be enrolled in accordance with the terms of the applicable Special Enrollment provisions of this Plan for coverage to continue beyond thirty(30)days. RETIREE COVERAGE Coverage for a Qualifying Retiree and eligible Dependents will become effective on the first day of the month following the date of retirement, provided that application for coverage is made on the Plan's enrollment form with thirty-one (31)days from the last day of the month following the date of retirement. Collier County Government-SPD 61 Group#2003021 -Eff Date 1/1/2014 Packet Page-600- 1/27/2015 16.E.3. Effective Date of Coverage OPEN ENROLLMENT PERIOD The Open Enrollment Period will begin November 1s`and will end as determined by the Plan Administrator. During any Open Enrollment Period an Employee and the Employee's eligible Dependents, who are not covered under this plan, may request Participant or Dependent coverage. Coverage must be requested on the Plan's enrollment form. Also during any Open Enrollment Period, Participants and their covered Dependents will be able to make a change in coverage under this Plan. Coverage or changes requested during any Open Enrollment Period will begin on January 1s`immediately following the Open Enrollment Period and will remain in effect until the next January 1st, except as otherwise allowed during a Special Enrollment Period. SPECIAL ENROLLMENT PERIOD In addition to other enrollment times allowed by this Plan, certain persons may enroll during the Special Enrollment Periods described below. "Special Enrollment Period"means a period of time allowed under this Plan, other than the eligible person's Initial Enrollment Period or an Open Enrollment Period,during which an eligible person can request coverage under this Plan as a result of certain events that create special enrollment rights. Coverage will become effective on the date of the event if the Employee or Retiree makes a special enrollment request,verbally or in writing,within thirty-one(31)days of any special enrollment event and application for such coverage is made on the Plan's enrollment form within sixty(60)days of the event. Any eligible Employee or Retiree and any of their eligible Dependents may enroll and become covered as a result of the following specific events: 1. Marriage to the Employee or Retiree; 2. Birth of the Employee's or Retiree's child; 3. Adoption of a child by the Employee or Retiree , provided the child is under the age of 19; 4. Placement for Adoption with the Employee or Retiree , provided such Employee or Retiree has a legal obligation for the partial or full support of such child,including providing coverage under the Plan pursuant to a written agreement and the child is under the age of 19; 5. Coverage under Medicaid or any state children's insurance program recognized under the Children's Health Insurance Program Reauthorization Act of 2009 is terminated due to loss of eligibility; 6. The date any eligible Employee or Retiree or any of their eligible Dependents becomes entitled to a Premium Assistance Subsidy authorized under the Children's Health Insurance Program Reauthorization Act of 2009. The date of entitlement shall be the date stated in the Premium Assistance Authorization entitlement notice issued by the applicable state agency(CHIP or Medicaid). A request for enrollment, either verbal or in writing, must be made within sixty (60) days after this special enrollment event, and written application for such coverage must be made in writing within ninety(90)days after such event. Collier County Government-SPD 62 Group#2003021 -Eff Date 1/1/2014 Packet Page-601- 1/27/2015 16.E.3. Effective Date of Coverage 7. Coverage under another health care plan or health insurance is terminated due to loss of eligibility or if employer contributions to the other coverage have been terminated (Loss of Coverage) Loss of Coverage means only one of the following: A. COBRA Continuation Coverage under another plan and the maximum period of COBRA Continuation Coverage under that other plan has been exhausted; or B. Group or insurance health coverage that has been terminated as a result of termination of Employer contributions*towards that other coverage; or C. Group or insurance health coverage(includes other coverage that is Medicare)that has been terminated only as a result of a loss of eligibility for coverage for any of the following: 1) Legal separation or divorce of the eligible Employee or Retiree; 2) Cessation of Dependent status; 3) Death of the eligible Employee or Retiree; 4) Termination of employment of the eligible Dependent; 5) Reduction in the number of hours of employment of the eligible Dependent; 6) Termination of the eligible Dependent's employer's plan; 7) Any loss of eligibility after a period that is measured by reference to any of the foregoing; or 8) Any loss of eligibility for individual or group coverage because the eligible Employee, Retiree or Dependent no longer resides, lives or works in the service area of the HMO or other such plan. *Employer contributions include contributions by any current or former employer that was contributing to the other non-COBRA coverage. A loss of eligibility for coverage does not occur if coverage was terminated due to a failure of the Employee, Retiree or Dependent to pay premiums on a timely basis or coverage was terminated for cause. CHANGE IN STATUS If a Covered Dependent under this Plan becomes an eligible Employee of the County, he/she may continue his/her coverage as a Participant only. If an eligible Employee who is covered as a Participant of this Plan ceases to be an Employee of the County, but is eligible to be covered as a Dependent under another Employee/Participant, he/she may elect to continue his/her coverage as a Dependent of such Employee/Participant. Application for coverage due to a Change in Status must be made on the Plan's enrollment form,within thirty- one(31)days immediately following the date the Employee becomes or ceases to be an eligible Employee. A Change in Status will not be deemed to be a break or termination of coverage and will not operate to reduce or increase any coverage or accumulations toward satisfaction of the deductible and Out-of-Pocket Maximum to which the Covered Person was entitled prior to the Change in Status. Collier County Government-SPD 63 Group#2003021-Eff Date 1/1/2014 Packet Page-602- 1/27/2015 16.E.3. QUALIFIED MEDICAL CHILD SUPPORT ORDER PROVISION PURPOSE Although the Collier County Government Employee Benefit Plan is not a Plan covered under ERISA,the Plan Administrator adopts the following procedures, pursuant to Section 609(a)of ERISA, to determine whether Medical Child Support Orders are qualified in accordance with ERISA's requirements,to administer payments and other provisions under Qualified Medical Child Support Orders (QMCSOs), and to enforce these procedures as legally required. The County adopts ERISA standards to comply with child support enforcement obligation of Part D of Title IV of the Social Security Act of 1975 as amended. DEFINITIONS For QMCSO requirements, the following definitions apply: 1. "Alternate Recipient" means any child of a Participant who is recognized under a Medical Child Support Order as having a right to enroll in this Plan with respect to the Participant. 2. "Medical Child Support Order"means any state or courtjudgment,decree or order(including approval of settlement agreement) issued by a court of competent jurisdiction, or issued through an administrative process established under State law and which has the same force and effect of law under applicable State law and: A. Provides for child support for a child of a Participant under this Plan, or B. Provides for health coverage for such a child under state domestic relations laws(including community property laws)and relates to benefits under this Plan; and C. Is made pursuant to a law relating to medical child support described in Section 1908 of the Social Security Act. 3. "Plan" means this self-funded Employee Health Benefit Plan, including all supplements and amendments in effect. 4. "Qualified Medical Child Support Order" means a Medical Child Support Order which creates (including assignment of rights) or recognizes an Alternate Recipient's right to receive benefits to which a Participant or Qualified Beneficiary is eligible under this Plan, and has been determined by the Plan Administrator to meet the qualification requirements as outlined under"Procedures"of this provision. CRITERIA FOR A QUALIFIED MEDICAL CHILD SUPPORT ORDER To be qualified, a Medical Child Support Order must clearly: 1. . Specify the name and the last known mailing address (if any) of the Participant and the name and mailing address of each Alternate Recipient covered by the order,except that,to the extent provided in the order, the name and mailing address of an official of a State or a political subdivision thereof may be substituted for the mailing address of any such Alternate Recipient; and 2. Include a reasonable description of the type of coverage to be provided by the Plan to each Alternate Recipient, or the manner in which such type of coverage is to be determined; and 3. Specify each period to which such order applies. Collier County Government-SPD 64 Group#2003021 -Eff Date 1/1/2014 Packet Page-603- 1/27/2015 16.E.3. Qualified Medical Child Support Order Provision In order to be qualified,a Medical Child Support Order must not require the Plan to provide any type or form of benefits, or any option, not otherwise provided under the Plan except to the extent necessary to meet the requirements of Section1908 of the Social Security Act(relating to enforcement of state laws regarding child support and reimbursement of Medicaid). PROCEDURES FOR NOTIFICATIONS AND DETERMINATIONS In the case of any Medical Child Support Order received by this Plan: 1. The Plan Administrator will promptly notify the Participant and each Alternate Recipient of the receipt of such order and the plan's procedures for determining whether Medical Child Support Orders are qualified orders; and 2. Within a reasonable period after receipt of such order,the Plan Administrator will determine whether such order is a Qualified Medical Child Support Order and notify the Participant and each Alternate Recipient of such determination. NATIONAL MEDICAL SUPPORT NOTICE If the Plan Administrator of a group health plan which is maintained by the Employer of a non-custodial parent of a child, or to which such an employer contributes, receives an appropriately completed National Medical Support Notice as described in Section 401(b)of the Child Support Performance and Incentive Act of 1998 in the case of such child, and the Notice meets the criteria shown above for a qualified order, the Notice will be deemed to be a Qualified Medical Child Support Order in the case of such child. Collier County Government-SPD 65 Group#2003021 -Eff Date 1/1/2014 Packet Page-604- 1/27/2015 16.E3. FAMILY AND MEDICAL LEAVE ACT OF 1993 The Family and Medical Leave Act (FMLA) requires Employers who are subject to FMLA to allow their "eligible" Employees to take unpaid, job-protected leave. The Employer may also require or allow the Employee to substitute appropriate paid leave including, but not limited to, vacation and sick leave, if the Employee has earned or accrued it. The maximum leave required by FMLA is twelve(12)workweeks in any twelve(12)month period for certain family and medical reasons and a maximum combined total of twenty-six (26)workweeks during any twelve(12)month period for certain family and medical reasons and for a serious injury or illness of a member of the Armed Forces to allow the Employee,who is the spouse, son, daughter, parent, or next of kin to the member of the Armed Forces, to care for that member of the Armed Forces. In certain cases,this leave may be taken on an intermittent basis rather than all at once, or the Employee may work a part-time schedule. DEFINITIONS For these Family and Medical Leave Act of 1993 provisions only, the following definitions apply: 1. "Member of the Armed Forces" includes members of the National Guard or Reserves who are undergoing medical treatment, recuperation or therapy. 2. "Next of Kin" means the nearest blood relative to the service member. 3. "Parent" means Employee's biological parent or someone who has acted as Employee's parent in place of Employee's biological parent when Employee was a son or daughter. 4. "Serious health condition" means an illness, injury impairment, or physical or mental condition that involves: A. Inpatient care in a hospital, hospice, or residential medical facility; or B. Continuing treatment by a health care provider(a doctor of medicine or osteopathy who is authorized to practice medicine or surgery as appropriate, by the state in which the doctor practices or any other person determined by the Secretary of Labor to be capable of providing health care services). 5. "Serious injury or illness" means an injury or illness incurred in the line of duty that may render the member of the Armed Forces medically unfit to perform his or her military duties. 6. "Son or daughter" means Employee's biological child, adopted child, stepchild, legal foster child, a child placed in Employee's legal custody, or a child for which Employee is acting as the parent in place of the child's natural blood related parent. The child must be: A. Under the age of eighteen (18); or B. Over the age of eighteen (18), but incapable of self-care because of a mental or physical disability. 7. "Spouse"means a husband or wife as defined or recognized under state law for purposes of marriage in the state where the employee resides,including"common law"marriage and same-sex marriage. EMPLOYERS SUBJECT TO FMLA In general, FMLA applies to any employer engaged in interstate commerce or in any industry or activity affecting interstate commerce who employs 50 or more Employees for each working day during each of 20 or more calendar work weeks in the current or preceding Calendar Year. FMLA also applies to those persons described in Section 3(d)of the Fair Labor Standards Act,29 U.S.C.203(d). The FMLA applies to government entities, including branches of the United States government, state governments and political subdivisions thereof. Collier County Government-SPD 66 Group#2003021 -Eff Date 1/1/2014 Packet Page-605- 1/27/2015 16.E.3. Family and Medical Leave Act ELIGIBLE EMPLOYEES Generally, an Employee is eligible for FMLA leave only if the Employee satisfies all of the following requirements as of the date on which any requested FMLA leave is to commence: (1)has been employed by the Employer for a total of at least twelve months(whether consecutive or not);(2)the Employee has worked (as defined under the Fair Labor Standards Act) at least 1,250 hours during the twelve-(12) month period immediately preceding the date the requested leave is to commence; (3)the Employee is employed in any state of the United States,the District of Columbia or any Territories or possession of the United States; and (4)at the time the leave is requested,the Employee is employed at a work site where 50 or more Employees are employed by the Employer within 75 surface miles of the work site. REASONS FOR TAKING LEAVE FMLA leave must be granted (1)to care for the Employee's newborn child; (2)to care for a child placed with the Employee for adoption or foster care;(3)to care for the Employee's spouse,son,daughter,or parent,who has a serious health condition; (4) because the Employee's own serious health condition prevents the Employee from performing his or her job; or (5) because of a qualifying exigency, as determined by the Secretary of Labor,arising out of the fact that a spouse,son,daughter or parent of the Employee is on active duty or has been called to active duty in the Armed Forces in support of a contingency operation (i.e., a war or national emergency declared by the President or Congress). ADVANCE NOTICE AND MEDICAL CERTIFICATION Ordinarily, an Employee must provide thirty (30) days advance notice when the requested leave is "foreseeable." If the leave is not foreseeable, the Employee must notify the Employer as soon as is practicable, generally within one to two working days. An employer may require medical certification to substantiate a request for leave requested due to a serious health condition. If the leave is due to the Employee's serious health condition, the Employer may require second or third opinions, at the Employer's expense, and a certification of fitness to return to work prior to allowing the Employee to return to work. PROTECTION OF JOB BENEFITS For the duration of FMLA leave, the Employer must maintain the Employee's health coverage under any "group health plan"on the same conditions as coverage would have been provided if the Employee had been in Active Service during FMLA leave period. Taking FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an Employee's leave,unless the loss would have occurred even if the Employee had been in Active Service. UNLAWFUL ACTS BY EMPLOYERS Employers cannot interfere with, restrain or deny the exercise of any right provided under the FMLA or to manipulate circumstances to avoid responsibilities under the FMLA. Employers may not discharge, or discriminate against any person who opposes any practice made unlawful by the FMLA or who may be involved in a proceeding under or relating to the FMLA. ENFORCEMENT The U.S. Department of Labor is authorized to investigate and resolve complaints of FMLA violations. An eligible Employee may also bring a civil action against an employer for FMLA violations. The FMLA does not supersede any federal or state law prohibiting discrimination, and does not supersede any state or local law or collective bargaining agreement which provides greater family or medical leave rights. For additional information, contact the nearest office of Wage and Hour Division, listed in most telephone directories under U.S. Government, Department of Labor. Collier County Government-SPD 67 Group#2003021 -Eff Date 1/1/2014 Packet Page-606- 1/27/2015 16.E.3. TERMINATION OF COVERAGE PARTICIPANT TERMINATION Participant coverage will automatically terminate immediately upon the earliest of the following dates,except as provided in any Continuation of Coverage Provision: 1. On the last day of the month in which the Participant's employment terminates; or 2. On the last day of the month in which the Participant ceases to be eligible for coverage; or 3. The date the Participant fails to make any required contribution for coverage; or 4. The date the Plan is terminated; or 5. The date the County terminates the Participant's coverage; or 6. The date the Participant dies; or 7. The date the Participant enters the armed forces of any country as a full-time member, if active duty is to exceed thirty-one (31)days; or 8. On the last day of the month in which the Plan receives the Plan's Health Coverage Waiver Form for the Participant. A Participant whose Active Service ceases because of Illness or Injury or as a result of any other approved leave of absence may remain covered as an Employee in Active Service for a period of twelve (12)weeks, or such other length of time that is consistent with and stated in the County's current Employee Personnel Policy Manual or pursuant to the Family and Medical Leave Act. Coverage under this provision will be subject to all the provisions of FMLA if the leave is classified as FMLA leave. If a Participant's coverage is to be continued during disability,approved leave of absence or temporary lay off, the amount of his or her coverage will be the same as the Plan benefits in force for an active Employee, subject to the Plan's right to amend coverage and benefits. RETIREE TERMINATION Coverage for a Retiree and eligible Dependents may continue until the earliest of the following dates: 1. The date the Retiree fails to make any required contribution for coverage; or 2. The date the Plan is terminated; or 3. The date the County terminates the Retiree's coverage; or 4. The date the Retiree dies; or 5. The date the Retiree enters the armed forces of any country as a full-time member, if active duty is to exceed thirty-one (31)days. Collier County Government-SPD 68 Group#2003021 -Eff Date 1/1/2014 Packet Page-607- 1/27/2015 16.E.3. Termination of Coverage If a Retiree becomes deceased or terminates coverage under this plan once the Retiree is eligible for Medicare, the spouse and eligible Dependent children who are covered at the time of the Retiree's death or termination of coverage may remain covered under the Plan until the earlier of the following: 1. The date the spouse becomes eligible for Medicare or eligible for any other individual or group health insurance or coverage; or 2. The date the Dependent child ceases to be eligible under this plan or becomes eligible for any other individual or group health insurance or coverage. DEPENDENT TERMINATION Each Covered Person, whether Participant or Dependent, is responsible for notifying the Plan Administrator, within sixty (60) days after loss of Dependent status due to death, divorce, legal separation or ceasing to be an eligible Dependent child. Failure to provide this notice may result in loss of eligibility for COBRA Continuation Coverage After Termination. Coverage for a Dependent will automatically terminate immediately upon the earliest of the following dates, except as provided in any Continuation of Coverage Provision: 1. On the last day of the month in which the Dependent ceases to be an eligible Dependent as defined in the Plan; or 2. On the last day of the month in which the Participant's coverage terminates under the Plan; or 3. On the last day of the month in which the Participant ceases to be eligible for Dependent Coverage; or 4. The date the Participant fails to make any required contribution for Dependent Coverage; or 5. The date the Plan is terminated; or 6. The date the County terminates the Dependent's coverage; or 7. On the last day of the month in which the Participant dies; or 8. On the last day of the month in which the Plan receives the Plan's Health Coverage Waiver Form for the Dependent whose coverage is to be terminated. REINSTATEMENT OF COVERAGE An Employee whose coverage terminates by reason of termination of employment or reduction in hours and who again becomes eligible for coverage under the Plan will be treated like a new employee. VOLUNTARY SEPARATION INCENTIVE PROGRAM Medical coverage provided by the County will be extended for those Employees eligible for the Voluntary Separation Incentive Program(VSIP). The Voluntary Separation Incentive Program(VSIP)will be extended to any regular full-time Employee who meets the eligibility criteria set forth by the action of the Board of County Commissioners. Under this Plan, if an eligible Employee chooses to take part in the program,the County will continue to pay the full premium costs for that Employee's medical benefits for a period of three(3)years,or will provide a financial incentive in lieu of benefits if the Employee so chooses. 1. Eligible Employees may elect to continue coverage at their current participation level (single or family). Collier County Government-SPD 69 Group#2003021 -Eff Date 1/1/2014 Packet Page-608- 1/27/2015 16.E.3. Termination of Coverage 2. Employees will not pay any 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. Eligible Employees will have a period of sixty(60)days to enroll. The plan enrollment period begins and ends as determined by the Employer. Employees who meet the Florida Retirement System(FRS)eligibility criteria outlined above between the dates specified by the Employer may also participate in this program. To participate, those who fall into this category will be required to enroll during the sixty (60) day window, but would not be considered to be enrolled into the Plan until the date they become eligible under Florida Retirement System(FRS)guidelines. Employees have a period of seven(7)calendar days during which time to change or revoke their participation. After that time period, their election is considered final. RESCISSION OF COVERAGE Coverage for an Employee and/or Dependent may be rescinded if the Plan Administrator determines that the Employee or a Dependent engaged in fraud or intentional misrepresentation in order to obtain coverage and/or benefits under the Plan. In such case,the Participant will receive written notice at least thirty(30)days before the coverage is rescinded. Collier County Government-SPD 70 Group#2003021 -Eff Date 1/1/2014 Packet Page-609- 1/27/2015 16.E.3. CONTINUATION COVERAGE AFTER TERMINATION Under the Public Health Service Act, as amended, Employees and their enrolled Dependents may have the right to continue coverage beyond the time coverage would ordinarily have ended. The law applies to employers who normally employ twenty(20)or more Employees. The Plan Administrator is Collier County Government;3311 East Tamiami Trail,Building D,Naples,FL 34112; (239)252-8461. COBRA Continuation Coverage for the Plan is administered by Allegiance COBRA Services, Inc.; P.O. Box 2097; Missoula, MT 59806,406-721-2222. COBRA Continuation Coverage is available to any Qualified Beneficiary whose coverage would otherwise terminate due to any Qualifying Event. COBRA Continuation Coverage under this provision will begin on the first day following the date of the Qualifying Event. 1. Qualifying Events for Participants,for purposes of this section,are the following events,if such event results in a loss of coverage under this Plan: A. The termination(other than by reason of gross misconduct)of the Participant's employment. B. The reduction in hours of the Participant's employment. 2. Qualifying Events for covered Dependents, for purposes of this section are the following events, if such event results in a loss of coverage under this Plan: A. Death of the Participant or Retiree. B. Termination of the Participant's employment. C. Reduction in hours of the Participant's employment. D. The divorce or legal separation of the Participant or Retiree from his or her spouse. E. A covered Dependent child ceases to be a Dependent as defined by the Plan. 3. Qualifying Events for covered Retirees,for purposes of this section are: A. Bankruptcy,if the covered Retiree retired on or before the date of any substantial elimination of group health coverage due to bankruptcy. 4. Qualifying Events for the Dependents of Covered Retirees, for purposes of this section are: A. Bankruptcy, if the Dependent was a Qualified Beneficiary of a covered Retiree on or before the day before the bankruptcy qualifying event. NOTIFICATION RESPONSIBILITIES The Covered Person must notify the Employer of the following Qualifying Events within sixty(60)days after the date the event occurs. The Employer must notify the Plan Administrator of any of the following: 1. Death of the Participant or Retiree. 2. The divorce or legal separation of the Participant or Retiree from his or her spouse. 3. A covered Dependent child ceases to be a Dependent as defined by the Plan. Collier County Government-SPD 71 Group#2003021 -Eff Date 1/1/2014 Packet Page -610- 1/27/2015 16.E.3. Continued Coverage After Termination The Employer must notify the Plan Administrator of the following Qualifying Events within thirty(30)days after the date of the event occurs: 1. Termination (other than by reason of gross misconduct)of the Participant's employment. 2. Reduction in hours of the Participant's employment. ELECTION OF COVERAGE When the Plan Administrator is notified of a Qualifying Event,the Plan Administrator will notify the Qualified Beneficiary of the right to elect continuation of coverage. Notice of the right to COBRA Continuation Coverage will be sent by the Plan no later than fourteen(14)days after the Plan Administrator is notified of the Qualifying Event. A Qualified Beneficiary has sixty(60)days from the date coverage would otherwise be lost or sixty(60)days from the date of notification from the Plan Administrator,whichever is later, to notify the Plan Administrator that he or she elects to continue coverage under the Plan. Failure to elect continuation within that period will cause coverage to end. MONTHLY PREMIUM PAYMENTS A Qualified Beneficiary is responsible for the full cost of continuation coverage. Monthly premium for continuation of coverage must be paid in advance to the Plan Administrator. The premium required under the provisions of COBRA is as follows: 1. For a Qualified Beneficiary: The premium is the same as applicable to any other similarly situated non-COBRA Participant plus an additional administrative expense of up to a maximum of two percent (2%). 2. Social Security Disability: For a Qualified Beneficiary continuing coverage beyond eighteen (18) months due to a documented finding of disability by the Social Security Administration within 60 days after becoming covered under COBRA, the premium may be up to a maximum of 150% of the premium applicable to any other similarly situated non-COBRA Participant. 3. For a Qualified Beneficiary with a qualifying Social Security Disability who experiences a second Qualifying Event: A. If another Qualifying Event occurs during the initial eighteen (18) months of COBRA coverage,such as a death,divorce or legal separation,the monthly fee for qualified disabled person may be up to a maximum of one hundred and two percent(102%)of the applicable premium. B. If the second Qualifying Event occurs during the nineteenth (19th)through the twenty-ninth (29th) month (the Disability Extension Period), the premium for a Qualified Beneficiary may be up to a maximum of one hundred fifty percent(150%)of the applicable premium. Payment of claims while covered under this COBRA Continuation Coverage Provision will be contingent upon the receipt by the Employer of the applicable monthly premium for such coverage. The monthly premium for continuation coverage under this provision is due the first of the month for each month of coverage. A grace period of thirty(30)days from the first of the month will be allowed for payment. Payment will be made in a manner prescribed by the Employer. Collier County Government-SPD 72 Group#2003021 -Eff Date 1/1/2014 Packet Page -611- 1/27/2015 16.E.3. Continued Coverage After Termination DISABILITY EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE If the Qualified Beneficiary who is covered under the Plan is determined by the Social Security Administration to be disabled at any time before the qualifying event or within sixty(60)days after the qualifying event, and the Plan Administrator is notified in a timely fashion, the Qualified Beneficiary covered under the Plan can receive up to an additional 11 months of COBRA Continuation Coverage,for a total maximum of 29 months. The Plan Administrator must be provided with a copy of the Social Security Administration's disability determination letter within sixty(60)days after the date of the determination and before the end of the original 18-month period of COBRA Continuation Coverage. This notice should be sent to: Allegiance COBRA Services, Inc.; P.O. Box 2097; Missoula, MT 59806. SECOND QUALIFYING EVENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE If another qualifying event occurs while receiving COBRA Continuation Coverage,the spouse and dependent children of the Employee can get additional months of COBRA Continuation Coverage, up to a maximum of thirty-six (36) months. This extension is available to the spouse and dependent children if the former employee dies or becomes divorced or legally separated. The extension is also available to a dependent child when that child stops being eligible under the Plan as a dependent child. In all of these cases, the Plan Administrator must be notified of the second qualifying event within sixty(60) days of the second qualifying event. This notice must be sent to: Allegiance COBRA Services, Inc.; P.O. Box 2097; Missoula, MT 59806. Failure to provide notice within the time required will result in loss of eligibility for COBRA Continuation Coverage. MEDICARE ENROLLMENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE The dependents of a former employee are eligible to elect COBRA Continuation Coverage if they lose coverage as a result of the former employee's enrollment in Part A, Part B or Part D of Medicare,whichever occurs earlier. When the former employee enrolls in Medicare before the Qualifying Event of termination, or reduction in hours, of employment occurs, the maximum period for COBRA Continuation Coverage for the spouse and dependent children ends on the later of: 1. Eighteen(18) months after the Qualifying Event of termination of employment or reduction in hours of employment; or 2. Thirty-six(36)months after the former employee's enrollment in Medicare. When the former employee enrolls in Medicare after the Qualifying Event of termination,or reduction in hours, of employment, the maximum period for COBRA Continuation Coverage for the spouse and dependent children ends eighteen(18)months after the Qualifying Event,unless a second Qualifying Event,as described above occurs within that eighteen (18)month period. WHEN COBRA CONTINUATION COVERAGE ENDS COBRA Continuation Coverage and any coverage under the Plan that has been elected with respect to any Qualified Beneficiary will cease on the earliest of the following: 1. On the date the Qualified Beneficiary becomes covered under another group health plan or health insurance. 2. On the date, after the date of election for COBRA Continuation Coverage, that the Qualified Beneficiary becomes enrolled in Medicare(either Part A, B or D). 3. On the first date that timely payment of any premium required under the Plan with respect to COBRA Continuation Coverage for a Qualified Beneficiary is not made to the Plan Administrator. Collier County Government-SPD 73 Group#2003021-Eff Date 1/1/2014 Packet Page-612- 1/27/2015 16.E.3. Continued Coverage After Termination 4. On the date the Employer ceases to provide any group health plan coverage to any Employee. 5. On the date of receipt of written notice that the Qualified Beneficiary wishes to terminate COBRA Continuation Coverage. 6. On the date that the maximum coverage period for COBRA Continuation Coverage ends,as follows: A. Eighteen (18) months for a former employee who is a Qualified Beneficiary as a result of termination, or reduction in hours, of employment; B. Eighteen (18) months for a Dependent who is a Qualified Beneficiary unless a second Qualifying Event occurs within that eighteen month period entitling that Dependent to an additional eighteen (18)months; C. For the Dependent who is a Qualified Beneficiary as a result of termination, or reduction in hours, of employment of the former employee if that former employee enrolled in Medicare before termination, or reduction in hours, of employment,the later of eighteen (18) months from the Qualifying Event, or thirty-six (36) months following the date of enrollment in Medicare. D. On the first day of the month beginning thirty (30) days after a Qualified Beneficiary is determined to be no longer disabled by the Social Security Administration if the Qualified Beneficiary was found to be disabled on or within the first sixty(60)days of the date of the Qualifying Event and has received at least eighteen (18) months of COBRA Continuation Coverage. COBRA Continuation Coverage will also terminate on such date for all Dependents who are Qualified Beneficiaries as a result of the Qualifying Event unless that Dependent is entitled to a longer period of COBRA Continuation Coverage without regard to disability. E. Twenty-nine (29) months for any Qualified Beneficiary if a Disability Extension Period of COBRA Continuation Coverage has been granted for such Qualified Beneficiary. F. Thirty-six(36)months for all other Qualified Beneficiaries. G. In the case of a Qualifying Event that is a bankruptcy, the date of death for the Qualified Beneficiary who is a retired employee. H. In the case of a Qualifying Event that is a bankruptcy,the earlier of the date of the Qualified Beneficiary's death or thirty-six (36) months following the retired employee's death for the Qualified Beneficiary who is a surviving spouse or dependent child of the retired employee. 7. On the same basis that the Plan can terminate for cause the coverage of a similarly situated non- COBRA Participant. QUESTIONS Any questions about COBRA Continuation Coverage should be directed to Allegiance COBRA Services, Inc. or contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website at www.dol.qov/ebsa. INFORM THE PLAN OF ADDRESS CHANGES In order to protect the Employee's family's rights,the Employee should keep the Plan Administrator informed of any changes in the addresses of family members. The Employee should also keep a copy, for his/her records, of any notices sent to the Plan Administrator. Collier County Government-SPD 74 Group#2003021 -Eff Date 1/1/2014 Packet Page-613- 1/27/2015 16.E.3. COVERAGE FOR A MILITARY RESERVIST To the extent required by the Uniform Services Employment and Reemployment Rights Act(USERRA),the following provisions will apply: 1. If a Participant is absent from employment with Employer by reason of service in the uniformed services,the Participant may elect to continue coverage under this Plan for himself or herself and his or her eligible Dependents as provided in this subsection. The maximum period of coverage under such an election will be the lesser of: A. The twenty-four(24)month period beginning on the date on which the Participant's absence begins; or B. The period beginning on the date on which the Participant's absence begins and ending on the day after the date on which the Participant fails to apply for or return to a position of employment, as required by USERRA. 2. A Participant who elects to continue Plan coverage under this Section may be required to pay not more than one hundred two percent (102%) of the full premium under the Plan (determined in the same manner as the applicable premium under Section 4980B(f)(4)of the Internal Revenue Code of 1986)associated with such coverage for the Employer's other Employees,except that in the case of a person who performs service in the uniformed services for less than thirty-one (31) days, such person may not be required to pay more than the regular Employee share,if any,for such coverage. 3. In the case of a Participant whose coverage under the Plan is terminated by reason of service in the uniformed services, an exclusion or Waiting Period may not be imposed in connection with the reinstatement of such coverage upon reemployment if an exclusion or Waiting Period would not have been imposed under the Plan had coverage of such person by the Plan not been terminated as a result of such service. This paragraph applies to the Employee who notifies the Employer of his or her intent to return to employment in a timely manner as defined by USERRA,and is reemployed and to any Dependent who is covered by the Plan by reason of the reinstatement of the coverage of such Employee. This provision will not apply to the coverage of any Illness or Injury determined by the Secretary of Veterans Affairs to have been caused by or aggravated during, performance of service in the uniformed services. Collier County Government-SPD 75 Group#2003021 -Eff Date 1/1/2014 Packet Page-614- 1/27/2015 16.E.3. FRAUD AND ABUSE THIS PLAN IS SUBJECT TO FEDERAL LAW WHICH PERMITS CRIMINAL PENALTIES FOR FRAUDULENT ACTS COMMITTED AGAINST THE PLAN. STATE LAW MAY ALSO APPLY. Anyone who knowingly defrauds or tries to defraud the Plan,or obtains Plan funds through false statements or fraudulent schemes,may be subject to criminal prosecution and penalties.The following may be considered fraudulent: 1. Falsifying eligibility criteria for a Dependent; 2. Falsifying or withholding medical history or information required to calculate benefits; 3. Falsifying or altering documents to get coverage or benefits; 4. Permitting a person not otherwise eligible for coverage to use a Plan ID card to get Plan benefits; or 5. Submitting a fraudulent claim or making untruthful statements to the Plan to get reimbursement from the Plan for services that may or may not have been provided to a Covered Person. The Plan Administrator, in its sole discretion, may take additional action against the Participant or Covered Person including,but not limited to,terminating the Participant or Covered Person's coverage under the Plan. MISSTATEMENT OF AGE If the Covered Person's age was misstated on an enrollment form or claim, the Covered Person's eligibility or amount of benefits,or both,will be adjusted to reflect the Covered Person's true age.If the Covered Person was not eligible for coverage under the Plan or for the amount of benefits received, the Plan has a right to recover any benefits paid by the Plan. A misstatement of age will not continue coverage that was otherwise properly terminated or terminate coverage that is otherwise validly in force. MISREPRESENTATION OF ELIGIBILITY If a Participant misrepresents a Dependent's marital status, age, full-time student status, dependent child relationship or other eligibility criteria to get coverage for that Dependent,when he or she would not otherwise be eligible, coverage for that Dependent will terminate as though never effective. MISUSE OF IDENTIFICATION CARD If a Covered Person permits any person who is not otherwise eligible as a Covered Person to use an ID card, the Plan Sponsor may, at the Plan Sponsor's sole discretion, terminate the Covered Person's coverage. REIMBURSEMENT TO PLAN Payment of benefits by the Plan for any person who was not otherwise eligible for coverage under this Plan but for whom benefits were paid based upon fraud as defined in this section must be reimbursed to the Plan by the Participant. Failure to reimburse the Plan upon request may result in an interruption or a loss of benefits by the Participant and Dependents. RESCISSION OF COVERAGE Coverage for an Employee and/or Dependent may be rescinded if the Plan Administrator determines that the Employee or a Dependent engaged in fraud or intentional misrepresentation in order to obtain coverage and/or benefits under the Plan. In such case,the Participant will receive written notice at least thirty(30)days before the coverage is rescinded. Collier County Government-SPD 76 Group#2003021 -Eff Date 1/1/2014 Packet Page-615- 1/27/2015 16.E.3. RECOVERY/REIMBURSEMENT/SUBROGATION By enrollment in this Plan, Covered Persons agree to the provisions of this section as a condition precedent to receiving benefits under this Plan. Failure of a Covered Person to comply with the requirements of this section may result in the Plan pending the payment of benefits. RIGHT TO RECOVER BENEFITS PAID IN ERROR If the Plan makes a payment in error to or on behalf of a Covered Person or an assignee of a Covered Person to which that Covered Person is not entitled, or if the Plan pays a claim that is not covered, the Plan has the right to recover the payment from the person paid or anyone else who benefitted from the payment. The Plan can deduct the amount paid from the Covered Person's future benefits,or from the benefits for any covered Family member even if the erroneous payment was not made on that Family member's behalf. Payment of benefits by the Plan for Participants'spouses, ex-spouses, or children, who are not eligible for coverage under this Plan,but for whom benefits were paid based upon inaccurate,false information provided by, or information omitted by,the Employee will be reimbursed to the Plan by the Employee. The Employee's failure to reimburse the Plan after demand is made, may result in an interruption in or loss of benefits to the Employee, and could be reported to the appropriate governmental authorities for investigation of criminal fraud. The Plan may recover such amount by any appropriate method that the Plan Administrator, in its sole discretion, will determine. The provisions of this section apply to any Physician or Licensed Health Care Provider who receives an assignment of benefits or payment of benefits under this Plan. If a Physician or Licensed Health Care Provider fails to refund a payment of benefits,the Plan may refuse to recognize future assignments of benefits to that provider. REIMBURSEMENT The Plan's right to Reimbursement is separate from and in addition to the Plan's right of Subrogation. If the Plan pays benefits for medical expenses on a Covered Person's behalf, and another party was responsible or liable for payment of those medical expenses,the Plan has a right to be reimbursed by the Covered Person for the amounts the Plan paid. Accordingly, if a Covered Person, or anyone on his or her behalf, settles, is reimbursed or recovers money from any person,corporation,entity, liability coverage, no-fault coverage,uninsured coverage, underinsured coverage, or other insurance policies or funds for any accident, Injury, condition or Illness for which benefits were provided by the Plan,the Covered Person agrees to hold the money received in trust for the benefit of the Plan. The Covered Person agrees to reimburse the Plan,in first priority,from any money recovered from a liable third party,for the amount of all money paid by the Plan to the Covered Person or on his or her behalf or that will be paid as a result of said accident, Injury,condition or Illness. Reimbursement to the Plan will be paid first, in its entirety, even if the Covered Person is not paid for all of his or her claim for damages and regardless of whether the settlement,judgment or payment he or she receives is for or specifically designates the recovery,or a portion thereof,as including health care,medical,disability or other expenses or damages. SUBROGATION The Plan's right to Subrogation is separate from and in addition to the Plan's right to Reimbursement. Subrogation is the right of the Plan to exercise the Covered Person's rights and remedies in order to recover from any third party who is liable to the Covered Person for a loss or benefits paid by the Plan. The Plan may proceed through litigation or settlement in the name of the Covered Person,with or without his or her consent, to recover benefits paid under the Plan. Collier County Government-SPD 77 Group#2003021 -Eff Date 1/1/2014 Packet Page-616- 1/27/2015 16.E.3. Recovery/Reimbursement/Subrogation The Covered Person agrees to subrogate to the Plan any and all claims,causes of action or rights that he or she has or that may arise against any entity who has or may have caused, contributed to or aggravated the accident, Injury,condition or Illness for which the Plan has paid benefits,and to subrogate any claims,causes of action or rights the Covered Person may have against any other coverage including, but not limited to, liability coverage, no-fault coverage, uninsured motorist coverage, underinsured motorist coverage, or other insurance policies, coverage or funds. In the event that a Covered Person decides not to pursue a claim against any third party or insurer, the Covered Person will notify the Plan, and specifically authorize the Plan, in its sole discretion, to sue for, compromise or settle any such claims in the Covered Person's name, to cooperate fully with the Plan in the prosecution of the claims, and to execute any and all documents necessary to pursue those claims. The Following Paragraphs Apply to Both Reimbursement and Subrogation: 1. Under the terms of this Plan, the Plan Supervisor is not required to pay any claim where there is evidence of liability of a third party unless the Covered Person signs the Plan's Third-Party Reimbursement Agreement and follows the requirements of this section. However, the Plan, in its discretion, may instruct the Plan Supervisor not to withhold payment of benefits while the liability of a party other than the Covered Person is being legally determined. If a repayment agreement is requested to be signed, the Plan's right of recovery through Reimbursement and/or Subrogation remains in effect regardless of whether the repayment agreement is actually signed. 2. If the Plan makes a payment which the Covered Person,or any other party on the Covered Person's behalf,is or may be entitled to recover against any liable third party,this Plan has a right of recovery, through reimbursement or subrogation or both, to the extent of its payment. 3. The Covered Person will cooperate fully with the Plan Administrator, its agents, attorneys and assigns, regarding the recovery of any benefits paid by the Plan from any liable third party. This cooperation includes, but is not limited to, make full and complete disclosure in a timely manner of all material facts regarding the accident, Injury, condition or Illness to the Plan Administrator; report all efforts by any person to recover any such monies; provide the Plan Administrator with any and all requested documents, reports and other information in a timely manner, regarding any demand, litigation or settlement involving the recovery of benefits paid by the Plan; and notify the Plan Administrator of the amount and source of funds received from third parties as compensation or damages for any event from which the Plan may have a reimbursement or subrogation claim. 