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Contract No. 268-2013 - TC Dune Restoration Services City of Miami Beach ITB Price Form The TOTAL BASE BID amount includes the all-inclusive total cost for the work specified in this bid,consisting of furnishing all materials,labor, equipment,supervision,mobilization,demobilization,warranty,overhead and profit,insurance,permits,and taxes to complete the work to the full intent as shown or indicated in the contract documents. Any or all alternates,if applicable,may be selected at the City's sole discretion and based on funding availability. Bidders must submit this ITB Price Form fully completed,including Sections 1 and 2,as part of the Bid response.Failure to do so shall deem the Bidder nonresponsive. In the event of arithmetical errors between the division totals and the total base bid,the Bidder agrees that the total base bid shall govern. In the event of a discrepancy between the numerical total base bid and the written total base bid,the written total base bid shall govern.In absence of totals submitted for any division cost,the City shall interpret as no bid for the division,which may disqualify bidder. PROJECT: ITB 268-2013TC-Dune Restoration Services COMPANY NAME: I Superior Landscaping&Lawn Service,Inc. Section 1-Bid Proposal Summary Est.Quantity Cost North Beach(64th to 79th Streets) Pioneer Zone Species(Planting,Maintenance and Warranty) 24,890 48535 Pioneer Zone Diversity Species(Planting, Maintenance and Warranty) 8,296 15762 Palmettos(Planting,Maintenance and Warranty) 315 6300 Strand Zone Species(Planting, Maintenance and Warranty) 377 1413 Removal and disposal of non-native and invasive plant species-1 Lot 1 28726 Watering(Initial and Maintenance)-1 Lot 1 21125 North Beach Subtotal: 121861 Middle Beach(23rd to 47th Streets) Pioneer Zone Species(Planting,Maintenance and Warranty) 22,300 43485 Pioneer Zone Diversity Species(Planting, Maintenance and Warranty) 7,440 14136 Palmettos(Planting,Maintenance and Warranty) 90 1800 Strand Zone Species(Planting,Maintenance and Warranty) 110 1870 Removal and disposal of non-native and invasive plant species-1 Lot 1 44235 Watering(Initial and Maintenance)-1 Lot 1 21125 Middle Beach Subtotal: 126651 South Beach A(14th to 23rd Streets) Pioneer Zone Species(Planting,Maintenance and Warranty) 2,950 5752 Pioneer Zone Diversity Species(Planting, Maintenance and Warranty) 990 1881 Palmettos(Planting,Maintenance and Warranty) 35 700 Strand Zone Species(Planting, Maintenance and Warranty) 40 680 Removal and disposal of non-native and invasive plant species-1 Lot 1 12745 Watering(Initial and Maintenance)-1 Lot 1 8450 South Beach A Subtotal: 30208 South Beach B(Government Cut to 3rd Street) Pioneer Zone Species(Planting,Maintenance and Warranty) 1,980 3861 Pioneer Zone Diversity Species(Planting,Maintenance and Warranty) 670 1273 Palmettos(Planting, Maintenance and Warranty) 10 200 Strand Zone Species(Planting,Maintenance and Warranty) 10 170 Removal and disposal of non-native and invasive plant species-1 Lot 1 6894 Watering(Initial and Maintenance)-1 Lot 1 8450 South Beach B Subtotal: 20848 Numerical Total Base Bid 1 299568 Written Total Base Bid(dollars)Z Two hundred ninety-nine thousand,five hundred sixty-eight dollars and 0/100 cents. Section 2-Bidder's Affirmation Company: Superior Landscaping&Lawn Service,Inc Address: 2200 NW 23 Avenue Miami,Florida 33142 Telephone: % 305-634-0717 Email: �' , �� superlandscape @bellsouth.net Signature: i i Title/Printed Name: Orlando Otero.President 1 Numerical totals should be written using numerical characters(e.g.,$1000.00). Z Written totals should be spelled out(e.g.,one thousand dollars). FAILURE TO SUBMIT THIS FORM WITH BID WILL RESULT IN BEING DEEMED NONRESPONSIVE. ITB 268-2013TC-Dune Restoration Services The following section is requested FOR INFORMATIONAL PURPOSES ONLY. Bidders should u y complete this form identifying specific plants to be planted per species including a unit and cost per unit. Should any bidder fail to submit this form fully completed,the City will request that the omitted information be provided within three(3)calendar days upon request from the City. Failure to provide the City with the omitted information within three(3)calendar days after the Bidder has received the request from the City may result in your bid being deemed non-responsive and disqualified from further consideration. Bidders may insert additional lines as necessary. Unit Cost per Unit Pioneer Zone Species 51120 $ 1.95 Sea Oats Pioneer Zone Diversity Species Panic grass 2896 $ 1.95 Shore.Paspalum 5000 $ 1.95 Railroad Vine 9500 $ 1.95 Palmettos Silver Palmetto 450 $ 22.00 Strand Zone Species Golden Creeper 300 $ 17.00 White indigoberry 100 $ 17.00 Marlberry 100 $ 17.00 Cocoplum horizontal 37 $ 17.00 DUNE RESTORATION