4. Covered Persons will respond within ten (10)days to all inquiries of the Plan regarding the status of any claim they may have against any third parties or insurers including,but not limited to, liability,no- fault, uninsured and underinsured insurance coverage. The Covered Person will notify the Plan immediately of the name and address of any attorney whom the Covered Person engages to pursue any personal Injury claim on his or her behalf. 5. The Covered Person will not act,fail to act, or engage in any conduct directly, indirectly, personally or through third parties,either before or after payment by the Plan,the result of which may prejudice or interfere with the Plan's rights to recovery hereunder. The Covered Person will not conceal or attempt to conceal the fact that recovery has occurred or will occur. 6. The Plan will not pay or be responsible,without its written consent, for any fees or costs associated with a Covered Person pursuing a claim against any third party or coverage including,but not limited to, attorney fees or costs of litigation. Monies paid by the Plan will be repaid in full, in first priority, notwithstanding any anti-subrogation, "made whole," "common fund" or similar statute, regulation, prior court decision or common law theory unless a reduction or compromise settlement is agreed to in writing or required pursuant to a court order or as limited by Florida state law. Collier County Government-SPD 78 Group#2003021-Eff Date 1/1/2014 Packet Page-617- 1/27/2015 16.E.3. Recovery/Reimbursement/Subrogation RIGHT OF OFF-SET The Plan has a right of off-set to satisfy reimbursement claims against Covered Persons for money received by the Covered Person from a third party, including any insurer. If the Covered Person fails or refuses to reimburse the Plan for funds paid for claims, the Plan may deny payment of future claims of the Covered Person,up to the full amount paid by the Plan and subject to reimbursement for such claims. This right of off- set applies to all reimbursement claims owing to the Plan whether or not formal demand is made by the Plan, and notwithstanding any anti-subrogation,"common fund,""made whole"or similar statutes,regulations,prior court decisions or common law theories. Collier County Government-SPD 79 Group#2003021 -Eff Date 1/1/2014 Packet Page-618- 1/27/2015 16.E.3. PLAN ADMINISTRATION PURPOSE The purpose of the Plan Document is to set forth the provisions of the Plan which provide for the payment or reimbursement of all or a portion of the claim. The terms of this Plan are legally enforceable and the Plan is maintained for the exclusive benefit of eligible Employees and their covered Dependents. EFFECTIVE DATE The effective date of the Plan is January 1, 2000, restated January 1, 2014. PLAN YEAR The Plan Year will commence January 1s`and end on December 31"of each year. PLAN SPONSOR The Plan Sponsor is Collier County Government. PLAN SUPERVISOR The Supervisor of the Plan is Allegiance Benefit Plan Management, Inc. NAMED FIDUCIARY AND PLAN ADMINISTRATOR The Named Fiduciary is Collier County Government, a political subdivision of the State of Florida, who has the authority to control and manage the operation and administration of the Plan. The Plan Administrator will have the authority to amend the Plan,to determine its policies,to appoint and remove other service providers of the Plan,to fix their compensation(if any),and exercise general administrative authority over them and the Plan. The Plan Administrator has the sole authority and responsibility to review and make final decisions on all claims to benefits hereunder. The Plan Administrator may delegate responsibilities for the operation and administration of the Plan. The authority to perform the day to day Plan Administration duties as described in this paragraph is delegated to the Director, Risk Management (the designee), or his or her equivalent, whichever is applicable, of the County. The Director, Risk Management may temporarily delegate these responsibilities,as needed. This delegation shall not include the final selection of a Plan Supervisor,Actuarial firm,Benefits Consulting firm,or Reinsurance Stop Loss Carrier. This delegation shall include the review and approval of weekly claims disbursements reports and check registers presented to the Plan Administrator by the Plan Supervisor. PLAN INTERPRETATION The Named Fiduciary and the Plan Administrator have full discretionary authority to interpret and apply all Plan provisions including,but not limited to,resolving all issues concerning eligibility and determination of benefits. The Plan Administrator may contract with an independent administrative firm to process claims,maintain Plan data,and perform other Plan-connected services. Final authority to interpret and apply the provisions of the Plan rests exclusively with the Plan Administrator. Decisions of the Plan Administrator made in good faith will be final and binding. Collier County Government-SPD 80 Group#2003021 -Eff Date 1/1/2014 Packet Page-619- 1/27/2015 16.E.3. Plan Administration CONTRIBUTIONS TO THE PLAN The amount of contributions to the Plan are to be made on the following basis: The County will from time to time evaluate the costs of the Plan and determine the amount to be contributed by the County, if any, and the amount to be contributed, if any, by each Participant. If the County terminates the Plan, the County and Participants will have no obligation to contribute to the Plan after the date of termination. PLAN AMENDMENTS/MODIFICATION/TERMINATION The Plan Document contains all the terms of the Plan and may be amended at any time by the Plan Administrator. Any changes will be binding on each Participant and on any other Covered Persons referred to in this Plan Document. The authority to amend the Plan is delegated by the Plan Administrator to the Director, Risk Management, or his or her equivalent, whichever is applicable, of the County. Any such amendment, modification, revocation or termination of the Plan will be authorized and signed by the Director, Risk Management, or his or her equivalent,whichever is applicable, of the County, pursuant to a resolution, granting that individual the authority to amend, modify,revoke or terminate this Plan. A copy of the executed policy will be supplied to the Plan Supervisor. Written notification of any amendments, modifications, revocations or terminations will be given to Plan Participants at least sixty(60)days prior to the effective date, except for amendments effective on the first day of a new Plan Year,for which thirty(30)days advance notice is required. TERMINATION OF PLAN The County reserves the right at any time to terminate the Plan by a written notice. All previous contributions by the County will continue to be issued for the purpose of paying benefits and fixed costs under provisions of this Plan with respect to claims arising before such termination,or will be used for the purpose of providing similar health benefits to Participants, until all contributions are exhausted. SUMMARY PLAN DESCRIPTIONS Each Participant covered under this Plan will be issued a Summary Plan Description (SPD) describing the benefits to which the Covered Persons are entitled,the required Plan procedures for eligibility and claiming benefits and the limitations and exclusions of the Plan. Collier County Government-SPD 81 Group#2003021 -Eff Date 1/1/2014 Packet Page-620- 1/27/2015 16.E.3. CREDITABLE COVERAGE PROCEDURES CERTIFICATE OF CREDITABLE COVERAGE The Plan will provide Certificate of Creditable Coverage for coverage under this Plan as required by the United States Public Health Service to any Covered Person or the Covered Person's designated and authorized agent, guardian, conservator, health care plan or health insurance as follows: 1. At the time the Covered Person ceases to be covered under this Plan; and 2. At the time a Covered Person ceases to be covered by the COBRA Continuation Coverage provided by this Plan, if any; and 3. At any other time that a request is made on behalf of the Covered Person for such certification, but not later than twenty four(24)months after cessation of coverage as set out in subparagraphs 1 and 2 above,whichever is later. The Plan will send a Certificate of Creditable Coverage for coverage under this Plan until December 31,2014 at which time no additional Certificate of Creditable Coverage will be issued. Collier County Government-SPD 82 Group#2003021 -Eff Date 1/1/2014 Packet Page-621- 1/27/2015 16.E.3. GENERAL PROVISIONS EXAMINATION The Plan will have the right and opportunity to have the Covered Person examined whenever Injury or Illness is the basis of a claim when and so often as it may reasonably require to adjudicate the claim. The Plan will also have the right to have an autopsy performed in case of death to the extent permitted by law. PAYMENT OF CLAIMS All Plan benefits are payable to a Participant, Qualified Beneficiary or Alternate Recipient, whichever is applicable. All or a portion of any benefits payable by the Plan may, at the Covered Person's option and unless the Covered Person requests otherwise in writing not later than the time of filing the claim, be paid directly to the health care provider rendering the service,if proper written assignment is provided to the Plan. No payments will be made to any provider of services unless the Covered Person is liable for such expenses. If any benefits remain unpaid at the time of the Covered Person's death or if the Covered Person is a minor or is, in the opinion of the Plan, legally incapable of giving a valid receipt and discharge for any payment,the Plan may, at its option, pay such benefits to the Covered Person's legal representative or estate. The Plan, in its sole option, may require that an estate, guardianship or conservatorship be established by a court of competent jurisdiction prior to the payment of any benefit. Any payment made under this subsection will constitute a complete discharge of the Plan's obligation to the extent of such payment and the Plan will not be required to oversee the application of the money so paid. LEGAL PROCEEDINGS No action at law or equity will be brought to recover on the Plan prior to the expiration of sixty(60)days after proof of loss has been filed in accordance with the requirements of the Plan, nor will such action be brought at all unless brought within three(3)years from the expiration of the time within which proof of loss is required by the Plan. NO WAIVER OR ESTOPPEL No term, condition or provision of this Plan will be waived, and there will be no estoppel against the enforcement of any provision of this Plan,except by written instrument of the party charged with such waiver or estoppel. No such written waiver will be deemed a continuing waiver unless specifically stated therein,and each such waiver will operate only as to the specific term or condition waived and will not constitute a waiver of such term or condition for the future or as to any act other than that specifically waived. VERBAL STATEMENTS Verbal statements or representations of the Plan Administrator, its agents and Employees, or Covered Persons will not create any right by contract, estoppel, unjust enrichment, waiver or other legal theory regarding any matter related to the Plan,or its administration,except as specifically stated in this subsection. No statement or representation of the Plan Administrator,its agents and Employees,or Covered Persons will be binding upon the Plan or a Covered Person unless made in writing by a person with authority to issue such a statement. This subsection will not be construed in any manner to waive any claim, right or defense of the Plan or a Covered Person based upon fraud or intentional material misrepresentation of fact or law. FREE CHOICE OF PHYSICIAN The Covered Person will have free choice of any licensed Physician, Licensed Health Care Provider or surgeon and the patient-provider relationship will be maintained. Collier County Government-SPD 83 Group#2003021 -Eff Date 1/1/2014 Packet Page-622- 1/27/2015 16.E.3. General Provisions WORKERS' COMPENSATION NOT AFFECTED This Plan is not in lieu of, supplemental to Workers' Compensation and does not affect any requirement for coverage by Workers' Compensation Insurance. CONFORMITY WITH LAW If any provision of this Plan is contrary to any law to which it is subject, such provision is hereby amended to conform to the minimum requirements of the applicable law.Only that provision which is contrary to applicable law will be amended to conform; all other parts of the Plan will remain in full force and effect. MISCELLANEOUS Section titles are for convenience of reference only, and are not to be considered in interpreting this Plan. No failure to enforce any provision of this Plan will affect the right thereafter to enforce such provision, nor will such failure affect its right to enforce any other provision of the Plan. FACILITY OF PAYMENT Whenever payments which should have been made under this Plan in accordance with this provision have been made under any other plan or plans, the Plan will have the right, exercisable alone and in its sole discretion,to pay to any insurance company or other organization or person making such other payments any amounts it determines in order to satisfy the intent of this provision. Amounts so paid will be deemed to be benefits paid under this Plan and to the extent of such payments,the Plan will be fully discharged from liability under this Plan. The benefits that are payable will be charged against any applicable maximum payment or benefit of this Plan rather than the amount payable in the absence of this provision. PROTECTION AGAINST CREDITORS No benefit payment under this Plan will be subject in any way to alienation,sale,transfer, pledge,attachment, garnishment, execution or encumbrance of any kind, and any attempt to accomplish the same will be void, except an assignment of payment to a provider of Covered Services. If the Plan Administrator finds that such an attempt has been made with respect to any payment due or which will become due to any Participant,the Plan Administrator, in its sole discretion, may terminate the interest of such Participant or former Participant in such payment. In such case, the Plan Administrator will apply the amount of such payment to or for the benefit of such Participant or covered Dependents or former Participant, as the Plan Administrator may determine. Any such application will be a complete discharge of all liability of the Plan with respect to such benefit payment. PLAN IS NOT A CONTRACT The Plan Document constitutes the primary authority for plan administration. The establishment, administration and maintenance of this Plan will not be deemed to constitute a contract of employment, give any Participant of the County the right to be retained in the service of the County,or to interfere with the right of the County to discharge or otherwise terminate the employment of any Participant. Collier County Government-SPD 84 Group#2003021 -Eff Date 1/1/2014 Packet Page-623- 1/27/2015 16.E.3. GENERAL DEFINITIONS Certain words and phrases in this Plan Document are defined below. If the defined term is not used in this document, the term does not apply to this Plan. Masculine pronouns used in this Plan Document will include either the masculine or feminine gender unless the context indicates otherwise. Any words used herein in the singular or plural will include the alternative as applicable. ACCIDENTAL INJURY "Accidental Injury" means an Injury sustained as a result of an external force or forces that is/are sudden, direct and unforeseen and is/are exact as to time and place. A hernia of any kind will only be considered as an Illness. ACTIVE SERVICE "Active Service"means that an Employee is in service with the County on a day which is one of the County's regularly scheduled work days and that the Employee is performing all of the regular duties of his/her employment with the County on a regular basis, either at one of the County's business establishments or at some location to which the County's business requires him/her to travel. ADVERSE BENEFIT DETERMINATION "Adverse Benefit Determination"means any of the following:a denial,reduction,or termination of,or a failure to provide or make payment, in whole or in part, for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Participant's or beneficiary's eligibility to participate in the Plan, and including,with respect to group health plans, a denial, reduction,or termination of,or a failure to provide or make payment,in whole or in part,for,a benefit resulting from the application of any utilization review,as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental or Investigational or not Medically Necessary or appropriate,or a rescission of coverage if the Plan Administrator determines that the Employee or a Dependent engaged in fraud or intentional misrepresentation in order to obtain coverage and/or benefits under the Plan. In such case, the Participant will receive written notice at least thirty(30) days before the coverage is rescinded. ALCOHOLISM "Alcoholism" means a morbid state caused by excessive and compulsive consumption of alcohol that interferes with the patient's health, social or economic functioning. ALCOHOLISM AND/OR CHEMICAL DEPENDENCY TREATMENT FACILITY "Alcoholism and/or Chemical Dependency Treatment Facility"means a licensed institution which provides a program for diagnosis, evaluation, and effective treatment of Alcoholism and/or Chemical Dependency; provides detoxification services needed with its effective treatment program;provides infirmary-level medical services or arranges with a Hospital in the area for any other medical services that may be required; is at all times supervised by a staff of Physicians; provides at all times skilled nursing care by licensed nurses who are directed by a full-time Registered Nurse (R.N.); prepares and maintains a written plan of treatment for each patient based on medical,psychological and social needs which is supervised by a Physician;and meets licensing standards. Collier County Government-SPD 85 Group#2003021 -Eff Date 1/1/2014 Packet Page-624- 1/27/2015 16.E.3. General Definitions AMBULANCE SERVICE "Ambulance Service"means an entity,its personnel and equipment including,but not limited to,automobiles, airplanes, boats or helicopters,which are licensed to provide Emergency medical and Ambulance services in the state in which the services are rendered. AMBULATORY SURGICAL CENTER "Ambulatory Surgical Center" (also called same-day surgery center or Outpatient surgery center) means a licensed establishment with an organized staff of Physicians and permanent facilities,either freestanding or as a part of a Hospital,equipped and operated primarily for the purpose of performing surgical procedures and which a patient is admitted to and discharged from within a twenty-four(24)hour period. Such facilities must provide continuous Physician and registered nursing services whenever a patient is in the facility. An Ambulatory Surgical Center must meet any requirements for certification or licensing for ambulatory surgery centers in the state in which the facility is located. "Ambulatory Surgical Center"does not include an office or clinic maintained by a Dentist or Physician for the practice of dentistry or medicine, a Hospital emergency room or trauma center. AUTISM SPECTRUM DISORDER "Autism Spectrum Disorder" means the following disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association: 1) autistic disorder; 2)Asperger's Syndrome; and 3)pervasive developmental disorder not otherwise specified. BENEFIT PERCENTAGE "Benefit Percentage"means that portion of Maximum Eligible Expenses payable by the Plan,which is stated as a percentage in the Schedule of Benefits. BENEFIT PERIOD "Benefit Period" refers to a time period of one year, which is either a Calendar Year or other annual period, as shown in the Schedule of Benefits. Such Benefit Period will terminate on the earliest of the following dates: 1. The last day of the one year period so established; or 2. The day the Maximum Lifetime Benefit applicable to the Covered Person becomes paid; or 3. The date the Plan terminates. BIRTHING CENTER A"Birthing Center"means a freestanding or hospital based facility which provides obstetrical delivery services under the supervision of a Physician, and through an arrangement or an agreement with a Hospital. CALENDAR YEAR "Calendar Year"means a period of time commencing on January 1 and ending on December 31 of the same year. CLOSE RELATIVE "Close Relative" means the spouse, parent, brother, sister, child, or in-laws of the Covered Person. Collier County Government-SPD 86 Group#2003021 -Eff Date 1/1/2014 Packet Page-625- 1/27/2015 16.E.3. General Definitions COBRA "COBRA"means Sections 2201 through 2208 of the Public Health Service Act[42 U.S.C.§300bb-1 through § 300bb-8], which contains provisions similar to Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. COBRA CONTINUATION COVERAGE "COBRA Continuation Coverage"means continuation coverage provided under the provisions of the Public Health Service Act referenced herein under the definition of"COBRA". CONVALESCENT NURSING FACILITY See"Skilled Nursing Facility". COSMETIC "Cosmetic" means services or treatment ordered or performed solely to change a Covered Person's appearance rather than for the restoration of bodily function. COUNTY "County"means Collier County Government or any affiliated agencies or boards that have adopted this Plan for its Employees. COVERED PERSON "Covered Person" means any Participant or Dependent of a Participant meeting the eligibility requirements for coverage and properly enrolled for coverage as specified in the Plan. CREDITABLE COVERAGE "Creditable Coverage"means health or medical coverage under which a Covered Person was covered, prior to that Covered Person's Enrollment Date under this Plan, which prior coverage was under any of the following: 1. A group health plan. 2. Health insurance coverage. 3. Part A, Part B or Part C of Title XVIII of the Social Security Act(Medicare). 4. Title XIX of the Social Security Act(Medicaid),other than coverage consisting solely of benefits under Section 1928 (program for distribution of pediatric vaccines). 5. Chapter 55 of Title 10, United States Code (TRICARE). 6. A medical care program of the Indian Health Service or a tribal organization. 7. A state health benefits risk pool. 8. The Federal Employee Health Benefits Program. 9. A public health plan, including any plan established or maintained by a State,the US Government, a foreign country or any political subdivision of the foregoing. Collier County Government-SPD 87 Group#2003021 -Eff Date 1/1/2014 Packet Page-626- 1/27/2015 16.E.3. General Definitions 10. A health benefit plan under Section 5 (e) of the Peace Corps Act. 11. The State Children's Health Insurance Program. CUSTODIAL CARE "Custodial Care"means the type of care or service,wherever furnished and by whatever name called,which is designed primarily to assist a Covered Person in the activities of daily living. Such activities include, but are not limited to: bathing, dressing,feeding, preparation of special diets,assistance in walking or in getting in and out of bed, and supervision over medication which can normally be self-administered. DEDUCTIBLE "Deductible" means a specified dollar amount that must be incurred before the Plan will pay any amount for any benefit during each Benefit Period. DENTIST "Dentist"means a person holding one of the following degrees—Doctor of Dental Science, Doctor of Medical Dentistry, Master of Dental Surgery or Doctor of Medicine(oral surgeon)--who is legally licensed as such to practice dentistry in the jurisdiction where services are rendered, and the services rendered are within the scope of his or her license. A"Dentist"will not include the Covered Person or any Close Relative of the Covered Person who does not regularly charge the Covered Person for services. DEPENDENT "Dependent"means a person who is eligible for coverage under the Dependent Eligibility subsection of this Plan. DEPENDENT COVERAGE "Dependent Coverage" means eligibility for coverage under the terms of the Plan for benefits payable as a consequence of Eligible Incurred Expenses for an Illness or Injury of a Dependent. DURABLE MEDICAL EQUIPMENT "Durable Medical Equipment" means equipment which is: 1. Able to withstand repeated use,i.e.,could normally be rented,and used by successive patients;and 2. Primarily and customarily used to serve a medical purpose; and 3. Not generally useful to a person in the absence of Illness or Injury. ELIGIBLE EXPENSES "Eligible Expenses"means the maximum amount of any charge for a covered service,treatment or supply that may be considered for payment by the Plan, including any portion of that charge that may be applied to the Deductible or used to satisfy the Out-of-Pocket Maximum. Eligible Expenses are equal to the actual billed charge or UCR, whichever is less or a contracted or negotiated rate, if applicable. Collier County Government-SPD 88 Group#2003021 -Eff Date 1/1/2014 Packet Page-627- 1/27/2015 16.E.3. General Definitions EMERGENCY "Emergency" means a medical condition manifesting itself by acute symptoms which occur suddenly and unexpectedly and for which the Covered Person receives medical care no later than 48 hours after the onset of the condition. Emergency is any medical condition for which a reasonable and prudent layperson, possessing average knowledge of health and medicine,would expect that failure to seek immediate medical attention would result in death,more severe or disabling medical condition(s),or continued severe pain without cessation in the absence of medical treatment. Emergency may include, but is not limited to, severe Injury, hemorrhaging, poisoning, loss of consciousness or respiration, fractures, convulsions, injuries reasonably likely to require sutures, severe acute pain, severe burns, prolonged high fever and symptoms normally associated with heart attack or stroke. "Emergency"will specifically exclude usual out-patient treatment of childhood diseases,flu,common cold, pre-natal examinations, physical examinations and minor sprains, lacerations, abrasions and minor burns,and other medical conditions usually capable of treatment at a clinic or doctor's office during regular working hours. EMPLOYEE "Employee"means a person employed by the Employer on a continuing and regular basis who is a common- law Employee and who is on the Employer's W-2 payroll. Employee does not include any employee leased from another employer including,but not limited to, those individuals defined in Internal Revenue Code Section 414(n),or an individual classified by the Employer as a contract worker, independent contractor, temporary, seasonal or casual employee, whether or not any such persons are on the Employer's W-2 payroll,or any individual who performs services for the Employer but who is paid by a temporary or other employment agency such as "Kelly," "Manpower," etc. EMPLOYER "Employer"means Collier County Government or any affiliated agencies or boards that have adopted this Plan for its Employees. ENROLLMENT DATE "Enrollment Date" means the date a person becomes eligible for coverage under this Plan or the eligible person's effective date of coverage under this Plan, whichever occurs first. EXPERIMENTAL/INVESTIGATIONAL "Experimental/Investigational" means: 1. Any drug or device that cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished; or 2. Any drug, device, medical treatment or procedure for which the patient informed consent document utilized with the drug, device, treatment or procedure, was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function,or if federal law requires such review or approval; or 3. That the drug, device or medical treatment or procedure is under study, prior to or in the absence of any clinical trial, to determine its maximum tolerated dose, its toxicity, or its safety; or Collier County Government-SPD 89 Group#2003021 -Eff Date 1/1/2014 Packet Page-628- 1/27/2015 16.E.3. General Definitions 4. That based upon Reliable Evidence,the drug,device, medical treatment or procedure is the subject of an on-going Phase I or Phase II clinical trial. (A Phase III clinical trial recognized by the National Institute of Health is not considered Experimental or Investigational.) For chemotherapy regimens, a Phase II clinical trial is not considered Experimental or Investigational when both of these criteria are met: A. The regimen or protocol has been the subject of a completed and published Phase II clinical trial which demonstrates benefits equal to or greater than existing accepted treatment protocols, and B. The regimen or protocol listed by the National Comprehensive Cancer Network is supported by level of evidence Category 1 or Category 2A; or 5. Based upon Reliable Evidence,any drug,device,medical treatment or procedure that the prevailing opinion among experts is that further studies or clinical trial are necessary to determine the maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with generally medically accepted means of treatment or diagnosis; or 6. Any drug, device, medical treatment or procedure used in a manner outside the scope of use for which it was approved by the FDA or other applicable regulatory authority(U.S.Department of Health, Centers for Medicare and Medicaid Services(CMS),American Dental Association,American Medical Association). "Reliable Evidence"means only reports and articles published in authoritative medical and scientific literature; the written protocol or protocols used by a treating facility or the protocol(s) of another facility studying substantially the same drug,device,medical treatment or procedure;or the informed consent document used by the treating facility or by another facility studying substantially the same drug, device, medical treatment or procedure. FAMILY "Family"means a Participant and his or her eligible Dependents as defined herein. FMLA "FMLA" means Family and Medical Leave Act. HIPAA "HIPAA"means the Health Insurance Portability and Accountability Act of 1996, as amended. HOME HEALTH CARE AGENCY "Home Health Care Agency" means an organization that provides skilled nursing services and therapeutic services(home health aide services, physical therapy,occupational therapy,speech therapy, medical social services)on a visiting basis, in a place of residence used as the Covered Person's home. The organization must be Medicare certified and licensed within the state in which home health care services are provided. HOME HEALTH CARE PLAN "Home Health Care Plan" means a program for continued care and treatment administered by a Medicare certified and licensed Home Health Care Agency, for the Covered Person who may otherwise have been confined as an Inpatient in a Hospital or Skilled Nursing Facility or following termination of a Hospital confinement as an Inpatient and is the result of the same related condition for which the Covered Person was hospitalized and is approved in writing by the Covered Person's attending Physician. Collier County Government-SPD 90 Group#2003021 -Eff Date 1/1/2014 Packet Page-629- 1/27/2015 16.E.3. General Definitions HOSPICE "Hospice" means a health care program providing a coordinated set of services rendered at home, in Outpatient settings or in institutional settings for Covered Persons suffering from a condition that has a terminal prognosis. A Hospice must have an interdisciplinary group of personnel which includes at least one Physician and one Registered Nurse (R.N.), and it must maintain central clinical records on all patients. A Hospice must meet the standards of the National Hospice Organization(NHO)and applicable state licensing requirements. HOSPITAL "Hospital" means an institution which meets all of the following conditions: 1. It is engaged primarily in providing medical care and treatment to ill and injured persons on an emergent or inpatient basis at the patient's expense; and 2. It is licensed as a hospital or a critical access hospital under the laws of the jurisdiction in which the facility is located; and 3. It maintains on its premises the facilities necessary to provide for the diagnosis and treatment of an Illness or an Injury or provides for the facilities through arrangement or agreement with another hospital; and 4. It provides treatment by or under the supervision of a physician or osteopathic physician with nursing services by registered nurses as required under the laws of the jurisdiction in which the facility is licensed; and 5. It is a provider of services under Medicare. This condition is waived for otherwise Eligible Incurred Expenses outside of the United States; and 6. It is not,other than incidentally,a place for rest,a place for the aged,a place for drug addicts,a place for alcoholics, or a nursing home. HOSPITAL MISCELLANEOUS EXPENSES "Hospital Miscellaneous Expenses"mean the actual charges made by a Hospital on its own behalf for services and supplies rendered to the Covered Person which are Medically Necessary for the treatment of such Covered Person. Hospital Miscellaneous Expenses do not include charges for Room and Board or for professional services,regardless of whether the services are rendered under the direction of the Hospital or otherwise. ILLNESS "Illness"means a bodily disorder,Pregnancy,disease,physical sickness,mental illness,or functional nervous disorder of a Covered Person. INCURRED EXPENSES OR EXPENSES INCURRED "Incurred Expenses" or "Expenses Incurred" means those services and supplies rendered to a Covered Person. Such expenses will be considered to have occurred at the time or date the treatment, service or supply is actually provided. INITIAL ENROLLMENT PERIOD "Initial Enrollment Period" means the time allowed by this Plan for enrollment when a person first becomes eligible for coverage. Collier County Government-SPD 91 Group#2003021 -Eff Date 1/1/2014 Packet Page-630- 1/27/2015 16.E.3. General Definitions INJURY "Injury" means physical damage to the Covered Person's body which is not caused by disease or bodily infirmity. INPATIENT "Inpatient"means the classification of a Covered Person when that person is admitted to a Hospital, Hospice, or Skilled Nursing Facility for treatment, and charges are made for Room and Board to the Covered Person as a result of such treatment. INPATIENT CONFINEMENT DAY "Inpatient Confinement Day"means any day a person is classified as Inpatient. An Inpatient Confinement Day will commence at 12:01 A.M. and will be calculated using a calendar day. INTENSIVE CARE UNIT "Intensive Care Unit"means a section,ward,or wing within the Hospital which is separated from other facilities and: 1. Is operated exclusively for the purpose of providing professional medical treatment for critically ill patients; 2. It has special supplies and equipment necessary for such medical treatment available on a standby basis for immediate use; and 3. It provides constant observation and treatment by Registered Nurses(R.N.'s)or other highly-trained Hospital personnel. LICENSED HEALTH CARE PROVIDER "Licensed Health Care Provider" means any provider of health care services who is licensed or certified by any applicable governmental regulatory authority to the extent that services are within the scope of the license or certification and are not specifically excluded by this Plan. LICENSED PRACTICAL NURSE "Licensed Practical Nurse" means an individual who has received specialized nursing training and practical nursing experience, and is licensed to perform such nursing services by the state or regulatory agency responsible for such licensing in the state in which that individual performs such services. LICENSED SOCIAL WORKER "Licensed Social Worker" means a person holding a Masters Degree (M.S.W.) in social work and who is currently licensed as a social worker in the state in which services are rendered,and who provides counseling and treatment in a clinical setting for Mental Illnesses. MAINTENANCE THERAPY "Maintenance Therapy"means medical and non-medical health-related services that do not seek to cure, or that which are provided during periods when the medical condition of the patient is not changing,or does not require continued administration by medical personnel. Collier County Government-SPD 92 Group#2003021 -Eff Date 1/1/2014 Packet Page-631- 1/27/2015 16.E.3. General Definitions MAXIMUM LIFETIME BENEFIT "Maximum Lifetime Benefit"means the maximum benefit payable while a person is covered under this Plan. The Maximum Lifetime Benefit will not be construed as providing lifetime coverage,or benefits for a person's Illness or Injury after coverage terminates under this Plan. MEDICAID "Medicaid" means that program of medical care and coverage established and provided by Title XIX of the Social Security Act, as amended. MEDICALLY NECESSARY "Medically Necessary"means treatment,tests,services or supplies provided by a Hospital,Physician,or other Licensed Health Care Provider which are not excluded under this Plan and which meet all of the following criteria: 1. Are to treat or diagnose an Illness or Injury; and 2. Are ordered by a Physician or Licensed Health Care Provider and are consistent with the symptoms or diagnosis and treatment of the Illness or Injury; and 3. Are not primarily for the convenience of the Covered Person,Physician or other Licensed Health Care Provider; and 4. Are the standard or level of services most appropriate for good medical practice that can be safely provided to the Covered Person and are in accordance with the Plan's Medical Policy; and 5. Are not of an Experimental/Investigational or solely educational nature; and 6. Are not provided primarily for medical or other research; and 7. Do not involve excessive, unnecessary or repeated tests; and 8. Are commonly and customarily recognized by the medical profession as appropriate in the treatment or diagnosis of the diagnosed condition; and 9. Are approved procedures or meet required guidelines or protocols of the Food and Drug Administration (FDA) or Centers For Medicare/Medicaid Services (CMS), pursuant to that entity's program oversight authority based upon the medical treatment circumstances. MEDICAL POLICY "Medical Policy"means a policy adopted by the Plan which is created and updated by physicians and other medical providers and is used to determine whether health care services including medical and surgical procedures, medication, medical equipment and supplies, processes and technology meet the following nationally accepted criteria: 1. Final approval from the appropriate governmental regulatory agencies; 2. Scientific studies showing conclusive evidence of improved net health outcome; and 3. In accordance with any established standards of good medical practice. Collier County Government-SPD 93 Group#2003021 -Eff Date 1/1/2014 Packet Page-632- 1/27/2015 16.E.3. General Definitions MEDICARE "Medicare"means the programs established under the"Health Insurance for the Aged Act,"Public Law 89-97 under Title XVIII of the Federal Social Security Act, as amended, to pay for various medical expenses for qualified individuals,specifically those who are eligible for Medicare Part A,Part B or Part D as a result of age, those with end-stage renal disease, or with disabilities. MENTAL ILLNESS "Mental Illness"means a medically recognized psychological, physiological,nervous or behavioral condition, affecting the brain,which can be diagnosed and treated by medically recognized and accepted methods, but will not include Alcoholism,Chemical Dependency or other addictive behavior. Conditions recognized by the Diagnostic Statistical Manual (the most current edition)will be included in this definition. MORBID OBESITY/CLINICALLY SEVERE OBESITY "Morbid Obesity/Clinically Severe Obesity" means maintaining a Body Mass Index(BMI)of 40 or more for a period of at least 12 consecutive months, or a BMI of at least 35 for a period of at least 12 consecutive months,combined with at least one of the following conditions which must be documented by a physician as life-threatening: 1. Severe sleep apnea; 2. Pickwickian syndrome; 3. Congestive heart failure; 4. Cardiomyopathy; 5. Insulin dependent or oral medication dependent diabetes; 6. Severe Musculoskeletal dysfunction; 7. Gastric Esophageal Reflux Disorder; 8. Pulmonary edema; or 9. Hypertension. Body Mass Index(BMI) is calculated by dividing a person's weight(in kilograms) by his/her height squared (in meters). NAMED FIDUCIARY "Named Fiduciary"means the Plan Administrator which has the authority to control and manage the operation and administration of the Plan. NEWBORN "Newborn"refers to an infant from the date of his/her birth until the initial Hospital discharge or until the infant is fourteen (14)days old, whichever occurs first. Collier County Government-SPD 94 Group#2003021 -Eff Date 1/1/2014 Packet Page-633- 1/27/2015 16.E.3. General Definitions OCCUPATIONAL THERAPY "Occupational Therapy"means a program of care ordered by a Physician which is for the purpose of improving the physical, cognitive and perceptual disabilities that influence the Covered Person's ability to perform functional tasks related to normal life functions or occupations, and which is for the purpose of assisting the Covered Person in performing such functional tasks without assistance. ORTHOPEDIC APPLIANCE "Orthopedic Appliance"means a rigid or semi-rigid support used to restrict or eliminate motion in a diseased, injured, weak or deformed body member. OUT-OF-POCKET MAXIMUM "Out-of-Pocket Maximum"means the maximum dollar amount,as stated in the Schedule of Medical Benefits or Pharmacy Benefit,that any Covered Person or Family will pay in any Benefit Period for covered services, treatments or supplies. OUTPATIENT "Outpatient" means a Covered Person who is receiving medical care, treatment, services or supplies at a clinic, a Physician's office, a Licensed Health Care Provider's office or at a Hospital if not a registered bed patient at that Hospital, Psychiatric Facility or Alcoholism and/or Chemical Dependency Treatment Facility. PARTICIPANT "Participant" means an Employee of the County who is eligible and enrolled for coverage under this Plan. PHYSICAL THERAPY "Physical Therapy"means a plan of care ordered by a Physician and provided by a licensed physical therapist, to return the Covered Person to the highest level of motor functioning possible. PHYSICIAN "Physician"means a person holding the degree of Doctor of Medicine,Dentistry or Osteopathy,or Optometry who is legally licensed as such. "Physician"does not include the Covered Person or any Close Relative of the Covered Person who does not regularly charge the Covered Person for services. PLACEMENT OR BEING PLACED FOR ADOPTION "Placement"or"Being Placed for Adoption"means the assumption and retention of a legal obligation for total or partial support of a child by a person with whom the child has been placed in anticipation of the child's adoption. The child's placement for adoption with such person ends upon the termination of such legal obligation. PLAN "Plan" means the Collier County Government Employee Benefit Plan, the Plan Document and any other relevant documents pertinent to its operation and maintenance. Collier County Government-SPD 95 Group#2003021 -Eff Date 1/1/2014 Packet Page-634- 1/27/2015 16.E.3. General Definitions PLAN ADMINISTRATOR "Plan Administrator"means the County and/or its designee which is responsible for the day-to-day functions and management of the Plan. The Plan Administrator may employ persons or firms to process claims and perform other Plan-connected services. For the purposes of any applicable state legislation of a similar nature,the County will be deemed to be the Plan Administrator of the Plan unless the County designates an individual or committee to act as Plan Administrator of the Plan. PLAN SUPERVISOR "Plan Supervisor" means the person or firm employed by the Plan to provide consulting services to the Plan in connection with the operation of the Plan and any other functions, including the processing and payment of claims. The Plan Supervisor is Allegiance Benefit Plan Management, Inc. The Plan Supervisor provides ministerial duties only, exercises no discretion over plan assets and will not be considered a fiduciary as defined by any other State or Federal law or regulation. PREGNANCY "Pregnancy"means a physical condition commencing with conception, and ending with miscarriage or birth. PREVENTIVE CARE "Preventive Care" means routine examinations or services provided when there is no objective indication or outward manifestation of impairment of normal health or normal bodily function, which is not provided for treatment or diagnosis of any Injury or Illness. PROSTHETIC APPLIANCE "Prosthetic Appliance" means a device or appliance that is designed to replace a natural body part lost or damaged due to Illness or Injury,the purpose of which is to restore full or partial bodily function or appearance, or in the case of Covered Dental Benefit, means any device which replaces all or part of a missing tooth or teeth. PSYCHIATRIC CARE "Psychiatric Care," also known as psychoanalytic care, means treatment for a Mental Illness or disorder, a functional nervous disorder,Alcoholism or drug addiction by a licensed psychiatrist, psychologist, Licensed Social Worker or licensed professional counselor acting within the scope and limitations of his/her respective license, provided that such treatment is Medically Necessary as defined by the Plan, and within recognized and accepted professional psychiatric and psychological standards and practices. PSYCHIATRIC FACILITY "Psychiatric Facility" means a licensed institution that provides Mental Illness treatment and which provides for a psychiatrist who has regularly scheduled hours in the facility,and who assumes the overall responsibility for coordinating the care of all patients. PSYCHOLOGIST "Psychologist"means a person currently licensed in the state in which services are rendered as a psychologist and acting within the scope of his/her license. QMCSO "QMCSO"means Qualified Medical Child Support Order as defined by Section 609(a)of ERISA,as amended. Collier County Government-SPD 96 Group#2003021 -Eff Date 1/1/2014 Packet Page-635- 1/27/2015 16.E.3. General Definitions QUALIFIED BENEFICIARY "Qualified Beneficiary" means an Employee, former Employee or Dependent of an Employee or former Employee who is eligible to continue coverage under the Plan in accordance with applicable provisions of Title X of COBRA or Section 609(a)of ERISA in relation to QMCSO's. "Qualified Beneficiary"will also include a child born to,adopted by or Placed for Adoption with an Employee or former Employee at any time during COBRA Continuation Coverage. REGISTERED NURSE "Registered Nurse" means an individual who has received specialized nursing training and is authorized to use the designation of"R.N."and who is licensed by the state or regulatory agency in the state in which the individual performs such nursing services. REHABILITATION FACILITY "Rehabilitation Facility" means a facility that meets all of the following requirements: 1. Care must be for the treatment of acute Injury or Illness; 2. Is licensed as an acute rehabilitation facility; 3. The care is under the direct supervision of a Physician; 4. Services are Medically Necessary; 5. Services are specific to an active written treatment plan; 6. The patient's condition requires skilled nursing care and interventions which cannot be achieved or managed at a lower level of care; 7. Twenty-four(24)hour nursing services are available; and 8. The confinement is not for Custodial or maintenance care. RESIDENTIAL TREATMENT FACILITY OR RTF "Residential Treatment Facility" or "RTF" means a facility for purposes of evaluation and treatment or evaluation and referral of any individual with Substance Abuse/Chemical Dependency or Mental Illness. Treatment received in a Residential setting for Mental Illness or Substance Abuse/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. RETIREE "Retiree" means an Employee who retires under a retirement program authorized by law and eligible to continue coverage with the Employer pursuant to the terms of Florida statute 112.0801, as amended. ROOM AND BOARD "Room and Board"refers to all charges which are made by a Hospital, Hospice, or Skilled Nursing Facility as a condition of occupancy. Such charges do not include the professional services of Physicians or intensive nursing care by whatever name called. Collier County Government-SPD 97 Group#2003021 -Eff Date 1/1/2014 Packet Page-636- 1/27/2015 16.E.3. General Definitions SEMI-PRIVATE "Semi-Private"refers to the class of accommodations in a Hospital or Skilled Nursing Facility in which at least two patient beds are available per room. SKILLED NURSING FACILITY "Skilled Nursing Facility" means an institution, or distinct part thereof, which meets all of the following conditions: 1. It is currently licensed as a long-term care facility or skilled nursing facility in the state in which the facility is located; 2. It is not,other than incidentally,a place for rest,the aged,drug addicts,alcoholics, mentally disabled persons, custodial or educational care, or care of mental disorders; and 3. It is certified by Medicare. This term also applies to Incurred Expenses in an institution known as a Convalescent Nursing Facility, Extended Care Facility, Convalescent Nursing Home, or any such other similar nomenclature. SPEECH THERAPY "Speech Therapy" means a course of treatment, ordered by a Physician, to treat speech deficiencies or impediments. SUBSTANCE ABUSE/CHEMICAL DEPENDENCY "Substance Abuse" or "Chemical Dependency" means the physiological and psychological addiction to a controlled drug or substance,or to alcohol. Dependence upon tobacco,nicotine,caffeine or eating disorders are not included in this definition. URGENT CARE FACILITY "Urgent Care Facility" means a free-standing facility which is engaged primarily in diagnosing and treating Illness or Injury for unscheduled,ambulatory Covered Persons seeking immediate medical attention. A clinic or office located in or in conjunction with or in any way made a part of a Hospital will be excluded from the terms of this definition. USERRA "USERRA" means the Uniformed Services Employment and Reemployment Rights Act, as amended. USUAL, CUSTOMARY AND REASONABLE (UCR)" "Usual,Customary and Reasonable(UCR)"means the maximum amount considered for payment by this Plan for any covered treatment, service, or supply, subject however, to all Plan annual and lifetime maximum benefit limitations. The following will apply in the order below to determination of the Usual, Customary, and Reasonable amount: 1. A contracted amount as established by a preferred provider or other discounting contract; or 2. An amount established through a nationally recognized,published Usual,Customary and Reasonable (UCR)data base utilized by the Plan Supervisor and adopted by the Plan Administrator using the 90th percentile of said database; or 3. The billed charge if less than 2 above. Collier County Government-SPD 98 Group#2003021 -Eff Date 1/1/2014 Packet Page-637- 1/27/2015 16.E.3. NOTICES NEWBORNS'AND MOTHERS'HEALTH PROTECTION ACT:Group health insurance issuers offering group health insurance coverage generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother,from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). IDENTIFICATION OF FUNDING: Your benefits under this plan will be paid from employee or employer contributions up to the limits defined in the Plan Document and Summary Plan Description (SPD). Benefits in excess of the amount stated in the stop loss policy are reimbursable to the employer by stop loss insurance, pursuant to the stop loss insurance contract or policy,subject, however,to the terms of this Plan and the stop loss insurance contract. WOMEN'S HEALTH AND CANCER RIGHTS ACT: Did you know that your plan,as required by the Women's Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all states of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Call your Plan Administrator for more information. Collier County Government-SPD 99 Group#2003021 -Eff Date 1/1/2014 Packet Page-638- 1/27/2015 16.E.3. HIPAA PRIVACY AND SECURITY STANDARDS These standards are intended to comply with all requirements of the Privacy and Security Rules of the Administrative Simplification Rules of HIPAA as stated in 45 CFR Parts 160, 162 and 164,as amended from time to time. DEFINITIONS "Protected Health Information"(PHI)means information,including demographic information,that identifies an individual and is created or received by a health care provider, health plan, employer, or health care clearinghouse, and relates to the physical or mental health of an individual, health care that individual has received,or the payment for health care provided to that individual. PHI does not include employment records held by the Plan Sponsor in its role as an employer. "Summary Health Information"means information summarizing claims history, expenses, or types of claims by individuals enrolled in a group health plan and has had the following identifiers removed: names; addresses, except for the first three digits of the Zip Code; dates related to the individual (ex: birth date); phone numbers; email addresses and related identifiers; social security numbers; medical record numbers; account or plan participant numbers; vehicle identifiers; and any photo or biometric identifier. PRIVACY CERTIFICATION The Plan Sponsor hereby certifies that the Plan Documents have been amended to comply with the privacy regulations by incorporation of the following provisions. The Plan Sponsor agrees to: 1. Not use or further disclose the information other than as permitted or required by the Plan Documents or as required by law. Such uses or disclosures may be for the purposes of plan administration including, but not limited to,the following: A. Operational activities such as quality assurance and utilization management, credentialing, and certification or licensing activities;underwriting,premium rating or other activities related to creating, renewing or replacing health benefit contracts (including reinsurance or stop loss); compliance programs; business planning; responding to appeals, external reviews, arranging for medical reviews and auditing, and customer service activities. Plan administration can include management of carve-out plans, such as dental or vision coverage. B. Payment activities such as determining eligibility or coverage, coordination of benefits, determination of cost-sharing amounts, adjudicating or subrogating claims, claims management and collection activities,obtaining payment under a contract for reinsurance or stop-loss coverage,and related data-processing activities;reviewing health care services for medical necessity, coverage or appropriateness of care, or justification of charges; or utilization review activities. C. For purposes of this certification, plan administration does not include disclosing Summary Health Information to help the plan sponsor obtain premium bids; or to modify, amend or terminate group health plan coverage. Plan administration does not include disclosure of information to the Plan Sponsor as to whether the individual is a participant in; is an enrollee of or has disenrolled from the group health plan. 2. Ensure that any agents, including a subcontractor, to whom it provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information; 3. Not use or disclose the PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor; Collier County Government-SPD 100 Group#2003021 -Eff Date 1/1/2014 Packet Page-639- 1/27/2015 16.E.3. HIPAA Privacy and Security Standards 4. Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for of which it becomes aware; 5. Make available PHI as required to allow the Covered Person a right of access to his or her PHI as required and permitted by the regulations; 6. Make available PHI for amendment and incorporate any amendments into PHI as required and permitted by the regulations; 7. Make available the PHI required to provide an accounting of disclosures as required by the regulations; 8. Make its internal practices,books,and records relating to the use and disclosure of PHI received from the Plan available to any applicable regulatory authority for purposes of determining the Plan's compliance with the law's requirements; 9. If feasible,return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible; and 10. Ensure that the adequate separation required between the Plan and the Plan Sponsor is established. To fulfill this requirement, the Plan Sponsor will restrict access to nonpublic personal information to the Plan Administrator(s) designated in this Plan Document or employees designated by the Plan Administrator(s)who need to know that information to perform plan administration and healthcare operations functions or assist eligible persons enrolling and disenrolling from the Plan. The Plan Sponsor will maintain physical, electronic, and procedural safeguards that comply with applicable federal and state regulations to guard such information and to provide the minimum PHI necessary for performance of healthcare operations duties. The Plan Administrator(s) and any employee so designated will be required to maintain the confidentiality of nonpublic personal information and to follow policies the Plan Sponsor establishes to secure such information. When information is disclosed to entities that perform services or functions on the Plan's behalf,such entities are required to adhere to procedures and practices that maintain the confidentiality of the Covered Person's nonpublic personal information,to use the information only for the limited purpose for which it was shared,and to abide by all applicable privacy laws. SECURITY CERTIFICATION The Plan Sponsor hereby certifies that its Plan Documents have been amended to comply with the security regulations by incorporation of the following provisions. The Plan Sponsor agrees to: 1. Implement and follow all administrative, physical, and technical safeguards of the HIPAA Security Rules, as required by 45 CFR§§164.308, 310 and 312. 2. Implement and install adequate electronic firewalls and other electronic and physical safeguards and security measures to ensure that electronic PHI is used and disclosed only as stated in the Privacy Certification section above. 3. Ensure that when any electronic PHI is disclosed to any entity that performs services or functions on the Plan's behalf,that any such entity shall be required to adhere to and follow all of the requirements for security of electronic PHI found in 45 CFR§§164.308, 310, 312, 314 and 316. 4. Report to the Plan Administrator or the Named Fiduciary of the Plan any attempted breach,or breach of security measures described in this certification, and any disclosure or attempted disclosure of electronic PHI of which the Plan Sponsor becomes aware. Collier County Government-SPD 101 Group#2003021 -Eff Date 1/1/2014 Packet Page-640- 1/27/2015 16.E.3. COLLIER COUNTY GOVERNMENT EMPLOYEE BENEFIT PLAN PLAN SUMMARY The following information, together with the information contained in this booklet, form the Summary Plan Description. 1. PLAN The name of the Plan is the COLLIER COUNTY GOVERNMENT EMPLOYEE BENEFIT PLAN,which Plan describes the benefits,terms, limitations and provisions for payment of benefits to or on behalf of eligible Participants. 2. PLAN BENEFITS This Plan provides benefits for covered expenses incurred by eligible participants for: Hospital, Surgical, Medical, Maternity, Pharmacy other eligible medically related, necessary expenses. 3. PLAN EFFECTIVE DATE This Plan was established effective January 1, 2000, and restated January 1, 2014. 4. PLAN SPONSOR Name: Collier County Government Phone (239)252-8461 Address: 3311 East Tamiami Trail, Building D Naples, FL 34112 5. PLAN ADMINISTRATOR The Plan Administrator is the Plan Sponsor. 6. NAMED FIDUCIARY Name: Collier County Government Phone (239)252-8461 Address: 3311 East Tamiami Trail, Building D Naples, FL 34112 7. PLAN FISCAL YEAR The Plan fiscal year ends December 3151 8. PLAN TERMINATION The right is reserved by the Sponsor to terminate, suspend, withdraw, amend or modify the Plan in whole or in part at any time. 9. IDENTIFICATION NUMBER Plan Number: 501 Group Number: 2003021 Employer Identification Number: 59-6000558 Collier County Government-SPD 102 Group#2003021 -Eff Date 1/1/2014 Packet Page-641- 1/27/2015 16.E.3. Plan Summary 10. PLAN SUPERVISOR Name: Allegiance Benefit Plan Management, Inc. Address: P.O. Box 3018 Missoula, MT 59806 11. ELIGIBILITY Employees and dependents of employees of the Plan Sponsor may participate in the Plan based upon the eligibility requirements set forth by the Plan. 12. PLAN FUNDING The Plan is funded by contributions from the employer and employees. 13. AGENT FOR SERVICE OF LEGAL PROCESS The Plan Administrator is the agent for service of legal process. Collier County Government-SPD 103 Group#2003021 -Eff Date 1/1/2014 Packet Page-642- 1/27/2015 16.E.3. AMENDMENT#1 TO THE PLAN DOCUMENT/SUMMARY PLAN DESCRIPTION HEALTH BENEFIT PLAN FOR THE EMPLOYEES OF COLUER COUNTY GOVERNMENT-Group#2003021 Effective January 1.2014,the Health Benefit Plan for Employees of Collier County Government is amended as follows: Within the"SCHEDULE OF BENEFITS-PREMIUM OPTION", under the"MEDICAL BENEFITS"table, "Scalp Hair Prosthesis(wigs/hair pieces)'row is replaced as follows: ? Y S !'"'fi �' 9 3°r F� k! E5 Y i Scalp Hair Prosthesis 80%after Deductible 80%after Deductible (wigs/hair pieces) Maximum Lifetime Benefit one wig or hair piece Within the "SCHEDULE OF BENEFITS -SELECT OPTION", under the "MEDICAL BENEFITS" table, "Scalp Hair Prosthesis(wigs/hair pieces)"row is replaced as follows: ;r na . , i- Tr j� y .,j11 Scalp Hair Prosthesis 80%after Deductible 80%after Deductible (wigs/hair pieces) Maximum Lifetime Benefit one wig or hair piece Within the"SCHEDULE OF BENEFITS-BASIC OPTION",under the"MEDICAL BENEFITS"table,"Scalp Hair Prosthesis(wigs/hair pieces)"row is replaced as follows: y d I L GENE 117Yn 0. y y .. ' K p�yyi' Scalp Hair Prosthesis 80%after Deductible 80%after Deductible (wigs/hair pieces) Maximum Lifetime Benefit one wig or hair piece Nothing in this amendment is deemed to change any other provision of the Plan Document of which it becomes a part. COWER COUNTY GOVERNMENT BY: r4i" TITLE: i►rcccor :StC Man&gentevt�" Packet Page-643- 1/27/2015 16.E.3. AMENDMENT#2 • TO THE PLAN DOCUMENT/SUMMARY PLAN DESCRIPTION COWER COUNTY GOVERNMENT EMPLOYEE BENEFIT PLAN • Group i 2003021 Effective January 1.2014,Collier County Government Employee Benefit Plan is amended as follows: Within the"MEDICAL BENEFITS"section,item 24"Hearing Aids"is replaced as follows: 24. Hearing Aids: Hearing aids and their fittings will be payable as shown in the Schedule of Benefits,regardless of Medial Necessity. V1Mhin the "GENERAL EXCLUSIONS AND LIMITATIONS" section, the following item 27 "Hearing Exams/Alds"is deleted in its entirety. -.1 •..:11.. 'L•il:: l•. L•.'!1_ L_=..1 L• =!'.11 -v• :h' !1;L' ;• �l." .�•��! _ 111��1Tt+f�U■,� «�•' •Lr�1�I111L=•_ .1,' 1��=1;1.•, =.li.�!1�LT-_�'-LL' •t: r'.=.511�i1L•i' Nothing in this amendment is deemed to change any other provision of the Plan Document of which it becomes a part. COWER COUNTY GOVERNMENT • BY: 97p..7 • • Packet Page-644- 1/27/2015 16.E.3. AMENDMENT#3 TO THE PLAN DOCUMENT/SUMMARY PLAN DESCRIPTION COWER COUNTY GOVERNMENT EMPLOYEE BENEFIT PLAN Group#2003021 Effective January 1.201,1,Collier County Government Employee Benefit Plan is amended as follows: The Notification Provisions"section is replaced as follows: NOTIFICATION PROVISIONS Community Health Partners (239)859-7770 or(888) 008 • 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 all elective (non-urgent, pre.ananged, non- emergency) Inpatient admissions in a Hospital, Hospice, Skilled Nursing, Rehabilitation or Chemical Dependency/Mental Illness Treatment Facilities. It also requires notification twenty-four(24)hours before any of the following that are done on an Outpatient basis:CAT Scans,MRI,MRA,CT Guided procedures, • transplants(ail),including initial consultation,evaluation,and actual transplant,rental or purchase of Durable Medical Equipment(DNE)with costa anticipated in excess of$500.00.Pro-notification is not requiredforvhtual colonoscopies or if any one of these procedures is performed in the emergency room. Fora non-emergency hospitalization,CHP will evaluate the proposed admission plan and length of stay.CHP will certify the number of days appropriate. in making these determinations,the diagnosis,physical status and any other complicating conditions of the patient will be taken into account. CHP will review any x-ray and laboratory results and confer with the attending Physician if necessary. The decision to be admitted will always rest with the patient and the Physician. The notification process will let the patient know, before expenses are incurred,whether or not the admission would be of days that have been certified. If the confinement will certified. will only be of days available for the longer than the number d 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 asthe 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. In a Covered Person Is admitted to the Hospital or other faculty 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,the Hospital,or the Physician. However,the Covered Person is ultimately responsible forth°notification. It is strongly recommended,therefore,that the Covered Person makes the cat! Notification requires only a brief phone call.to CHP at(239)859-7770 or toll free at(888)594-9008. If the call is made after hours,the following information must be left on CHPs confidential voice marl: 1. Employee's name. 2. Employee ID number. 3. Patient's name and relationship to the Employee. 4. The name of the Hospital where the procedure Will take place(if applicable). 5. The procedure to be performed. 8. The name and telephone number of the Physician. v Packet Page-645- 1/27/2015 16.E.3. Collor Coudy cormorant-crow s2003021 Amendment 03-Effective Jani y 1,2014 Pape 2 It is vital the cal occurs within the time frames list above. If notification Is not made,eligible expenses will be reduced by$300 per procedure or confinement except for Urgent Care claims as stated in the Procedures for Claiming Benefits section. if notification is not provided within the times outlined,CHP will review the claim to determine whether the admission,test,or procedure was Medicaly Necessary. Irrespective of the eventual determination by CHP, the penalty will still be applied and cannot be rescinded. Hospital stays in connection with childbirth foreither the mother or Newborn may not be less than forty-eight (48) hours following a vaginal delivery or ninety-six (96) hours following a cesarean section. These requirements can only be waived by the attending Physician in consultation with the mother. The Covered Person or provider is not required to notify CHP of the maternity admission,unless the stay extends past the applicable forty-eight(48)or ninety-sec(98)hour stay. A Hospital stay begins at the tine of delivery or for deliveries outside the Hospital,the time the Newborn or mother is admitted to a Hospital blowing 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. Nothing in this amendment is deemed to change any other provision of the Plan Document of which It becomes a part. COWER COUNTY GOVERNMENT BY: 5-0?"047%,...,„0.14 TITLE: R:ek m3,* Packet Page-646- 1/27/2015 16.E.3. CORRECTED AMENDMENT 04 TO THE PLAN DOCUMENT/SUMMARY PLAN DESCRIPTION COLLIER COUNTY GOVERNMENT EMPLOYEE BENEFIT PLAN Group#2003021 Effective January 1.2015,Collier County Government Employee Benefit Plan is amended as follows: Within the"SCHEDULE OF BENEFITS -BASIC OPTION",the"MEDICAL BENEFIT COST SHARING PROVISIONS"table is replaced as follows: r?i-! ti �' DEDUCTIBLE Per Covered Person per Benefit Period $2,000 $4,000 Per Family per Benefit Period $4,000 $8,000 The Deductible applies to all Eligible Expenses,unless specifically stated otherwise. An individual Covered Person cannot receive credit toward the Family Deductible for more than the individual Annual Deductible. he Deductible is combined for both In-Network Providers and Out-of-Network Providers. •UT-OF-POCKET MAXIMUM Per Covered Person per Benefit Period $5,200* $14,000* Per Family per Benefit Period $10,400` $28,000* Includes the Deductible and any Medical Benefit Copayments - Out-of-Pocket Maximum applies to all Eligible Expenses,unless specifically stated otherwise. The Out- -Pocket Maximum is combined for both In-Network Provider and Out-of-Network Providers. Expenses incurred forthe following do not apply toward the Out-of-Pocket Maximum:1)any penalty amounts; 2)any charges defined in the General Exclusions and Limitations Section;3)Dental Care expenses due o Illness or injury. BENEFIT PERCENTAGE Before satisfaction of Out-of-Pocket Maximum 80% 60% After satisfaction of Out-of-Pocket Maximum 100% 100% Benefit Percentage applies to all Eligible Expenses, unless specifically stated otherwise. Eligible Expenses will be paid by the Plan according to the applicable Benefit Percentage. NON-COMPUANCE PENALTY - Mandatory Case Management Non Participation in Case Management Penalty $1,000 Non Participation in Notification Provisions $300 PHYSICIAN REGIONAL HOSPITAL COPAYMENT Copayment applies to any non-emergent or scheduled Inpatient $1,000 -dmission or Outpatient service. MAXIMUM LIFETIME BENEFIT FOR ALL CAUSES Unlimited Packet Page -647- 1/27/2015 16.E.3. Collier county Government-Group#2003021 Corrected Amendment*4-Effective January 1,2015 Pape 2 The"NOTIFICATION PROVISIONS"section,as amended,is replaced as follows: NOTIFICATION PROVISIONS Community Health Partners (239)659-7770 or(888)-594-9008 To ensure the most appropriate care is provided,and to control the costs of this Plan,the Plan contains a notification provision. The notification provision requires that a Covered Person call Community Health Partners(CHP)at least twenty-four(24)hours before: 1. All elective (non-urgent, pre-arranged, non-emergency) Inpatient admissions in a Hospital, Hospice, Skilled Nursing, Rehabilitation or Chemical Dependency/Mental Illness Treatment Facilities. 2. Any of the following that are done on an Outpatient basis:CAT Scans,MRI,MRA,CT Guided procedures,transplants(all),including initial consultation,evaluation,and actual transplant,rental or purchase of Durable Medical Equipment(DME)with cost anticipated in excess of$500.00. Pre-notification is not required for virtual colonoscopies or if any one of these procedures is performed in the emergency room. 3. When an Observation Stay is greater than twenty-four(24)hours(greater than one midnight)or converts to an Inpatient admission. 'Observation Stay' is an alternative to an Inpatient admission that allows reasonable and necessary time to evaluate and render Medically Necessary services to a patient whose diagnosis and treatment are not expected to exceed twenty-four(24)hours but may extend to forty-eight (48)hours,and the need for an Inpatient admission can be determined within this specific period. An Inpatient admission is generally appropriate when the patient is expected to need two(2)or more midnights of Medically Necessary Hospital care. For a non-emergency hospitalization,CHP will evaluate the proposed admission plan and length of stay. CHP will certify the number of days appropriate. In making these determinations,the diagnosis,physical status and any other complicating conditions of the patient will be taken into account CHP will review any x-ray and laboratory results and confer with the attending Physician if necessary. The decision to be admitted will always rest with the patient and the Physician. The notification process will let the patient know,before expenses are incurred,whether or not the admission would be certified. Benefits will only be available for the number of days that have been certified. If the confinement will last longer than the number of days certified,CHP must be notified. At this point,CHP will conduct a Continued Stay Review. The Continued Stay Review will be conducted in much the same way as the initial notification. The case will be reviewed with the attending Physician to determine any additional Inpatient days. Benefits will not be available for any days beyond those certified. In a Covered Person is admitted to the Hospital or other facility 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,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. Packet Page -648- 1/27/2015 16.E.3. Collier County Government-Group#2003021 Corrected Amendment#4-Effective January 1,2015 Page 3 Notification requires only a brief phone call to CHP at(239)659-7770 or toll free at(888)594-9008. If the call is made after hours,the following information must be left on CHP's confidential voice mail: 1. Employee's name. 2. Employee ID number. 3. Patient's name and relationship to the Employee. 4. The name of the Hospital where the procedure will take place(if applicable). 5. The procedure to be performed. 6. The name and telephone number of the Physician. It is vital the call occurs within the time frames list above. If notification Is not made,eligible expenses will be reduced by$300 per procedure or confinement except for Urgent Care claims as stated in the Procedures for Claiming Benefits section. If notification is not provided within the times outlined,CHP will review the claim to determine whether the admission,test,or procedure was Medically Necessary. Irrespective of the eventual determination by CHP,the penalty will still be applied and cannot be rescinded. 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-slot(96)hours following a cesarean section. These requirements can only be waived by the attending Physician in consultation with the mother. The Covered Person or provider is not required to notify CHP of the maternity admission,unless the stay extends past the applicable forty-eight(48)or ninety-six(96)hour stay. A Hospital stay begins at the time of delivery or for deliveries outside the Hospital,the time the Newborn or mother is admitted to a Hospital following birth,in connection with childbirth. If the patient is unconscious, in a coma or unable to contact CHP due to Illness or Injury rendering the patient physically or mentally incapable,the notification requirement will be waived until the patient is able to contact CHP. Certification will be retroactive to the date of admission. Within the"EUGIBIUTY PROVISIONS"section,the'EMPLOYEE ELIGIBILITY"and`WAITING PERIOD" subsections are replaced as follows: EMPLOYEE ELIGIBILITY An Employee becomes eligible under this Plan for each classification of employees as follows: 1. Class I-Is classified as a Regular Full-Time Employee and is employed by the County on a continuing and regular basis for an average of at least thirty(30)hours per week;or 2. Class II-Is classified as a Regular Part-lime Employee and who is employed by the County on a continuing and regular basis for an average of at least twenty(20)hours per week. An Employee is not eligible while on active military duty if that duty exceeds a period of thirty-one(31) consecutive days. The following classes of Employees as defined below are ineligible for coverage: 1. Temporary Full-Time: Such positions require the Employee to work on a full-time basis(forty(40) hours per week)fora special project,to replace an employee on leave of absence or any other work of a temporary nature. Temporary Employees receive no benefits except workers' compensation but may qualify for membership in the Florida Retirement System(FRS)depending on then applicable Florida Law. 2. Temporary Part-Time:Such positions require the Employee to work less than forty(40)hours per week for a temporary period as defined above. Employees in this category receive no benefits except worker's compensation but may qualify for membership in the Florida Retirement System (FRS)depending on then applicable Florida Law. Packet Page-649- _ I 1/27/2015 16.E.3. Collier County Government-Group#2003021 Corrected Amendment#4-Effective January 1,2015 Page 4 3. Seasonal: A Seasonal Employee is considered an Employee who performs duties interrupted by periods of low demand, and who may be recalled to work during periods of high demand. Breaks between seasonal employment is considered"on leave"and not a termination. 4. On-Call: Employees assigned to an"on call"status works intermittently for special events,during peak demand periods,to fill in for leaves or other similar circumstances. A position defined as "On Call"has to do with the frequency of the work assignment,not taking on additional work after regularly scheduled hours. Within the "EFFECTIVE DATE OF COVERAGE" section, the "PARTICIPANT COVERAGE" and "DEPENDENT COVERAGE"subsections are replaced as follows: PARTICIPANT COVERAGE Participant coverage under the Plan will become effective on the first day immediately after the Employee satisfies the applicable eligibility requirements and Waiting Period. If these requirements are met, the Employee must be offered coverage or an opportunity to waive coverage even if the offer is after the date coverage should become effective, regardless of the time that has elapsed, provided that the reason coverage was not offered before the end of the Waiting Period was as a result of a administrative error on the part of the Employer, Plan Administrator or Plan Supervisor. Ij An eligible Employee who declines Participant coverage under the Plan during the Initial Enrollment Period will be able to become covered later in only two situations, Open Enrollment and Special Enrollment. If an eligible Employee chooses not to enroll or fails to enroll for coverage under the Plan during the Initial Enrollment Period,coverage for the Employee and Dependents will be deemed waived. If a Participant chooses not to re-enroll or fails to re-enroll during any Open Enrollment Period,coverage for the Participant and any Dependents covered at the time will remain the same as that elected prior to the Open Enrollment Period. DEPENDENT COVERAGE Each Participant who requests Dependent Coverage on the Plan's enrollment form will become covered for Dependent Coverage as follows: 1. On the Participant's effective date of coverage, if application for Dependent Coverage is made on the same enrollment form used by the Participant to enroll for coverage. This subsection applies only to Dependents who are eligible on the Participant's effective date of coverage. 2. In the event a Dependent is acquired after the Participant's effective date of coverage as a result of a legal guardianship or in the event that a Participant is required to provide coverage as a result of a valid court order, or if the Dependent is acquired as a result of operation of law, Dependent Coverage will begin on the first day of the month following the Plan's receipt of an enrollment form and copy of said court order, if applicable. Nothing in this amendment is deemed to change any other provision of the Plan Document of which it becomes a part. COLLIER COUNTY GOVERNMENT BY: 2,,,ii,L.Acee%-e—. TITLE: PIr- AC.,sr�+: CC` Packet Page-650- 1/27/2015 16.E.3. SAME GENDER MARRIAGE COMPLIANCE AMENDMENT TO THE PLAN DOCUMENT/SUMMARY PLAN DESCRIPTION COLLIER COUNTY GOVERNMENT EMPLOYEE BENEFIT PLAN Group#2003021 Effective January 5.2015, Collier County Government Employee Benefit Plan is amended as follows: Within the"ELIGIBILITY PROVISIONS"section,the first paragraph and item#1 under the`DEPENDENT ELIGIBILITY'subsection are replaced as follows: DEPENDENT ELIGIBILITY An eligible Dependent includes any person who is a citizen,resident alien,or is otherwise legally present in the United States or in any other jurisdiction that the related Participant has been assigned by the Employer,and who is either: 1. The Participant's legal spouse according to the marriage laws of the state of Florida on the date enrollment is requested, and provided that the marriage was recognized as a legal marriage in the state where it was first solemnized or established. An eligible Dependent does not include a spouse who is legally separated or divorced from the Participant and has a court order or decree stating such from a court of competent jurisdiction. Nothing in this amendment is deemed to change any other provision of the Plan Document of which it becomes a part. COLLIER COUNTY GOVERNMENT BY: TITLE: Packet Page -651- 1/27/2015 16.E.3. SAME GENDER MARRIAGE COMPLIANCE AMENDMENT TO THE PLAN DOCUMENT/SUMMARY PLAN DESCRIPTION COLLIER COUNTY GOVERNMENT DENTAL EMPLOYEE BENEFIT PLAN Group#2003021 Effective January 5.2015,Collier County Government Dental Employee Benefit Plan is amended as follows: Within the"ELIGIBILITY PROVISIONS"section,the first paragraph and item#1 under the"DEPENDENT ELIGIBILITY"subsection are replaced as follows: DEPENDENT ELIGIBILITY An eligible Dependent includes any person who is a citizen,resident alien,or is otherwise legally present in the United States or in any other jurisdiction that the related Participant has been assigned by the Employer,and who is either. 1. The Participant's legal spouse according to the marriage laws of the state of Florida on the date enrollment is requested, and provided that the marriage was recognized as a legal marriage in the state where it was first solemnized or established. An eligible Dependent does not include a spouse who is legally separated or divorced from the Participant and has a court order or decree stating such from a court of competent jurisdiction. Nothing in this amendment is deemed to change any other provision of the Plan Document of which it becomes a part. COLLIER COUNTY GOVERNMENT BY: TITLE: (2) Packet Page-652- 1/27/2015 16.E.3. HEALTH REIMBURSEMENT ARRANGEMENT BASIC PLAN DOCUMENT FOR COLLIER COUNTY Packet Page -653- 1/27/2015 16.E.3. TABLE OF CONTENTS ARTICLE I DEFINITIONS ARTICLE II PARTICIPATION 2.1 Eligibility 3 2.2 Effective Date of Participation 3 2.3 Termination of Participation 3 ARTICLE III BENEFITS 3.1 Establishment of Plan 4 3.2 Nondiscrimination Requirements 4 3.3 Health Reimbursement Arrangement Claims 5 ARTICLE IV ERISA PROVISIONS 4.1 Claim for Benefits 5 4.2 Named Fiduciary 7 4.3 General Fiduciary Responsibilities 7 4.4 Nonassignability of Rights 8 ARTICLE V ADMINISTRATION 5.1 Plan Administration 8 5.2 Examination of Records 9 5.3 Payment of Expenses 9 5.4 Indemnification of Administrator 9 ARTICLE VI AMENDMENT OR TERMINATION OF PLAN 6.1 Amendment 9 6.2 Termination 9 ARTICLE VII MISCELLANEOUS 7.1 Plan Interpretation 10 7.2 Gender and Number 10 7.3 Written Document 10 (53 Packet Page-654- 1/27/2015 16.E.3. 7.4 Exclusive Benefit 10 7.5 Participant's Rights 10 7.6 Action by the Employer 10 7.7 No Guarantee of Tax Consequences 11 7.8 Indemnification of Employer by Participants 11 7.9 Funding 11 7.10 Governing Law 11 7.11 Severability 11 7.12 Captions 12 7.13 Continuation of Coverage 12 7.14 Family and Medical Leave Act 12 7.15 Health Insurance Portability and Accountability Act 12 7.16 Uniformed Services Employment and Reemployment Rights Act 12 ®2) Packet Page -655- 1/27/2015 16.E.3. HEALTH REIMBURSEMENT ARRANGEMENT As used in this Plan, the following words and phrases shall have the meanings set forth herein unless a different meaning is clearly required by the context: ARTICLE I DEFINITIONS 1.1 "Administrator" means the individual(s) or committee appointed by the Employer to carry out the administration of the Plan. In the event the Administrator has not been appointed, or resigns from a prior appointment, the Employer shall be deemed to be the Administrator. 1.2 "Affiliated Employer"means any corporation which is a member of a controlled group of corporations (as defined in Code Section 414(b)) which includes the Employer; any trade or business (whether or not incorporated) which is under common control (as defined in Code Section 414(c)) with the Employer; any organization (whether or not incorporated) which is a member of an affiliated service group (as defined in Code Section 414(m)) which includes the Employer; and any other entity required to be aggregated with the Employer pursuant to Treasury regulations under Code Section 414(o). 1.3 "Code"means the Internal Revenue Code of 1986, as amended. 1.4 "Coverage Period"means the time period as set forth in the Adoption Agreement. 1.5 "Dependent" means any individual who qualifies as a dependent under Code Section 152 (as modified by Code Section 105(b)). 1.6 "Effective Date"means January 1,2012. 1.7 "Eligible Employee". means any Eligible Employee as elected in the Adoption Agreement and as provided herein. An individual shall not be an "Eligible Employee" if such individual is not reported on the payroll records of the Employer as a common law employee. In particular, it is expressly intended that individuals not treated as common law employees by the Employer on its payroll records are not "Eligible Employees" and are excluded from Plan participation even if a court or administrative agency determines that such individuals are common law employees and not independent contractors. Furthermore, Employees of an Affiliated Employer will not be treated as "Eligible Employees"prior to the date the Affiliated Employer adopts the Plan as a Participating Employer. However, a self-employed individual as defined under Code Section 401(c) or a 2-percent shareholder as defined under Code Section 1372(b) shall not be eligible to participate in this Plan. 1 Packet Page-656- 1/27/2015 16.E.3. 1.8 "Employee" means any person who is employed by the Employer. The term "Employee" shall also include any person who is an employee of an Affiliated Employer and any Leased Employee deemed to be an Employee as provided in Code Section 414(n) or(o). 1.9 "Employer" means Collier County, and any successor which shall maintain this Plan and any predecessor which has maintained this Plan. In addition, unless the context means otherwise, the term "Employer" shall include any Participating Employer which shall adopt this Plan. 1.10 "Employer Contribution"means the amounts contributed to the Plan by the Employer. 1.11 "ERISA" means the Employee Retirement Income Security Act of 1974, as amended from time to time. 1.12 "Leased Employee" means, effective with respect to Plan Years beginning on or after January 1, 1997, any person (other than an Employee of the recipient Employer) who, pursuant to an agreement between the recipient Employer and any other person or entity ("leasing organization"), has performed services for the recipient (or for the recipient and related persons determined in accordance with Code Section 414(n)(6)) on a substantially full time basis for a period of at least one year, and such services are performed under primary direction or control by the recipient Employer. Contributions or benefits provided a Leased Employee by the leasing organization which are attributable to services performed for the recipient Employer shall be treated as provided by the recipient Employer. Furthermore, Compensation for a Leased Employee shall only include Compensation from the leasing organization that is attributable to services performed for the recipient Employer. A Leased Employee shall not be considered an employee of the recipient Employer if: (a) such employee is covered by a money purchase pension plan providing: (1) a nonintegrated employer contribution rate of at least ten percent(10%) of compensation, as defined in Code Section 415(c)(3), but for Plan Years beginning prior to January 1, 1998, including amounts contributed pursuant to a salary reduction agreement which are excludable from the employee's gross income under Code Sections 125, 402(e)(3), 402(h)(1)(B), 403(b), or for Plan Years beginning on or after January 1, 2001 (or as of a date, no earlier than January 1, 1998, as specified in an addendum to the Adoption Agreement), 132(0(4), (2) immediate participation, and (3) full and immediate vesting; and (b) leased employees do not constitute more than twenty percent (20%) of the recipient Employer's nonhighly compensated workforce. 1.13 "Participant" means any Eligible Employee who has satisfied the requirements of Section 2.1 and has not for any reason become ineligible to participate further in the Plan. 1.14 "Plan" means this Basic Plan Document and the Adoption Agreement as adopted by the Employer, including all amendments thereto. 1.15 "Premiums" mean the Participant's cost for any health plan coverage. Cpt 2 Packet Page-657- 1/27/2015 16.E.3. 1.16 "Qualifying Medical Expenses" means any expense eligible for reimbursement under the Health Reimbursement Arrangement which would qualify as a "medical expense" (within the meaning of Code Section 213 and the rulings and Treasury regulations thereunder) of the Participant, the Participant's spouse or a Dependent and not otherwise used by the Participant as a deduction in determining the Participant's tax liability under the Code or reimbursed under any other health coverage, including a health Flexible Spending Account. Qualifying Medical Expenses covered by this Plan are limited as elected in the Adoption Agreement. Furthermore, a Participant may not be reimbursed for "qualified long-term care services" as defined in Code Section 7702B(c). ARTICLE II PARTICIPATION 2.1 Eligibility Any Eligible Employee shall be eligible to participate hereunder on the date such Employee satisfies the conditions of eligibility elected in the Adoption Agreement. 2.2 Effective Date of Participation An Eligible Employee who has satisfied the conditions of eligibility pursuant to Section 2.1 shall become a Participant effective as of the date elected in the Adoption Agreement. If an Employee, who has satisfied the Plan's eligibility requirements and would otherwise have become a Participant, shall go from a classification of a noneligible Employee to an Eligible Employee, such Employee shall become a Participant on the date such Employee becomes an Eligible Employee or, if later, the date that the Employee would have otherwise entered the Plan had the Employee always been an Eligible Employee. If an Employee, who has satisfied the Plan's eligibility requirements and would otherwise become a Participant, shall go from a classification of an Eligible Employee to a noneligible class of Employees, such Employee shall become a Participant in the Plan on the date such Employee again becomes an Eligible Employee, or, if later, the date that the Employee would have otherwise entered the Plan had the Employee always been an Eligible Employee. 2.3 Termination of Participation This Section shall be applied and administered consistent with any rights a Participant and the Participant's Dependents may be entitled to pursuant to Code Section 4980B, Section 7.13 of the Plan, or any election on the Adoption Agreement. In the case of the death of the Participant, any remaining balances may only be paid out as reimbursements for Qualifying Medical Expenses and shall not constitute a death benefit to the Participant's estate and/or the Participant's beneficiaries. ARTICLE III bJ 3 Packet Page-658- 1/27/2015 16.E.3. BENEFITS 3.1 Establishment of Plan (a) This Health Reimbursement Arrangement is intended to qualify as a Health Reimbursement Arrangement under Code Section 105 and shall be interpreted in a manner consistent with such Code Section and the Treasury regulations thereunder. (b) Participants in this Health Reimbursement Arrangement may submit claims for the reimbursement of Qualifying Medical Expenses as defined under the Plan and the Adoption Agreement. Unless otherwise elected in the Adoption Agreement, this Plan shall reimburse any expenses only after amounts in all other Plans that could reimburse the expense have been exhausted. (c) The Employer shall make available to each Participant an Employer Contribution as elected in the Adoption Agreement, for the reimbursement of Qualifying Medical Expenses. No salary reductions may be made to this Health Reimbursement Arrangement. (d) This Plan shall not be coordinated or otherwise connected to the Employer's cafeteria plan (as defined in Code Section 125), except as permitted by the Code and the Treasury regulations thereunder, to the extent necessary to maintain this Plan as a Health Reimbursement Arrangement. 3.2 Nondiscrimination Requirements (a) It is the intent of this Health Reimbursement Arrangement not to discriminate in violation of the Code and the Treasury regulations thereunder. (b) If the Administrator deems it necessary to avoid discrimination under this Health Reimbursement Arrangement, it may, but shall not be required to reduce benefits provided to"highly compensated individuals" (as defined in Code Section 105(h)) in order to assure compliance with this Section. Any act taken by the Administrator under this Section shall be carried out in a uniform and nondiscriminatory manner. 3 4 Packet Page-659- 1/27/2015 16.E.3. 3.3 Expense Reimbursement (a) The Administrator shall direct the reimbursement to each eligible Participant for all Qualifying Medical Expenses. All Qualifying Medical Expenses eligible for reimbursement pursuant to Section 3.1(b) shall be reimbursed during the Coverage Period, even though the submission of such a claim occurs after his participation hereunder ceases; but provided that the Qualifying Medical Expenses were incurred during a Coverage Period. Claims must include receipts or documentation that the expense being incurred is eligible for reimbursement, in order to claim reimbursement. Expenses may be reimbursed in subsequent Coverage Periods. However, a Participant may not submit claims incurred prior to beginning participation in the Plan and/or the Effective Date of the Plan, whichever is earlier. (b) Notwithstanding the foregoing, if elected in the Adoption Agreement, Qualifying Medical Expenses shall not be reimbursable under this Plan if eligible for reimbursement and claimed under the Employer's Health Flexible Spending Account. (c) Claims for the reimbursement of Qualifying Medical Expenses incurred in any Coverage Period shall be paid as soon after a claim has been filed as is administratively practicable; provided however, that if a Participant fails to submit a claim within the period elected in the Adoption Agreement immediately following the end of the Coverage Period,those Medical Expense claims shall not be considered for reimbursement by the Administrator. (d) Reimbursement payments under this Plan shall be made directly to the Participant. (e) If the maximum amount available for reimbursement for a Coverage Period is not utilized in its entirety, such remainder shall be carried forward to another Coverage Period or forfeited,as elected in the Adoption Agreement. ARTICLE IV ERISA PROVISIONS 4.1 Claim for Benefits Any claim for Benefits shall be made to the Administrator. The following timetable for claims and rules below apply: Notification of whether claim is accepted or denied 30 days Extension due to matters beyond the control of the Plan 15 days 5 Packet Page -660- 1/27/2015 16.E.3. Insufficient information on the Claim: Notification of 15 days Response by Participant 45 days Review of claim denial 60 days The Administrator will provide written or electronic notification of any claim denial. The notice will state: (1) The specific reason or reasons for the denial. (2) Reference to the specific Plan provisions on which the denial was based. (3) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary. (4) A description of the Plan's review procedures and the time limits applicable to such procedures. This will include a statement of the right to bring a civil action under section 502 of ERISA following a denial on review. (5) A statement that the claimant is entitled to receive, upon request and free of charge reasonable access to, and copies of, all documents, records, and other information relevant to the Claim. (6) If the denial was based on an internal rule, guideline, protocol, or other similar criterion, the specific rule, guideline, protocol, or criterion will be provided free of charge. If this is not practical, a statement will be included that such a rule, guideline, protocol, or criterion was relied upon in making the denial and a copy will be provided free of charge to the claimant upon request. When the Participant receives a denial, the Participant shall have 180 days following receipt of the notification in which to appeal the decision. The Participant may submit written comments, documents, records, and other information relating to the Claim. If the Participant requests, the Participant shall be provided, free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Claim. The period of time within which a denial on review is required to be made will begin at the time an appeal is filed in accordance with the procedures of the Plan. This timing is without regard to whether all the necessary information accompanies the filing. A document,record, or other information shall be considered relevant to a Claim if it: 6 /6,1 Packet Page-661- v 1/27/2015 16.E.3. (1) was relied upon in making the claim determination; (2) was submitted, considered, or generated in the course of making the claim determination, without regard to whether it was relied upon in making the claim determination; (3) demonstrated compliance with the administrative processes and safeguards designed to ensure and to verify that claim determinations are made in accordance with Plan documents and Plan provisions have been applied consistently with respect to all claimants; or (4) constituted a statement of policy or guidance with respect to the Plan concerning the denied claim. The review will take into account all comments, documents, records, and other information submitted by the claimant relating to the Claim, without regard to whether such information was submitted or considered in the initial claim determination. The review will not afford deference to the initial denial and will be conducted by a fiduciary of the Plan who is neither the individual who made the adverse determination nor a subordinate of that individual. 