SERVICES BID#268-2013-TC INSURANCE CHECK LIST XXX 1. Workers'Compensation and Employer's Liability per the Statutory limits of the state of Florida. XXX 2. Comprehensive General Liability(occurrence form), limits of liability$500,000.00 per occurrence for bodily injury property damage to include Premises/ Operations; Products, Completed Operations and Contractual Liability. Contractual Liability and Contractual Indemnity (Hold harmless endorsement exactly as written in "insurance requirements"of specifications). XXX 3. Automobile Liability-$500,000 each occurrence-owned/non-owned/hired automobiles included. -_ 4. Excess Liability-$----------00 per occurrence to follow the primary coverages. XXX 5. The City must be named as and additional insured on the liability policies; and it must be stated on the certificate. 6. Other Insurance as indicated: ___ Builders Risk completed value $_—------00 ___ Liquor Liability $________.00 ___ Fire Legal Liability $ __.00 __- Protection and Indemnity $__— -.00 ___ Employee Dishonesty Bond $__ Other $ —.00 XXX 7. Thirty(30) days written cancellation notice required. XXX 8. Best's guide rating B+:VI or better, latest edition. XXX 9. The certificate must state the bid number and title BIDDER AND INSURANCE AGENT STATEMENT: We understand the Insurance Requirements of these 4ecific"ations a-d at-evidence of this insurance may be required within five (5) days after bid openi,g.� Bidder Sligntu /are '.rider The City of Miami Beach is self-insured. Any and all claim payments made from self- insurance are subject to the limits and provisions of Florida Statute 768.28, the Florida Constitution, and any other applicable Statutes. ITB 268-2013TC June 25,2013 30 DUNE RESTORATION SERVICES BID#268-2013-TC CUSTOMER REFERENCE LISTING Bidder's shall furnish the names,addresses,and telephone numbers of a minimum of six(6)firms or government organizations for which the Bidders is currently furnishing or has furnished, similar services. 1 Company Name _ ' Address J1- l_ 1_1 _ & _ trr L Contact Person 0_rx_,c o_st__ sLje-w ---------------- Telephone No. �_ ���_01-cl S'G1 Fax No._ E-ma i I cC klm------------------ 2) Company Name �Q �i _ _ o f .rn o., luFAp ke- 1:7d Address 55(� Contact Person ors --- -�r �,�,�---------------------------- Telephone No._ = U - �? 5 Fax No. �?`�=_`1�'u=/$5q E-mail Str))P 3,-PLwme,�, -m � ��1�_.x/._15--------------- _. . 3) Company Name --cJ I _ 0 ---�'�� �--5 ------------- Address log- a —�� -�--- 3L1 ►3'D Contact Person Da tAk'd L_��c IY Telephone No.___o`3`�L4 _&:a+& _— Fax No._ '23,t_`� E-mail a�-� �_ ITB 268-2013TC June 25, 2013 31 DUNE RESTORATION SERVICES BID #268-2013-TC CUSTOMER REFERENCE LISTING (CONTD.) 4) Company Name L t__g _ '-r, ®�_Ac�c_k � n Address _ a -.L--E�jA�� -- � _ £c�� L�_3 7 13 Contact Person j�---� �� - --------------------------- Telephone No._ j=��l a- L� ® --- Fax No._,S ;q 2_(e ' E-mail _ � � � 1.uT------------ -------------- 5) Company Name , 11 Address 1�1LL� � r - ------------------------- Contact Person too_Lo 5 L, 411'11 M 1 j ���� 0 Telephone Fax No._ ` E-mail LL.f1L CPa _ T �? /----------- 6) Company Name _J ---° -- _- ------------ Address � _ ---7 �u - (u �_ L_q 7/`�� Contact Person _ �----------- —_ Telephone No. ��?�_3 -�aLd Fax No._?? E-mail -®- (�� �5- �< < ---------------- ITB 268-2013TC June 25,2013 ' 32 DUNE RESTORATION SERVICES BID ##268-2013-TC CONTRACTOR'S/ BIDDERS QUESTIONNAIRE NOTE: Information supplied in response to this questionnaire is subject to verification. Inaccurate or incomplete answers may be grounds for disqualification from award of this bid. Submitted to The Mayor and City Commission of the City of Miami Beach, Florida: By— Principal Offices a__P ik__ate__ (c t _—LN1La 7-�C�.._ � How many years has your organization been in business under your present business name? 10 Does your organization have current occupational licenses entitling it to do the work/service contemplated in this Contract? _V�j Please state license(s)type and number:Cif � L �� � �� ;L-�C1 q Include copies of above licenses and certificates with bid. Have you ever had a contract terminated due to failure to comply with contractual specifications?_ � If so, where and why?_AL 01_eT 0,�1 _______________ _ - ------- In what other lines of business are you financially interested or engaged e T1i� CsiT_ ls1c ive references as to experience, ability, and financial standing -----i �----------------- -----_---- ----_ Is the business tity a Miami-Beach based Contractor? Yes ( No ( ) If Yes, please submit a copy of a Business Tax Receipt issued by the City of Miami Beach, or documentation to demonstrate that the headquarters is in the City of Miami Beach, or documentation which proves that goods and/or contractual services are being produced or performed, as appropriate, in the City of Miami Beach. ITB 268-2013TC June 25, 2013 33 Is the business entity owned by a certified service-disabled veteran,and or a small business owned and controlled by veterans, as defined on Section 502 of the Veteran Benefit Health, and Information Technology Actpf 2006, and cited in the Database of Veteran-owned Business? Yes ( ) No Contractor Campaign Contribution(s): a. You must provide the names of all individuals or entities (including your sub-consultants) with a controlling financial interest. The term "controlling financial interest" shall mean the ownership, directly or indirectly, of 10% or more of the outstanding capital stock in any corporation or a direct or indirect interest of 10% or more in a firm. The term "firm" shall mean any corporation, partnership, business trust or any legal entity other than a natural person. 0 7. f 0 e7� I ------------------------------------------ b. Individuals or entities (including our sub-consultants) with a controlling financial interest: ___have have not contributed to the campaign either directly or indirectly,of a candidate who has been elected to the office of Mayor or City Commissioner for the City of Miami Beach. Please provide the name(s)-and date(s) of said contributions and to whom said contribution was made. ---------------------------------------------------------- I HERE E hK I tha tf�e a ve wers are true and correct. / / / --- --,------- -- ----= --�=------------------------------(SEAL) --------------------------------------------------------(SEAL) ITB 268-2013TC June 25, 2013 34 I Financial References Bank of America Isabel Reyes 2195 SW 8 Street Miami,Fl.33135 305 643-5500 Vida Verde Farms Maria Vila 20451 SW 216 Street Miami,FL 33170 305-969-1032 BV Oil Company Alex Venegas P.O.Box 667568 Miami,FL 33166 305-593-0705 MIAMIBEACH CITY OF MIAMI BEACH DECLARATION: NONDISCRIMINATION IN CONTRACTS AND BENEFITS Section 1.Contractor Information Name of Company: L 1 d4-Name of Company Contact Person: Phone Number: -(0 3 4-D I I Fax Number: '56%i 34-02 L1 Y E-mail: -5u T Ppc 45,14 1 42e Contractor Number(if known): Federal ID or Social Security Number: Approximate Number of Employees in the U.S.:—j ----(if 50 or less,skip to Section 4,date and sign) Are any of your employees covered by a collective bargaining agreement or union trust fund?—_Yes /—,(No Union name(s):. &10- ------------------------------- Section 2.Compliance Questions Question 1. Nondiscrimination-Protected Classes A.Does your company agree to not discriminate against your employees,applicants for employment, employees of the City,or members of the public on the basis of the fact or perception of a person's membership in the categories listed below?.Please note:.a "YES"answer means your company agrees it will not discriminate;a"NO"answer means your company refuses to agree that it will not discriminate. Please answer yes or no to each category. ❑Race Yes-No ❑Sex ✓ YeS_ No ❑Color ,l'es_No ❑Sexual orientation , Yes_No ❑Creed ;z Yes-No ❑Gender identity(transgender status) Yes_No ❑Religion Z�es_No [I Domestic partner status , Yes_No ❑National origin ;y'es_ No []Marital status Yes_No El Ancestry ;�'es_No ❑Disability ,/Yes-No ❑Age Yes_No ❑AIDS/HIV status ;/ es_No []Height ZYes-No ❑Weight Lz�es_No B. Does your company agree to insert a similar nondiscrimination provision in any subcontract you enter into for the performance of a substantial portion of the contract you have with the City?Please note:you Zust answer this question,even if you do not intend to enter into any subcontracts. Yes No ITB 268-2013TC June 25, 2013 35 Question 2. Nondiscrimination- Equal Benefits for Employees with Spouses and Employees with Domestic Partners Questions 2A and 2B should be answered YES even if your employees must pay some or all of the cost of spousal or domestic partner benefits. A. Does your company provide or offer access to any benefits to employees with spouses or to spouse,%-of employees that may be assigned to work on the City of Miami Beach contract? Yes No B. Does your company provide or offer access to any benefits to employees with(same or opposite sex) domestic partners*or to domestic partners of employees that may be assigned to work on the City of Wmi Beach contract? es No *The term Domestic Partner shall mean any two (2) adults of the same or different sex, who have registered as domestic partners with a government body pursuant to state or local law authorizing such registration, or with an internal registry maintained by the employer of at least one of the domestic partners.A Contractor may institute an internal registry to allow for the provision of equal benefits to employees with domestic partner who do not register their partnerships pursuant to a governmental body authorizing such registration,or who are located in a jurisdiction where