4.2 Named Fiduciary The "named Fiduciaries" of this Plan are (1)the Employer and (2)the Administrator. The named Fiduciaries shall have only those specific powers, duties, responsibilities, and obligations as are specifically given them under the Plan including, but not limited to, any agreement allocating or delegating their responsibilities, the terms of which are incorporated herein by reference. In general, the Employer shall have the sole responsibility for providing benefits under the Plan; and shall have the sole authority to appoint and remove the Administrator; and to amend the elective provisions of the Adoption Agreement or terminate, in whole or in part,the Plan.The Administrator shall have the sole responsibility for the administration of the Plan, which responsibility is specifically described in the Plan. Furthermore, each named Fiduciary may rely upon any such direction, information or action of another named Fiduciary as being proper under the Plan, and is not required under the Plan to inquire into the propriety of any such direction, information or action. It is intended under the Plan that each named Fiduciary shall be responsible for the proper exercise of its own powers, duties, responsibilities and obligations under the Plan. Any person or group may serve in more than one Fiduciary capacity. 4.3 General Fiduciary Responsibilities The Administrator and any other fiduciary under ERISA shall discharge their duties with respect to this Plan solely in the interest of the Participants and their beneficiaries and (a) for the exclusive purpose of providing Benefits to Participants and their 7 Packet Page-662- 1/27/2015 16.E.3. beneficiaries and defraying reasonable expenses of administering the Plan; (b) with the care, skill, prudence and diligence under the circumstances then prevailing that a prudent man acting in like capacity and familiar with such matters would use in the conduct of an enterprise of a like character and with like aims; and (c) in accordance with the documents and instruments governing the Plan insofar as such documents and instruments are consistent with ERISA. 4.4 Nonassignability of Rights i The right of any Participant to receive any reimbursement under the Plan shall not be alienable by the Participant by assignment or any other method, and shall not be subject to the rights of creditors, and any attempt to cause such right to be so subjected shall not be recognized, except to such extent as may be required by law. ARTICLE V ADMINISTRATION 5.1 Plan Administration The operation of the Plan shall be under the supervision of the Administrator. It shall be a principal duty of the Administrator to see that the Plan is carried out in accordance with its terms, and for the exclusive benefit of Employees entitled to participate in the Plan. The Administrator shall have full power to administer the Plan in all of its details, subject, however, to the pertinent provisions of the Code. The Administrator's powers shall include, but shall not be limited to the following authority, in addition to all other powers provided by this Plan: (a) To make and enforce such rules and regulations as the Administrator deems necessary or proper for the efficient administration of the Plan; (b) To interpret the Plan, the Administrator's interpretations thereof in good faith to be final and conclusive on all persons claiming benefits under the Plan; (c) To decide all questions concerning the Plan and the eligibility of any person to participate in the Plan and to receive benefits provided under the Plan; (d) To limit benefits for certain highly compensated individuals if it deems such to be desirable in order to avoid discrimination under the Plan in violation of applicable provisions of the Code; (e) To approve reimbursement requests and to authorize the payment of benefits; and 8 ( ,) Packet Page-663- 1/27/2015 16.E.3. (f) To appoint such agents, counsel, accountants, consultants, and actuaries as may be required to assist in administering the Plan. Any procedure, discretionary act, interpretation or construction taken by the Administrator shall be done in a nondiscriminatory manner based upon uniform principles consistently applied and shall be consistent with the intent that the Plan shall continue to comply with the terms of Code Section 105(h) and the Treasury regulations thereunder. 5.2 Examination of Records The Administrator shall make available to each Participant, Eligible Employee and any other Employee of the Employer such records as pertain to their interest under the Plan for examination at reasonable times during normal business hours. 5.3 Indemnification of Administrator The Employer agrees to indemnify and to defend to the fullest extent permitted by law any Employee serving as the Administrator or as a member of a committee designated as Administrator (including any Employee or former Employee who previously served as Administrator or as a member of such committee) against all liabilities, damages, costs and expenses (including attorney's fees and amounts paid in settlement of any claims approved by the Employer) occasioned by any act or omission to act in connection with the Plan, if such act or omission is in good faith. ARTICLE VI AMENDMENT OR TERMINATION OF PLAN 6.1 Amendment The Employer, at any time or from time to time, may amend any or all of the provisions of the Plan without the consent of any Employee or Participant. 6.2 Termination The Employer is establishing this Plan with the intent that it will be maintained for an indefinite period of time. Notwithstanding the foregoing, the Employer reserves the right to terminate the Plan, in whole or in part, at any time. In the event the Plan is terminated,no further reimbursements shall be made. 9 Packet Page -664- 1/27/2015 16.E.3. ARTICLE VII MISCELLANEOUS 7.1 Plan Interpretation All provisions of this Plan shall be interpreted and applied in a uniform, nondiscriminatory manner. This Plan shall be read in its entirety and not severed except as provided in Section 7.11. 7.2 Gender and Number Wherever any words are used herein in the masculine, feminine or neuter gender, they shall be construed as though they were also used in another gender in all cases where they would so apply, and whenever any words are used herein in the singular or plural form, they shall be construed as though they were also used in the other form in all cases where they would so apply. 7.3 Written Document This Plan, in conjunction with any separate written document which may be required by law, is intended to satisfy the written Plan requirement of Code Section 105 and any Treasury regulations thereunder. 7.4 Exclusive Benefit This Plan shall be maintained for the exclusive benefit of the Employees who participate in the Plan. 7.5 Participant's Rights This Plan shall not be deemed to constitute an employment contract between the Employer and any Participant or to be a consideration or an inducement for the employment of any Participant or Employee. Nothing contained in this Plan shall be deemed to give any Participant or Employee the right to be retained in the service of the Employer or to interfere with the right of the Employer to discharge any Participant or Employee at any time regardless of the effect which such discharge shall have upon him as a Participant of this Plan. 7.6 Action by the Employer Whenever the Employer under the terms of the Plan is permitted or required to do or perform any act or matter or thing, it shall be done and performed by a person duly authorized by its legally constituted authority. ( d 10 \ v Packet Page-665- 1/27/2015 16.E.3. 7.7 No Guarantee of Tax Consequences Neither the Administrator nor the Employer makes any commitment or guarantee that any amounts paid to or for the benefit of a Participant under the Plan will be excludable from the Participant's gross income for federal or state income tax purposes, or that any other federal or state tax treatment will apply to or be available to any Participant. It shall be the obligation of each Participant to determine whether each payment under the Plan is excludable from the Participant's gross income for federal and state income tax purposes, and to notify the Employer if the Participant has reason to believe that any such payment is not so excludable. Notwithstanding the foregoing, the rights of Participants under this Plan shall be legally enforceable. 7.8 Indemnification of Employer by Participants If any Participant receives one or more payments or reimbursements under the Plan that are not for a permitted Medical Expense such Participant shall indemnify and reimburse the Employer for any liability it may incur for failure to withhold federal or state income tax or Social Security tax from such payments or reimbursements. However, such indemnification and reimbursement shall not exceed the amount of additional federal and state income tax(plus any penalties)that the Participant would have owed if the payments or reimbursements had been made to the Participant as regular cash compensation, plus the Participant's share of any Social Security tax that would have been paid on such compensation, less any such additional income and Social Security tax actually paid by the Participant. 7.9 Funding Unless otherwise required by law, amounts made available by the Employer need not be placed in trust, but may instead be considered general assets of the Employer. Furthermore, and unless otherwise required by law, nothing herein shall be construed to require the Employer or the Administrator to maintain any fund or segregate any amount for the benefit of any Participant, and no Participant or other person shall have any claim against, right to, or security or other interest in, any fund, account or asset of the Employer from which any payment under the Plan may be made. 7.10 Construction of Plan This Plan and Trust shall be construed and enforced according to the Code, ERISA, and the laws of the state or commonwealth in which the Employer's principal office is located (unless otherwise designated in the Adoption Agreement), other than its laws respecting choice of law,to the extent not pre-empted by ERISA. 7.11 Severability If any provision of the Plan is held invalid or unenforceable, its invalidity or unenforceability shall not affect any other provisions of the Plan, and the Plan shall be construed and enforced as if such provision had not been included herein. 11 c Packet Page-666- 1/27/2015 16.E.3. 7.12 Headings The headings and subheadings of this Plan have been inserted for convenience of reference and are to be ignored in any construction of the provisions hereof. 7.13 Continuation of Coverage Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan subject to the continuation coverage requirement of Code Section 4980B becomes unavailable, each qualified beneficiary (as defined in Code Section 4980B) will be entitled to continuation coverage as prescribed in Code Section 4980B. 7.14 Family and Medical Leave Act Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan becomes subject to the requirements of the Family and Medical Leave Act and regulations thereunder, this Plan shall be operated in accordance with Proposed Regulation 1.125-3. 7.15 Health Insurance Portability and Accountability Act Notwithstanding anything in this Plan to the contrary, this Plan shall be operated in accordance with HIPAA and regulations thereunder. 7.16 Uniformed Services Employment and Reemployment Rights Act Notwithstanding any provision of this Plan to the contrary, contributions, benefits and service credit with respect to qualified military service shall be provided in accordance with USERRA and the regulations thereunder. 12 ,'1.c) Packet Page-667- 1/27/2015 16.E.3. CERTIFICATE OF ADOPTING RESOLUTION The undersigned Principal of Collier County (the Employer) hereby certifies that the following resolutions were duly adopted by the board on , and that such resolutions have not been modified or rescinded as of the date hereof: RESOLVED, that the Health Reimbursement Arrangement effective January 1, 2014, presented to this meeting is hereby approved and adopted and that the proper officers of the Employer are hereby authorized and directed to execute and deliver to the Administrator of the Plan one or more counterparts of the Plan. RESOLVED, that the Administrator shall be instructed to take such actions that are deemed necessary and proper in order to implement the Plan, and to set up adequate accounting and administrative procedures to provide benefits under the Plan. The undersigned further certifies that attached hereto is a true copy of the Health Reimbursement Arrangement and the Summary Plan Description approved and adopted in the foregoing resolutions. By: Title: Date: ATTEST pproved as o fo and legality DWIGHT E.'BROCK, CLERK Scott R.Teach,Deputy County Attorney f 13 Packet Page-668- 1/27/201516.E.3. CERTIFICATE OF ADOPTING RESOLUTION The undersigned Principal of Collier County (the Employer) hereby certifies that the following resolutions were duly adopted by the board on , and that such resolutions have not been modified or rescinded as of the date hereof: effective January 1, 2014, presented to this meeting is hereby approved and adopted and that the proper officers of the Employer are hereby authorized and directed to execute and deliver to the Administrator of the Plan one or more counterparts of the Plan. RESOLVED, that the Administrator shall be instructed to take such actions that are deemed necessary and proper in order to implement the Plan, and to set up adequate accounting and administrative procedures to provide benefits under the Plan. The undersigned further certifies that attached hereto is a true copy of the Health Reimbursement Arrangement and the Summary Plan Description approved and adopted in the foregoing resolutions. By: Title: Date: A„I TE$.t. proved as to f� and legality DWIGHT E.BROCK,CLERK / Scott R.Teach,Deputy County Attorney BY: Packet Page -669- 1/27/2015 16.E.3. PLAN DOCUMENT for the FLEXIBLE BENEFITS PLAN For The Employees of COLLIER COUNTY PLAN EFFECTIVE DATE: JANUARY 1, 1992 PLAN DOCUMENT EFFECTIVE DATE: JANUARY 1, 2015 GROUP NUMBER: 2003021 EMPLOYER ID NUMBER: 59-6000558 PLAN NUMBER: 510 ( .j AIIe iance g Flex Advantage Packet Page -670- 1/27/2015 16.E.3. TABLE OF CONTENTS ARTICLE I DEFINITIONS ARTICLE II PARTICIPATION 2.1 ELIGIBILITY 4 2.2 EFFECTIVE DATE OF PARTICIPATION 4 2.3 APPLICATION TO PARTICIPATE 4 2.4 TERMINATION OF PARTICIPATION 4 2.5 CHANGE OF EMPLOYMENT STATUS 5 2.6 TERMINATION OF EMPLOYMENT 5 2.7 DEATH 6 ARTICLE III CONTRIBUTIONS TO THE PLAN 3.1 SALARY REDIRECTION 6 3.2 APPLICATION OF CONTRIBUTIONS 6 3.3 PERIODIC CONTRIBUTIONS 7 ARTICLE IV BENEFITS 4.1 BENEFIT OPTIONS 7 4.2 HEALTH FLEXIBLE SPENDING ACCOUNT BENEFIT 7 4.3 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT BENEFIT 7 4.4 HEALTH INSURANCE BENEFIT 7 4.5 DENTAL INSURANCE BENEFIT 8 4.6 NONDISCRIMINATION REQUIREMENTS g ARTICLE V PARTICIPANT ELECTIONS 5.1 INITIAL ELECTIONS 9 5.2 SUBSEQUENT ANNUAL ELECTIONS 9 5.3 FAILURE TO ELECT 9 5.4 CHANGE IN STATUS 10 ARTICLE VI HEALTH FLEXIBLE SPENDING ACCOUNT 6.1 ESTABLISHMENT OF PLAN 13 6.2 DEFINITIONS 13 6.3 FORFEITURES 14 Packet Page -671- pd� 1/27/2015 16.E.3. 6.4 LIMITATION ON ALLOCATIONS 14 6.5 NONDISCRIMINATION REQUIREMENTS 15 6.6 COORDINATION WITH CAFETERIA PLAN 15 6.7 HEALTH FLEXIBLE SPENDING ACCOUNT CLAIMS 16 6.8 QUALIFIED RESERVIST DISTRIBUTIONS 16 ARTICLE VII DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT 7.1 ESTABLISHMENT OF ACCOUNT 18 7.2 DEFINITIONS 18 7.3 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS 19 7.4 INCREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS 19 7.5 DECREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS 19 7.6 ALLOWABLE DEPENDENT CARE REIMBURSEMENT 19 7.7 ANNUAL STATEMENT OF BENEFITS 20 7.8 FORFEITURES 20 7.9 LIMITATION ON PAYMENTS 20 7.10 NONDISCRIMINATION REQUIREMENTS 20 7.11 COORDINATION WITH CAFETERIA PLAN 21 7.12 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT CLAIMS 21 ARTICLE VIII BENEFITS AND RIGHTS 8.1 CLAIM FOR BENEFITS 22 8.2 APPLICATION OF BENEFIT PLAN SURPLUS 23 ARTICLE IX ADMINISTRATION 9.1 PLAN ADMINISTRATION 24 9.2 EXAMINATION OF RECORDS 25 9.3 PAYMENT OF EXPENSES 25 -9.4 INSURANCE CONTROL CLAUSE 25 9.5 INDEMNIFICATION OF ADMINISTRATOR 26 ARTICLE X AMENDMENT OR TERMINATION OF PLAN 10.1 AMENDMENT 26 10.2 TERMINATION 26 Packet Page -672- dJ I 1/27/2015 16.E.3. ARTICLE XI MISCELLANEOUS 11.1 PLAN INTERPRETATION 26 11.2 GENDER AND NUMBER 26 11.3 WRITTEN DOCUMENT 27 11.4 EXCLUSIVE BENEFIT 27 11.5 PARTICIPANT'S RIGHTS 27 11.6 ACTION BY THE EMPLOYER 27 11.7 NO GUARANTEE OF TAX CONSEQUENCES 27 11.8 INDEMNIFICATION OF EMPLOYER BY PARTICIPANTS 27 11.9 FUNDING 28 11.10 GOVERNING LAW 28 11.11 SEVERABILITY 28 11.12 CAPTIONS 28 11.13 CONTINUATION OF COVERAGE (COBRA) 28 11.14 FAMILY AND MEDICAL LEAVE ACT (FMLA) 28 11.15 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) 28 11.16 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT(USERRA) 29 11.17 COMPLIANCE WITH HIPAA PRIVACY STANDARDS 29 11.18 COMPLIANCE WITH HIPAA ELECTRONIC SECURITY STANDARDS 31 11.19 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT 31 11.20 GENETIC INFORMATION NONDISCRIMINATION ACT(GINA) 31 11.21 WOMEN'S HEALTH AND CANCER RIGHTS ACT 31 11.22 NEWBORNS'AND MOTHERS' HEALTH PROTECTION ACT 31 Odd Packet Page -673- 1/27/2015 16.E.3. COLLIER COUNTY FLEXIBLE BENEFITS PLAN INTRODUCTION The Employer has amended this Plan effective January 1, 2015, to recognize the contribution made to the Employer by its Employees. Its purpose is to reward them by providing benefits for those Employees who shall qualify hereunder and their Dependents and beneficiaries. The concept of this Plan is to allow Employees to choose among different types of benefits based on their own particular goals, desires and needs. This Plan is a restatement of a Plan which was originally effective on January 1, 1992. The Plan shall be known as Collier County Flexible Benefits Plan (the"Plan"). The intention of the Employer is that the Plan qualify as a "Cafeteria Plan" within the meaning of Section 125 of the Internal Revenue Code of 1986, as amended, and that the benefits which an Employee elects to receive under the Plan be excludable from the Employee's income under Section 125(a) and other applicable sections of the Internal Revenue Code of 1986, as amended. ARTICLE I DEFINITIONS 1.1 "Administrator" means the Employer unless another person or entity has been designated by the Employer pursuant to Section 9.1 to administer the Plan on behalf of the Employer. If the Employer is the Administrator, the Employer may appoint any person, including, but not limited to, the Employees of the Employer, to perform the duties of the Administrator. Any person so appointed shall signify acceptance by filing written acceptance with the Employer. Upon the resignation or removal of any individual performing the duties of the Administrator, the Employer may designate a successor. 1.2 "Affiliated Employer" means the Employer and any corporation which is a member of a controlled group of corporations (as defined in Code Section 414(b)) which includes the Employer; any trade or business (whether or not incorporated) which is under common control (as defined in Code Section 414(c)) with the Employer; any organization (whether or not incorporated) which is a member of an affiliated service group (as defined in Code Section 414(m)) which includes the Employer; and any other entity required to be aggregated with the Employer pursuant to Treasury regulations under Code Section 414(o). 1.3 "Benefit" or "Benefit Options" means any of the optional benefit choices available to a Participant as outlined in Section 4.1. 1.4 "Cafeteria Plan Benefit Dollars" means the amount available to Participants to purchase Benefit Options as provided under Section 4.1. Each dollar contributed to this Plan shall be converted into one Cafeteria Plan Benefit Dollar. 1.5 "Code" means the Internal Revenue Code of 1986, as amended or replaced from time to time. 1.6 "Compensation" means the amounts received by the Participant from the Employer during a Plan Year. Packet Page -674- 1/27/2015 16.E.3. 1 1.7 "Dependent" means any individual who qualifies as a dependent under the self-funded plan for purposes of that plan or under Code Section 152 (as modified by Code Section 105(b)). "Dependent" shall include any Child of a Participant who is covered under an insurance Contract, as defined in the Contract, or under the Health Flexible Spending Account or as allowed by reason of the Affordable Care Act. For purposes of the Health Flexible Spending Account, a Participant's "Child" includes his/her natural child, stepchild, foster child, adopted child, or a child placed with the Participant for adoption. A Participant's Child will be an eligible Dependent until reaching the limiting age of 26, without regard to student status, marital status, financial dependency or residency status with the Employee or any other person. When the child reaches the applicable limiting age, coverage will end at the end of the calendar year. The phrase"placed for adoption" refers to a child whom the Participant intends to adopt, whether or not the adoption has become final, who has not attained the age of 18 as of the date of such placement for adoption. The term"placed" means the assumption and retention by such Employee of a legal obligation for total or partial support of the child in anticipation of adoption of the child. The child must be available for adoption and the legal process must have commenced. 1.8 "Effective Date" means January 1, 1992. 1.9 "Election Period" means the period immediately preceding the beginning of each Plan Year established by the Administrator, such period to be applied on a uniform and nondiscriminatory basis for all Employees and Participants. However, an Employee's initial Election Period shall be determined pursuant to Section 5.1. 1.10 "Eligible Employee" means any Employee who has satisfied the provisions of Section 2.1. An individual shall not be an "Eligible Employee" if such individual is not reported on the payroll records of the Employer as a common law employee. In particular, it is expressly intended that individuals not treated as common law employees by the Employer on its payroll records are not "Eligible Employees" and are excluded from Plan participation even if a court or administrative agency determines that such individuals are common law employees and not independent contractors. However, there are some Employees who are not eligible to participate in this Plan. They are: -- Employees who are"leased employees" as defined in Code Section 414(n)(2). — Part-time Employees who work, or are expected to work on a regular basis, less than 20 hours a week and are designated as a part-time Employee on the Employer's personnel records. -- Independent Contractors. 2 Packet Page -675- 1/27/2015 16.E.3. -- Contract Workers. --Temporary Employees. -- Seasonal Employees. -- Casual Employees. 1.11 "Employee" means any person who is employed by the Employer. The term Employee shall include leased employees within the meaning of Code Section 414(n)(2). 1.12 "Employer" means Collier County and any successor which shall maintain this Plan; and any predecessor which has maintained this Plan. In addition, where appropriate, the term Employer shall include any Participating,Affiliated or Adopting Employer. 1.13 "Insurance Contract" means any contract issued by an Insurer underwriting a Benefit. 1.14 "Insurer" means any insurance company that underwrites a Benefit under this Plan or, with respect to any self-funded benefits,the Employer. 1.15 "Key Employee" means an Employee described in Code Section 416(i)(1) and the Treasury regulations thereunder. 1.16 "Participant" means any Eligible Employee who elects to become a Participant pursuant to Section 2.3 and has not for any reason become ineligible to participate further in the Plan. 1.17 "Plan" means this instrument, including all amendments thereto. 1.18 "Plan Year" means the 12-month period beginning January 1 and ending December 31. The Plan Year shall be the coverage period for the Benefits provided for under this Plan. In the event a Participant commences participation during a Plan Year, then the initial coverage period shall be that portion of the Plan Year commencing on such Participant's date of entry and ending on the last day of such Plan Year. 1.19 "Premium Expenses" or "Premiums" mean the Participant's cost for the self- funded Benefits described in Section 4.1. 1.20 "Premium Expense Reimbursement Account" means the account established for a Participant pursuant to this Plan to which part of his Cafeteria Plan Benefit Dollars may be allocated and from which Premiums of the Participant shall be paid or reimbursed. If more than one type of insured or self-funded Benefit is elected, sub-accounts shall be established for each type of insured or self-funded Benefit. 1.21 "Salary Redirection" means the contributions made by the Employer on behalf of Participants pursuant to Section 3.1. These contributions shall be converted to Cafeteria Plan Benefit Dollars and allocated to the funds or accounts established under the Plan pursuant to the Participants' elections made under Article V. 3 Packet Page-676- _ _ 1/27/2015 16.E.3. 1.22 "Salary Redirection Agreement" means an agreement between the Participant and the Employer under which the Participant agrees to reduce his Compensation or to forego all or part of the increases in such Compensation and to have such amounts contributed by the Employer to the Plan on the Participant's behalf. The Salary Redirection Agreement shall apply only to Compensation that has not been actually or constructively received by the Participant as of the date of the agreement (after taking this Plan and Code Section 125 into account) and, subsequently does not become currently available to the Participant. 1.23 "Spouse" means"spouse"as defined in the self-funded plan for purposes of that plan or the "spouse," as defined under Federal law, of a Participant, unless legally separated by court decree. ARTICLE II PARTICIPATION 2.1 ELIGIBILITY Any Eligible Employee shall be eligible to participate hereunder as of his date of employment (or the Effective Date of the Plan, if later). However, any Eligible Employee who was a Participant in the Plan on the effective date of this amendment shall continue to be eligible to participate in the Plan. 2.2 EFFECTIVE DATE OF PARTICIPATION An Eligible Employee shall become a Participant effective as of the first day of the month coinciding with or next following the date on which he met the eligibility requirements of Section 2.1. 2.3 APPLICATION TO PARTICIPATE An Employee who is eligible to participate in this Plan shall, during the applicable Election Period, complete an application to participate in a manner set forth by the Administrator. The election shall be irrevocable until the end of the applicable Plan Year unless the Participant is entitled to change his Benefit elections pursuant to Section 5.4 hereof. An Eligible Employee shall also be required to complete a Salary Redirection Agreement during the Election Period for the Plan Year during which he wishes to participate in this Plan. Any such Salary Redirection Agreement shall be effective for the first pay period beginning on or after the Employee's effective date of participation pursuant to Section 2.2. Notwithstanding the foregoing, an Employee who is eligible to participate in this Plan and who is covered by the Employer's insured or self-funded Benefits under this Plan shall automatically become a Participant to the extent of the Premiums for such insurance unless the Employee elects, during the Election Period, not to participate in the Plan. 2.4 TERMINATION OF PARTICIPATION A Participant shall no longer participate in this Plan upon the occurrence of any of the following events: 4 Packet Page -677- 1/27/2015 16.E.3. (a) Termination of employment. The Participant's termination of employment, subject to the provisions of Section 2.6; (b) Change in employment status. The end of the Plan Year during which the Participant became a limited Participant because of a change in employment status pursuant to Section 2.5; (c) Death.The Participant's death, subject to the provisions of Section 2.7; or (d) Termination of the plan. The termination of this Plan, subject to the provisions of Section 10.2. 2.5 CHANGE OF EMPLOYMENT STATUS If a Participant ceases to be eligible to participate because of a change in employment status or classification (other than through termination of employment), the Participant shall become a limited Participant in this Plan for the remainder of the Plan Year in which such change of employment status occurs. As a limited Participant, no further Salary Redirection may be made on behalf of the Participant, and, except as otherwise provided herein, all further Benefit elections shall cease, subject to the limited Participant's right to continue coverage under any Insurance Contracts. However, any balances in the limited Participant's Dependent Care Flexible Spending Account may be used during such Plan Year to reimburse the limited Participant for any allowable Employment-Related Dependent Care incurred during the Plan Year. Subject to the provisions of Section 2.6, if the limited Participant later becomes an Eligible Employee, then the limited Participant may again become a full Participant in this Plan, provided he otherwise satisfies the participation requirements set forth in this Article II as if he were a new Employee and made an election in accordance with Section 5.1. 2.6 TERMINATION OF EMPLOYMENT If a Participant's employment with the Employer is terminated for any reason other than death, his participation in the Benefit Options provided under Section 4.1 shall be governed in accordance with the following: (a) Insurance Benefit. With regard to Benefits provided under Section 4.1, the Participant's participation in the Plan shall cease, subject to the Participant's right to continue coverage under any Insurance Contract or self-funded benefit for which premiums have already been paid. (b) Dependent Care FSA. With regard to the Dependent Care Flexible Spending Account, the Participant's participation in the Plan shall cease and no further Salary Redirection contributions shall be made. However, such Participant may submit claims for employment related Dependent Care Expense reimbursements for claims incurred through the remainder of the Plan Year in which such termination occurs and submitted within 90 days after the end of the Plan Year, based on the level of the Participant's Dependent Care Flexible Spending Account as of the date of termination. (c) COBRA applicability. With regard to the Health Flexible Spending Account, the Participant may submit claims for expenses that were incurred during the portion of the Plan Year employed. Such Participant must submit claims for services 5 Packet Page-678- odp 1/27/2015 16.E.3. incurred prior to their termination date within 90 days after the end of the Plan Year. Thereafter, the health benefits under this Plan including the Health Flexible Spending Account shall be applied and administered consistent with such further rights a Participant and his Dependents may be entitled to pursuant to Code Section 4980B and Section 11.14 of the Plan. 2.7 DEATH If a Participant dies, his participation in the Plan shall cease. However, such Participant's spouse or Dependents may submit claims for expenses or benefits for the remainder of the Plan Year or until the Cafeteria Plan Benefit Dollars allocated to each specific benefit are exhausted. In no event may reimbursements be paid to someone who is not a spouse or Dependent. If the Plan is subject to the provisions of Code Section 4980B, then those provisions and related regulations shall apply for purposes of the Health Flexible Spending Account. ARTICLE III CONTRIBUTIONS TO THE PLAN 3.1 SALARY REDIRECTION Benefits under the Plan shall be financed by Salary Redirections sufficient to support Benefits that a Participant has elected hereunder and to pay the Participant's Premium Expenses. The salary administration program of the Employer shall be revised to allow each Participant to agree to reduce his pay during a Plan Year by an amount determined necessary to purchase the elected Benefit Options. The amount of such Salary Redirection shall be specified in the Salary Redirection Agreement and shall be applicable for a Plan Year. Notwithstanding the above, for new Participants,the Salary Redirection Agreement shall only be applicable from the first day of the pay period following the Employee's entry date up to and including the last day of the Plan Year. These contributions shall be converted to Cafeteria Plan Benefit Dollars and allocated to the funds or accounts established under the Plan pursuant to the Participants' elections made under Article IV. Any Salary Redirection shall be determined prior to the beginning of a Plan Year(subject to initial elections pursuant to Section 5.1) and prior to the end of the Election Period and shall be irrevocable for such Plan Year. However, a Participant may revoke a Benefit election or a Salary Redirection Agreement after the Plan Year has commenced and make a new election with respect to the remainder of the Plan Year, if both the revocation and the new election are on account of and consistent with a change in status and such other permitted events as determined under Article V of the Plan and consistent with the rules and regulations of the Department of the Treasury. Salary Redirection amounts shall be contributed on a pro rata basis for each pay period during the Plan Year. All Individual Salary Redirection Agreements are deemed to be part of this Plan and incorporated by reference hereunder. 3.2 APPLICATION OF CONTRIBUTIONS As soon as reasonably practical after each payroll period, the Employer shall apply the Salary Redirection to provide the Benefits elected by the affected Participants. Any contribution made or withheld for the Health Flexible Spending Account or Dependent Care Flexible Spending Account shall be credited to such fund or account. Amounts designated for the 6 ()VD Packet Page-679- 1/27/2015 16.E.3. Participant's Premium Expense Reimbursement Account shall likewise be credited to such account for the purpose of paying Premium Expenses. 3.3 PERIODIC CONTRIBUTIONS Notwithstanding the requirement provided above and in other Articles of this Plan that Salary Redirections be contributed to the Plan by the Employer on behalf of an Employee on a level and pro rata basis for each payroll period, the Employer and Administrator may implement a procedure in which Salary Redirections are contributed throughout the Plan Year on a periodic basis that is not pro rata for each payroll period. However, with regard to the Health Flexible Spending Account, the payment schedule for the required contributions may not be based on the rate or amount of reimbursements during the Plan Year. ARTICLE IV BENEFITS 4.1 BENEFIT OPTIONS Each Participant may elect any one or more of the following optional Benefits: (1) Health Flexible Spending Account (2) Dependent Care Flexible Spending Account In addition, each Participant shall have a sufficient portion of his Salary Redirections applied to the following Benefits unless the Participant elects not to receive such Benefits: (3) Health Insurance Benefit (4) Dental Insurance Benefit 4.2 HEALTH FLEXIBLE SPENDING ACCOUNT BENEFIT Each Participant may elect to participate in the Health Flexible Spending Account option, in which case Article VI shall apply. 4.3 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT BENEFIT Each Participant may elect to participate in the Dependent Care Flexible Spending Account option, in which case Article VII shall apply. 4.4 HEALTH INSURANCE BENEFIT (a) Coverage for Participant and Dependents. Each Participant may elect to be covered under a health Contract for the Participant, his or her Spouse, and his or her Dependents. (b) Employer selects contracts. The Employer may select suitable health Contracts for use in providing this health insurance benefit, which policies will provide uniform benefits for all Participants electing this Benefit. 7 Packet Page -680- ;z 1/27/2015 16.E.3. (c) Contract incorporated by reference. The rights and conditions with respect to the benefits payable from such health Contract shall be determined therefrom, and such Contract shall be incorporated herein by reference. 4.5 DENTAL INSURANCE BENEFIT (a) Coverage for Participant and/or Dependents. Each Participant may elect to be covered under the Employer's dental Insurance Contract. In addition, the Participant may elect either individual or family coverage under such Insurance Contract. (b) Employer selects contracts. The Employer may select suitable dental Insurance Contracts for use in providing this dental insurance benefit, which policies will provide uniform benefits for all Participants electing this Benefit. (c) Contract incorporated by reference. The rights and conditions with respect to the benefits payable from such dental Insurance Contract shall be determined therefrom, and such dental Insurance Contract shall be incorporated herein by reference. 4.6 NONDISCRIMINATION REQUIREMENTS (a) Intent to be nondiscriminatory. It is the intent of this Plan to provide benefits to a classification of employees which the Secretary of the Treasury finds not to be discriminatory in favor of the group in whose favor discrimination may not occur under Code Section 125. (b) 25% concentration test. It is the intent of this Plan not to provide qualified benefits as defined under Code Section 125 to Key Employees in amounts that exceed 25% of the aggregate of such Benefits provided for all Eligible Employees under the Plan. For purposes of the preceding sentence, qualified benefits shall not include benefits which (without regard to this paragraph) are includible in gross income. (c) Adjustment to avoid test failure. If the Administrator deems it necessary to avoid discrimination or possible taxation to Key Employees or a group of employees in whose favor discrimination may not occur in violation of Code Section 125, it may, but shall not be required to, reduce contributions or non-taxable Benefits in order to assure compliance with this Section. Any act taken by the Administrator under this Section shall be carried out in a uniform and nondiscriminatory manner. If the Administrator decides to reduce contributions or non-taxable Benefits, it shall be done in the following manner. First, the non-taxable Benefits of the affected Participant(either an employee who is highly compensated or a Key Employee, whichever is applicable) who has the highest amount of non-taxable Benefits for the Plan Year shall have his non-taxable Benefits reduced until the discrimination tests set forth in this Section are satisfied or until the amount of his non-taxable Benefits equals the non-taxable Benefits of the affected Participant who has the second highest amount of non-taxable Benefits. This process shall continue until the nondiscrimination tests set forth in this Section are satisfied. With respect to any affected Participant who has had Benefits reduced pursuant to this Section, the reduction shall be made proportionately among Health Flexible Spending Account Benefits and Dependent Care Flexible Spending Account Benefits, and once all these Benefits are expended, proportionately among self-funded s Packet Page-681- �`'t' 1/27/2015 16.E.3. Benefits. Contributions which are not utilized to provide Benefits to any Participant by virtue of any administrative act under this paragraph shall be forfeited and deposited into the benefit plan surplus. ARTICLE V PARTICIPANT ELECTIONS 5.1 INITIAL ELECTIONS An Employee who meets the eligibility requirements of Section 2.1 on the first day of, or during, a Plan Year may elect to participate in this Plan for all or the remainder of such Plan Year, provided he elects to do so on or before his effective date of participation pursuant to Section 2.2. Notwithstanding the foregoing, an Employee who is eligible to participate in this Plan and who is covered by the Employer's insured or self-funded benefits under this Plan shall automatically become a Participant to the extent of the Premiums for such insurance unless the Employee elects, during the Election Period, not to participate in the Plan. 5.2 SUBSEQUENT ANNUAL ELECTIONS During the Election Period prior to each subsequent Plan Year, each Participant shall be given the opportunity to elect, on an election of benefits form to be provided by the Administrator, which spending account Benefit options he wishes to select. Any such election shall be effective for any Benefit expenses incurred during the Plan Year which follows the end of the Election Period. With regard to subsequent annual elections, the following options shall apply: (a) A Participant or Employee who failed to initially elect to participate may elect different or new Benefits under the Plan during the Election Period; (b) A Participant may terminate his participation in the Plan by notifying the Administrator in writing during the Election Period that he does not want to participate in the Plan for the next Plan Year; (c) An Employee who elects not to participate for the Plan Year following the Election Period will have to wait until the next Election Period before again electing to participate in the Plan, except as provided for in Section 5.4. 5.3 FAILURE TO ELECT With regard to Benefits available under the Plan for which no Premium Expenses apply, any Participant who fails to complete a new benefit election form pursuant to Section 5.2 by the end of the applicable Election Period shall be deemed to have elected not to participate in the Plan for the upcoming Plan Year. No further Salary Redirections shall therefore be authorized or made for the subsequent Plan Year for such Benefits. With regard to Benefits available under the Plan for which Premium Expenses apply, any Participant who fails to complete a new benefit election form pursuant to Section 5.2 by the end of the applicable Election Period shall be deemed to have made the same Benefit elections as 9 Packet Page-682- 1/27/2015 16.E.3. are then in effect for the current Plan Year. The Participant shall also be deemed to have elected Salary Redirection in an amount necessary to purchase such Benefit options. 5.4 CHANGE IN STATUS (a) Change in status defined. Any Participant may change a Benefit election after the Plan Year (to which such election relates) has commenced and make new elections with respect to the remainder of such Plan Year if, under the facts and circumstances, the changes are necessitated by and are consistent with a change in status which is acceptable under rules and regulations adopted by the Department of the Treasury, the provisions of which are incorporated by reference. Notwithstanding anything herein to the contrary, if the rules and regulations conflict, then such rules and regulations shall control. In general, a change in election is not consistent if the change in status is the Participant's divorce, annulment or legal separation from a Spouse, the death of a Spouse or Dependent, or a Dependent ceasing to satisfy the eligibility requirements for coverage, and the Participant's election under the Plan is to cancel accident or health insurance coverage for any individual other than the one involved in such event. In addition, if the Participant, Spouse or Dependent gains or loses eligibility for coverage, then a Participant's election under the Plan to cease or decrease coverage for that individual under the Plan corresponds with that change in status only if coverage for that individual becomes applicable or is increased under the family member plan. Regardless of the consistency requirement, if the individual's dependent becomes eligible for continuation coverage under the Employer's group health plan as provided in Code Section 4980B or any similar state or federal law, then the individual may elect to increase payments under this Plan in order to pay for the continuation coverage. However, this does not apply for COBRA eligibility due to divorce, annulment or legal separation. Any new election shall be effective at such time as the Administrator shall prescribe, but not earlier than the first pay period beginning after the election form is completed and returned to the Administrator. For the purposes of this subsection, a change in status shall only include the following events or other events permitted by Treasury regulations: (1) Legal Marital Status: events that change a Participant's legal marital • status, including marriage, divorce, death of a Spouse, legal separation or annulment; (2) Number of Dependents: Events that change a Participant's number of Dependents, including birth, adoption, placement for adoption, or death of a Dependent; (3) Employment Status: Any of the following events that change the employment status of the Participant, Spouse, or Dependent: termination or commencement of employment, a strike or lockout, commencement or return from an unpaid leave of absence, or a change in worksite. In addition, if the eligibility conditions of this Plan or other employee benefit plan of the Employer of the Participant, Spouse, or Dependent depend on the employment status of that individual and there is a change in that individual's employment status with the to Packet Page-683- 1/27/2015 16.E.3. consequence that the individual becomes (or ceases to be) eligible under the plan, then that change constitutes a change in employment under this subsection; (4) Dependent satisfies or ceases to satisfy the eligibility requirements: An event that causes the Participant's Dependent to satisfy or cease to satisfy the requirements for coverage due to attainment of age, student status, or any similar circumstance; and (5) Residency: A change in the place of residence of the Participant, Spouse or Dependent, that would lead to a change in status (such as a loss of HMO coverage). For the Dependent Care Flexible Spending Account, a Dependent becoming or ceasing to be a "Qualifying Dependent" as defined under Code Section 21(b) shall also qualify as a change in status. Notwithstanding anything in this Section to the contrary, the gain of eligibility or change in eligibility of a child, as allowed under Code Sections 105(b) and 106, and IRS Notice 2010-38, shall qualify as a change in status. (b) Special enrollment rights. Notwithstanding subsection (a), the Participants may change an election for accident or health coverage during a Plan Year and make a new election that corresponds with the special enrollment rights provided in Code Section 9801(f), including those authorized under the provisions of the Children's Health Insurance Program Reauthorization Act of 2009 (SCHIP); provided that such Participant meets the sixty (60) day notice requirement imposed by Code Section 9801(f) (or such longer period as may be permitted by the Plan and communicated to Participants). Such change shall take place on a prospective basis, unless otherwise required by Code Section 9801(f)to be retroactive. (c) Qualified Medical Support Order. Notwithstanding subsection (a), in the event of a judgment, decree, or order (including approval of a property settlement) ("order") resulting from a divorce, legal separation, annulment, or change in legal custody which requires accident or health coverage for a Participant's child (including a foster child who is a Dependent of the Participant): (1) The Plan may change an election to provide coverage for the child if the order requires coverage under the Participant's plan; or (2) The Participant shall be permitted to change an election to cancel coverage for the child if the order requires the former Spouse to provide coverage for such child, under that individual's plan and such coverage is actually provided. (d) Medicare or Medicaid. Notwithstanding subsection (a), a Participant may change elections to cancel accident or health coverage for the Participant or the Participant's Spouse or Dependent if the Participant or the Participant's Spouse or Dependent is enrolled in the accident or health coverage of the Employer and becomes entitled to coverage (i.e., enrolled) under Part A or Part B of the Title XVIII of the Social Security Act (Medicare) or Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under Section 1928 of the Social Security Act (the 11 Packet Page -684- 1/27/2015 16.E.3. program for distribution of pediatric vaccines). If the Participant or the Participant's Spouse or Dependent who has been entitled to Medicaid or Medicare coverage loses eligibility, that individual may prospectively elect coverage under the Plan if a benefit package option under the Plan provides similar coverage. (e) Cost increase or decrease. If the cost of a Benefit provided under the Plan increases or decreases during a Plan Year, then the Plan shall automatically increase or decrease, as the case may be, the Salary Redirections of all affected Participants for such Benefit. Alternatively, if the cost of a benefit package option increases significantly, the Administrator shall permit the affected Participants to either make corresponding changes in their payments or revoke their elections and, in lieu thereof, receive on a prospective basis coverage under another benefit package option with similar coverage, or drop coverage prospectively if there is no benefit package option with similar coverage. A cost increase or decrease refers to an increase or decrease in the amount of elective contributions under the Plan, whether resulting from an action taken by the Participants or an action taken by the Employer. (f) Loss of coverage. If the coverage under a Benefit is significantly curtailed or ceases during a Plan Year, affected Participants may revoke their elections of such Benefit and, in lieu thereof, elect to receive on a prospective basis coverage under another plan with similar coverage, or drop coverage prospectively if no similar coverage is offered. (g) Addition of a new benefit. If, during the period of coverage, a new benefit package option or other coverage option is added, an existing benefit package option is significantly improved, or an existing benefit package option or other coverage option is eliminated, then the affected Participants may elect the newly-added option, or elect another option if an option has been eliminated prospectively and make corresponding election changes with respect to other benefit package options providing similar coverage. In addition, those Eligible Employees who are not participating in the Plan may opt to become Participants and elect the new or newly improved benefit package option. (h) Loss of coverage under certain other plans. A Participant may make a prospective election change to add group health coverage for the Participant, the Participant's Spouse or Dependent if such individual loses group health coverage sponsored by a governmental or educational institution, including a state children's health insurance program under the Social Security Act, the Indian Health Service or a health program offered by an Indian tribal government, a state health benefits risk pool, or a foreign government group health plan. (i) Change of coverage due to change under certain other plans. A Participant may make a prospective election change that is on account of and corresponds with a change made under the plan of a Spouse's, former Spouse's or Dependent's employer if (1) the cafeteria plan or other benefits plan of the Spouse's, former Spouse's or Dependent's employer permits its participants to make a change; or (2) the cafeteria plan permits participants to make an election for a period of coverage that is different from the period of coverage under the cafeteria plan of a Spouse's, former Spouse's or Dependent's employer. 