no such governmental domestic partnership exists.A Contractor that institutes such registry shall not impose criteria for registration that are more stringent than those required for domestic partnership registration by the City of Miami Beach If you answered "NO" to both Questions 2A and 2B, go to Section 4 (at the bottom of this page), complete and sign the form,filling in all items requested. If you answered"YES"to either or both Questions 2A and 2B,please continue to Question 2C below. C. Please check all benefits that apply to your answers above and list in the "other" section any additional benefits not already specified.Note:some benefits are provided to employees because they have a spouse or domestic partner,such as bereavement leave;other benefits are provided directly to the spouse or domestic partner,such as medical insurance. BENEFIT Yes for Yes for Employees No,this Documentation of this Employees with with Domestic Benefit is Not Benefit is Submitted Spouses Partners Offered with this Form Health Dental ❑ ° �' ° Vision ❑ ° ®� ° Retirement(Pension, ❑ ❑ ° 401(k),etc. Bereavement ° ° Family Leave ° Parental Leave Employee Assistance ❑ ❑ ° Pro ram Relocation&Travel ❑ ❑ ° Company Discount, ° Facilities&Events Credit Union ❑ Child Care ❑ Other ❑ ° ®� ° Note: If you can not offer a benefit in a nondiscriminatory manner because of reasons outside your control,(e.g.,there are no insurance providers in your area willing to offer domestic partner coverage) you may be eligible for Reasonable Measures compliance.To comply on this basis,you must agree to pay a cash equivalent, submit a completed Reasonable Measures Application with all necessary attachments,and have your application approved by the City Manager,or his designee. ITB 268-2013TC June 25,2013 36 Section 3. Required Documentation YOU MUST SUBMIT SUPPORTING DOCUMENTATION to verify each benefit marked in Question 2C.Without proper documentation, your company cannot be certified as complying with the City's Equal Benefits Requirement for Domestic Partner Ordinance.For example,to document medical insurance submit a statement from your insurance provider or a copy of the eligibility section of your plan document; to document leave programs,submit a copy of your company's employee handbook.If documentation for a particular benefit does not exist, attach an explanation. Have you submitted supporting documentation for each benefit offered? _Yes_No Section 4. Executing the Document declare under penalty of perjury under the laws of the State of Florida that the foregoing is true and correct, and that I am authorized to bind this entity contractually. Executed this day of in the year , at City State Signature Mailing Address Name of Signatory(please print) City, State,Zip Code Title ITB 268-2013TC June 25,2013 37 Section 3. Required Documentation YOU MUST SUBMIT SUPPORTING DOCUMENTATION to verify each benefit marked in Question 2C.Without proper documentation, your company cannot be certified as complying with the City's Equal Benefits Requirement for Domestic Partner Ordinance.For example,to document medical insurance submit a statement from your insurance provider or a copy of the eligibility section of your plan document; to document leave programs,submit a copy of your company's employee handbook.If documentation for a particular benefit does not exist,attach an explanation. Have you submitted supporting documentation for each benefit offered? _ es_No Section 4. Executing the Document declare under penalty of perjury under the laws of the State of Florida that the foregoing is true and correct, and that I am authorized to bind this entity contractually. Executed this of,1l uy , in the year o�0 —,at1!2 --r�L --- — �% City State Signat4e Mailing Address Uri a 40 04 r"o Name of Signatory(please print) City,State,Zip Code ���� L ---- - ---- Title ITB 268-2013TC June 25, 2013 37 Definition of Terms A. REASONABLE MEASURES The City of Miami Beach will determine whether a City Contractor has taken all reasonable measures provided by the City Contractor that demonstrates that it is not possible for the City Contractor to end discrimination in benefits. A determination that it is not possible for the City Contractor to end discrimination in benefits shall be based upon a consideration of such factors as: (1)The number of benefits providers identified and contacted, in writing, by the City Contractor, and written documentation from these providers that they will not provide equal benefits; (2) The existence of benefits providers willing to offer equal benefits to the City Contractor; and (3) The existence of federal or state laws which preclude the City Contractor from ending discrimination in benefits. B. CASH EQUIVALENT "Cash Equivalent"means the amount of money paid to an employee with a Domestic Partner(or spouse, if applicable)in lieu of providing Benefits to the employees'Domestic partner(or spouse, if applicable). The Cash Equivalent is equal to the employer's direct expense of providing Benefits to an employee for his or her spouse. Cash Equivalent. The cash equivalent of the following benefits apply: a. For bereavement leave,cash payment for the number of days that would be allowed as paid time off for death of a spouse. Cash payment would be in the form of wages of the domestic partner employee for the number of days allowed. b. For health benefits,the cost to the Contractor of the Contractor's share of the single monthly premiums that are being paid for the domestic partner employee, to be paid on a regular basis while the domestic partner employee maintains the such insurance in force for himself or herself. c. For family medical leave, cash payments for the number of days that would be allowed as time off for an employee to care for a spouse that has a serious health condition. Cash payment would be in the form of wages of the domestic partner employee for the number of days allowed. ITB 268-2013TC June 25,2013 39 MIAAMBEACH QUICK REFERENCE GUIDE TO EQUAL BENEFITS COMPLIANCE STEP 1:UNDERSTANDING THE LAW STEP 2: HOW TO COMPLETE THE DECLARATION: NON-DISCRIMINATION IN CONTRACTS AND What does the law require? BENEFITS FORM The proposed Ordinance will require certain contractors doing business with the City of Miami Beach, who are awarded a Section 1 asks for information about your company.If the contract pursuant to competitive bids,to provide"Equal Benefits" company employs 50 or less employees in the to their employees with domestic partners, as they provide to U.S.,skip to Section 4,date and sign. employees with spouses. Section 2. Question 1 A asks whether your company Who is covered by this Ordinance? prohibits discrimination against people based on the Competitively bid City contracts valued at over$100,000 whose categories listed. contractors maintain 51 or more full time employees on their - Answer "YES" if your company does have such a payrolls during 20 or more calendar work weeks. For more policy. information,see Equal Benefits Ordinance Summary. - Answer"NO" if your company does not have such a policy. What benefits are covered? The Ordinance applies to all benefits offered by a contractor to its Question 19 asks whether your company agrees to include employees who have spouses or domestic partners and all benefits a nondiscrimination clause in all subcontracts entered into offered directly to such spouses or domestic partners,even when for the performance of a substantial portion of the any the employee pays the entire cost of the benefit.This includes but contracts you have with the City. This clause must include is not limited to: sick leave, bereavement leave, family medical all of the categories listed in question IA.You must answer leave,and health benefits. this question even if your company will not be entering into any subcontracts associated with work performed for the What is a Domestic Partner? City. A"Domestic Partner"shall mean any two(2)adults of the some or Answer "YES" if you will agree to include a different sex who have registered as domestic partners with a nondiscrimination clause in subcontracts. government body pursuant to state and local law authorizing such - Answer "NO" if you will not agree to include a registration, or with an internal registry maintained by the nondiscrimination clause in subcontracts. employer of at least one of the domestic partners. Question 2A asks whether your company offers benefits What if a contractor is unable to offer benefits (such as medical insurance) to employees' spouses or to equally? employees because they are married(such as bereavement Some contractors are unable to find an insurance company willing leave which can be taken because of the death of a to offer domestic partner coverage. When a contractor takes all spouse, or family medical leave which can be taken reasonable measures to stop discriminating, but can't for reasons because of a spouse having a serious medical condition). outside its control,it can comply with the Equal Benefits Ordinance - Answer"YES"if you offer any such benefits. if it agrees to pay a cash equivalent. A cash equivalent is the a Answer"NO"if you do not offer any such benefits. amount of money paid by an employer for the spousal benefit that is unavailable for domestic partners, or vice versa. For more NOTE: You are considered as offering a benefit even if information,see Reasonable Measures Application. you don't pay for it. If access to the benefit is offered, but the cost must be paid in whole or in part by the employee, What if a company will comply but needs time to do you should still answer OYES'. it? Once a contractor