12 Packet Page -685- �` 1/27/2015 16.E.3. Q) Change in dependent care provider. A Participant may make a prospective election change that is on account of and corresponds with a change by the Participant in the dependent care provider. The availability of dependent care services from a new childcare provider is similar to a new benefit package option becoming available. A cost change is allowable in the Dependent Care Flexible Spending Account only if the cost change is imposed by a dependent care provider who is not related to the Participant, as defined in Code Section 152(a)(1)through (8). (k) Health FSA cannot change due to insurance change. A Participant shall not be permitted to change an election to the Health Flexible Spending Account as a result of a cost or coverage change under any health insurance benefits. ARTICLE VI HEALTH FLEXIBLE SPENDING ACCOUNT 6.1 ESTABLISHMENT OF PLAN This Health Flexible Spending Account is intended to qualify as a medical reimbursement plan under Code Section 105 and shall be interpreted in a manner consistent with such Code Section and the Treasury regulations thereunder. Participants who elect to participate in this Health Flexible Spending Account may submit claims for the reimbursement of Medical Expenses. All amounts reimbursed shall be periodically paid from amounts allocated to the Health Flexible Spending Account. Periodic payments reimbursing Participants from the Health Flexible Spending Account shall in no event occur less frequently than monthly. 6.2 DEFINITIONS For the purposes of this Article and the Cafeteria Plan, the terms below have the following meaning: (a) "Health Flexible Spending Account" means the account established for Participants pursuant to this Plan to which part of their Cafeteria Plan Benefit Dollars may be allocated and from which all allowable Medical Expenses incurred by a Participant, his or her Spouse and his or her Dependents may be reimbursed. (b) "Highly Compensated Participant" means, for the purposes of this Article and determining discrimination under Code Section 105(h), a participant who is: (1) one of the 5 highest paid officers; (2) a shareholder who owns (or is considered to own applying the rules of Code Section 318) more than 10 percent in value of the stock of the Employer; or (3) among the highest paid 25 percent of all Employees (other than exclusions permitted by Code Section 105(h)(3)(B) for those individuals who are not Participants). (c) "Medical Expenses" means any expense for medical care within the meaning of the term "medical care" as defined in Code Section 213(d) and the rulings 13 iFa ) Packet Page -686- 1/27/2015 16.E.3. and Treasury regulations thereunder, and not otherwise used by the Participant as a deduction in determining his tax liability under the Code. "Medical Expenses" can be incurred by the Participant, his or her Spouse and his or her Dependents. "Incurred" means, with regard to Medical Expenses, when the Participant is provided with the medical care that gives rise to the Medical Expense and not when the Participant is formally billed or charged for, or pays for, the medical care. A Participant may not be reimbursed for the cost of any medicine or drug that is not"prescribed"within the meaning of Code Section 106(f) or is not insulin. A Participant may not be reimbursed for the cost of other health coverage such as premiums paid under plans maintained by the employer of the Participant's Spouse or individual policies maintained by the Participant or his Spouse or Dependent. A Participant may not be reimbursed for "qualified long-term care services" as defined in Code Section 7702B(c). (d) The definitions of Article I are hereby incorporated by reference to the extent necessary to interpret and apply the provisions of this Health Flexible Spending Account. 6.3 FORFEITURES Any amount in excess of the $500.00 carryover amount in the Health Flexible Spending Account as of the end of any Plan Year(and after the processing of all claims for such Plan Year pursuant to Section 6.7 hereof) shall be forfeited and credited to the benefit plan surplus. In such event, the Participant shall have no further claim to such amount for any reason, subject to Section 8.2. 6.4 LIMITATION ON ALLOCATIONS (a) Notwithstanding any provision contained in this Health Flexible Spending Account to the contrary, the maximum amount that may be allocated to the Health Flexible Spending Account by a Participant in or on account of any Plan Year is $2,550 or as adjusted by law. (b) Cost of Living Adjustment. In no event shall the amount of salary redirections on the Health Flexible Spending Account exceed $2,550 as adjusted by law. Such amount shall be adjusted for increases in the cost-of-living in accordance with Code Section 125(i)(2). The cost-of-living adjustment in effect for a calendar year applies to any Plan Year beginning with or within such calendar year. The dollar increase in effect on January 1 of any calendar year shall be effective for the Plan Year beginning with or within such calendar year. For any short Plan Year, the limit shall be an amount equal to the limit for the calendar year in which the Plan Year begins multiplied by the ratio obtained by dividing the number of full months in the short Plan Year by twelve (12). (c) Participation in Other Plans. All employers that are treated as a single employer under Code Sections 414(b), (c), or (m), relating to controlled groups and affiliated service groups, are treated as a single employer for purposes of the $2,550 (as adjusted) limit. If a Participant participates in multiple cafeteria plans offering health 14 OVD Packet Page-687- 1/27/2015 16.E.3. flexible spending accounts maintained by members of a controlled group or affiliated service group, the Participant's total Health Flexible Spending Account contributions under all of the cafeteria plans are limited to $2,550 (as adjusted). However, a Participant employed by two or more employers that are not members of the same controlled group may elect up to $2,550 (as adjusted) under each Employer's Health Flexible Spending Account. (d) Carryover. A Participant in the Health Flexible Spending Account may roll over up to $500 of unused amounts in the Health Flexible Spending Account remaining at the end of one Plan Year to the immediately following Plan Year. These amounts can be used during the following Plan Year for expenses incurred in that Plan Year. Amounts carried over do not affect the maximum amount of salary redirection contributions for the Plan Year to which they are carried over. Unused amounts are those remaining after expenses have been reimbursed during the runout period. These amounts may not be cashed out or converted to any other taxable or nontaxable benefit. Amounts in excess of $500 will be forfeited. The Plan is allowed, but not required, to treat claims as being paid first from the current year amounts, then from the carryover amounts. 6.5 NONDISCRIMINATION REQUIREMENTS (a) Intent to be nondiscriminatory. It is the intent of this Health Flexible Spending Account not to discriminate in violation of the Code and the Treasury regulations thereunder. (b) Adjustment to avoid test failure. If the Administrator deems it s_ necessary to avoid discrimination under this Health Flexible Spending Account, it may, but shall not be required to, reject any elections or reduce contributions or Benefits in order to assure compliance with this Section. Any act taken by the Administrator under this Section shall be carried out in a uniform and nondiscriminatory manner. If the Administrator decides to reject any elections or reduce contributions or Benefits, it shall be done in the following manner. First, the Benefits designated for the Health Flexible Spending Account by the member of the group in whose favor discrimination may not occur pursuant to Code Section 105 that elected to contribute the highest amount to the fund for the Plan Year shall be reduced until the nondiscrimination tests set forth in this Section or the Code are satisfied, or until the amount designated for the fund equals the amount designated for the fund by the next member of the group in whose favor discrimination may not occur pursuant to Code Section 105 who has elected the second highest contribution to the Health Flexible Spending Account for the Plan Year. This process shall continue until the nondiscrimination tests set forth in this Section or the Code are satisfied. Contributions which are not utilized to provide Benefits to any Participant by virtue of any administrative act under this paragraph shall be forfeited and credited to the benefit plan surplus. 6.6 COORDINATION WITH CAFETERIA PLAN All Participants under the Cafeteria Plan are eligible to receive Benefits under this Health Flexible Spending Account. The enrollment under the Cafeteria Plan shall constitute enrollment under this Health Flexible Spending Account. In addition, other matters concerning contributions, elections and the like shall be governed by the general provisions of the Cafeteria Plan. 15 1t,) Packet Page-688- 1/27/2015 16.E.3. 6.7 HEALTH FLEXIBLE SPENDING ACCOUNT CLAIMS (a) Expenses must be incurred during Plan Year. All Medical Expenses incurred by a Participant, his or her Spouse and his or her Dependents during the Plan Year shall be reimbursed during the Plan Year subject to Section 2.6, even though the submission of such a claim occurs after his participation hereunder ceases; but provided that the Medical Expenses were incurred during the applicable Plan Year. Medical Expenses are treated as having been incurred when the Participant is provided with the medical care that gives rise to the medical expenses, not when the Participant is formally billed or charged for, or pays for the medical care. (b) Reimbursement available throughout Plan Year. The Administrator shall direct the reimbursement to each eligible Participant for all allowable Medical Expenses, up to a maximum of the amount designated by the Participant for the Health Flexible Spending Account for the Plan Year. Reimbursements shall be made available to the Participant throughout the year without regard to the level of Cafeteria Plan Benefit Dollars which have been allocated to the fund at any given point in time. Furthermore, a Participant shall be entitled to reimbursements only for amounts in excess of any payments or other reimbursements under any health care plan covering the Participant and/or his Spouse or Dependents. (c) Payments. Reimbursement payments under this Plan shall be made directly to the Participant. However, in the Administrator's discretion, payments may be made directly to the service provider. The application for payment or reimbursement shall be made to the Administrator on an acceptable form within a reasonable time of incurring the debt or paying for the service. The application shall include a written • statement from an independent third party stating that the Medical Expense has been incurred and the amount of such expense. Furthermore, the Participant shall provide a written statement that the Medical Expense has not been reimbursed or is not reimbursable under any other health plan coverage and, if reimbursed from the Health Flexible Spending Account, such amount will not be claimed as a tax deduction. The Administrator shall retain a file of all such applications. (d) Claims for reimbursement. Claims for the reimbursement of Medical Expenses incurred in any Plan Year shall be paid as soon after a claim has been filed as is administratively practicable; provided however, that if a Participant fails to submit a claim within 90 days after the end of the Plan Year, those Medical Expense claims shall not be considered for reimbursement by the Administrator. 6.8 QUALIFIED RESERVIST DISTRIBUTIONS (a) Qualified Reservist Distribution. A Participant may request a Qualified Reservist Distribution, provided the following provisions are satisfied. "Qualified Reservist Distribution" means any distribution to a Participant of all or a portion of the balance in the Participant's Health Flexible Spending Account if: (1) Such Participant was an individual who was (by reason of being a member of a reserve component (as defined in Section 101 of Title 37, United States Code)) ordered or called to active duty for a period of 180 days or more or for an indefinite period. 16 ))Packet Page-689- r)-c7 -- I 1/27/2015 16.E.3. (2) A Participant may have been called prior to June 18, 2008, provided the individual's active duty continues after June 18, 2008 and the period of duty complies with subsection (a). (3) The distribution is made during the period beginning on the date of the order or call that applies to the Participant and ending on the last day of the Plan Year which includes the date of such order or call. (4) The Qualified Reservist Distribution option is offered to all Participants who qualify under this Article. (5) Qualified Reservist Distributions may only be made if the Participant is ordered or called to active duty, not the Participant's spouse or dependents. (6) Under Section 101 of the Title 37 of the United States Code, "reserve component" means: (1) the Army National Guard, (2) the Army Reserve, (3) the Navy Reserve, (4) the Marine Corps Reserve, (5) the Air National Guard, (6) the Air Force Reserve, (7) the Coast Guard Reserve, or(8) the Reserve Corps of the Public Health Service. (b) Conditions: The following conditions apply: (1) The Employer must receive a copy of the order or call to active duty and may rely on the order or call to determine the period that the Participant has been ordered or called to duty. (2) Eligibility for a Qualified Reservist Distribution is not affected if the order or call is for 180 days or more or is indefinite, but the actual period of active duty is less than 180 days or is changed otherwise from the order or call. (3) If the original order is less than 180 days, then no Qualified Reservist Distribution is allowed. However, if subsequent calls or orders increase the total days of active duty to 180 or more, then a Qualified Reservist Distribution will be allowed. (c) Amount: The amount a Participant may be reimbursed from the Health Flexible Spending Account is the amount contributed by the Participant to the Health Flexible Spending Account as of the date of the distribution request, less any reimbursements received as of the date of the distribution request. (d) Procedure. The Employer must specify a process for requesting the distribution. The Employer may limit the number of distributions processed for a Participant to one per Plan Year. The distribution request must be made on or after the call or order and before the last day of the Plan Year. The QRD shall be paid within a reasonable time but in no event more than 60 days after the date of the request. (e) Claims. Claims incurred prior to the date of the request of the distribution shall be paid as any other claim. Claims incurred after the date of the distribution shall not be paid and the Participant's right to submit a claim shall be terminated as of the date of the distribution request. 17 Packet Page -690- 1/27/2015 16.E.3. ARTICLE VII DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT 7.1 ESTABLISHMENT OF ACCOUNT This Dependent Care Flexible Spending Account is intended to qualify as a program under Code Section 129 and shall be interpreted in a manner consistent with such Code Section. Participants who elect to participate in this program may submit claims for the reimbursement of Employment-Related Dependent Care Expenses. All amounts reimbursed shall be paid from amounts allocated to the Participant's Dependent Care Flexible Spending Account. 7.2 DEFINITIONS For the purposes of this Article and the Cafeteria Plan the terms below shall have the following meaning: (a) "Dependent Care Flexible Spending Account" means the account established for a Participant pursuant to this Article to which part of his Cafeteria Plan Benefit Dollars may be allocated and from which Employment-Related Dependent Care Expenses of the Participant may be reimbursed for the care of the Qualifying Dependents of Participants. (b) "Earned Income" means earned income as defined under Code Section 32(c)(2), but excluding such amounts paid or incurred by the Employer for dependent care assistance to the Participant. (c) "Employment-Related Dependent Care Expenses" means the amounts paid for expenses of a Participant for those services which if paid by the Participant would be considered employment related expenses under Code Section 21(b)(2). Generally, they shall include expenses for household services and for the care of a Qualifying Dependent, to the extent that such expenses are incurred to enable the Participant to be gainfully employed for any period for which there are one or more Qualifying Dependents with respect to such Participant. Employment-Related Dependent Care Expenses are treated as having been incurred when the Participant's Qualifying Dependents are provided with the dependent care that gives rise to the Employment-Related Dependent Care Expenses, not when the Participant is formally billed or charged for, or pays for the dependent care. The determination of whether an amount qualifies as an Employment-Related Dependent Care Expense shall be made subject to the following rules: (1) If such amounts are paid for expenses incurred outside the Participant's household, they shall constitute Employment-Related Dependent Care Expenses only if incurred for a Qualifying Dependent as defined in Section 7.2(d)(1) (or deemed to be, as described in Section 7.2(d)(1) pursuant to Section 7.2(d)(3)), or for a Qualifying Dependent as defined in Section 7.2(d)(2) (or deemed to be, as described in Section 7.2(d)(2) pursuant to Section 7.2(d)(3)) who regularly spends at least 8 hours per day in the Participant's household; 18 Packet Page-691- 1/27/2015 16.E.3. (2) If the expense is incurred outside the Participant's home at a facility that provides care for a fee, payment, or grant for more than 6 individuals who do not regularly reside at the facility, the facility must comply with all applicable state and local laws and regulations, including licensing requirements, if any; and (3) Employment-Related Dependent Care Expenses of a Participant shall not include amounts paid or incurred to a child of such Participant who is under the age of 19 or to an individual who is a Dependent of such Participant or such Participant's Spouse. (d) "Qualifying Dependent" means, for Dependent Care Flexible Spending Account purposes, (1) a Participant's Dependent(as defined in Code Section 152(a)(1))who has not attained age 13; (2) a Dependent or the Spouse of a Participant who is physically or mentally incapable of caring for himself or herself and has the same principal place of abode as the Participant for more than one-half of such taxable year; or (3) a child that is deemed to be a Qualifying Dependent described in paragraph (1) or (2) above, whichever is appropriate, pursuant to Code Section 21(e)(5). (e) The definitions of Article I are hereby incorporated by reference to the extent necessary to interpret and apply the provisions of this Dependent Care Flexible Spending Account. 7.3 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS The Administrator shall establish a Dependent Care Flexible Spending Account for each Participant who elects to apply Cafeteria Plan Benefit Dollars to Dependent Care Flexible Spending Account benefits. 7.4 INCREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS A Participant's Dependent Care Flexible Spending Account shall be increased each pay period by the portion of Cafeteria Plan Benefit Dollars that he has elected to apply toward his Dependent Care Flexible Spending Account pursuant to elections made under Article V hereof. 7.5 DECREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS A Participant's Dependent Care Flexible Spending Account shall be reduced by the amount of any Employment-Related Dependent Care Expense reimbursements paid or incurred on behalf of a Participant pursuant to Section 7.12 hereof. 7.6 ALLOWABLE DEPENDENT CARE REIMBURSEMENT Subject to limitations contained in Section 7.9 of this Program, and to the extent of the amount contained in the Participant's Dependent Care Flexible Spending Account, a Participant who incurs Employment-Related Dependent Care Expenses shall be entitled to receive from the 19 Packet Page-692- 1/27/2015 16.E.3. Employer full reimbursement for the entire amount of such expenses incurred during the Plan Year or portion thereof during which he is a Participant. 7.7 ANNUAL STATEMENT OF BENEFITS On or before January 31st of each calendar year, the Employer shall furnish to each Employee who was a Participant and received benefits under Section 7.6 during the prior calendar year, a statement of all such benefits paid to or on behalf of such Participant during the prior calendar year. This statement is set forth on the Participant's Form W-2. 7.8 FORFEITURES The amount in a Participant's Dependent Care Flexible Spending Account as of the end of any Plan Year (and after the processing of all claims for such Plan Year pursuant to Section 7.12 hereof) shall be forfeited and credited to the benefit plan surplus. In such event, the Participant shall have no further claim to such amount for any reason. 7.9 LIMITATION ON PAYMENTS (a) Code limits. Notwithstanding any provision contained in this Article to the contrary, amounts paid from a Participant's Dependent Care Flexible Spending Account in or on account of any taxable year of the Participant shall not exceed the lesser of the Earned Income limitation described in Code Section 129(b) or $5,000 ($2,500 if a separate tax return is filed by a Participant who is married as determined under the rules of paragraphs(3) and (4) of Code Section 21(e)). 7.10 NONDISCRIMINATION REQUIREMENTS (a) Intent to be nondiscriminatory. It is the intent of this Dependent Care Flexible Spending Account that contributions or benefits not discriminate in favor of the group of employees in whose favor discrimination may not occur under Code Section 129(d). (b) 25% test for shareholders. It is the intent of this Dependent Care Flexible Spending Account that not more than 25 percent of the amounts paid by the Employer for dependent care assistance during the Plan Year will be provided for the class of individuals who are shareholders or owners (or their Spouses or Dependents), each of whom (on any day of the Plan Year) owns more than 5 percent of the stock or of the capital or profits interest in the Employer. (c) Adjustment to avoid test failure. If the Administrator deems it necessary to avoid discrimination or possible taxation to a group of employees in whose favor discrimination may not occur in violation of Code Section 129 it may, but shall not be required to, reject any elections or reduce contributions or non-taxable benefits in order to assure compliance with this Section. Any act taken by the Administrator under this Section shall be carried out in a uniform and nondiscriminatory manner. If the Administrator decides to reject any elections or reduce contributions or Benefits, it shall be done in the following manner. First, the Benefits designated for the Dependent Care Flexible Spending Account by the affected Participant that elected to contribute the highest amount to such account for the Plan Year shall be reduced until the nondiscrimination tests set forth in this Section are satisfied, or until the amount 20 . Packet Page-693- 1/27/2015 16.E.3. designated for the account equals the amount designated for the account of the affected Participant who has elected the second highest contribution to the Dependent Care Flexible Spending Account for the Plan Year. This process shall continue until the nondiscrimination tests set forth in this Section are satisfied. Contributions which are not utilized to provide Benefits to any Participant by virtue of any administrative act under this paragraph shall be forfeited. 7.11 COORDINATION WITH CAFETERIA PLAN All Participants under the Cafeteria Plan are eligible to receive Benefits under this Dependent Care Flexible Spending Account. The enrollment and termination of participation under the Cafeteria Plan shall constitute enrollment and termination of participation under this Dependent Care Flexible Spending Account. In addition, other matters concerning contributions, elections and the like shall be governed by the general provisions of the Cafeteria Plan. 7.12 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT CLAIMS The Administrator shall direct the payment of all such Dependent Care claims to the Participant upon the presentation to the Administrator of documentation of such expenses in a form satisfactory to the Administrator. However, in the Administrator's discretion, payments may be made directly to the service provider. In its discretion in administering the Plan, the Administrator may utilize forms and require documentation of costs as may be necessary to verify the claims submitted. At a minimum, the form shall include a statement from an independent third party as proof that the expense has been incurred during the Plan Year and the amount of such expense. In addition, the Administrator may require that each Participant who desires to receive reimbursement under this Program for Employment-Related Dependent Care Expenses submit a statement which may contain some or all of the following information: (a) The Dependent or Dependents for whom the services were performed; (b) The nature of the services performed for the Participant, the cost of which he wishes reimbursement; (c) The relationship, if any, of the person performing the services to the Participant; (d) If the services are being performed by a child of the Participant, the age of the child; (e) A statement as to where the services were performed; (f) If any of the services were performed outside the home, a statement as to whether the Dependent for whom such services were performed spends at least 8 hours a day in the Participant's household; (g) If the services were being performed in a day care center, a statement: (1) that the day care center complies with all applicable laws and regulations of the state of residence, 21 )\. Packet Page-694- 1/27/2015 16.E.3. (2) that the day care center provides care for more than 6 individuals (other than individuals residing at the center), and (3) of the amount of fee paid to the provider. (h) If the Participant is married, a statement containing the following: (1) the Spouse's salary or wages if he or she is employed, or (2) if the Participant's Spouse is not employed, that (i) he or she is incapacitated, or (ii) he or she is a full-time student attending an educational institution and the months during the year which he or she attended such institution. (i) Claims for reimbursement. If a Participant fails to submit a claim within 90 days after the end of the Plan Year, those claims shall not be considered for reimbursement by the Administrator. ARTICLE VIII BENEFITS AND RIGHTS 8.1 CLAIM FOR BENEFITS (a) Insurance claims. Any claim for Benefits underwritten by an Insurance Contract shall be made to the Insurer. If the Insurer denies any claim, the Participant or beneficiary shall follow the Insurer's claims review procedure. Any other claim for Benefits shall be made to the Administrator. If the Administrator denies a claim, in whole or in part, the Administrator will provide notice to the Participant or beneficiary, in writing, within 30 days after the claim is filed unless special circumstances require an extension of time for processing the claim. The notice of a denial of a claim or adverse benefit determination shall be written in a manner calculated to be understood by the claimant and shall set forth below: (b) Dependent Care Flexible Spending Account or Health Flexible Spending Account claims. Any claim for Dependent Care Flexible Spending Account or Health Flexible Spending Account Benefits shall be made to the Administrator. For the Health Flexible Spending Account, if a Participant fails to submit a claim within 90 days after the end of the Plan Year, those claims shall not be considered for reimbursement by the Administrator. For the Dependent Care Flexible Spending Account, if a Participant fails to submit a claim within 90 days after the end of the Plan Year, those claims shall not be considered for reimbursement by the Administrator. If the Administrator denies a claim, the Administrator may provide notice to the Participant or beneficiary, in writing, within 30 days after the claim is filed unless special circumstances require an extension of time for processing the claim. The notice of a denial of a claim shall be written in a manner calculated to be understood by the claimant and shall set forth below: (1) specific references to the pertinent Plan provisions on which the denial is based; 22 Packet Page-695- 1/27/2015 16.E.3. (2) a description of any additional material or information necessary for the claimant to perfect the claim and an explanation as to why such information is necessary; and (3) an explanation of the Plan's claim procedure. (c) Appeal. Within 60 days after receipt of the above material, the claimant shall have a reasonable opportunity to appeal the claim denial to the Administrator for a full and fair review. The claimant or his duly authorized representative may: (1) request a review upon written notice to the Administrator; (2) review pertinent documents; and (3) submit issues and comments in writing. (d) Review of appeal. A decision on the review by the Administrator will be made not later than 60 days after receipt of a request for review, unless special circumstances require an extension of time for processing (such as the need to hold a hearing), in which event a decision should be rendered as soon as possible, but in no event later than 120 days after such receipt. The decision of the Administrator shall be written and shall include specific reasons for the decision, written in a manner calculated to be understood by the claimant, with specific references to the pertinent Plan provisions on which the decision is based. (e) Forfeitures. Any balance remaining in the Participant's Dependent Care Flexible Spending Account or any balance in excess of$500.00, which may be carried over to the next plan year, remaining in the Participant's Health Flexible Spending Account as of the end of the time for claims reimbursement for each Plan Year shall be forfeited and deposited in the benefit plan surplus of the Employer pursuant to Section 6.3 or Section 7.8, whichever is applicable, unless the Participant had made a claim for such Plan Year, in writing, which has been denied or is pending; in which event the amount of the claim shall be held in his account until the claim appeal procedures set forth above have been satisfied or the claim is paid. If any such claim is denied on appeal, the amount held beyond the end of the Plan Year shall be forfeited and credited to the benefit plan surplus. 8.2 APPLICATION OF BENEFIT PLAN SURPLUS Any forfeited amounts credited to the benefit plan surplus by virtue of the failure of a Participant to incur a qualified expense or seek reimbursement in a timely manner may, but need not be, separately accounted for after the close of the Plan Year(or after such further time specified herein for the filing of claims) in which such forfeitures arose. Up to $500.00 remaining in a Participant's Health Flexible Spending Account at the end if the Plan Year be carried over to reimburse a Participant for expenses incurred during the subsequent Plan Year. Amounts forfeited by a particular Participant may not be made available to such Participant in any other form or manner, except as permitted by Treasury regulations. Amounts in the benefit plan surplus shall be used to pay reasonable administrative costs, to reduce required premium payments in the subsequent year or in any other manner permitted by law. 23 Packet Page-696- 1/27/2015 16.E.3. ARTICLE IX ADMINISTRATION 9.1 PLAN ADMINISTRATION The Employer shall be the Administrator, unless the Employer elects otherwise. The Employer may appoint any person, including, but not limited to, the Employees of the Employer, to perform the duties of the Administrator. Any person so appointed shall signify acceptance by filing written acceptance with the Employer. Upon the resignation or removal of any individual performing the duties of the Administrator, the Employer may designate a successor. If the Employer elects, the Employer shall appoint one or more Administrators. Any person, including, but not limited to, the Employees of the Employer, shall be eligible to serve as an Administrator. Any person so appointed shall signify acceptance by filing written acceptance with the Employer. An Administrator may resign by delivering a written resignation to the Employer or be removed by the Employer by delivery of written notice of removal, to take effect at a date specified therein, or upon delivery to the Administrator if no date is specified. The Employer shall be empowered to appoint and remove the Administrator from time to time as it deems necessary for the proper administration of the Plan to ensure that the Plan is being operated for the exclusive benefit of the Employees entitled to participate in the Plan in accordance with the terms of the Plan and the Code. The operation of the Plan shall be under the supervision of the Administrator. It shall be a principal duty of the Administrator to see that the Plan is carried out in accordance with its terms, and for the exclusive benefit of Employees entitled to participate in the Plan. The Administrator shall have full power and discretion to administer the Plan in all of its details and determine all questions arising in connection with the administration, interpretation, and application of the Plan. The Administrator may establish procedures, correct any defect, supply any information, or reconciles any inconsistency in such manner and to such extent as shall be deemed necessary or advisable to carry out the purpose of the Plan. The Administrator shall have all powers necessary or appropriate to accomplish the Administrator's duties under the Plan. The Administrator shall be charged with the duties of the general administration of the Plan as set forth under the Plan, including, but not limited to, in addition to all other powers provided by this Plan: (a) To make and enforce such procedures, rules and regulations as the Administrator deems necessary or proper for the efficient administration of the Plan; (b) To interpret the provisions of the Plan, the Administrator's interpretations thereof in good faith to be final and conclusive on all persons claiming benefits by operation of the Plan; (c) To decide all questions concerning the Plan and the eligibility of any person to participate in the Plan and to receive benefits provided by operation of the Plan; (d) To reject elections or to limit contributions or Benefits for certain highly compensated participants if it deems such to be desirable in order to avoid discrimination under the Plan in violation of applicable provisions of the Code; 24 Packet Page -697- ��'�? 1/27/2015 16.E.3. (e) To provide Employees with a reasonable notification of their benefits available by operation of the Plan and to assist any Participant regarding the Participant's rights, benefits or elections under the Plan; (f) To keep and maintain the Plan documents and all other records pertaining to and necessary for the administration of the Plan; (g) To review and settle all claims against the Plan, to approve reimbursement requests, and to authorize the payment of benefits if the Administrator determines such shall be paid if the Administrator decides in its discretion that the applicant is entitled to them. This authority specifically permits the Administrator to settle disputed claims for benefits and any other disputed claims made against the Plan; (h) To appoint such agents, counsel, accountants, consultants, and other persons or entities as may be required to assist in administering the Plan. Any procedure, discretionary act, interpretation or construction taken by the Administrator shall be done in a nondiscriminatory manner based upon uniform principles consistently applied and shall be consistent with the intent that the Plan shall continue to comply with the terms of Code Section 125 and the Treasury regulations thereunder. 9.2 EXAMINATION OF RECORDS The Administrator shall make available to each Participant, Eligible Employee and any other Employee of the Employer such records as pertain to their interest under the Plan for examination at reasonable times during normal business hours. 9.3 PAYMENT OF EXPENSES Any reasonable administrative expenses shall be paid by the Employer unless the Employer determines that administrative costs shall be borne by the Participants under the Plan or by any Trust Fund which may be established hereunder. The Administrator may impose reasonable conditions for payments, provided that such conditions shall not discriminate in favor of highly compensated employees. 9.4 INSURANCE CONTROL CLAUSE In the event of a conflict between the terms of this Plan and the terms of an Insurance Contract of an independent third party Insurer whose product is then being used in conjunction with this Plan, the terms of the Insurance Contract shall control as to those Participants receiving coverage under such Insurance Contract. For this purpose, the Insurance Contract shall control in defining the persons eligible for insurance, the dates of their eligibility, the conditions which must be satisfied to become insured, if any, the benefits Participants are entitled to and the circumstances under which insurance terminates. • 25 )V Packet Page -698- 1/27/2015 16.E.3. 9.5 INDEMNIFICATION OF ADMINISTRATOR The Employer agrees to indemnify and to defend to the fullest extent permitted by law any Employee serving as the Administrator or as a member of a committee designated as Administrator (including any Employee or former Employee who previously served as Administrator or as a member of such committee) against all liabilities, damages, costs and expenses (including attorney's fees and amounts paid in settlement of any claims approved by the Employer) occasioned by any act or omission to act in connection with the Plan, if such act or omission is in good faith. ARTICLE X AMENDMENT OR TERMINATION OF PLAN 10.1 AMENDMENT The Employer, at any time or from time to time, may amend any or all of the provisions of the Plan without the consent of any Employee or Participant. No amendment shall have the effect of modifying any benefit election of any Participant in effect at the time of such amendment, unless such amendment is made to comply with Federal, state or local laws, statutes or regulations. 10.2 TERMINATION The Employer reserves the right to terminate this Plan, in whole or in part, at any time. In the event the Plan is terminated, no further contributions shall be made. Benefits under any Contract shall be paid in accordance with the terms of the Contract. No further additions shall be made to the Health Flexible Spending Account or Dependent Care Flexible Spending Account, but all payments from such fund shall continue to be made according to the elections in effect until 90 days after the termination date of the Plan. Any amounts remaining in any such fund or account as of the end of such period shall be forfeited and deposited in the benefit plan surplus after the expiration of the filing period. ARTICLE XI MISCELLANEOUS 11.1 PLAN INTERPRETATION All provisions of this Plan shall be interpreted and applied in a uniform, nondiscriminatory manner. This Plan shall be read in its entirety and not severed except as provided in Section 11.11. 11.2 GENDER AND NUMBER Wherever any words are used herein in the masculine, feminine or neuter gender, they shall be construed as though they were also used in another gender in all cases where they would so apply, and whenever any words are used herein in the singular or plural form, they shall be construed as though they were also used in the other form in all cases where they would so apply. 26 Packet Page -699- 1/27/2015 16.E.3. 11.3 WRITTEN DOCUMENT This Plan, in conjunction with any separate written document which may be required by law, is intended to satisfy the written Plan requirement of Code Section 125 and any Treasury regulations thereunder relating to cafeteria plans. 11.4 EXCLUSIVE BENEFIT This Plan shall be maintained for the exclusive benefit of the Employees who participate in the Plan. 11.5 PARTICIPANTS RIGHTS This Plan shall not be deemed to constitute an employment contract between the Employer and any Participant or to be a consideration or an inducement for the employment of any Participant or Employee. Nothing contained in this Plan shall be deemed to give any Participant or Employee the right to be retained in the service of the Employer or to interfere with the right of the Employer to discharge any Participant or Employee at any time regardless of the effect which such discharge shall have upon him as a Participant of this Plan. 11.6 ACTION BY THE EMPLOYER Whenever the Employer under the terms of the Plan is permitted or required to do or perform any act or matter or thing, it shall be done and performed by a person duly authorized by its legally constituted authority. 11.7 NO GUARANTEE OF TAX CONSEQUENCES Neither the Administrator nor the Employer makes any commitment or guarantee that any amounts paid to or for the benefit of a Participant under the Plan will be excludable from the Participant's gross income for federal or state income tax purposes, or that any other federal or state tax treatment will apply to or be available to any Participant. It shall be the obligation of each Participant to determine whether each payment under the Plan is excludable from the Participant's gross income for federal and state income tax purposes, and to notify the Employer if the Participant has reason to believe that any such payment is not so excludable. Notwithstanding the foregoing, the rights of Participants under this Plan shall be legally enforceable. 11.8 INDEMNIFICATION OF EMPLOYER BY PARTICIPANTS If any Participant receives one or more payments or reimbursements under the Plan that are not for a permitted Benefit, such Participant shall indemnify and reimburse the Employer for any liability it may incur for failure to withhold federal or state income tax or Social Security tax from such payments or reimbursements. However, such indemnification and reimbursement shall not exceed the amount of additional federal and state income tax (plus any penalties) that the Participant would have owed if the payments or reimbursements had been made to the Participant as regular cash compensation, plus the Participant's share of any Social Security tax that would have been paid on such compensation, less any such additional income and Social Security tax actually paid by the Participant. 27 Packet Page-700- ') 1/27/2015 16.E.3. 11.9 FUNDING Unless otherwise required by law, contributions to the Plan need not be placed in trust or dedicated to a specific Benefit, but may instead be considered general assets of the Employer. Furthermore, and unless otherwise required by law, nothing herein shall be construed to require the Employer or the Administrator to maintain any fund or segregate any amount for the benefit of any Participant, and no Participant or other person shall have any claim against, right to, or security or other interest in, any fund, account or asset of the Employer from which any payment under the Plan may be made. 11.10 GOVERNING LAW This Plan is governed by the Code and the Treasury regulations issued thereunder (as they might be amended from time to time). In no event shall the Employer guarantee the favorable tax treatment sought by this Plan. To the extent not preempted by Federal law, the provisions of this Plan shall be construed, enforced and administered according to the laws of the State of Florida. 11.11 SEVERABILITY If any provision of the Plan is held invalid or unenforceable, its invalidity or unenforceability shall not affect any other provisions of the Plan, and the Plan shall be construed and enforced as if such provision had not been included herein. 11.12 CAPTIONS The captions contained herein are inserted only as a matter of convenience and for reference, and in no way define, limit, enlarge or describe the scope or intent of the Plan, nor in any way shall affect the Plan or the construction of any provision thereof. 11.13 CONTINUATION OF COVERAGE(COBRA) Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan subject to the continuation coverage requirement of Code Section 4980B becomes unavailable, each Participant will be entitled to continuation coverage as prescribed in Code Section 4980B, and related regulations. This Section shall only apply if the Employer employs at least twenty (20) employees on more than 50% of its typical business days in the previous calendar year. 11.14 FAMILY AND MEDICAL LEAVE ACT(FMLA) Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan becomes subject to the requirements of the Family and Medical Leave Act and regulations thereunder, this Plan shall be operated in accordance with Regulation 1.125-3. 11.15 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT(HIPAA) Notwithstanding anything in this Plan to the contrary, this Plan shall be operated in accordance with HIPAA and regulations thereunder. 28 Packet Page -701- 1/27/2015 16.E.3. 11.16 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) Notwithstanding any provision of this Plan to the contrary, contributions, benefits and service credit with respect to qualified military service shall be provided in accordance with the Uniform Services Employment And Reemployment Rights Act (USERRA) and the regulations thereunder. 