makes it clear that it will comply with the Question 2B asks whether you company offers benefits Declaration, in certain situations ending discrimination in benefits (such as medical insurance) to employees' domestic may be delayed.For instance,offering medical insurance may be partners or to employees because they are in a domestic delayed until the contractors next enrollment period; other partnership(such as bereavement leave which can be taken benefits, such as bereavement leave, may be delayed until the because of the death of a domestic partner, or family contractor's personnel policies can be revised. For more medical leave which can be taken because of a domestic information,see Rules of Procedure of the Substantial Compliance partner having a serious medical condition). Form. • Answer"YES"if you offer any such benefits. Answer'NO'if you do not offer any such benefits ITB 268-2013TC June 25, 2013 40 NOTE: To comply, your answers to questions 2A and 2B should Family Leave Your company's Family and Medical be the same. In very limited circumstances, you may comply Leave Act policy. All companies with 50 or more without offering benefits equally. See Reasonable Measures employees must offer this benefit. Your policy should Application Form. indicate that employees may take leave because of the serious medical condition of their spouse or domestic Question 2C should be filled out ONLY if you have answered partner. "YES" to question 2A and/or 2B. It asks you to indicate which benefits you offer to spouses (or employees because they are Parental Leave Your company's policy indicating that married), which benefits you offer to domestic partners (or employees may take leave for the birth or adoption of a employees because they are in a domestic partnership), and child,to care for a child who is ill,and/or to attend school which benefits you do not offer.Please indicate only those benefits appointments. If leave is available for step-children (the offered. if you offer benefits not already listed,write them in where spouse's child) then leave also should be available for the it says "other". Remember, offering access to a benefit is still child of a domestic partner. considered a benefit,even if your company does not pay for it. Employee Assistance Program Your company's Note: If you can't offer oil benefit in a nondiscriminatory manner employee assistance program policy confirming that because of reasons outside your control, (e.g. there are no spouses, domestic partners and their parents and children insurance providers willing to offer domestic partner coverage) are equally eligible(or ineligible)for such benefits. you may be eligible for Reasonable Measures compliance. To comply on this basis, you must agree to pay a cash equivalent, Relocation A Travel Your company's policy confirming submit a completed Reasonable Measures Application Form with that expenses for travel or relocation will be paid on the all necessary attachments and have your application approved by same basis for spouses and domestic partners of the Procurement Division of the City of Miami Beach. employees. Discounts, Facilities & Events Your company's policy Step 3:ATTACH THE NECESSARY DOCUMENTATION confirming that discounts, facilities (e.g. gym) and events (e.g. holiday party) are equally available to spouses and Section 3 states that you must submit documentation that verifies domestic partners of employees. all benefits marked in your answer to Question 2C are offered in a nondiscriminatory manner. When possible, it is best if you submit Credit Union Documentation from the credit union this documentation along with your Declaration form. For policies indicating that spouses and domestic partners have equal that are unwritten, submit a letter to the Procurement Division access to credit union services. indicating this. Use the list below as a guide for the type of documentation needed. Child Care Documentation that the children of spouses (stepchildren)and children of domestic partners have equal Medical Insurance A statement from your medical insurance access to child care services. provider that confirms spouses and domestic partners (as defined under this Ordinance) receive equal coverage in your medical Other Benefits Documentation of any other benefits listed plan. This may be in a letter from your insurance provider, or to indicate that they are offered equally. reflected in the eligibility section of your official insurance plan document. Similar documentation is needed for other types of For medical insurance companies providing domestic insurance plans. partner coverage in the State of Florida, refer to the Domestic Partner Insurance Coverage Search available Retirement Plans(including 401 k&pension plans) online at: www.miamibeachfl.gov under Business, The sections of your pension plan detailing how employees Procurement drop down list. receive benefits. This should cover joint annuity options and pre retirement death benefits. Documentation should indicate that For any questions on the City of Miami Beach Equal employees with domestic partners and employees with spouses Benefits Ordinance or how to complete the applicable receive the some benefits and payment options. forms,please contact: Bereavement Leave Your bereavement leave of funeral leave Cristina Delvat,Contracts Compliance Specialist PROCUREMENT DIVISION policy indicating the benefit is offered equally. If your policy 1700 Convention Center Drive,Miami Beach,FL 33139 allows employees time off from work because of the death of a Tel:305-673-7496/Fax:7136-394-4000/ spouse, it should also allow for time off because of the death of a cristinadelvot@miamibeachfl.gov domestic partner. If the policy allows for time off due to the death of a parent in-law or other relative of a spouse,it must include time We are committed to providing excellent public service and safety off for the death of a domestic partner's equivalent relative. to all who live,work and play in our vibrant tropical,historic community. ITB 268-2013TC June 25, 2013 41 DW $25/$45/$200/$5000 R W/Direct Access Rider NEIGHBORHOOD HEALTH PARTNERSHIP HMO SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to the important advantages of the Neighborhood Health Partnership (NHP), a Florida HMO. The Summary of Benefits, although a helpful tool, is only a summary. Always refer to your Member Handbook for a fuller explanation of your coverage or call Customer Services at the phone number numbers on your NHP ID Card when you have a question about your plan. In the event of a conflict between this Summary of Benefits and the Member Handbook, the Member Handbook will control. Services must be provided by health care providers which have contracts with NHP, referred to as "Plan Providers," "Plan Physicians"or"Plan Hospitals," unless in an Emergency or with prior authorization by NHP. Features Please note: if your Plan has a deductible, the deductible must be satisfied unless otherwise specified. You are also responsible for any copayments and/or coinsurance listed below. Deductible $5,000 per member, and/or$10,000 per family, whichever comes first. Individual deductible amounts will count toward the family deductible. However, an individual will not have to pay more than the individual deductible amount. Any deductible is on a calendar year basis. Coinsurance Benefits as defined below may be subject to a coinsurance of 0% once the calendar year deductible is met. Out of Pocket The limit which you and your eligible family members must pay in Maximum copayments (including Pharmacy copayments) and coinsurance per calendar year is $3,000 per member. Out of Pocket Maximum does not include the Deductible. Out of Pocket Maximum does not include amounts paid toward Pharmacy coinsurance. Maximum Benefit No Maximum Benefit Primary Care Physician (PCP) Copayments (Office Visit) $25 copayment per visit Specialist(Office Visit) $45 copayment per visit Urgent Care Center $50 copayment per visit Emergency Room $200 copayment per visit % UnitedH altlicares NHP HMO HSA 4/11 -1- DV4$25/$45/$200/$5000 R Outpatient Therapy $50 copayment per visit Inpatient Hospital After deductible is satisfied $500 copayment per admission and 0% Coinsurance. Radiology No copayment for minor diagnostics; $200 copayment for major diagnostics including CT, MRI, MRA, PET scans and nuclear imaging. Allergy Testing $25 copayment per visit Primary Care Your PCP is responsible for coordinating all your health care services, including referrals to Specialists. Your PCP or Physician Specialist must obtain Pre-Authorization for designated services including, but not limited to, all inpatient care, outpatient surgical procedures, durable medical equipment (DME), home health services, home infusion, hospice care, rehabilitation, skilled nursing facility, and transplant services. Referrals Your PCP is responsible for coordinating all referrals to specialists, except for the following specialties which you may access directly: • Podiatry. • Chiropractic. • Dermatology (5 visits per calendar year). Additional visits require referrals • Gynecology • Substance Use Disorders. Services must be provided by NHP's behavioral health network. • Mental Health Services must be provided by NHP's behavioral health network. • Neurobiological Disorder Services—Autism Spectrum Disorder. Services must be provided by NHP's behavioral health network. Note: If your Employer purchased a Direct Access Rider, you may see a Specialist without a referral from your PCP. Please refer to your NHP ID Card or call Customer Services to verify the need to obtain a referral to a