11.17 COMPLIANCE WITH HIPAA PRIVACY STANDARDS (a) Application. If any benefits under this Cafeteria Plan are subject to the Standards for Privacy of Individually Identifiable Health Information (45 CFR Part 164, the"Privacy Standards"), then this Section shall apply. (b) Disclosure of PHI. The Plan shall not disclose Protected Health Information to any member of the Employer's workforce unless each of the conditions set out in this Section are met. "Protected Health Information" shall have the same definition as set forth in the Privacy Standards but generally shall mean individually identifiable information about the past, present or future physical or mental health or condition of an individual, including genetic information and information about treatment or payment for treatment. (c) PHI disclosed for administrative purposes. Protected Health Information disclosed to members of the Employer's workforce shall be used or disclosed by them only for purposes of Plan administrative functions. The Plan's administrative functions shall include all Plan payment functions and health care operations. The terms "payment" and "health care operations" shall have the same definitions as set out in the Privacy Standards, but the term "payment" generally shall mean activities taken to determine or fulfill Plan responsibilities with respect to eligibility, coverage, provision of benefits, or reimbursement for health care. Genetic information will not be used or disclosed for underwriting purposes. (d) PHI disclosed to certain workforce members. The Plan shall disclose Protected Health Information only to members of the Employer's workforce who are designated and authorized to receive such Protected Health Information, and only to the extent and in the minimum amount necessary for that person to perform his or her duties with respect to the Plan. "Members of the Employer's workforce" shall refer to all employees and other persons under the control of the Employer. The Employer shall keep an updated list of those authorized to receive Protected Health Information. (1) An authorized member of the Employer's workforce who receives Protected Health Information shall use or disclose the Protected Health Information only to the extent necessary to perform his or her duties with respect to the Plan. (2) In the event that any member of the Employer's workforce uses or discloses Protected Health Information other than as permitted by this Section and the Privacy Standards, the incident shall be reported to the Plan's privacy official. The privacy official shall take appropriate action, including: 29 Packet Page-702- �� 1/27/2015 16.E.3. (i) investigation of the incident to determine whether the breach occurred inadvertently, through negligence or deliberately; whether there is a pattern of breaches; and the degree of harm caused by the breach; (ii) appropriate sanctions against the persons causing the breach which, depending upon the nature of the breach, may include oral or written reprimand, additional training, or termination of employment; (iii) mitigation of any harm caused by the breach, to the extent practicable; and (iv) documentation of the incident and all actions taken to resolve the issue and mitigate any damages. (e) Certification. The Employer must provide certification to the Plan that it agrees to: (1) Not use or further disclose the information other than as permitted or required by the Plan documents or as required by law; (2) Ensure that any agent or subcontractor, to whom it provides Protected Health Information received from the Plan, agrees to the same restrictions and conditions that apply to the Employer with respect to such information; (3) Not use or disclose Protected Health Information for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Employer; (4) Report to the Plan any use or disclosure of the Protected Health Information of which it becomes aware that is inconsistent with the uses or disclosures permitted by this Section, or required by law; (5) Make available Protected Health Information to individual Plan members in accordance with Section 164.524 of the Privacy Standards; (6) Make available Protected Health Information for amendment by individual Plan members and incorporate any amendments to Protected Health Information in accordance with Section 164.526 of the Privacy Standards; (7) Make available the Protected Health Information required to provide an accounting of disclosures to individual Plan members in accordance with Section 164.528 of the Privacy Standards; (8) Make its internal practices, books and records relating to the use and disclosure of Protected Health Information received from the Plan available to the Department of Health and Human Services for purposes of determining compliance by the Plan with the Privacy Standards; (9) If feasible, return or destroy all Protected Health Information received from the Plan that the Employer still maintains in any form, and retain no copies 30 Packet Page -703- 1/27/2015 16.E.3. of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible; and (10) Ensure the adequate separation between the Plan and members of the Employer's workforce, as required by Section 164.504(f)(2)(iii) of the Privacy Standards and set out in (d) above. 11.18 COMPLIANCE WITH HIPAA ELECTRONIC SECURITY STANDARDS Under the Security Standards for the Protection of Electronic Protected Health Information (45 CFR Part 164.300 et. seq., the"Security Standards"): (a) Implementation. The Employer agrees to implement reasonable and appropriate administrative, physical and technical safeguards to protect the confidentiality, integrity and availability of Electronic Protected Health Information that the Employer creates, maintains or transmits on behalf of the Plan. "Electronic Protected Health Information" shall have the same definition as set out in the Security Standards, but generally shall mean Protected Health Information that is transmitted by or maintained in electronic media. (b) Agents or subcontractors shall meet security standards. The Employer shall ensure that any agent or subcontractor to whom it provides Electronic Protected Health Information shall agree, in writing, to implement reasonable and appropriate security measures to protect the Electronic Protected Health Information. (c) Employer shall ensure security standards. The Employer shall ensure that reasonable and appropriate security measures are implemented to comply with the conditions and requirements set forth in Section 11.17. 11.19 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT Notwithstanding anything in the Plan to the contrary, the Plan will comply with the Mental Health Parity and Addiction Equity Act and ERISA Section 712. 11.20 GENETIC INFORMATION NONDISCRIMINATION ACT(GINA) Notwithstanding anything in the Plan to the contrary, the Plan will comply with the Genetic Information Nondiscrimination Act. 11.21 WOMEN'S HEALTH AND CANCER RIGHTS ACT Notwithstanding anything in the Plan to the contrary, the Plan will comply with the Women's Health and Cancer Rights Act of 1998. 11.22 NEWBORNS'AND MOTHERS' HEALTH PROTECTION ACT Notwithstanding anything in the Plan to the contrary, the Plan will comply with the Newborns' and Mothers' Health Protection Act. 31 \ Packet Page -704- 1/27/2015 16.E.3. IN WITNESS WHEREOF, this Plan document is hereby executed this day of Collier County By EMPLOYER ATTEST pproved as to orm and legality DWIGHT E. BROCK,CLERK ,.a ay: Scott R.Teach,Deputy County Attorney 32 Packet Page -705- 0 V 1/27/2015 16.E.3. IN WITNESS WHEREOF, this Plan document is hereby executed this day of Collier County By EMPLOYER ATTEST proved as t rm d legality DWIGHT E. BROCK, CLERK BY. Scott R.Teach,Deputy County Attorney Plan Docume Sign and return this page fib.) Packet Page -706- 1/27/2015 16.E.3. • PLAN DOCUMENT SUMMARY PLAN DESCRIPTION for the COLLIER COUNTY GOVERNMENT DENTAL EMPLOYEE BENEFIT PLAN This booklet describes the Plan Benefits in effect as of January 1, 2015 The Plan has been established for the benefit of Eligible employees and their dependents of: COLLIER COUNTY GOVERNMENT Claims Processed By: ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. 2806 South Garfield Street PO Box 3018 Missoula,MT 59806-3018 Phone Number:(855)333-1004 Collier County Government Dental Plan-Group#2003021 Plan Document/SPD-Effective 1/1/2015 Packet Page-707- 1/27/2015 16.E.3. COVER/SIGNATURE PAGE Effective January 1, 2015, Collier County Government establishes its self-funded Dental Care Plan for the benefit of eligible Employees and their eligible Dependents entitled, COLLIER COUNTY GOVERNMENT DENTAL EMPLOYEE BENEFIT PLAN (the"Plan"). The purpose of this Plan is to provide reimbursement for Expenses Incurred for covered services,treatment or supplies as a result of Dentally Necessary treatment for Illness or Injury of the County's eligible Employees and their eligible Dependents. The County, in conjunction with any required contributions by its Employees, agrees to make payments to the Plan's Trust in order for payments to be made for covered services, treatments or supplies as provided by this Plan. The County has caused this instrument to be executed as of the day first mentioned above. COLLIER COUNTY GOVERNMENT BY: TITLE: ATTEST Quad a to f a legality DWIGHT E.BROCK, CLERK BY: Scott R.Teach,Deputy County Attorney Collier County Government Dental Plan-Group#2003021 Plan Document/SPD-Effective 1/1/2015 CA Packet Page -708- 1/27/2015 16.E.3. TABLE OF CONTENTS INTRODUCTION 1 SCHEDULE OF DENTAL BENEFITS-BASIC OPTION 2 SCHEDULE OF DENTAL BENEFITS-SELECT OPTION 3 DENTAL BENEFITS 4 ELIGIBLE EXPENSES 4 DEDUCTIBLE AND BENEFIT PERCENTAGE 4 APPLICATION OF DEDUCTIBLE AND ORDER OF BENEFIT PAYMENT 4 MAXIMUM BENEFIT PAYABLE 4 EXPENSES INCURRED 5 PREDETERMINATION OF BENEFITS 5 DENTAL EXPENSES 5 TYPE A(PREVENTIVE CARE)EXPENSES 5 TYPE B(BASIC CARE) EXPENSES 6 TYPE C(MAJOR RESTORATIVE) EXPENSES 6 TYPE D TEMPOROMANDIBULAR JOINT DYSFUNCTION DENTAL EXPENSES 7 ORTHODONTIC TREATMENT BENEFIT 7 PROSTHESIS REPLACEMENT RULE 7 DENTAL BENEFIT LIMITATIONS 7 GENERAL PLAN EXCLUSIONS AND LIMITATIONS 9 COORDINATION OF BENEFITS 13 DEFINITIONS 13 ORDER OF BENEFIT DETERMINATION 14 Non-Dependent/Dependent 14 Child Covered Under More Than One Plan 14 Active or Inactive Employee 15 Longer or Shorter Length of Coverage 15 No Rules Apply 15 COORDINATION WITH MEDICAID 15 COORDINATION WITH TRICARE/CHAMPVA 15 PROCEDURES FOR CLAIMING BENEFITS 16 CLAIM DECISIONS ON CLAIMS AND ELIGIBILITY 16 APPEALING AN UN-REIMBURSED CLAIM 17 FIRST LEVEL OF BENEFIT DETERMINATION REVIEW 17 SECOND LEVEL OF BENEFIT DETERMINATION REVIEW 18 ELIGIBILITY PROVISIONS 19 EMPLOYEE ELIGIBILITY 19 WAITING PERIOD 19 DEPENDENT ELIGIBILITY 19 PARTICIPANT ELIGIBILITY FOR DEPENDENT COVERAGE 20 DECLINING COVERAGE 20 EFFECTIVE DATE OF COVERAGE 21 PARTICIPANT COVERAGE 21 DEPENDENT COVERAGE 21 OPEN ENROLLMENT PERIOD 21 SPECIAL ENROLLMENT PERIOD 21 CHANGE IN STATUS 22 Collier County Government Dental Plan-Group#2003021 i Plan Document!SPD-Effective 1/1/2015 GP Packet Page -709- 1/27/2015 16.E.3. QUALIFIED MEDICAL CHILD SUPPORT ORDERS PROVISION 24 PURPOSE 24 DEFINITIONS 24 CRITERIA FOR A QUALIFIED MEDICAL CHILD SUPPORT ORDER 24 PROCEDURES FOR NOTIFICATIONS AND DETERMINATIONS 25 NATIONAL MEDICAL SUPPORT NOTICE 25 FAMILY AND MEDICAL LEAVE 26 DEFINITIONS 26 EMPLOYERS SUBJECT TO FMLA 27 ELIGIBLE EMPLOYEES 27 REASONS FOR TAKING LEAVE 27 ADVANCE NOTICE AND MEDICAL CERTIFICATION 27 PROTECTION OF JOB BENEFITS 27 UNLAWFUL ACTS BY EMPLOYERS 27 ENFORCEMENT 28 TERMINATION OF COVERAGE 29 PARTICIPANT TERMINATION 29 DEPENDENT TERMINATION 29 REINSTATEMENT OF COVERAGE 30 CONTINUATION COVERAGE AFTER TERMINATION 31 NOTIFICATION RESPONSIBILITIES 31 ELECTION OF COVERAGE 32 MONTHLY PREMIUM PAYMENTS 32 DISABILITY EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE 32 SECOND QUALIFYING EVENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE 33 MEDICARE ENROLLMENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE 33 WHEN COBRA CONTINUATION COVERAGE ENDS 33 QUESTIONS 34 INFORM THE PLAN OF ADDRESS CHANGES 34 COVERAGE FOR A MILITARY RESERVIST 35 FRAUD AND ABUSE 36 MISSTATEMENT OF AGE 36 MISREPRESENTATION OF ELIGIBILITY 36 MISUSE OF IDENTIFICATION CARD 36 REIMBURSEMENT TO PLAN 36 RECOVERY/REIMBURSEMENT/SUBROGATION 37 RIGHT TO RECOVER BENEFITS PAID IN ERROR 37 REIMBURSEMENT 37 SUBROGATION 37 PLAN ADMINISTRATION 39 PURPOSE 39 EFFECTIVE DATE 39 PLAN YEAR 39 PLAN SPONSOR 39 PLAN SUPERVISOR 39 NAMED FIDUCIARY AND PLAN ADMINISTRATOR 39 PLAN INTERPRETATION 39 Collier County Government Dental Plan-Group#2003021 ii Plan Document/SPD-Effective 1/1/2015 Packet Page -710- CA 1/27/2015 16.E.3. CONTRIBUTIONS TO THE PLAN 40 PLAN AMENDMENTS/MODIFICATION/TERMINATION 40 NOTICE OF REDUCTION OF BENEFITS 40 TERMINATION OF PLAN 40 SUMMARY PLAN DESCRIPTIONS 40 GENERAL PROVISIONS 41 EXAMINATION 41 PAYMENT OF CLAIMS 41 LEGAL PROCEEDINGS 41 NO WAIVER OR ESTOPPEL. 41 VERBAL STATEMENTS 41 FREE CHOICE OF DENTAL SERVICE PROVIDER 41 WORKERS'COMPENSATION NOT AFFECTED 42 CONFORMITY WITH LAW 42 MISCELLANEOUS 42 FACILITY OF PAYMENT 42 PROTECTION AGAINST CREDITORS 42 PLAN IS NOT A CONTRACT 42 GENERAL DEFINITIONS 43 HIPAA PRIVACY AND SECURITY STANDARDS 50 DEFINITIONS 50 PRIVACY CERTIFICATION 50 SECURITY CERTIFICATION 51 PLAN SUMMARY 52 Collier County Government Dental Plan-Group#2003021 iii Plan Document/SPD-Effective 1/1/2015 Packet Page-711- CA 1/27/2015 16.E.3. INTRODUCTION Effective January 1,2015,Collier County Government,hereinafter referred to as the"County"or"Employer", establishes the benefits, rights and privileges which will pertain to participating Employees, referred to as "Participants",and the eligible Dependents of such Participants,as defined,and which benefits are provided through a fund established by the County and referred to as the"Plan." This booklet describes the Plan in effect as of January 1, 2015. Coverage provided under this Plan for Employees and their Dependents will be in accordance with the Eligibility,Effective Date,Qualified Medical Child Support Order,Termination,Family and Medical Leave Act and other applicable provisions as stated in this Plan. Collier County Government(the Plan Sponsor)has retained the services of an independent Plan Supervisor, experienced in claims processing,to handle health claims. The Plan Supervisor for the Plan is: Allegiance Benefit Plan Management, Inc. P.O. Box 3018 Missoula, MT 59806-3018 We recommend that you read this booklet carefully before incurring any dental expenses. If you have specific questions regarding coverage or benefits,you are urged to refer to the Plan Document which is available for your review in the Personnel Office or at the office of the Plan Supervisor. If you wish,you may call or write to Allegiance Benefit Plan Management, Inc.regarding any detailed questions you may have concerning the Plan. This Plan is not intended to,and cannot be used as workers compensation coverage for any employee or any covered dependent of an employee. Therefore,this plan generally excludes claims related to any activity engaged in for wage or profit including,but not limited to,farming,ranching,part-time and seasonal activities. See Plan Exclusions for specific information. The information contained in this Plan Document/Summary Plan Description is only a general statement regarding FMLA,COBRA,USERRA,and QMCSO's. It is not intended to be and should not be relied upon as complete legal information about those subjects. Covered Persons and Employers should consult their own legal counsel regarding these matters. Collier County Government Dental Plan-Group#2003021 1 Plan Document/SPD-Effective 1/1/2015 Packet Page -712- CA 1/27/2015 16.E.3. SCHEDULE OF DENTAL BENEFITS-BASIC OPTION FOR ELIGIBLE PARTICIPANTS AND DEPENDENTS This Plan provides benefits through a group of contracted providers(Participating Providers). Participating Provider services are paid based on the contracted fee. Non-Participating Provider means a provider who is not a Participating Provider. Non-Participating Provider services are paid based on the Usual,Customary and Reasonable limits of the Plan which is calculated at the 95th percentile. To determine if a provider qualifies as an eligible Participating Provider under this Plan, please consult Allegiance's website at www.askallegiance.com/ccq to access links for directories of Participating Providers. THE BENEFIT PERIOD IS A CALENDAR YEAR DEDUCTIBLE Annual Deductible Per Covered Person per Benefit Period $50 Annual Deductible Per Family per Benefit Period $150 DENTAL EXPENSES Type A(Preventive Care) Dental Expenses Deductible Waived Benefit Percentage 100% Type B(Basic Restorative Care) Dental Expenses Deductible Applies Benefit Percentage 50% Type C (Major Restorative) Dental Expenses Deductible Applies Benefit Percentage 50% Type D Temporomandibular Joint Dysfunction Dental Expenses Deductible Applies Benefit Percentage 50% Orthodontic Treatment Not Covered BENEFIT LIMITS: Type A, B and C Expenses Maximum Benefit Per Benefit Period $1,000 Type D Maximum Lifetime Benefit $1,000 Collier County Government Dental Plan-Group#2003021 2 Plan Document/SPD-Effective 1/1/2015 Packet Page -713- 1/27/2015 16.E.3. SCHEDULE OF DENTAL BENEFITS-SELECT OPTION FOR ELIGIBLE PARTICIPANTS AND DEPENDENTS This Plan provides benefits through a group of contracted providers(Participating Providers). Participating Provider services are paid based on the contracted fee. Non-Participating Provider means a provider who is not a Participating Provider. Non-Participating Provider services are paid based on the Usual,Customary and Reasonable limits of the Plan which is calculated at the 95th percentile. To determine if a provider qualifies as an eligible Participating Provider under this Plan, please consult Allegiance's website at www.askalleaiance.com/ccq to access links for directories of Participating Providers. THE BENEFIT PERIOD IS A CALENDAR YEAR DEDUCTIBLE Annual Deductible Per Covered Person per Benefit Period $50 Annual Deductible Per Family per Benefit Period $150 DENTAL EXPENSES Type A(Preventive Care)Dental Expenses Deductible Waived Benefit Percentage 100% Type B(Basic Restorative Care)Dental Expenses Deductible Applies Benefit Percentage 80% Type C(Major Restorative) Dental Expenses Deductible Applies Benefit Percentage 80% Type D Temporomandibular Joint Dysfunction Dental Expenses Deductible Applies Benefit Percentage 80% Orthodontic Treatment Not Covered BENEFIT LIMITS: Type A, B and C Expenses Maximum Benefit Per Benefit Period $2,000 Type D Maximum Lifetime Benefit $2,000 Collier County Government Dental Plan-Group#2003021 3 Plan Document/SPD-Effective 1/1/2015 Packet Page-714- 1/27/2015 16.E.3. DENTAL BENEFITS ELIGIBLE EXPENSES Services,treatments or supplies are an eligible Dental Expense if they meet all of the following requirements: 1. They are administered, provided by or ordered by a Dentist, Denturist, Dental Hygienist or other Licensed Health Care Provider covered by the Plan; and 2. They are Dentally Necessary for the diagnosis and treatment of a dental condition or dental disease unless otherwise specifically included as an Eligible Expense; and 3. Charges therefore do not exceed the Usual,Customary and Reasonable limits of the Plan. If two or more procedures are separately suitable for the correction of a specific condition,the Eligible Expense will be based upon the least expensive procedure; and 4. They are not excluded under any provision or section of this Plan. All benefits under the this Plan must be exhausted before services can be considered under the medical plan. DEDUCTIBLE AND BENEFIT PERCENTAGE The Deductible applies to Eligible Expenses incurred during each Benefit Period,unless specifically waived, but it applies only once for each Covered Person within a Benefit Period. Also, if members of a Family have satisfied individual Deductible amounts that collectively equal the Deductible per Family, as stated in the Schedule of Dental Benefits,during the same Benefit Period,no further Deductible will apply to any member of that Family during that Benefit Period. An individual Covered Person cannot receive credit toward the Family Deductible for more than the Individual Annual Deductible as stated in the Schedule of Dental Benefits. Eligible Expenses Incurred by a Covered Person will be paid by the Plan according to the applicable Benefit Percentage stated in the Schedule of Dental Benefits. The Plan will pay the percentage of the Eligible Expense indicated as the Benefit Percentage. APPLICATION OF DEDUCTIBLE AND ORDER OF BENEFIT PAYMENT Deductibles will be applied to Eligible Expenses in the chronological order in which they are adjudicated by the Plan. Eligible Expenses will be paid by the Plan in the chronological order in which they are adjudicated by the Plan. The manner in which the Deductible is applied and Eligible Expenses are paid by the Plan will be conclusive and binding on all Covered Persons and their assignees. MAXIMUM BENEFIT PAYABLE The Maximum Benefit per Benefit Period as specified in the Schedule of Dental Benefits is the maximum amount that may be paid by the Plan for Eligible Expenses Incurred by each individual Covered Person in each Benefit Period as indicated in the Schedule of Dental Benefits.The amount payable by the Plan will not exceed any Maximum Benefit or Maximum Lifetime Benefit as stated in the Schedule of Dental Benefits,for any reason. Collier County Government Dental Plan-Group#2003021 4 Plan Document/SPD-Effective 1/1/2015 9G Packet Page -715- 1/27/2015 16.E.3. Packet Page -716- 1/27/2015 16.E.3. Dental Benefits EXPENSES INCURRED For a dental appliance,or modification of a dental appliance,an expense is considered Incurred at the time the impression is made. For a crown,bridge or gold restoration an expense is considered Incurred at the time the tooth or teeth are prepared. For root canal therapy an expense is considered Incurred at the time the pulp chamber is opened. All other expenses are considered Incurred at the time a service is rendered or a supply furnished. PREDETERMINATION OF BENEFITS Charges that are expected to exceed five hundred dollars ($500.00) may be predetermined by having the Dentist complete the Predetermination of Benefits portion of the claim form and listing the procedures he/she is recommending, including an estimate of charges for the procedures and submit the claim form to the Plan Supervisor for Predetermination of Benefits payable. Upon the Plan's receipt of the Predetermination of Benefits request, the Plan Supervisor will determine the eligibility of the Covered Person and determine the coverage available under the Plan for the recommended dental procedures. After determining the benefits payable under the Plan,the Plan Supervisor will return the claim form to the Dentist. A copy of the predetermination of benefits will also be mailed to the covered Employee, informing the Employee of the amount of benefits estimated to be covered by the Plan for the recommended dental procedures. A PREDETERMINATION OF BENEFITS IS NOT A GUARANTEE OF PAYMENT. PAYMENT OF PLAN BENEFITS IS SUBJECT TO PLAN PROVISIONS AND ELIGIBILITY AT THE TIME SERVICES ARE PERFORMED OR CHARGES ARE INCURRED. DENTAL EXPENSES TYPE A (PREVENTIVE CARE)EXPENSES The following general dental expenses will be considered"Type A"for reimbursement purposes as stated in the Schedule of Dental Benefits: 1. Oral Examination (including prophylaxis—scaling and cleaning of teeth), but not more than twice in any Benefit Period. 2. Periodontal maintenance procedure(following active therapy),prophylaxis for periodontal treatment, but not more than twice per Benefit Period. 3. Topical application of sodium fluoride or stannous fluoride for Dependent children under age fourteen (14). Benefits for topical application of sodium fluoride or stannous fluoride will be provided only once every Benefit Period. 4. Dental x-rays required in connection with the diagnosis of a specific condition requiring treatment;also other dental x-rays, but not more than one full mouth x-ray or series in any three(3)Benefit Periods and not more than two(2)sets of supplementary bitewing x-rays in any Benefit Period. 5. Topical application of sealant limited to one treatment per tooth per lifetime for children under fourteen (14)years old only payable on an unrestored permanent bicuspid or molar teeth. 6. Clinical oral evaluation, but not more than two(2)per Benefit Period. 7. Space maintainers-limited to non-orthodontic treatment for prematurely removed or missing teeth for a person less than fourteen (14)years old.. Collier County Government Dental Plan-Group#2003021 5 Plan Document/SPD-Effective 1/1/2015 Packet Page-717- 1/27/2015 16.E.3. Dental Benefits TYPE B (BASIC CARE)EXPENSES The following general dental expenses will be considered"Type B"for reimbursement purposes as stated in the Schedule of Dental Benefits: 1. Emergency palliative care to relieve dental pain. 2. Extractions, except for orthodontic extractions. 3. Oral surgery. 4. Fillings. 5. Nitrous Oxide when administered in connection with covered dental services. 6. General anesthesia or conscious intravenous "IV" sedation when Dentally Necessary and administered in connection with oral surgery or other Covered Dental Benefits. 7. Treatment,including periodontal surgery of diseased periodontal structures for periodontal and other diseases affecting such structures. 8. Endodontic treatment, including root canal therapy. 9. Injection of antibiotic drugs. TYPE C(MAJOR RESTORATIVE)EXPENSES The following general dental expenses will be considered"Type C"for reimbursement purposes: 1. Gold fillings, inlays, onlays or crowns(including precision attachments for dentures). 2. Repair or recementing of crowns, inlays, bridgework or dentures; or relining of dentures. 3. Initial installation of fixed bridgework(including crowns and inlays to form abutments)to replace one or more natural teeth extracted while the individual is a Covered Person. . 4. Replacement of an existing partial denture or fixed bridgework by a new fixed bridgework, or the addition of teeth to an existing fixed bridgework. However,this item will apply only to replacements and additions that meet the"Prosthesis Replacement Rule"below. 5. Initial installation of partial or full removable dentures (including adjustments for the six (6) month period following installation) to replace one or more natural teeth extracted while the individual is covered. 6. Replacement of an existing partial or full removable denture or fixed bridgework by a new partial or full removable denture, or the addition of teeth to an existing partial denture. However, this item applies only to replacements and additions that meet the"Prosthesis Replacement Rule" below. 7. Surgical placement of an implant body or framework, of any type; any device, index, or surgical template guide used for implant surgery; prefabricated or custom implant abutments;or removal of an existing implant. Implant removal is covered only if the implant is not serviceable and cannot be repaired. 8. A prosthetic device, supported by an implant or implant abutment. Replacement of any type of prosthesis with a prosthesis supported by an implant or implant abutment is covered only if the existing prosthesis is at least seven(7)since it was placed,is not serviceable and cannot be repaired. Collier County Government Dental Plan-Group#2003021 6 Plan Document/SPD-Effective 1/1/2015 111) Packet Page-718- 1/27/2015 16.E.3. Dental Benefits 9. Removable mouth guard or appliance(occlusal guard or night guard)to alleviate thub-sucking and bruxism(grinding of the teeth). This benefit is limited to$500 per appliance. TYPE D TEMPOROMANDIBULAR JOINT DYSFUNCTION DENTAL EXPENSES The following dental expenses for the treatment of Temporomandibular Joint Dysfunction will be considered "Type D"for reimbursement purposes: 1. Office visit-adjustment to appliance. No more than 6(six)adjustments in six(6)consecutive months after seating or placement of appliance. 2. Transcutaneous Electro-neural Stimulation. No more than four(4)treatments in a six-month period. 3. Trigger Point Injection of local anesthetic into muscle fascia. No more than four(4)treatment in a six- month period. 4. Mandibular Orthopedic Repositioning Appliance. Only one appliance per Covered Person in any five- year period. ORTHODONTIC TREATMENT BENEFIT There is no coverage for Orthodontic Treatment. PROSTHESIS REPLACEMENT RULE Replacement of or additions to existing dentures or bridgework as described under Type C Expenses will be covered only if evidence satisfactory to the Plan Supervisor is furnished that one of the following applies: 1. The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or bridgework was installed and while the individual was a Covered Person. 2. The existing denture or bridgework cannot be made serviceable and was installed at least seven(7) years prior to its replacement. 3. The existing denture is an immediate temporary denture which cannot be made permanent and replacement by a permanent denture is required and takes place within twelve(12)months from the date of initial installation of the immediate temporary denture. DENTAL BENEFIT LIMITATIONS The following examples describe limitations in coverage under the Plan. 1. Restorative: A. Gold,baked porcelain restorations,crowns,jackets: If a tooth can be restored with a material such as amalgam, and the Covered Person and dental service provider select another type of restoration,the Eligible Expense for the dental procedure actually performed will be limited to the Usual, Customary and Reasonable fee appropriate to the procedure using amalgam or a similar material. B. Reconstruction. Eligible Expenses will include only the appropriate Usual, Customary and Reasonable charges for those procedures necessary to eliminate oral disease and to replace missing teeth. Collier County Government Dental Plan-Group#2003021 7 Plan Document/SPD-Effective 1/1/2015 Packet Page -719- 1/27/2015 16.E.3. Dental Benefits 2. Prosthodontics: A. Partial Dentures. If a cast chrome or acrylic partial denture will restore the dental arch satisfactorily,and the Covered Person and the dental service provider elect a more elaborate appliance,Eligible Expenses for the Covered Dental Service performed will be limited to the Usual,Customary and Reasonable charges appropriate to the cast chrome or acrylic denture. B. Complete Dentures. If the Covered Person and the dental service provider decide on personalized or specialized techniques as opposed to standard procedures, the eligible expense for the dental procedure actually performed will be limited to the Usual,Customary and Reasonable charges appropriate to the standard procedure. C. Replacement of existing dentures or removable or fixed bridgework. Charges for the replacement of existing dentures or removable or fixed bridgework will be considered an eligible expense only if the existing appliance is not serviceable and cannot be repaired. Otherwise, the Eligible Expense for the procedure performed will be limited to the Usual, Customary and Reasonable charges appropriate for those services which would be necessary to render such appliances serviceable. Collier County Government Dental Plan-Group#2003021 8 Plan Document/SPD-Effective 1/1/2015 ED Packet Page-720- 1/27/2015 16.E.3. GENERAL PLAN EXCLUSIONS AND LIMITATIONS The following general exclusions and limitations apply to all Expenses Incurred under this Plan: 1. Charges for any services or supplies to the extent that benefits are otherwise provided under this Plan, or under any other plan of group benefits that the Participant's Employer contributes to or sponsors. 2. Charges for treatment which is not rendered by or in the presence of a Dentist or other Licensed Health Care Provider covered by the Plan except that cleaning or scaling of teeth and topical application of fluoride may be performed by a licensed Dental Hygienist,if the treatment is rendered under the supervision or the direction of the Dentist. 3. Charges for dentures,crowns, inlays,onlays,bridgework or other appliances which are not dentally necessary and performed solely or primarily for Cosmetic or personal reasons, personal comfort, convenience, or beautification items, including charges for personalization or characterization of dentures. Charges for veneers, composite, plastic, silicate or similar restorations placed on or replacing any teeth other than the ten (10) upper and lower anterior teeth are considered optional services and not dentally necessary. Eligible Expenses will include only the charge for a corresponding amalgam restoration. 4. Charges for any procedure,service,supply or appliance,the sole or primary purpose of which relates to the change or maintenance of vertical dimension. 5. Charges for facility,Ambulatory Surgery Center and Hospital charges. 6. Charges for local anesthesia administered in conjunction with covered dental services or procedures, when billed separately(unbundled)from the charge for the Covered Service or procedure. 7. Charges for the replacement of a lost,missing,or stolen appliance device or for an additional(spare) appliance. 8. Charges for procedures, appliances or restorations whose main purpose is to diagnose or treat jaw joint problems, including craniomandibular disorders or other conditions of the joints linking the jawbone and skull, including the complex muscles, nerves and other tissues related to that joint. 9. Charges for the alteration or restoration of occlusion. 10. Charges for the restoration of teeth which have been damaged by erosion, attrition or abrasion. 11. Charges for bite registration or bite analysis. 12. Charges for core build-ups. 13. Charges for replacement of teeth beyond the normal complement of thirty-two(32). 14. Expenses Incurred by the Covered Person for all services and supplies resulting from any Illness or Injury which occurs in the course of employment for wage or profit,or in the course of any volunteer work when the organization,for whom the Covered Person is volunteering,has elected or is required by law to obtain coverage for such volunteer work under state or federal workers'compensation laws or other legislation, including Employees' compensation or liability laws of the United States (collectively called "Workers' Compensation"). This exclusion applies to all such services and supplies resulting from a work-related Illness or Injury even though: A. Coverage for the Covered Person under Workers'Compensation provides benefits for only a portion of the services Incurred; Collier County Government Dental Plan-Group#2003021 9 Plan Document/SPD-Effective 1/1/2015 CCDC.2. Packet Page -721- 1/27/2015 16.E.3. General Plan Exclusions and Limitations B. The Covered Person's employer/volunteer organization has failed to obtain such coverage required by law; C. The Covered Person waived his/her rights to such coverage or benefits; D. The Covered Person fails to file a claim within the filing period allowed by law for such benefits; E. The Covered Person fails to comply with any other provision of the law to obtain such coverage or benefits; or F. The Covered Person is permitted to elect not to be covered by Workers'Compensation but failed to properly make such election effective. G. The Covered Person is permitted to elect not to be covered by Workers'Compensation and has affirmatively made that election. This exclusion will not apply to household and domestic employment,employment not in the usual course of the trade, business, profession or occupation of the Covered Person or Employee, or employment of a Dependent member of an Employee's family for whom an exemption may be claimed by the Employee under the Internal Revenue Code. This exclusion also does not apply to the claims of a Covered Person whose workers' compensation coverage has ended specifically because the Covered person has reached Maximum Medical Improvement(MMI)as finally determined and certified without objection or appeal by a workers' compensation fund or insurance carrier. 15. Charges for which the Covered Person is not, in the absence of this coverage, legally obligated to pay, or for which a charge would not ordinarily be made in the absence of this coverage. 16. Charges for oral hygiene and dietary instructions. 17. Charges for root canal therapy for which the pulp chamber was opened before the individual became a Covered Person. 18. Charges for temporary dentures. 19. Charges incurred for services rendered or started,or supplies furnished prior to the effective date of coverage under the Plan, or after coverage is terminated under the Plan, except as specifically provided for in the Plan provisions. This includes charges for dentures, crowns, inlays, onlays, bridgework or other appliances or services which were not ordered while the individual was a Covered Person. The date a prosthetic dental appliance is placed in the mouth is considered the date of service. 20. Charges for any services, supplies or appliances which are not specifically listed as a benefit of this Plan. 21. Charges which are caused by or arising out of war or act of war, (whether declared or undeclared), civil unrest, armed invasion or aggression, or caused during service in the armed forces of any country. 22. Broken or missed appointments. 23. Charges for infection control(OSHA)fees or claim filing. 24. Travel Expenses Incurred by any person for any reason. Collier County Government Dental Plan-Group#2003021 10 Plan Document/SPD-Effective 1/1/2015 .y Packet Page-722- 1/27/2015 16.E.3. General Plan Exclusions and Limitations 25. Charges for non-dental services such as training, education, instructions or educational materials, even if they are performed or provided by a dental service provider. 26. Hypnosis, prescribed drugs, premedications or any euphoric drugs, with the exception of nitrous oxide. 27. Biopsies or oral pathology, except as specifically provided for under Covered Dental Services. 28. To the extent that the Covered Person could have obtained payment, in whole or in part, if he or she had applied for coverage or obtained treatment under any federal, state or other governmental program or in a treatment facility operated by a government agency,except where required by law, such as for cases of dental emergencies or for coverage provided by Medicaid. 29. Charges for services,supplies or treatments or procedures,surgical or otherwise,not recognized as generally accepted and Dentally Necessary for the diagnosis and/or treatment of an active Dental condition or dental disease,or which are Experimental or Investigational,except as specifically stated as a Covered Benefit of this Plan. 30. Expenses Incurred by persons other than the person receiving treatment. 31. Charges in connection with services and supplies which are in excess of Usual, Customary and Reasonable charges. 32. Charges for services rendered by a Physician or Licensed Health Care Provider who is a Close Relative of the Covered Person, or resides in the same household of the Covered Person and who does not regularly charge the Covered Person for services. 33. Charges for extracoronal and other periodontal splinting. 34. Charges for athletic mouth guards. 35. Charges for myofunctional therapy. 36. Charges for precision or semiprecision attachments. 37. Charges for denture duplication. 38. Charges for treatment of jaw fractures and orthognathic surgery. 39. Charges for Orthodontic Treatment, except for the treatment of cleft lip and cleft palate. 40. Charges for diagnostic casts, diagnostic models, or study models. 41. Charges for professional services on an Outpatient basis in connection with disorders of any type or cause,that can be credited towards earning a degree or furtherance of the education or training of a Covered Person regardless of the diagnosis. 42. Charges for services,treatment or supplies not considered legal in the United States. 43. Charges for preparation of reports or itemized bills in connection with Eligible Expenses, unless specifically requested and approved by the Plan. Collier County Government Dental Plan-Group#2003021 11 Plan Document/SPD-Effective 1/1/2015 Packet Page-723- 1/27/2015 16.E.3. General Plan Exclusions and Limitations 44. Charges for the following treatments, services or supplies: A. Charges related to or connected with treatments, services or supplies that are excluded under this Plan. B. Charges that are the result of any complication resulting from a treatment,service or supply which is, or was at the time the charge was incurred, excluded from coverage under this Plan. 45. Charges for treatment, services or supplies not actually rendered to or received and used by the Covered Person. Collier County Government Dental Plan-Group#2003021 12 Plan Document/SPD-Effective 1/1/2015 9 Packet Page -724- 1/27/2015 16.E.3. COORDINATION OF BENEFITS The Coordination of Benefits provision prevents the payment of benefits which exceed the Allowable Expense. It applies when the Participant or Dependent who is covered by this Plan is or may also be covered by any other plan(s). This Plan will always pay either its benefits in full or a reduced amount which,when added to the benefits payable by the other plan(s),will not exceed 100%of the Allowable Expense. Only the amount paid by this Plan will be charged against the Plan maximums. In the event of a motor vehicle or premises accident;or an act of violence with the intent to disrupt electronic, communications, or any other business system, this Plan will be secondary to any auto "no fault" and traditional auto"fault"type contracts,homeowners,commercial general liability insurance and any other dental benefits coverage. The Coordination of Benefits provision applies whether or not a claim is filed under the other plan or plans. If needed,authorization is hereby given this Plan to obtain information as to benefits or services available from the other plan or plans, or to recover overpayments. All benefits contained in the Plan Document are subject to this provision. DEFINITIONS "Allowable Expense"as used herein means: 1. If the claim as applied to the primary plan is subject to a contracted or negotiated rate, Allowable Expense will be equal to that contracted or negotiated amount. 2. If the claim as applied to the primary plan is not subject to a contracted or negotiated rate, but the claim as applied to the secondary plan is subject to a contracted or negotiated rate, the Allowable Expense will be equal to that contracted or negotiated amount of the secondary plan. 3. If the claim as applied to the primary plan and the secondary plan is not subject to a contracted or negotiated rate, then the Allowable Expense will be equal to the secondary plan's chosen limits for non-contracted providers. "Plan"as used herein will mean any Plan providing benefits or services for or by reason of medical,dental or vision treatment, and such benefits or services are provided by: 1. Group insurance or any other arrangement for coverage for Covered Persons in a group whether on an insured or uninsured basis including, but not limited to: A. Hospital indemnity benefits; and B. Hospital reimbursement-type plans which permit the Covered Person to elect indemnity at the time of claims;or 2. Hospital, medical or dental service organizations on a group basis, group practice and other group pre-payment plans; or 3. Hospital, medical or dental service organizations on an individual basis having a provision similar in effect to this provision; or 4. A licensed Health Maintenance Organization(H.M.O.); or 5. Any coverage for students which is sponsored by,or provided through a school or other educational institution; or Collier County Government Dental Plan-Group#2003021 13 Plan Document/SPD-Effective 1/1/2015 Packet Page -725- I► 1/27/2015 16.E.3. Coordination of Benefits 6. Any coverage under a Governmental program,and any coverage required or provided by any statute; or 7. Automobile insurance; or 8. Individual automobile insurance coverage on an automobile leased or owned by the County or any responsible third-party tortfeasor; or 9. Individual automobile insurance coverage based upon the principles of"No-Fault"coverage; or 10. Homeowner or premise liability insurance, individual or commercial. "Plan"will be construed separately with respect to each policy,contract,or other arrangement for benefits or services,and separately with respect to that portion of any such policy,contract,or other arrangement which reserves the right to take the benefits or services of other Plans into consideration in determining its benefits and that portion which does not. ORDER OF BENEFIT DETERMINATION, 1. Non-Dependent/Dependent The plan that covers the person as other than a dependent, (e.g., as an employee, member, subscriber, retiree) is primary and the plan that covers the person as a dependent is secondary. 2. Child Covered Under More Than One Plan A. The primary plan is the plan of the parent whose birthday is earlier in the year if: 1) The parents are married; 2) The parents are not separated (whether or not they have ever been married); or 3) A court decree awards joint custody without specifying that one parent has the responsibility to provide health care coverage. B. If both parents have the same birthday,the plan that has covered either of the parents longer is primary. C., If the specific terms of a court decree state that one of the parents is responsible for the child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms,that plan is primary. If the parent with financial responsibility has no coverage for the child's health care services or expenses,but that parent's spouse does, the spouse's plan is primary. This subparagraph will not apply with respect to any claim determination period, Benefit Period or Plan Year during which benefits are paid or provided before the entity has actual knowledge. D. If the parents are not married or are separated(whether or not they were ever married)or are divorced, and there is no court decree allocating responsibility for the child's health care services or expenses,the order of benefit determination among the plans of the parents and the parents' spouses(if any)is: 1) The plan of the custodial parent. 2) The plan of the spouse of the custodial parent. 3) The plan of the non-custodial parent. 4) The plan of the spouse of the non-custodial parent. Collier County Government Dental Plan-Group#2003021 14 Plan Document 1 SPD-Effective 1/1/2015 i Packet Page -726- 1/27/2015 16.E.3. Coordination of Benefits 3. Active or Inactive Employee The Plan that covers a person as an employee who is neither laid-off nor retired (or as that employee's dependent) is primary. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule will not be followed. 4. Longer or Shorter Length of Coverage If the preceding rules do not determine the order of benefits,the plan that has covered the person for the longer period of time is primary. A. To determine the length of time a person has been covered under a plan,two plans will be treated as one if the Covered Person was eligible under the second within 24 hours after the first ended. B. The start of a new plan does not include: 1) A change in the amount or scope of a plan's benefits; 2) A change in the entity that pays, provides, or administers the plan's benefits; or 3) A change from one type of plan to another(such as from a single employer plan to that of a multiple-employer plan). C. A person's length of time covered under a plan is measured from the person's first date of coverage under that plan. If that date is not readily available for a group plan,the date the person first became a member of the group will be used as the date from which to determine the length of time the person's coverage under the present plan has been in force. 