Specialist. Even when the Plan includes a Direct Access Rider, you must select a PCP or NHP will assign one to you. If you need assistance, call Customer Services. Prescription Drugs If your Employer has elected to provide coverage for prescription drugs, you will receive a copy of a Prescription Drug Rider which explains your prescription drug coverage. NHP HMO HSA 4/11 -2- DV4$25/$45/$200/$5000 R YOUR NHP PLAN COVERAGE IMPORTANT Unless otherwise stated, care, services or treatment not managed by your Primary NOTICE: Care Physician, not Medically Necessary, or not pre-certified by NHP are not Covered Services. Services must be provided by Plan Providers, except when prior authorized or in the case of an Emergency Medical Condition. You must check your Member Handbook for further details relating to your coverage. Please note: if your Plan has a deductible, the deductible must be Services & Supplies satisfied unless otherwise specified. You are also responsible for any copayments and/or coinsurance listed below. Ambulance 0% after deductible in emergency situations or when authorized by NHP to transfer you to a NHP facility. Chiropractic Services $25 copayment per visit Limited to 20 treatments per calendar year; PCP referral not required. Dermatology $45 copayment per visit PCP referral not required for 5 visits per calendar year; further visits require PCP referral. Diabetes $45 copayment per visit Services include outpatient self management training and educational services. Durable Medical Equipment 0% after deductible (DME) and disposable medical Limited to$2,500 per calendar year. supplies This benefit category contains services/devices that may be Essential or non-Essential Health Benefits as defined by the Patient Protection and Affordable Care Act depending upon the service or device delivered. A benefit review will take place once the dollar limit is exceeded. If the service/device is determined to be rehabilitative or habilitative in nature, it is an Essential Health Benefit and will be paid. If the benefit/device is determined to be non-essential, the maximum will have been met and the claim will not be paid. Emergency Room Services $200 copayment per visit Any deductible and/or copayment for the emergency room is waived if the patient is admitted to the hospital. Enteral Formula 0%. Deductible does not apply. Limited to $2,500 per calendar year. For the treatment of inherited diseases of amino acid, organic acid, carbohydrate, or fat metabolism as well as malabsorption originating from congenital defects present at birth or acquired during the neonatal period. Coverage for inherited diseases of amino acids and organic acids shall include food products modified to be low protein, for individuals, through the age of 24 Family Planning Covered as any other eligible service, based on place of service. Limited to surgical sterilization, implantable contraceptives and intrauterine birth control devices. NHP HMO HSA 4/11 -3- DV4$25/$45/$200/$5000 R Please note: if your Plan has a deductible, the deductible must be Services & Supplies satisfied unless otherwise specified. You are also responsible for any copayments and/or coinsurance listed below. Gynecology $45 copayment per visit PCP referral is not required. Hearing Aids 0% after deductible Limited to $2,500 per year and to a single purchase (including repair/replacement)every three years. Hearing Exams No copayment when performed by PCP to determine need for hearing (children through age 21) correction. Limited to one exam per calendar year. Deductible does not apply. Home Health Services 00yo after deductible Limited to 60 visits per calendar year not to exceed 60 visits per spell of Illness. Custodial care is not covered. Home Infusion Services 0% after deductible Limited to 60 visits per calendar year not to exceed 60 visits per spell of Illness Hospice Care 0% after deductible Limited to a Maximum Benefit of 180 days of inpatient and/or outpatient care for a terminally ill member when requested by a Plan Physician. Hospital Facility Care Inpatient. After deductible is satisfied $500 copayment per admission and 0% Coinsurance. Outpatient Facility- Surgical Procedures: After deductible is satisfied $250 copayment per visit and 0% Coinsurance. Outpatient Facility-Non-Surgical Procedures: 0% after deductible Minor Diagnostic/X-Ray 0%. Deductible does not apply. Major Diagnostic Services, $200 copayment per service including CT, MRI, MRA, PET Scans and Nuclear Imaging Mammography Screening No copayment for one baseline for women age 35 through 39, one every year for women age 40 and over, or more frequently based on physician's recommendation. Deductible does not apply. Mastectomy Covered as any other eligible service, based on place of service. NHP HMO HSA 4/11 -4- DV4$25/$45/$200/$5000 R