5. No Rules Apply If none of these preceding rules determines the primary plan, the Allowable Expense will be determined equally between the plans. COORDINATION WITH MEDICAID If a Covered Person is also entitled to and covered by Medicaid,the Plan will always be primary and Medicaid will always be secondary coverage. COORDINATION WITH TRICARE/CHAMPVA If a Covered Person is also entitled to and covered under TRICARE/CHAMPVA, the Plan will always be primary and TRICARE/CHAMPVA will always be secondary coverage. TRICARE coverage will include programs established under its authority, known as TRICARE Standard, TRICARE Extra and TRICARE Prime. If the Covered Person is eligible for Medicare and entitled to veterans benefits through the Department of Veterans Affairs(VA),the Plan will always be primary and the VA will always be secondary for non-service connected medical claims. For these claims, the Plan will make payment to the VA as though the Plan was making payment secondary to Medicare. Collier County Government Dental Plan-Group#2003021 15 Plan Document/SPD-Effective 1/1/2015 Packet Page -727- lk 1/27/2015 16.E.3. PROCEDURES FOR CLAIMING BENEFITS Claims must be submitted to the Plan within twelve (12) months after the date services or treatment are received or completed. Non-electronic claims may be submitted on any approved claim,available from the provider. The claim must be completed in full with all the requested information. A complete claim must include the following information: • Date of service; • Name of the Participant; • Name and date of birth of the patient receiving the treatment or service and his/her relationship to the Participant; • Diagnosis[code]of the condition being treated; • Treatment or service[code]performed; • Amount charged by the provider for the treatment or service; and • Sufficient documentation, in the sole determination of the Plan Administrator,to support the dental necessity of the treatment or service being provided and sufficient to enable the Plan Supervisor to adjudicate the claim pursuant to the terms and conditions of the Plan. When completed,the claim must be sent to the Plan Supervisor,Allegiance Benefit Plan Management, Inc., at P.O. Box 3018, Missoula, Montana 59806-3018, (855) 333-1004 or through any electronic claims submission system or clearinghouse to which Allegiance Benefit Plan Management, Inc. has access. In no event will any claim be considered for payment of benefits if it is initially submitted to the Plan more than twelve (12)months from the date that such claim was incurred. Upon termination of the Plan, final claims must be received within three (3) months of termination or such lesser time as is established by the Plan Administrator. CLAIMS WILL NOT BE DEEMED TO BE SUBMITTED UNTIL RECEIVED BY THE PLAN SUPERVISOR. The Plan will have the right, in its sole discretion and at its own expense,to require a claimant to undergo a dental examination,when and as often as may be reasonable,and to require the claimant to submit,or cause to be submitted,any and all dental and other relevant records it deems necessary to properly adjudicate the claim. CLAIM DECISIONS ON CLAIMS AND ELIGIBILITY Claims will be considered for payment according to the Plan's terms and conditions,industry-standard claims processing guidelines and administrative practices. The Plan may,when appropriate orwhen required by law, consult with relevant health care professionals and access professional industry resources in making decisions about claims that involve specialized dental knowledge or judgment. Initial eligibility and claims decisions will be made within the time periods stated below. For purposes of this section,"Covered Person"will include the claimant and the claimant's Authorized Representative;however,"Covered Person°does not include a health care provider or other assignee,and said health care provider or assignee does not have an independent right to appeal an Adverse Benefit Determination simply by virtue of the assignment of benefits. "Authorized Representative" means a representative authorized by the claimant to act on their behalf in pursuing a benefit claim or appeal of an Adverse Benefit Determination. The claimant must authorize the representative in writing,and this written authorization must be provided to the Plan. The Plan will recognize this Authorized Representative when the Plan receives the written authorization. Collier County Government Dental Plan-Group#2003021 16 Plan Document/SPD-Effective 1/1/2015 Packet Page -728- 1/27/2015 16.E.3. Procedures for Claiming Benefits In most cases,initial claims decisions on Post-Service Claims will be made within thirty(30)days of the Plan's receipt of the claim. The Plan will provide timely notice of the initial determination once sufficient information is received to make an initial determination, but no later than thirty(30)days after receiving the claim. Upon written notice to the Covered Person of the circumstances requiring an extension and the date by which the Plan expects to render a decision,this time period may be extended fifteen(15)days for reasons beyond the Plan's control. If the extension is necessary due to a failure of the claimant to submit information necessary to decide the claim, the extension notice will specifically describe the information needed, and the claimant will be afforded forty-five(45)days from receipt of the notice within which to provide the specified information. Once sufficient information is received to decide the claim, the Plan will provide timely notice of the determination after receiving sufficient information. APPEALING AN UN-REIMBURSED CLAIM If a claim is denied in whole or in part, the Covered Person will receive written notification of the Adverse Benefit Determination. A claim Explanation of Benefits(EOB)will be provided by the Plan showing: 1. The reason the claim was denied; 2. Reference(s)to the specific plan provision(s)or rule(s) upon which the decision was based which resulted in the Adverse Benefit Determination; 3. Any additional information needed to perfect the claim and why such information is needed; and 4. An explanation of the Covered Person's right to appeal the Adverse Benefit Determination for a full and fair review. If a Covered Person does not understand the reason for any Adverse Benefit Determination,he or she should contact the Plan Supervisor at the address or telephone number shown on the EOB form. The Covered Person must appeal the Adverse Benefit Determination before the Covered Person may exercise his or her right to bring a civil action under Section 502(a)of ERISA.This Plan provides two (2)levels of benefit determination review and the Covered Person must exercise both levels of review before bringing a civil action. A Covered Person has no more than one hundred eighty(180)days after an Adverse Benefit Determination to appeal the denial. When appealing an Adverse Benefit Determination,the Covered Person should include any additional information supporting the claim or the information required by the Plan which was not initially provided and forward it to the Plan Supervisor within the permitted time period. Failure to appeal the Adverse Benefit Determination within the permitted time period will render the determination final; appeals received after the permitted time period has expired will receive no further consideration. Appeals or requests for review of Adverse Benefit Determinations must be submitted to the Plan in writing to P.O.Box 1269,Missoula,MT 59806-1269. Supporting materials may be submitted via mail, electronic claims submission process,facsimile(fax)or electronic mail(e-mail). If a claimant requests review of an Adverse Benefit Determination,this Plan provides two(2)levels of benefit determination review. FIRST LEVEL OF BENEFIT DETERMINATION REVIEW The first level of benefit determination review is done by the Plan Supervisor. The Plan Supervisor will research the information initially received and determine if the initial determination was appropriate based on the terms and conditions of the Plan and other relevant information. Notice of the decision on the first level of review will be sent to the Covered Person within sixty(60) days following the date the Plan Supervisor receives the request for reconsideration. Collier County Government Dental Plan-Group#2003021 17 Plan Document/SPD-Effective 1/1/2015 Packet Page-729- 1/27/2015 16.E.3. Procedures for Claiming Benefits If, based on the Plan Supervisor's review, the initial Adverse Benefit Determination remains the same, the Covered Person has the right to a second level of review as stated below. To obtain a second level of review, the Covered Person must request the second review in writing and send it to the Plan Supervisor not later than sixty (60)days after receipt of the Plan Supervisor's decision from the first level of review. SECOND LEVEL OF BENEFIT DETERMINATION REVIEW The Plan Administrator will review the claim in question along with the additional information submitted by the Covered Person. The Plan will conduct a full and fair review of the claim by the Plan Administrator who is neither the original decisionmaker nor the decisionmaker's subordinate. The Plan Administrator cannot give deference to the initial benefit determination. The Plan Administrator may,when appropriate or if required by law,consult with relevant health care professionals in making decisions about appeals that involve specialized dental judgment. Where the appeal involves issues of dental necessity or experimental treatment,the Plan Administrator will consult with a health care professional with appropriate training who was neither the dental professional consulted in the initial determination or his or her subordinate. After a full and fair review of the Covered Person's appeal,the Plan will provide a written or electronic notice of the final benefit determination,within a reasonable time,but no later than sixty(60)days from the date the appeal is received by the Plan. Such notice will contain the same information as notices for the initial determination. All claim payments are based upon the terms and provisions contained in the Plan Document which is on file with the Plan Administrator and the Plan Supervisor. The Covered Person may also request,free of charge, more detailed information, names of any dental professionals consulted and copies of relevant documents, as defined in and required by law,which were used by the Plan to adjudicate the claim. Collier County Government Dental Plan-Group#2003021 18 Plan Document/SPD-Effective 1/1/2015 (.770 Packet Page-730- 1/27/2015 16.E.3. ELIGIBILITY PROVISIONS If both the husband and wife are employed by the County, and both are eligible for Dependent Coverage, either the husband or wife,but not both,may elect Dependent Coverage for their eligible Dependents. No one can be covered under this Plan as both an Employee and a Dependent. No one can be covered under this Plan as a Dependent by more than one Participant. EMPLOYEE ELIGIBILITY An Employee is eligible to participate in this Plan who is employed by the County and classified as regular full- time or part-time,as those terms are defined by the County,and are regularly scheduled to work a minimum of twenty (20) hours per week as a part-time Employee and a minimum of thirty(30) hours per week as a regular full-time Employee. An Employee is not eligible while on active military duty if that duty exceeds a period of thirty-one (31) consecutive days. WAITING PERIOD With respect to an eligible employee,coverage under the Plan will not start until the Employee completes a Waiting Period,which commences on the Enrollment Date(eligibility date)and will be either of the following: 1. If the Enrollment Date occurs on the first day of the month,the Waiting Period is waived;or 2. If the Enrollment Date occurs on any day other than the first day of the month,the Waiting Period will end on the first day of the month following the Enrollment Date. DEPENDENT ELIGIBILITY An eligible Dependent includes any person who is a citizen, resident alien,or is otherwise legally present in the United States or in any other jurisdiction that the related Participant has been assigned by the Employer, and who is either: 1. The Participant's legal spouse of the opposite sex,according to the marriage laws of the state where the marriage was first solemnized or established. An eligible Dependent does not include a spouse who is legally separated or divorced from the Participant and has a court order or decree stating such from a court of competent jurisdiction. 2. The Participant's Dependent child who meets all of the following"Required Eligibility Conditions": A. Is a natural child; step-child; legally adopted child; a child who has been Placed with the Participant for adoption and for whom as part of such placement the Participant has a legal obligation for the partial or full support of such child, including providing coverage under the Plan pursuant to a written agreement;a person for whom the Participant has been appointed the legal guardian by a court of competent jurisdiction prior to the person attaining nineteen (19)years of age; and B. Is less than twenty-six(26)years of age. A Dependent child is eligible until the end of the Calendar Year in which twenty-six(26)years of age is attained. This requirement is waived if the Participant's child is mentally handicapped/challenged or physically handicapped/challenged, provided that the child was incapable of self-supporting employment and was chiefly dependent upon the Participant for support and maintenance prior to end of the Calendar month in which he/she attained twenty-six(26)years of age. Proof of incapacity must be furnished to the Plan Administrator upon request,and additional proof may be required from time to time. Collier County Government Dental Plan-Group#2003021 19 Plan Document/SPD-Effective 1/1/2015 110 Packet Page -731- 1/27/2015 16.E.3. Eligibility Provisions PARTICIPANT ELIGIBILITY FOR DEPENDENT COVERAGE Each Employee will become eligible for Dependent Coverage on the latest of: 1) the date the Employee becomes eligible for Participant coverage;or 2)the date on which the Employee first acquires a Dependent. DECLINING COVERAGE If an eligible person declines coverage under this Plan, he/she will state his/her reason(s)for declining, in writing. Failure to provide those reasons in writing may result in the Plan refusing enrollment at a later date. Collier County Government Dental Plan-Group#2003021 20 Plan Document!SPD-Effective 1/1/2015 Packet Page -732- 1/27/2015 16.E.3. EFFECTIVE DATE OF COVERAGE All coverage under the Plan will commence at 12:01 A.M. in the time zone in which the Covered Person permanently resides, on the date such coverage becomes effective. PARTICIPANT COVERAGE Participant coverage under the Plan will become effective on the first day immediately after the Employee satisfies the applicable eligibility requirements and Waiting Period,provided that application for such coverage is made on the Plan's enrollment form within thirty-one(31)days immediately following the Enrollment Date. An eligible Employee who declines Participant coverage under the Plan during the Initial Enrollment Period will be able to become covered later in only two situations, Open Enrollment and Special Enrollment. DEPENDENT COVERAGE Each Participant who requests Dependent Coverage on the Plan's enrollment form will become covered for Dependent Coverage as follows: 1. On the Participant's effective date of coverage,if application for Dependent Coverage is made on the Plan's enrollment form within thirty-one(31)days immediately following the Participant's Enrollment Date. This subsection applies only to Dependents who are eligible on the Participant's effective date of coverage. 2. In the event a Dependent is acquired after the Participant's effective date of coverage as a result of a legal guardianship or in the event that a Participant is required to provide coverage as a result of a valid court order, or if the Dependent is acquired as a result of operation of law, Dependent Coverage will begin on the first day of the month following the Plan's receipt of an enrollment form and copy of said court order, if applicable. OPEN ENROLLMENT PERIOD The Open Enrollment Period will begin November 1st and will end as determined by the Plan Administrator. During any Open Enrollment Period an Employee and the Employee's eligible Dependents, who are not covered under this plan, may request Participant or Dependent coverage. Coverage must be requested on the Plan's enrollment form. Also during any Open Enrollment Period, Participants and their covered Dependents will be able to make a change in coverage under this Plan. Coverage or changes requested during any Open Enrollment Period will begin on January 1s`immediately following the Open Enrollment Period and will remain in effect until the next January 1st,except as otherwise allowed during a Special Enrollment Period. SPECIAL ENROLLMENT PERIOD In addition to other enrollment times allowed by this Plan, certain persons may enroll during the Special Enrollment Periods described below. "Special Enrollment Period"means a period of time allowed under this Plan,other than the eligible person's Initial Enrollment Period or an Open Enrollment Period,during which an eligible person can request coverage under this Plan as a result of certain events that create special enrollment rights. Coverage will become effective on the date of the event if the Employee makes a special enrollment request, verbally or in writing, within thirty-one (31) days of any special enrollment event and application for such coverage is made on the Plan's enrollment form within sixty (60) days of the event. Collier County Government Dental Plan-Group#2003021 21 Plan Document/SPD-Effective 1/1/2015 0 Packet Page-733- 1/27/2015 16.E.3. Effective Date of Coverage Any eligible Employee and any of their eligible Dependents may enroll and become covered as a result of the following specific events: 1. Marriage to the Employee; 2. Birth of the Employee's child; 3. Adoption of a child by the Employee, provided the child is under the age of 19; 4. Placement for Adoption with the Employee, provided such Employee has a legal obligation for the partial or full support of such child, including providing coverage under the Plan pursuant to a written agreement and the child is under the age of 19; 5. Coverage under Medicaid or any state children's insurance program recognized under the Children's Health Insurance Program Reauthorization Act of 2009 is terminated due to loss of eligibility; 6. The date any eligible Employee or any of their eligible Dependents becomes entitled to a Premium Assistance Subsidy authorized under the Children's Health Insurance Program Reauthorization Act of 2009. The date of entitlement shall be the date stated in the Premium Assistance Authorization entitlement notice issued by the applicable state agency (CHIP or Medicaid). A request for enrollment,either verbal or in writing,must be made within sixty(60)days after this special enrollment event,and written application for such coverage must be made in writing within ninety(90)days after such event. 7. Coverage under another health care plan or health insurance is terminated due to loss of eligibility or if employer contributions to the other coverage have been terminated(Loss of Coverage) Loss of Coverage means only one of the following: A. COBRA Continuation Coverage under another plan and the maximum period of COBRA Continuation Coverage under that other plan has been exhausted; or B. Group or insurance health coverage that has been terminated as a result of termination of Employer contributions*towards that other coverage; or C. Group or insurance health coverage(includes other coverage that is Medicare)that has been terminated only as a result of a loss of eligibility for coverage for any of the following: 1) Legal separation or divorce of the eligible Employee; 2) Cessation of Dependent status; 3) Death of the eligible Employee; 4) Termination of employment of the eligible Dependent; 5) Reduction in the number of hours of employment of the eligible Dependent; 6) Termination of the eligible Dependent's employer's plan; 7) Any loss of eligibility after a period that is measured by reference to any of the foregoing; or 8) Any loss of eligibility for individual or group coverage because the eligible Employee or Dependent no longer resides, lives or works in the service area of the HMO or other such plan. *Employer contributions include contributions by any current or former employer that was contributing to the other non-COBRA coverage. A loss of eligibility for coverage does not occur if coverage was terminated due to a failure of the Employee or Dependent to pay premiums on a timely basis or coverage was terminated for cause. CHANGE IN STATUS Collier County Government Dental Plan-Group#2003021 22 Plan Document!SPD-Effective 1/1/2015 Packet Page -734- 1/27/2015 16.E.3. Effective Date of Coverage If a Covered Dependent under this Plan becomes an eligible Employee of the County, he/she may continue his/her coverage as a Participant only. If an eligible Employee who is covered as a Participant of this Plan ceases to be an Employee of the County, but is eligible to be covered as a Dependent under another Employee/Participant, he/she may elect to continue his/her coverage as a Dependent of such Employee/Participant. Application for coverage due to a Change in Status must be made on the Plan's enrollment form,within thirty- one(31)days immediately following the date the Employee becomes or ceases to be an eligible Employee. A Change in Status will not be deemed to be a break or termination of coverage and will not operate to reduce or increase any coverage or accumulations toward satisfaction of the deductible and Out-of-Pocket Maximum to which the Covered Person was entitled prior to the Change in Status. Collier County Government Dental Plan-Group#2003021 23 Plan Document/SPD-Effective 1/1/2015 Packet Page -735- -- 1/27/2015 16.E.3. QUALIFIED MEDICAL CHILD SUPPORT ORDERS PROVISION PURPOSE Pursuant to Section 609(a)of ERISA,the Plan Administrator adopts the following procedures to determine whether Medical Child Support Orders are qualified in accordance with ERISA's requirements,to administer payments and other provisions under Qualified Medical Child Support Orders (QMCSOs), and to enforce these procedures as legally required. Employer adopts ERISA standards to comply with child support enforcement obligation of Part D of Title IV of the Social Security Act of 1975 as amended. DEFINITIONS For QMCSO requirements,the following definitions apply: 1. "Alternate Recipient" means any child of a Participant who is recognized under a Medical Child Support Order as having a right to enroll in this Plan with respect to the Participant. 2. "Medical Child Support Order"means any state or courtjudgment,decree or order(including approval of settlement agreement) issued by a court of competent jurisdiction, or issued through an administrative process established under State law and which has the same force and effect of law under applicable State law and: A. Provides for child support for a child of a Participant under this Plan; or B. Provides for health coverage for such a child under state domestic relations laws(including community property laws)and relates to benefits under this Plan;and C. Is made pursuant to a law relating to medical child support described in Section 1908 of the Social Security Act. 3. "Plan" means this self-funded Employee Health Benefit Plan, including all supplements and amendments in effect. 4. "Qualified Medical Child Support Order" means a Medical Child Support Order which creates (including assignment of rights) or recognizes an Alternate Recipient's right to receive benefits to which a Participant or Qualified Beneficiary is eligible under this Plan, and has been determined by the Plan Administrator to meet the qualification requirements as outlined under"Procedures"of this provision. CRITERIA FOR A QUALIFIED MEDICAL CHILD SUPPORT ORDER To be qualified, a Medical Child Support Order must clearly: 1. Specify the name and the last known mailing address (if any)of the Participant and the name and mailing address of each Alternate Recipient covered by the order,except that,to the extent provided in the order,the name and mailing address of an official of a State or a political subdivision thereof may be substituted for the mailing address of any such Alternate Recipient; and 2. Include a reasonable description of the type of coverage to be provided by the Plan to each Alternate Recipient, or the manner in which such type of coverage is to be determined; and 3. Specify each period to which such order applies. Collier County Government Dental Plan-Group#2003021 24 Plan Document!SPD-Effective 1/1/2015 Packet Page-736- 1/27/2015 16.E.3. Qualified Medical Child Support Orders Provision In order to be qualified,a Medical Child Support Order must not require the Plan to provide any type or form of benefits, or any option,not otherwise provided under the Plan except to the extent necessary to meet the requirements of Section1908 of the Social Security Act(relating to enforcement of state laws regarding child support and reimbursement of Medicaid). PROCEDURES FOR NOTIFICATIONS AND DETERMINATIONS In the case of any Medical Child Support Order received by this Plan: 1. The Plan Administrator will promptly notify the Participant and each Alternate Recipient of the receipt of such order and the plan's procedures for determining whether Medical Child Support Orders are qualified orders;and 2. Within a reasonable period after receipt of such order,the Plan Administrator will determine whether such order is a Qualified Medical Child Support Order and notify the Participant and each Alternate Recipient of such determination. NATIONAL MEDICAL SUPPORT NOTICE If the Plan Administrator of a group health plan which is maintained by the Employer of a non-custodial parent of a child, or to which such an employer contributes, receives an appropriately completed National Medical Support Notice as described in Section 401(b)of the Child Support Performance and Incentive Act of 1998 in the case of such child, and the Notice meets the criteria shown above for a qualified order,the Notice will be deemed to be a Qualified Medical Child Support Order in the case of such child. Collier County Government Dental Plan-Group#2003021 25 Plan Document!SPD-Effective 1/1/2015 Packet Page -737- 1/27/2015 16.E.3. FAMILY AND MEDICAL LEAVE ACT OF 1993 The Family and Medical Leave Act (FMLA) requires Employers who are subject to FMLA to allow their "eligible" Employees to take unpaid, job-protected leave. The Employer may also require or allo rf the Employee to substitute appropriate paid leave including, but not limited to, vacation and sick leave, Employee has earned or accrued it. The maximum leave required by FMLA is twelve(12)workweeks in any twelve(12)month period for certain family and medical reasons and a maximum combined total of twenty-six (26)workweeks during any twelve(12)month period for certain family and medical reasons and for a serious injury or illness of a member of the Armed Forces to allow the Employee,who is the spouse, son,daughter, parent,or next of kin to the member of the Armed Forces,to care for that member of the Armed Forces. In certain cases,this leave may be taken on an intermittent basis rather than all at once, or the Employee may work a part-time schedule. DEFINITIONS For these Family and Medical Leave Act of 1993 provisions only,the following definitions apply: 1. "Member of the Armed Forces" includes members of the National Guard or Reserves who are undergoing medical treatment, recuperation or therapy. 2. "Next of Kin"means the nearest blood relative to the service member. 3. "Parent"means Employee's biological parent or someone who has acted as Employee's parent in place of Employee's biological parent when Employee was a son or daughter. 4. "Serious health condition" means an illness, injury impairment, or physical or mental condition that involves: A. Inpatient care in a hospital, hospice,or residential medical facility;or B. Continuing treatment by a health care provider(a doctor of medicine or osteopathy who is authorized to practice medicine or surgery as appropriate, by the state in which the doctor practices or any other person determined by the Secretary of Labor to be capable of providing health care services). 5. member of the Armed Forces medically unfit to perform his or her military dutie that may render the duties. 6. "Son or daughter" means Employee's biological child, adopted child, stepchild, legal foster child, a child placed in Employee's legal custody, or a child for which Employee is acting as the parent in place of the child's natural blood related parent. The child must be: A. Under the age of eighteen(18); or B. Over the age of eighteen (18), but incapable of self-care because of a mental or physical disability. 7. "Spouse"means a husband or wife as defined or recognized under state law for purposes of marriage in the state where the employee resides,including"comm on law"marriage and same-sex marriage. Collier County Government Dental Plan-Group#2003021 26 Plan Document I SPD-Effective 11112015 Cel Packet Page-738- 1/27/2015 16.E.3. Family and Medical Leave Act of 1993 EMPLOYERS SUBJECT TO FMLA In general, FMLA applies to any employer engaged in interstate commerce or in any industry or activity affecting interstate commerce who employs 50 or more Employees for each working day during each of 20 or more calendar work weeks in the current or preceding Calendar Year. FMLA also applies to those persons described in Section 3(d)of the Fair Labor Standards Act,29 U.S.C.203(d). The FMLA applies to government entities, including branches of the United States government, state governments and political subdivisions thereof. ELIGIBLE EMPLOYEES Generally, an Employee is eligible for FMLA leave only if the Employee satisfies all of the following requirements as of the date on which any requested FMLA leave is to commence:(1)has been employed by the Employer for a total of at least twelve months(whether consecutive or not);(2)the Employee has worked (as defined under the Fair Labor Standards Act) at least 1,250 hours during the twelve-(12) month period immediately preceding the date the requested leave is to commence; (3)the Employee is employed in any state of the United States,the District of Columbia or any Territories or possession of the United States; and (4)at the time the leave is requested,the Employee is employed at a work site where 50 or more Employees are employed by the Employer within 75 surface miles of the work site. REASONS FOR TAKING LEAVE FMLA leave must be granted(1)to care for the Employee's newborn child; (2)to care for a child Placed For Adoption or foster care with the Employee;(3)to care for the Employee's spouse,son,daughter,or parent, who has a serious health condition; (4)because the Employee's own serious health condition prevents the Employee from performing his or her job; or(5) because of a qualifying exigency, as determined by the Secretary of Labor,arising out of the fact that a spouse,son,daughter or parent of the Employee is on active duty or has been called to active duty in the Armed Forces in support of a contingency operation(i.e., a war or national emergency declared by the President or Congress). ADVANCE NOTICE AND MEDICAL CERTIFICATION Ordinarily, an Employee must provide thirty (30) days advance notice when the requested leave is "foreseeable." If the leave is not foreseeable, the Employee must notify the Employer as soon as is practicable, generally within one to two working days. An employer may require medical certification to substantiate a request for leave requested due to a serious health condition. If the leave is due to the Employee's serious health condition,the Employer may require second or third opinions, at the Employer's expense, and a certification of fitness to return to work prior to allowing the Employee to return to work. PROTECTION OF JOB BENEFITS For the duration of FMLA leave, the Employer must maintain the Employee's health coverage under any "group health plan"on the same conditions as coverage would have been provided if the Employee had been in Active Service during FMLA leave period. Taking FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an Employee's leave,unless the loss would have occurred even if the Employee had been in Active Service. UNLAWFUL ACTS BY EMPLOYERS Employers cannot interfere with, restrain or deny the exercise of any right provided under the FMLA or to manipulate circumstances to avoid responsibilities under the FMLA. Employers may not discharge, or discriminate against any person who opposes any practice made unlawful by the FMLA or who may be involved in a proceeding under or relating to the FMLA. Collier County Government Dental Plan-Group#2003021 27 Plan Document 1 SPD-Effective 1/1/2015 Packet Page-739- 1/27/2015 16.E.3. Family and Medical Leave Act of 1993 ENFORCEMENT The U.S. Department of Labor is authorized to investigate and resolve complaints of FMLA violations. An eligible Employee may also bring a civil action against an employer for FMLA violations. The FMLA does not supersede any federal or state law prohibiting discrimination,and does not supersede any state or local law or collective bargaining agreement which provides greater family or medical leave rights. For additional information,contact the nearest office of Wage and Hour Division, listed in most telephone directories under U.S. Government, Department of Labor. Collier County Government Dental Plan-Group#2003021 28 Plan Document/SPD-Effective 1/1/2015 Packet Page-740- 1/27/2015 16.E.3. TERMINATION OF COVERAGE PARTICIPANT TERMINATION Participant coverage will automatically terminate immediately upon the earliest of the following dates,except as provided in any Continuation of Coverage Provision: 1. On the last day of the month in which the Participant's employment terminates; or 2. On the last day of the month in which the Participant ceases to be eligible for coverage;or 3. The date the Participant fails to make any required contribution for coverage;or 4. The date the Plan is terminated; or 5. The date the County terminates the Participant's coverage; or 6. The date the Participant dies; or 7. The date the Participant enters the armed forces of any country as a full-time member, if active duty is to exceed thirty-one(31)days;or 8. On the last day of the month in which the Plan receives the Plan's Health Coverage Waiver Form for the Participant. A Participant whose Active Service ceases because of Illness or Injury or as a result of any other approved leave of absence may remain covered as an Employee in Active Service for a period of twelve(12)weeks, or such other length of time that is consistent with and stated in the County's current Employee Personnel Policy Manual or pursuant to the Family and Medical Leave Act. Coverage under this provision will be subject to all the provisions of FMLA if the leave is classified as FMLA leave. If a Participant's coverage is to be continued during disability,approved leave of absence or temporary lay off, the amount of his or her coverage will be the same as the Plan benefits in force for an active Employee, subject to the Plan's right to amend coverage and benefits. DEPENDENT TERMINATION Each Covered Person, whether Participant or Dependent, is responsible for notifying the Plan Administrator, within sixty (60) days after loss of Dependent status due to death, divorce, legal separation or ceasing to be an eligible Dependent child. Failure to provide this notice may result in loss of eligibility for COBRA Continuation Coverage After Termination. Coverage for a Dependent will automatically terminate immediately upon the earliest of the following dates, except as provided in any Continuation of Coverage Provision: 1. On the last day of the month in which the Dependent ceases to be an eligible Dependent as defined in the Plan; or 2. On the last day of the month in which the Participant's coverage terminates under the Plan; or 3. On the last day of the month in which the Participant ceases to be eligible for Dependent Coverage; or 4. The date the Participant fails to make any required contribution for Dependent Coverage; or Collier County Government Dental Plan-Group#2003021 29 Plan Document/SPD-Effective 1/1/2015 101 Packet Page -741- 1/27/2015 16.E.3. Termination of Coverage 5. The date the Plan is terminated; or 6. The date the County terminates the Dependent's coverage;or 7. On the last day of the month in which the Participant dies; or 8. On the last day of the month in which the Plan receives the Plan's Health Coverage Waiver Form for the Dependent whose coverage is to be terminated. REINSTATEMENT OF COVERAGE An Employee whose coverage terminates by reason of termination of employment or reduction in hours and who again becomes eligible for coverage under the Plan will be treated like a new employee. n, Collier County Government Dental Plan-Group#2003021 30 Plan Document/SPD-Effective 1/1/2015 y Packet Page-742- 1/27/2015 16.E.3. CONTINUATION COVERAGE AFTER TERMINATION Under the Public Health Service Act,as amended, Employees and their enrolled Dependents may have the right to continue coverage beyond the time coverage would ordinarily have ended. The law applies to employers who normally employ twenty(20)or more Employees. The Plan Administrator is Collier County Government;3311 East Tamiami Trail,Building D,Naples,FL 34112; (239)252-8461. COBRA Continuation Coverage for the Plan is administered by Allegiance COBRA Services, Inc.; P.O. Box 2097; Missoula, MT 59806,406-721-2222. COBRA Continuation Coverage is available to any Qualified Beneficiary whose coverage would otherwise terminate due to any Qualifying Event. COBRA Continuation Coverage under this provision will begin on the first day following the date of the Qualifying Event. 1. Qualifying Events for Participants,for purposes of this section,are the following events,if such event results in a loss of coverage under this Plan: A. The termination(other than by reason of gross misconduct)of the Participant's employment. B. The reduction in hours of the Participant's employment. 2. Qualifying Events for covered Dependents,for purposes of this section are the following events, if such event results in a loss of coverage under this Plan: A. Death of the Participant. B. Termination of the Participant's employment. C. Reduction in hours of the Participant's employment. D. The divorce or legal separation of the Participant from his or her spouse. E. A covered Dependent child ceases to be a Dependent as defined by the Plan. NOTIFICATION RESPONSIBILITIES The Covered Person must notify the Employer of the following Qualifying Events within sixty(60)days after the date the event occurs. The Employer must notify the Plan Administrator of any of the following: 1. Death of the Participant. 2. The divorce or legal separation of the Participant from his or her spouse. 3. A covered Dependent child ceases to be a Dependent as defined by the Plan. The Employer must notify the Plan Administrator of the following Qualifying Events within thirty(30)days after the date of the event occurs: 1. Termination(other than by reason of gross misconduct)of the Participant's employment. 2. Reduction in hours of the Participant's employment. Collier County Government Dental Plan-Group#2003021 31 Plan Document/SPD-Effective 1/1/2015 i \ Packet Page-743- 1/27/2015 16.E.3. Continuation Coverage After Termination ELECTION OF COVERAGE When the Plan Administrator is notified of a Qualifying Event,the Plan Administrator will notify the Qualified Beneficiary of the right to elect continuation of coverage. Notice of the right to COBRA Continuation Coverage will be sent by the Plan no later than fourteen(14)days after the Plan Administrator is notified of the Qualifying Event. A Qualified Beneficiary has sixty(60)days from the date coverage would otherwise be lost or sixty(60)days from the date of notification from the Plan Administrator,whichever is later,to notify the Plan Administrator that he or she elects to continue coverage under the Plan. Failure to elect continuation within that period will cause coverage to end. MONTHLY PREMIUM PAYMENTS A Qualified I h Monthly onntnution of coverage must be paid n ad a e to the Plan Adm n strator. The p emim requi ed under the provisions of COBRA is as follows: 1. For a Qualified Beneficiary: The premium is the same as applicable to any other similarly situated non-COBRA Participant plus an additional administrative expense of up to a maximum of two percent (2%). 2. Social Security Disability: For a Qualified Beneficiary continuing coverage beyond eighteen (18) months due to a documented finding of disability by the Social Security Administration within 60 days after becoming covered under COBRA, the premium may be up to a maximum of 150% of the premium applicable to any other similarly situated non-COBRA Participant. 3. For a Qualified Beneficiary with a qualifying Social Security Disability who experiences a second Qualifying Event: A. If another Qualifying Event occurs during the initial eighteen (18) months of COBRA coverage, such as a death,divorce, legal separation,the monthly fee for qualified disabled person may be up to a maximum of one hundred and two percent(102%)of the applicable premium. B. If the second Qualifying Event occurs during the nineteenth (19t)through the twenty-ninth (29th) month(the Disability Extension Period),the premium for a Qualified Beneficiary may be up to a maximum of one hundred fifty percent(150%)of the applicable premium. Payment of claims while covered under this COBRA Continuation Coverage Provision will be contingent upon the receipt by the Employer of the applicable monthly premium for such coverage. The monthly premium for continuation coverage under this provision is due the first of the month for each month of coverage. A grace period of thirty(30)days from the first of the month will be allowed for payment. Payment will be made in a manner prescribed by the Employer. DISABILITY EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE If the Qualified Beneficiary who is covered under the Plan is determined by the Social Security Administration to be disabled at any time before the qualifying event or within sixty(60)days after the qualifying event,and the Plan Administrator is notified in a timely fashion,the Qualified Beneficiary covered under the Plan can receive up to an additional 11 months of COBRA Continuation Coverage,for a total maximum of 29 months. The Plan Administrator must be provided with a copy of the Social Security Administration's disability determination letter within sixty(60)days after the date of the determination and before the end of the original 18-month period of COBRA Continuation Coverage. This notice should be sent to: Allegiance COBRA Services, Inc.; P.O. Box 2097; Missoula, MT 59806. t!SPD-Effective 1/1/2015 {� Collier County Government Dental Plan-Group#2003021 32 Plan Document yam/ Packet Page -744- 1/27/201516.E.3. Continuation Coverage After Termination SECOND QUALIFYING EVENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE If another qualifying event occurs while receiving COBRA Continuation Coverage,the spouse and dependent children of the Employee can get additional months of COBRA Continuation Coverage,up to a maximum of thirty-six (36) months. This extension is available to the spouse and dependent children if the former employee dies or becomes divorced or legally separated. The extension is also available to a dependent child when that child stops being eligible under the Plan as a dependent child. in all of these cases,the Plan Administrator must be notified of the second qualifying event within sixty (60) days of the second qualifying event. This notice must be sent to: Allegiance COBRA Services, Inc.; P.O. Box 2097; Missoula,MT 59806. Failure to provide notice within the time required will result in loss of eligibility for COBRA Continuation Coverage. MEDICARE ENROLLMENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE The dependents of a former employee are eligible to elect COBRA Continuation Coverage if they lose coverage as a result of the former employee's enrollment in Part A or Part B of Medicare,whichever occurs earlier. When the former employee enrolls in Medicare before the Qualifying Event of termination, or reduction in hours, of employment occurs, the maximum period for COBRA Continuation Coverage for the spouse and dependent children ends on the later of: 1. Eighteen(18)months after the Qualifying Event of termination of employment or reduction in hours of employment; or 2. Thirty-six(36)months after the former employee's enrollment in Medicare. When the former employee enrolls in Medicare after the Qualifying Event of termination,or reduction in hours, of employment, the maximum period for COBRA Continuation Coverage for the spouse and dependent children ends eighteen(18)months after the Qualifying Event,unless a second Qualifying Event,as described above occurs within that eighteen(18)month period. WHEN COBRA CONTINUATION COVERAGE ENDS COBRA Continuation Coverage and any coverage under the Plan that has been elected with respect to any Qualified Beneficiary will cease on the earliest of the following: 1. On the date the Qualified Beneficiary becomes covered under another group health plan or health insurance. 2. On the date, after the date of election for COBRA Continuation Coverage, that the Qualified Beneficiary becomes enrolled in Medicare(either Part A or B). 3. On the first date that timely payment of any premium required under the Plan with respect to COBRA Continuation Coverage for a Qualified Beneficiary is not made to the Plan Administrator. 4. On the date the Employer ceases to provide any group health plan coverage to any Employee. 5. On the date of receipt of written notice that the Qualified Beneficiary wishes to terminate COBRA Continuation Coverage. 6. On the date that the maximum coverage period for COBRA Continuation Coverage ends,as follows: A. Eighteen (18) months for a former employee who is a Qualified Beneficiary as a result of termination, or reduction in hours,of employment; Collier County Government Dental Plan-Group#2003021 33 Plan Document/SPD-Effective 1/1/2015 Packet Page -745- 1/27/2015 16.E.3. Continuation Coverage After Termination fir.° B. Eighteen (18) months for a Dependent who is a Qualified Beneficiary unless a second Qualifying Event occurs within that eighteen month period entitling that Dependent to an additional eighteen (18)months; C. For the Dependent who is a Qualified Beneficiary as a result of termination, or reduction in hours,of employment of the former employee if that former employee enrolled in Medicare before termination, or reduction in hours,of employment,the later of eighteen (18)months from the Qualifying Event, or thirty-six (36) months following the date of enrollment in Medicare. D. On the first day of the month beginning thirty (30) days after a Qualified Beneficiary is determined to be no longer disabled by the Social Security Administration if the Qualified Beneficiary was found to be disabled on or within the first sixty(60)days of the date of the Qualifying Event and has received at least eighteen (18) months of COBRA Continuation Coverage. COBRA Continuation Coverage will also terminate on such date for all Dependents who are Qualified Beneficiaries as a result of the Qualifying Event unless that Dependent is entitled to a longer period of COBRA Continuation Coverage without regard to disability. E. Twenty-nine (29) months for any Qualified Beneficiary if a Disability Extension Period of COBRA Continuation Coverage has been granted for such Qualified Beneficiary. F. Thirty-six(36) months for all other Qualified Beneficiaries. 7. On the same basis that the Plan can terminate for cause the coverage of a similarly situated non- COBRA Participant. QUESTIONS Any questions about COBRA Continuation Coverage should be directed to Allegiance COBRA Services,Inc. or contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website at www.dol.00v/ebsa. INFORM THE PLAN OF ADDRESS CHANGES In order to protect the Employee's family's rights,the Employee should keep the Plan Administrator informed of any changes in the addresses of family members. The Employee should also keep a copy, for his/her records, of any notices sent to the Plan Administrator. Collier County Government Dental Plan-Group#2003021 34 Plan Document/SPD-Effective 1/112015 Packet Page -746- 1/27/2015 16.E.3. COVERAGE FOR A MILITARY RESERVIST To the extent required by the Uniform Services Employment and Reemployment Rights Act(USERRA),the following provisions will apply: 1. If a Participant is absent from employment with Employer by reason of service in the uniformed services,the Participant may elect to continue coverage under this Plan for himself or herself and his or her eligible Dependents as provided in this subsection. The maximum period of coverage under such an election will be the lesser of: A. The twenty-four(24)month period beginning on the date on which the Participants absence begins; or B. The the Participant Participant's absence the day a fter the date on which the failso apply for or return to a position of employment, as required by USERRA. 2. A Participant who elects to continue Plan coverage under this Section may be required to pay not more than one hundred two percent(102%)of the full premium under r the Plan( (determined in the e same manner as the applicable premium under Section 4980B(f)(4) 1986)associated with such coverage for the Employer's other Employees,except that in the case of a person who performs service in the uniformed services for less than thirty-one (31) days, such person may not be required to pay more than the regular Employee share,if any,for such coverage. 3. In the case of a Participant whose coverage under the Plan is terminated by reason of service in the uniformed services, a Waiting Period may not be imposed in connection with the reinstatement of such coverage upon reemployment if a Waiting Period would not have been imposed under the Plan had coverage of such person by the Plan not been terminated as a result of such service. This paragraph applies to the Employee who notifies the Employer of his or her intent to return to employment in a timely manner as defined by USERRA, and is reemployed and to any Dependent who is covered by the Plan by reason of the reinstatement of the coverage of such Employee. This provision will not apply to the coverage of any Illness or Injury determined by the Secretary of Veterans Affairs to have been caused by or aggravated during,performance of service in the uniformed services. • r u #2003021 35 Collier County Government Dental Plan Group Plan Document!SPD-Effective 1/112015 o Cq Packet Page -747- 1/27/2015 16.E.3. FRAUD AND ABUSE THIS PLAN IS SUBJECT TO FEDERAL ST THE PLANC STATE LAW MAY ALSO APPNY LTIES FOR FRAUDULENT ACTS COMMITTED AGAINST Anyone who knowingly defrauds or tries to defraud the Plan,or obtains Plan funds through false statements or fraudulent schemes,may be subject to criminal prosecution and penalties.The following may be considered fraudulent: 1. Falsifying eligibility criteria for a Dependent,such as marital status or age,to get or continue coverage for that Dependent when not otherwise eligible for coverage; 2. Falsifying or withholding dental history or information required to calculate benefits; 3. Falsifying or altering documents to get coverage or benefits; 4. Permitting a person not otherwise eligible for coverage to use a Plan ID card to get Plan benefits;or 5. Submitting a fraudulent claim or making untruthful statements to the Plan to get reimbursement from the Plan for services that may or may not have been provided to a Covered Person; The Plan Administrator, in its sole discretion, may take additional action against the Participant or Covered Person including,but not limited to,terminating the Participant or Covered Person's coverage under the Plan. MISSTATEMENT OF AGE If the Covered Person's age was misstated on an enrollment form or claim,the Covered Person's eligibility or amount of benefits,or both,will be adjusted to reflect the Covered Person's true age.If the Covered Person was not eligible for coverage under the Plan or for the amount of benefits received,the Plan has a right to recover any benefits paid by the Plan. A misstatement of age will not continue coverage that was otherwise properly terminated or terminate coverage that is otherwise validly in force. MISREPRESENTATION OF ELIGIBILITY If a Participant misrepresents a Dependent's marital status, age, full-time student status, dependent child relationship or other eligibility criteria to get coverage for that Dependent,when he or she would not otherwise be eligible, coverage for that Dependent will terminate as though never effective. MISUSE OF IDENTIFICATION CARD If a Covered Person permits any person who is not otherwise eligible as a Covered Person to use an ID card, the Plan Sponsor may, at the Plan Sponsor's sole discretion,terminate the Covered Person's coverage. REIMBURSEMENT TO PLAN Payment of benefits by the Plan for any person who was not otherwise eligible for coverage under this Plan but for whom benefits were paid based upon fraud as defined in this section must be reimbursed to the Plan by the Participant. Failure to reimburse the Plan upon request may result in an interruption or a loss of benefits by the Participant and Dependents. Plan Document/SPD-Effective 1/1/2015 Collier County Government Dental Plan-Group#2003021 36 t,-1O Packet Page-748- 1/27/2015 16.E.3. RECOVERY/REIMBURSEMENT/SUBROGATION By enrollment in this Plan,Covered Persons agree to the provisions of this section as a condition precedent to receiving benefits under this Plan. Failure of a Covered Person to comply with the requirements of this section may result in the Plan pending the payment of benefits. RIGHT TO RECOVER BENEFITS PAID IN ERROR If the Plan makes a payment in error to or on behalf of a Covered Person or an assignee of a Covered Person to which that Covered Person is not entitled,or if the Plan pays a claim that is not covered,the Plan has the right to recover the payment from the person paid or anyone else who benefitted from the payment. The Plan can deduct the amount paid from the Covered Person's future benefits,or from the benefits for any covered Family member even if the erroneous payment was not made on that Family member's behalf. Payment of benefits by the Plan for Participants' spouses, ex-spouses, or children, who are not eligible for coverage under this Plan,but for whom benefits were paid based upon inaccurate,false information provided by, or information omitted by,the Employee will be reimbursed to the Plan by the Employee. The Employee's failure to reimburse the Plan after demand is made,may result in an interruption in or loss of benefits to the Employee, and could be reported to the appropriate governmental authorities for investigation of criminal fraud. The Plan may recover such amount by any appropriate method that the Plan Administrator, in its sole discretion,will determine. The provisions of this section apply to any Physician or Licensed Health Care Provider who receives an assignment of benefits or payment of benefits under this Plan. If a Physician or Licensed Health Care Provider fails to refund a payment of benefits,the Plan may refuse to recognize future assignments of benefits to that provider. REIMBURSEMENT The Plan's right to Reimbursement is separate from and in addition to the Plan's right of Subrogation. If the Plan pays benefits for dental expenses on a Covered Person's behalf,and another party was responsible or liable for payment of those dental expenses,the Plan has a right to be reimbursed by the Covered Person for the amounts the Plan paid. Accordingly, if a Covered Person, or anyone on his or her behalf, settles, is reimbursed or recovers money from any person,corporation,entity,liability coverage, no-fault coverage,uninsured coverage,underinsured coverage,or other insurance policies or funds for any accident,Injury,condition or Illness for which benefits were provided by the Plan,the Covered Person agrees to hold the money received in trust for the benefit of the Plan. The Covered Person agrees to reimburse the Plan,in first priority,from any money recovered from a liable third party,for the amount of all money paid by the Plan to the Covered Person or on his or her behalf or that will be paid as a result of said accident, Injury,condition or Illness. Reimbursement to the Plan will be paid first, in its entirety, even if the Covered Person is not paid for all of his or her claim for damages and regardless of whether the settlement,judgment or payment he or she receives is for or specifically designates the recovery,or a portion thereof, as including health care,dental,disability or other expenses or damages. SUBROGATION The Plan's right to Subrogation is separate from and in addition to the Plan's right to Reimbursement. Subrogation is the right of the Plan to exercise the Covered Person's rights and remedies in order to recover from any third party who is liable to the Covered Person for a loss or benefits paid by the Plan. The Plan may proceed through litigation or settlement in the name of the Covered Person,with or without his or her consent, to recover benefits paid under the Plan. 1.3 Effective 1!1!2015!SPD- Collier County Government Dental Plan-Group#2003021 37 Plan Document `C4t Packet Page -749- 1/27/2015 16.E.3. Recovery/Reimbursement/Subrogation The Covered Person agrees to subrogate to the Plan any and all claims,causes of action or rights that he or she has or that may arise against any entity who has or may have caused, contributed to or aggravated the accident,Injury,condition or Illness for which the Plan has paid benefits,and to subrogate any claims,causes of action or rights the Covered Person may have against any other coverage including, but not limited to, liability coverage, no-fault coverage,uninsured motorist coverage,underinsured motorist coverage,or other insurance policies, coverage or funds. In the event that a Covered Person decides not to pursue a claim against any third party or insurer, the Covered Person will notify the Plan, and specifically authorize the Plan, in its sole discretion, to sue for, compromise or settle any such claims in the Covered Person's name,to cooperate fully with the Plan in the prosecution of the claims, and to execute any and all documents necessary to pursue those claims. The Following Paragraphs Apply to Both Reimbursement and Subrogation: 1. Under the terms of this Plan, the Plan Supervisor is not required to pay any claim where there is evidence of liability of a third party unless the Covered Person signs the Plan's Third-Party Reimbursement Agreement and follows the requirements of this section. However,the Plan, in its discretion, may instruct the Plan Supervisor not to withhold payment of benefits while the liability of a party other than the Covered Person is being legally determined. If a repayment agreement is requested to be signed, the Plan's right of recovery through Reimbursement and/or Subrogation remains in effect regardless of whether the repayment agreement is actually signed. 2. If the Plan makes a payment which the Covered Person,or any other party on the Covered Person's behalf,is or may be entitled to recover against any liable third party,this Plan has a right of recovery, through reimbursement or subrogation or both,to the extent of its payment. 3. The Covered Person will cooperate fully with the Plan Administrator, its agents, attorneys and assigns, regarding the recovery of any benefits paid by the Plan from any liable third party. T cooperation includes, but is not limited to, make full and complete disclosure in a timely manner of all material facts regarding the accident, Injury,condition or Illness to the Plan Administrator; report all efforts by any person to recover any such monies;provide the Plan Administrator with any and all requested documents, reports and other information in a timely manner, regarding any demand, litigation or settlement involving the recovery of benefits paid by the Plan; and notify the Plan Administrator of the amount and source of funds received from third parties as compensation or damages for any event from which the Plan may have a reimbursement or subrogation claim. 4. Covered Persons will respond within ten(10)days to all inquiries of the Plan regarding the status of any claim they may have against any third parties or insurers including,but not limited to,liability,no- fault, uninsured and underinsured insurance coverage. The Covered Person will notify the Plan immediately of the name and address of any attorney whom the Covered Person engages to pursue any personal Injury claim on his or her behalf. 5. The Covered Person will not act,fail to act,or engage in any conduct directly, indirectly,personally or through third parties,either before or after payment by the Plan,the result of which may prejudice or interfere with the Plan's rights to recovery hereunder. The Covered Person will not conceal or attempt to conceal the fact that recovery has occurred or will occur. 6. The Plan will not pay or be responsible,without its written consent,for any fees or costs associated with a Covered Person pursuing a claim against any third party or coverage including,but not limited to, attorney fees or costs of litigation. Monies paid by the Plan will be repaid in full, in first priority, notwithstanding any anti-subrogation, "made whole,""common fund"or similar statute, regulation, prior court decision or common law theory unless a reduction or compromise settlement is agreed to in writing or required pursuant to a court order or as limited by Florida state law. Collier County Government Dental Plan-Group#2003021 38 Plan Document/SPD-Effective 1/1/2015 Cg Packet Page-750- 1/27/2015 16.E.3. PLAN ADMINISTRATION PURPOSE The purpose of the Plan Document is to set forth the provisions of the Plan which provide for the payment or reimbursement of all or a portion of Eligible Expenses for dental services. The terms of this Plan are legally enforceable and the Plan is maintained for the exclusive benefit of eligible Employees and their covered Dependents. EFFECTIVE DATE The effective date of the Plan is January 1, 2015. PLAN YEAR • The Plan Year will commence January 181 and end on December 31"of each year. PLAN SPONSOR The Plan Sponsor is Collier County Government. PLAN SUPERVISOR The Supervisor of the Plan is Allegiance Benefit Plan Management, Inc. NAMED FIDUCIARY AND PLAN ADMINISTRATOR The Named Fiduciary is Collier County Government, a political subdivision of the State of Florida,who has the authority to control and manage the operation and administration of the Plan. The Plan Administrator will have the authority to amend the Plan,to determine its policies,to appoint and remove other service providers of the Plan,to fix their compensation(if any),and exercise general administrative authority over them and the Plan. The Plan Administrator has the sole authority and responsibility to review and make final decisions on all claims to benefits hereunder. The Plan Administrator may delegate responsibilities for the operation and administration of the Plan. The authority to perform the day to day Plan Administration duties as described in this paragraph is delegated to the Director, Risk Management (the designee), or his or her equivalent, whichever is applicable, of the County. The Director, Risk Management may temporarily delegate these responsibilities,as needed. This delegation shall not include the final selection of a Plan Supervisor,Actuarial firm,Benefits Consulting firm,or Reinsurance Stop Loss Carrier. This delegation shall include the review and approval of weekly claims disbursements reports and check registers presented to the Plan Administrator by the Plan Supervisor. PLAN INTERPRETATION The Named Fiduciary and the Plan Administrator have full discretionary authority to interpret and apply all Plan provisions including,but not limited to,resolving all issues concerning eligibility and determination of benefits. The Plan Administrator may contract with an independent administrative firm to process claims,maintain Plan data,and perform other Plan-connected services. Final authority to interpret and apply the provisions of the Plan rests exclusively with the Plan Administrator. Decisions of the Plan Administrator made in good faith will be final and binding. Collier County Government Dental Plan Group#2003021 39 Plan Document/SPD-Effective 1/1/2015 441111) CAC) Packet Page-751- 1/27/2015 16.E.3. Plan Administration ems'.. CONTRIBUTIONS TO THE PLAN The amount of contributions to the Plan are to be made on the following basis: The County will periodically evaluate the costs of the Plan and determine the amount to be contributed by the County,if any,and the amount to be contributed, if any, by each Participant. If the County terminates the Plan,the County and Participants will have no obligation to contribute to the Plan after the date of termination. PLAN AMENDMENTS/MODIFICATION/TERMINATION The Plan Document contains all the terms of the Plan and may be amended at any time by the Plan Administrator. Any changes will be binding on each Participant and on any other Covered Persons referred the to in this Plan Document. The authority to amend the Plan is delegated by the o Plan Administrator such Director, Risk Management, or his or her equivalent, whichever is app' amendment,modification,revocation or termination of the Plan will be authorized and signed by the Director, Risk Management,or his or her equivalent,whichever is applicable,of the County,pursuant to a resolution, granting that individual the authority to amend,modify,revoke or terminate this Plan. A copy of the executed policy will be supplied to the Plan Supervisor. Written notification of any amendments, modifications, revocations or terminations will be given to Plan Participants at least sixty(60)days prior to the effective date, except for amendments effective on the first day of a new Plan Year,for which thirty(30)days advance notice is required. NOTICE OF REDUCTION OF BENEFITS All changes or amendments to this Plan that directly or indirectly reduce any benefit or coverage under the Plan, including any increase in contribution for coverage required from a Participant,will be reported to all eligible Participants and Dependents within sixty(60)days of the date such change or amendment is adopted. TERMINATION OF PLAN The County reserves the right at any time to terminate the Plan by a written notice. All previous contributions by the County will continue to be issued for the purpose of paying benefits and fixed costs under provisions of this Plan with respect to claims arising before such termination,or will be used for the purpose of providing similar health benefits to Participants, until all contributions are exhausted. SUMMARY PLAN DESCRIPTIONS Each Participant covered under this Plan will be issued a Summary Plan Description(SPD)describing the benefits to which the Covered Persons are entitled,the required Plan procedures for eligibility and claiming benefits,the limitations and exclusions of the Plan and summarizing the provisions of the Plan. Collier County Government Dental Plan-Group#2003021 40 Plan Document/SPD-Effective 1/1/2015 AO Packet Page-752- 1/27/2015 16.E.3. • GENERAL PROVISIONS EXAMINATION, The Plan will have the right and opportunity to have the Covered Person examined whenever Injury or Illness is the basis of a claim hereunder when and so often as it may reasonably require during pendency of the claim hereunder. The Plan will also have the right and opportunity to have an autopsy performed in case of death where it is not forbidden by law. PAYMENT OF CLAIMS All Plan benefits are payable to a Participant, Qualified Beneficiary or Alternate Recipient, whichever is applicable. All or a portion of any benefits payable by the Plan may, at the Covered Person's option and unless the Covered Person requests otherwise in writing not later than the time of filing the claim, be paid directly to the health care provider rendering the service,if proper written assignment is provided to the Plan. No payments will be made to any provider of services unless the Covered Person is liable for such expenses. If any benefits remain unpaid at the time of the Covered Person's death or if the Covered Person is a minor or is,in the opinion of the Plan,legally incapable of giving a valid receipt and discharge for any payment,the Plan may,at its option,pay such benefits to the Covered Person's legal representative or estate. The Plan, in its sole option, may require that an estate, guardianship or conservatorship be established by a court of competent jurisdiction prior to the payment of any benefit. Any payment made under this subsection will constitute a complete discharge of the Plan's obligation to the extent of such payment and the Plan will not be required to oversee the application of the money so paid. LEGAL PROCEEDINGS No action at law or equity will be brought to recover on the Plan prior to the expiration of sixty(60)days after proof of loss has been filed in accordance with the requirements of the Plan,nor will such action be brought at all unless brought within three(3)years from the expiration of the time within which proof of loss is required by the Plan. NO WAIVER OR ESTOPPEL No term, condition or provision of this Plan will be waived, and there will be no estoppel against the enforcement of any provision of this Plan,except by written instrument of the party charged with such waiver or estoppel. No such written waiver will be deemed a continuing waiver unless specifically stated therein,and each such waiver will operate only as to the specific term or condition waived and will not constitute a waiver of such term or condition for the future or as to any act other than that specifically waived. VERBAL STATEMENTS Verbal statements or representations of the Plan Administrator, its agents and Employees, or Covered Persons will not create any right by contract, estoppel, unjust enrichment, waiver or other legal theory regarding any matter related to the Plan,or its administration,except as specifically stated in this subsection. No statement or representation of the Plan Administrator,its agents and Employees,or Covered Persons will be binding upon the Plan or a Covered Person unless made in writing by a person with authority to issue such a statement. This subsection will not be construed in any manner to waive any claim,right or defense of the Plan or a Covered Person based upon fraud or intentional material misrepresentation of fact or law. FREE CHOICE OF DENTAL SERVICE PROVIDER The Covered Person will have free choice of any licensed Dental Service Provider and the patient-provider relationship will be maintained. Group#2003021 41 Plan Document/SPD-Effective 1/112015 Cotner County Government Dental Plan p e Packet Page -753- • 1/27/2015 16.E.3. General Provisions '116rrr WORKERS'COMPENSATION NOT AFFECTED This Plan is not in lieu of, supplemental to Workers'Compensation and does not affect any requirement for coverage by Workers'Compensation Insurance. CONFORMITY WITH LAW If any provision of this Plan is contrary to any law to which it is subject, such provision is hereby amended to law will be the to conform;alltother parts applicable of the Plan will remain n full force and effectry to applicable MISCELLANEOUS Section titles are for convenience of reference only, and are not to be considered in interpreting this Plan. No failure to enforce any provision of this Plan will affect the right thereafter to enforce such provision,nor will such failure affect its right to enforce any other provision of the Plan. FACILITY OF PAYMENT Whenever payments which should have been made under this Plan in accordance with this provision have been made under any other plan or plans, the Plan will have the right, exercisable alone and in its sole discretion,to pay to any insurance company or other organization or person making such other payments any benefits paid eunder this lPlan and to the extent of such payments,the Plan will be fully discharged from liabilty under this Plan. The benefits that are payable will be charged against any applicable maximum payment or benefit of this Plan rather than the amount payable in the absence of this provision. PROTECTION AGAINST CREDITORS No benefit payment under this Plan will be subject in any way to alienation,sale,transfer,pledge,attachment, garnishment,execution or encumbrance of any kind, and any attempt to accomplish the same will be void, except an assignment of payment to a provider of Covered Services. If the Plan Administrator finds that such an attempt has been made with respect to any payment due or which will become due to any Participant,the Plan Administrator,in its sole discretion,may terminate the interest of such Participant or former Participant in such payment. In such case,the Plan Administrator will apply the amount of such payment to or for the benefit of such Participant or covered Dependents or former Participant, as the Plan Administrator may determine. Any such application will be a complete discharge of all liability of the Plan with respect to such benefit payment. PLAN IS NOT A CONTRACT The Plan Document constitutes the primary authority for plan administration. The establishment, administration and maintenance of this Plan will not be deemed to constitute a contract of employment, give any Participant of the County the right to be retained in the service of the County,or to interfere with the right of the County to discharge or otherwise terminate the employment of any Participant. /SPD-Effective 1/1/2015 Collier County Government Dental Plan-Group#2003021 42 Plan Document 1C n Packet Page -754- 1 1/27/2015 16.E.3. GENERAL DEFINITIONS Certain words and phrases in this Plan Document are defined below. If the defined term is not used in this document,the term does not apply to this Plan. Masculine pronouns used in this Plan Document will include either the masculine or feminine gender unless the context indicates otherwise. Any words used herein in the singular or plural will include the alternative as applicable. ACTIVE SERVICE "Active Service"means that an Employee is in service with the County on a day which is one of the County's regularly scheduled work days and that the Employee is performing all of the regular duties of his/her employment with the County on a regular basis, either at one of the County's business establishments or at some location to which the County's business requires him/her to travel. ADVERSE BENEFIT DETERMINATION "Adverse Benefit Determination"means any of the following:a denial,reduction,or termination of,or a failure to provide or make payment,in whole or in part,for a benefit,including any such denial,reduction,termination, or failure to provide or make payment that is based on a determination of a Participant's or beneficiary's eligibility to participate in the Plan, and including,with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part,for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental or Investigational or not Dentally Necessary or appropriate. "`R AMBULATORY SURGICAL CENTER "Ambulatory Surgical Center" (also called same-day surgery center or outpatient surgery center) means a licensed establishment with an organized staff of physicians and permanent facilities,either freestanding or as a part of a hospital,equipped and operated primarily for the purpose of performing surgical procedures and which a patient is admitted to and discharged from within a twenty-four(24)hour period. Such facilities must provide continuous physician and registered nursing services whenever a patient is in the facility. An Ambulatory Surgical Center must meet any requirements for certification or licensing for surgical facilities in the state in which the facility is located. "Ambulatory Surgical Center" does not include an office or clinic maintained by a dentist or physician for the practice of dentistry or medicine,a hospital emergency room or trauma center. BENEFIT PERCENTAGE "Benefit Percentage" means that portion of Eligible Expenses payable by the Plan, which is stated as a percentage in the Schedule of Benefits. BENEFIT PERIOD "Benefit Period"refers to a time period of one year,which is either a Calendar Year or Plan Year, as shown in the Schedule of Benefits. Such Benefit Period will terminate on the earliest of the following dates: 1. The last day of the one year period so established; or 2. The date the Plan terminates. Collier County Government Dental Plan-Group#2003021 43 Plan Document!SPD-Effective 1/1/2015 CA Packet Page -755- 1 I 1/27/2015 16.E.3. General Definitions CALENDAR YEAR "Calendar Year"means a period of time commencing on January 1 and ending on December 31 of the same year. CLOSE RELATIVE "Close Relative" means the spouse, parent, brother, sister, child, or in-laws of the Covered Person. COBRA "COBRA"means Sections 2201 through 2208 of the Public Health Service Act[42 U.S.C.§300bb-1 through §300bb-8],which contains provisions similar to Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. COBRA CONTINUATION COVERAGE "COBRA Continuation Coverage"means continuation coverage provided under the provisions of the Public Health Service Act referenced herein under the definition of"COBRA". COSMETIC "Cosmetic" means services or treatment ordered or performed solely to change a Covered Person's appearance rather than for the restoration of bodily function. COUNTY "County"means Collier County Government or any affiliated agencies or boards that have adopted this Plan for its Employees. COVERED PERSON "Covered Person" means any Participant or Dependent of a Participant meeting the eligibility requirements for coverage and properly enrolled for coverage as specified in the Plan. DEDUCTIBLE "Deductible"means a specified dollar amount of Eligible Expenses that must be incurred before the Plan will pay any amount for any Eligible Expense during each Benefit Period. DENTAL HYGIENIST "Dental Hygienist' means a person who is licensed to practice dental hygiene and who works under the supervision and direction of a Dentist. DENTALLY NECESSARY "Dentally Necessary"means treatment,tests,services or supplies provided by a Hospital,Physician,or other Licensed Health Care Provider which are not excluded under this Plan and which meet all of the following criteria: 1. Are to treat or diagnose a Dental condition or dental disease;and 2. Are ordered by a Dentist or Licensed Health Care Provider and are consistent with the symptoms or diagnosis and treatment of the dental condition or dental disease; and Collier County Government Dental Plan-Group#2003021 44 Plan Document/SPD-Effective 1/1/2015 Packet Page-756- 1/27/2015 16.E.3. General Definitions 3. Are not primarily for the convenience of the Covered Person, Dentist or other Licensed Health Care Provider;and 4. Are the standard or level of services most appropriate for good dental practice that can be safely provided to the Covered Person; and 5. Are not of an Experimental/Investigational or solely educational nature; and 6. Are not provided primarily for dental, medical or other research; and 7. Do not involve excessive, unnecessary or repeated tests; and 8. Are commonly and customarily recognized by the dental profession as appropriate in the treatment or diagnosis of the diagnosed condition; and 9. Are approved procedures or guidelines by the Food and Drug Administration,Healthcare Financing Administration(HCFA),the American Dental Association,pursuant to that entity's program oversight authority based upon the dental treatment circumstances. DENTIST "Dentist"means a person holding one of the following degrees—Doctor of Dental Science, Doctor of Medical Dentistry, Master of Dental Surgery or Doctor of Medicine(oral surgeon)—who is legally licensed as such to practice dentistry in the jurisdiction where services are rendered, and the services rendered are within the scope of his or her license. A"Dentist°will not include the Covered Person or any Close Relative of the Covered Person who does not regularly charge the Covered Person for services. DENTURIST A dental technician, duly licensed, specializing in the making and fitting of dentures. DEPENDENT "Dependent" means a person who is eligible for coverage under the Dependent Eligibility subsection of this Plan. DEPENDENT COVERAGE "Dependent Coverage"means eligibility for coverage under the terms of the Plan for benefits payable as a consequence of Eligible Incurred Expenses for a dental condition or dental disease of a Dependent. ELIGIBILITY DATE "Eligibility Date" means that first day of the first week during which the Employee is regularly scheduled to work the number of hours per week required by this Plan to become eligible for coverage. ELIGIBLE EXPENSES "Eligible Expenses"means the maximum amount of any charge for a covered service,treatment or supplies listed as Covered Services and that are not specifically excluded by the Plan and which meet all the requirements outlined in the Covered Expenses provision may be considered for payment by the Plan, including any portion of that charge that may be applied to the Deductible. Eligible Expenses are equal to the actual billed charge or UCR,whichever is less. Collier County Government Dental Plan-Group#2003021 45 Plan Document!SPD-Effective 1/1/2015 LC/D'S Packet Page -757- 1/27/2015 16.E.3. General Definitions Ssk EMPLOYEE "Employee"means a person employed by the Employer on a continuing and regular basis who is a common- law Employee and who is on the Employer's W-2 payroll. Employee does not include any employee leased from another employer including,but not limited to, those individuals defined in Internal Revenue Code Section 414(n),or an individual classified by the Employer as a contract worker, independent contractor,temporary employee or casual employee, whether or not any such persons are on the Employer's W-2 payroll,or any individual who performs services for the Employer but who is paid by a temporary or other employment agency such as "Kelly," "Manpower,"etc. EMPLOYER "Employer"means Collier County Government or any affiliated agencies or boards that have adopted this Plan for its Employees. ERISA The term"ERISA" refers to the Employee Retirement Income Security Act of 1974,as amended. EXPERIMENTAL/INVESTIGATIONAL "Experimental/Investigational" means: 1. Any drug or device that cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished;or 2. The services,supplies,treatments or procedures are not recognized in the dental community as an accepted standard of dental care or not dentally necessary for the diagnosis and/or treatment of an active dental condition or dental disease; or 3. Any drug, device, dental treatment or procedure for which the patient informed consent document utilized with the drug, device, treatment or procedure,was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function,or if federal law requires such review or approval; or 4. Based upon Reliable Evidence,any drug, device,treatment or procedure that is the subject of on- going Phase I or Phase II clinical trials,is the research,Experimental,study or investigational arm of on-going Phase III clinical trials, or is otherwise under ongoing study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with generally dentally accepted means of treatment or diagnosis;or 5. Based upon Reliable Evidence,any drug,device,treatment or procedure that the prevailing opinion among experts 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 generally accepted means of treatment or diagnosis;or 6. Any drug,device,treatment or procedure used in a manner outside the scope of use for which it was approved by the FDA or other applicable regulatory authority(U.S.Department of Health,Health Care Financing Administration,American Dental Association,American Medical Association). "Reliable Evidence"means only reports and articles published in authoritative medical and scientific literature; the written protocol or protocols used by a treating facility or the protocol(s) of another facility studying substantially the same drug,device,treatment or procedure;or the informed consent document used by the treating facility or by another facility studying substantially the same drug,device,treatment or procedure. t!SPD-Effective 1/1/2015 Collier County Government Dental Plan-Group#2003021 46 Plan Document ?(TS) Packet Page -758- 1/27/2015 16.E.3. General Definitions FAMILY "Family"means a Participant and his or her eligible Dependents as defined herein. FMLA "FMLA"means Family and Medical Leave Act. HOSPITAL "Hospital" means an institution which meets all of the following conditions: 1. It is engaged primarily in providing dental care and treatment to ill and injured persons on an Inpatient basis at the patient's expense;and 2. It is licensed as a Hospital under authority of the laws of the jurisdiction in which the facility is physically located;and 3. It maintains on its premises all the facilities necessary to provide for the diagnosis and dental and surgical treatment of an Illness or an Injury; and 4. It provides treatment for compensation by or under the supervision of Physicians with continuous twenty-four(24)hour nursing services by Registered Nurses(R.N.'s); and 5. It is a provider of services under Medicare. This condition is waived for otherwise Eligible Incurred Expenses outside of the United States;and 6. It is not,other than incidentally,a place for rest,a place for the aged,a place for drug addicts,a place for alcoholics, or a nursing home. ILLNESS "Illness"means a bodily disorder,Pregnancy,disease,physical sickness,mental illness,or functional nervous disorder of a Covered Person. INCURRED EXPENSES OR EXPENSES INCURRED "Incurred Expenses" or "Expenses Incurred" means those services and supplies rendered to a Covered Person. Such expenses will be considered to have occurred at the time or date the treatment, service or supply is actually provided. INITIAL ENROLLMENT PERIOD "Initial Enrollment Period" means the time allowed by this Plan for enrollment when a person first becomes eligible for coverage. INJURY "Injury" means physical damage to the Covered Person's natural teeth or gums sustained as a result of an external force or forces and which is not caused by disease or bodily infirmity. LATE ENROLLMENT OR LATE ENROLLEE "Late Enrollment" or "Late Enrollee" means an eligible person who makes application for Participant or Dependent Coverage under this Plan other than during the Initial Enrollment Period or any other enrollment opportunity provided under the terms of this Plan. v Collier County Government Dental Plan-Group#2003021 47 Plan Document/SPD-Effective 1/1/2015 Packet Page-759- 1/27/2015 16.E.3. General Definitions LICENSED HEALTH CARE PROVIDER "Licensed Health Care Provider"means any provider of health care services who is licensed or certified by any applicable regulatory authority to the extent that services are within the scope of its license or certification and are not specifically excluded by this Plan. MAXIMUM LIFETIME BENEFIT "Maximum Lifetime Benefit"means the maximum benefit payable while a person is covered under this Plan. It will not be construed as providing lifetime coverage, or benefits for a person's Dental condition or dental disease after coverage terminates under this Plan. MEDICAID "Medicaid" means that program of dental care and coverage established and provided by Title XIX of the Social Security Act, as amended. MEDICARE "Medicare"means the programs established under the"Health Insurance for the Aged Act,"Public Law 89-97 under Title XVIII of the Federal Social Security Act, as amended,to pay for various medical expenses for qualified individuals,specifically those age 65 or older,those with end-stage renal disease,or with disabilities. NAMED FIDUCIARY "Named Fiduciary"means the Plan Administrator which has the authority to control and manage the operation and administration of the Plan. NATURAL TEETH "Natural Teeth"means any tooth or part of a tooth that is organic and formed by the natural development for the body(i.e.,not manufactured). Organic portions of a tooth include the crown enamel and dentin,the root cementum and dentin,and the enclosed pulp(nerve). ORTHODONTIC TREATMENT "Orthodontic Treatment"means an appliance or the surgical or functional/myofunctional treatment of dental irregularities which either result from abnormal growth and development of the teeth, gums or jaws, or from Injury which requires the positioning of the teeth to establish normal occlusion. PARTICIPANT "Participant"means an Employee of the County who is eligible and enrolled for coverage under this Plan. PLACEMENT OR BEING PLACED FOR ADOPTION "Placement"or"Being Placed for Adoption"means the assumption and retention of a legal obligation for total or partial support of a child by a person with whom the child has been placed in anticipation of the child's adoption. The child's placement for adoption with such person ends upon the termination of such legal obligation. PLAN "Plan"means the Collier County Government Dental Benefit Plan,the Plan Document and any other relevant documents pertinent to its operation and maintenance. Collier County Government Dental Plan-Group#2003021 48 Plan Document/SPD-Effective 1/1/2015 CP Packet Page-760- 1/27/2015 16.E.3. General Definitions PLAN ADMINISTRATOR "Plan Administrator"means the County and/or its designee which is responsible for the day-to-day functions and management of the Plan. The Plan Administrator may employ persons or firms to process claims and perform other Plan-connected services. For the purposes of any applicable state legislation of a similar nature,the County will be deemed to be the Plan Administrator of the Plan unless the County designates an individual or committee to act as Plan Administrator of the Plan. PLAN SUPERVISOR "Plan Supervisor"means the person or firm employed by the Plan to provide consulting services to the Plan in connection with the operation of the Plan and any other functions, including the processing and payment of claims. The Plan Supervisor is Allegiance Benefit Plan Management, Inc. The Plan Supervisor provides ministerial duties only, exercises no discretion over plan assets and will not be considered a fiduciary as defined by ERISA(Employee Retirement Income Security Act)or any other State or Federal law or regulation. PROSTHETIC APPLIANCE "Prosthetic Appliance"means a device or appliance that is designed to replace all or part of a missing tooth or teeth. QUALIFIED BENEFICIARY "Qualified Beneficiary" means an Employee, former Employee or Dependent of an Employee or former Employee who is eligible to continue coverage under the Plan in accordance with applicable provisions of Title X of COBRA or Section 609(a)of ERISA in relation to QMCSO's. "Qualified Beneficiary"will also include a child born to,adopted by or placed for adoption with an Employee or former Employee at any time during COBRA Continuation Coverage. QMCSO "QMCSO"means Qualified Medical Child Support Order as defined by Section 609(a)of ERISA,as amended. USERRA "USERRA" means the Uniformed Services Employment and Reemployment Rights Act, as amended. USUAL, CUSTOMARY AND REASONABLE FEE(UCR) "Usual,Customary and Reasonable(UCR)"means the maximum amount considered for payment by this Plan for any covered treatment, service, or supply, subject however, to all Plan annual and lifetime maximum benefit limitations. The following will apply in the order below to determine the Usual, Customary and Reasonable amount: 1. A contracted amount as established by a preferred provider or other discounting contract; or 2. An amount established through a nationally recognized,published Usual,Customary and Reasonable (UCR)data base utilized by the Plan Supervisor and adopted by the Plan Administrator using the 95"' percentile of said database;or 3. The billed charge if less than 2 above. Collier County Government Dental Plan-Group#2003021 49 Plan Document/SPD-Effective 1/1/2015 Packet Page-761- 1/27/2015 16.E.3. HIPAA PRIVACY AND SECURITY STANDARDS These standards are intended to comply with all requirements of the Privacy and Security Rules of the Administrative Simplification Rules of HIPAA as stated in 45 CFR Parts 160, 162 and 164,as amended from time to time. DEFINITIONS "Protected Health Information"(PHI)means information,including demographic information,that identifies an individual and is created or received by a health care provider, health plan, employer, or health care clearinghouse, and relates to the physical or mental health of an individual, health care that individual has received,or the payment for health care provided to that individual. PHI does not include employment records held by the Plan Sponsor in its role as an employer. "Summary Health Information" means information summarizing claims history,expenses,or types of claims by individuals enrolled in a group health plan and has had the following identifiers removed: names; addresses, except for the first three digits of the ZIP Code; dates related to the individual (ex: birth date); phone numbers;email addresses and related identifiers; social security numbers; medical record numbers; account or plan participant numbers;vehicle identifiers; and any photo or biometric identifier. PRIVACY CERTIFICATION The Plan Sponsor hereby certifies that the Plan Documents have been amended to comply with the privacy regulations by incorporation of the following provisions. The Plan Sponsor agrees to: 1. Not use or further disclose the information other than as permitted or required by the Plan Documents or as required by law. Such uses or disclosures may be for the purposes of plan administration including, but not limited to,the following: A. Operational activities such as quality assurance and utilization management,credentialing, and certification or licensing activities;underwriting,premium rating or other activities related to creating, renewing or replacing health benefit contracts (including reinsurance or stop loss); compliance programs; business planning; responding to appeals, external reviews, arranging for medical reviews and auditing, and customer service activities. Plan administration can include management of carve-out plans, such as dental or vision coverage. B. Payment activities such as determining eligibility or coverage, coordination of benefits, determination of cost-sharing amounts, adjudicating or subrogating claims, claims management and collection activities,obtaining payment under a contract for reinsurance or stop-loss coverage,and related data-processing activities;reviewing health care services for medical necessity, coverage or appropriateness of care, or justification of charges; or utilization review activities. C. For purposes of this certification, plan administration does not include disclosing Summary Health Information to help the plan sponsor obtain premium bids; or to modify, amend or terminate group health plan coverage. Plan administration does not include disclosure of information to the Plan Sponsor as to whether the individual is a participant in;is an enrollee of or has disenrolled from the group health plan. 2. Ensure that any agents, including a subcontractor,to whom it provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information; 3. Not use or disclose the information for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor, Collier County Government Dental Plan-Group#2003021 50 Plan Document/SPD-Effective 1/1/2015 Packet Page -762- 1/27/2015 16.E.3. HIPAA Privacy and Security Standards 4. Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for of which it becomes aware; 5. Make available PHI as required to allow the Covered Person a right of access to his or her PHI as required and permitted by the regulations; 6. Make available PHI for amendment and incorporate any amendments into PHI as required and permitted by the regulations; 7. Make available the information required to provide an accounting of disclosures as required by the regulations; 8. Make its internal practices,books,and records relating to the use and disclosure of PHI received from the Plan available to any applicable regulatory authority for purposes of determining the Plan's compliance with the law's requirements; 9. If feasible,return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made,except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible; and 10. Ensure that the adequate separation required between the Plan and the Plan Sponsor is established. To fulfill this requirement,the Plan Sponsor will restrict access to nonpublic personal information to the Plan Administrator(s) designated in this Plan Document or employees designated by the Plan Administrator(s)who need to know that information to perform plan administration and healthcare operations functions or assist eligible persons enrolling and disenrolling from the Plan. The Plan Sponsor will maintain physical, electronic, and procedural safeguards that comply with applicable federal and state regulations to guard such information and to provide the minimum PHI necessary for performance of healthcare operations duties. The Plan Administrator(s)and any employee so designated will be required to maintain the confidentiality of nonpublic personal information and to follow policies the Plan Sponsor establishes to secure such information. When information is disclosed to entities that perform services or functions on the Plan's behalf,such entities are required to adhere to procedures and practices that maintain the confidentiality of the Covered Person's nonpublic personal information,to use the information only for the limited purpose for which it was shared,and to abide by all applicable privacy laws. SECURITY CERTIFICATION The Plan Sponsor hereby certifies that its Plan Documents have been amended to comply with the security regulations by incorporation of the following provisions. The Plan Sponsor agrees to: 1. Implement and follow all administrative, physical, and technical safeguards of the HIPAA Security Rules, as required by 45 CFR§§164.308, 310 and 312. 2. Implement and install adequate electronic firewalls and other electronic and physical safeguards and security measures to ensure that electronic PHI is used and disclosed only as stated in the Privacy Certification section above. 3. Ensure that when any electronic PHI is disclosed to any entity that performs services or functions on the Plan's behalf,that any such entity shall be required to adhere to and follow all of the requirements for security of electronic PHI found in 45 CFR§§164.308, 310, 312, 314 and 316. 4. Report to the Plan Administrator or the Named Fiduciary of the Plan any attempted breach,or breach of security measures described in this certification, and any disclosure or attempted disclosure of electronic PHI of which the Plan Sponsor becomes aware. Collier County Government Dental Plan-Group#2003021 51 Plan Document/SPD-Effective 1/1/2015 -f7. Packet Page-763- 1/27/2015 16.E.3. *Pr., COLLIER COUNTY GOVERNMENT DENTAL EMPLOYEE BENEFIT PLAN PLAN SUMMARY The following information, together with the information contained in this booklet, form the Summary Plan Description. 1. PLAN The name of the Plan is the COLLIER COUNTY GOVERNMENT DENTAL EMPLOYEE BENEFIT PLAN,which Plan describes the benefits,terms, limitations and provisions for payment of benefits to or on behalf of eligible Participants. 2. PLAN BENEFITS This Plan provides benefits for covered expenses incurred by eligible participants for: Dental and other eligible dentally related, necessary expenses. 3. PLAN EFFECTIVE DATE This Plan was established effective January 1,2015. 4. PLAN SPONSOR Name: Cornier County Government Phone: (239)252-8461 Address: 3311 East Tamiami Trail, Building D Naples, FL 34112 5. PLAN ADMINISTRATOR The Plan Administrator is the Plan Sponsor. 6. NAMED FIDUCIARY Name: Colllier County Government Phone: (239)252-8461 Address: 3311 East Tamiami Trail, Building D Naples, FL 34112 8. PLAN FISCAL YEAR The Plan fiscal year ends December 31'`. 9. PLAN TERMINATION The right is reserved by the Sponsor to terminate, suspend,withdraw, amend or modify the Plan in whole or in part at any time. 10. IDENTIFICATION NUMBER Group Number: 2003021 Employer Identification Number: 59-6000558 ) Collier County Government Dental Plan-Group#2003021 52 Plan Document/SPD-Effective 1/1/2015 U, Packet Page-764- 1/27/2015 16.E.3. Plan Summary 11. PLAN SUPERVISOR Name: Allegiance Benefit Plan Management, Inc. Address: P.O. Box 3018 Missoula, MT 59806-3018 12. ELIGIBILITY Employees and dependents of employees of the Sponsor may participate in the Plan based upon the eligibility requirements set forth by the Plan. 13. PLAN FUNDING The Plan is funded by contributions from the employer and employees. 14. AGENT FOR SERVICE OF LEGAL PROCESS The Plan Administrator has authority to control and manage the Plan and is the agent for service of legal process. ( Jl Collier County Government Dental Plan-Group#2003021 53 Plan Document/SPD-Effective 1/1/2015 \Q/ Packet Page-765-