Basic Point of Service Summary.Plan Description
of the
Basic Point of Service
Medical and Prescription Drug Option
for the
City of Miami Beach
Group Health Plan
Effective October 1, 2015 through September 30, 2016
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
TABLE OF CONTENTS
SERVICE AREAS iii
I. INTRODUCTION 1
II. DEFINITIONS 2
III. ELIGIBILITY 12
IV. ENROLLMENT 14
V. EFFECTIVE DATE OF COVERAGE 16
VI. MONTHLY PAYMENTS AND COPAYMENTS 16
VII. TERMINATION OF PARTICIPATION 17
VIII. SCHEDULE OF BASIC BENEFITS 21
IX. LINIITATIONS OF BASIC BENEFITS 38
X. EXCLUSIONS FROM BASIC BENEFITS 39
XI. COORDINATION OF BENEFITS 45
XII. SUBROGATION AND RIGHT OF RECOVERY 48
XIII. DISCLAIMER OF LIABILITY 49
XIV. REVIEW PROCEDURE 49
XV. MISCELLANEOUS 55
SUMMARY PLAN DESCRIPTION INFORMATION 57
ii
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
AVMED CORPORATE OFFICE
9400 S.DADELAND BLVD.
MIAMI,FL 33156-9004
AVMED MEMBER SERVICES-ALL AREAS
1-800-88 AVMED
(1-800-882-8633)
CITY OF MIAMI BEACH DEDICATED TELEPHONE LINE:
1-877-535-1397
SERVICE AREAS
MIAMI GAINESVILLE JACKSONVILLE
9400 South Dadeland Boulevard 4300 Northwest 89th Boulevard 1300 Riverplace Boulevard
Miami,Florida 33156-9004 Post Office Box 749 Suite 640
(305)671-5437 Gainesville,Florida 32606-0749 Jacksonville,Florida 32207
(800)432-6676 (352)372-8400 . (904)858-1300
Miami-Dade (800)346-0231 (800)227-4184
Alachua Baker
Bradford Clay
Citrus Duval
FT.LAUDERDALE Columbia Nassau
13450 West Sunrise Boulevard Dixie St.Johns
Suite 370 Gilchrist
Sunrise,Florida 33323-2947 Hamilton
(954)462-2520 Levy
(800)368-9189 Marion TAMPA BAY/SOUTHWEST
Broward. Suwannee FLORIDA
Palm Beach Union 1511 North Westshore Boulevard
Suite 450
Tampa,Florida 33607
(813)281-5650
ORLANDO (800)257-2273
1800 Pembrook Drive Hernando
Suite 190 Hillsboro
Orlando,Florida 32810 Lee
(407)539-0007 Pasco
(800)227-4848 Pinellas
Lake • Polk
Orange Sarasota
Osceola
Seminole
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
I. INTRODUCTION
Your employer has contracted with AvMed, Inc. (hereinafter `AvMed') to arrange for the provision of Medical
Services or benefits which are Medically Necessary for the diagnosis and treatment of Participants through a
network of contracted independent physicians and Hospitals and other health care providers, known as the
AvMed Point of Service Plan. The AvMed Point of Service Plan provides Participants with several choices for
the provision of health care services. A Participant's choice of providers and where they receive services will
determine the level of benefits they receive. Under this Plan, a Participant may choose to receive services from
the AvMed Participating Provider Network(high Benefit Level), or any Out-of-Network Provider (low Benefit
Level). With the AvMed Point of Service Plan, a Participant is not required to select a Primary Care Physician
nor are referrals to specialists required. However,prior authorization from AvMed is required for some services
(See Section VIII(SCHEDULE OF BASIC BENEFITS).
AvMed, in arranging for the delivery of Medical Services or benefits, does not directly provide these Medical
Services or benefits. AvMed arranges for the provision of said services in accordance with the covenants and
Conditions contained in this Summary Plan Description. AvMed will rely upon the statements of the Participant
in his application in providing coverage and benefits hereunder.
You Must Enroll to Receive Benefits! You must affirmatively enroll to receive benefits under the Plan, as
explained in Section III (ELIGIBILITY). If you do not take the actions outlined in Section III to affirmatively
enroll to receive benefits,you will not be entitled to any benefits of any kind under this Plan.
This document is a Summary Plan Description (SPD) of the medical benefits provided to you by the City of
Miami Beach (the Employer) under the City of Miami Beach Group Health Plan (hereinafter, the `Plan'). This
SPD is made available for your reference and is subject to various legal requirements, including the
requirements of the Health Insurance Portability and Accountability Act of 1996(HIPAA).
Unless otherwise noted in this document, if the terms of this document and the terms of the Plan conflict, the
Plan document shall control.
The Employer may designate any other third-party administrators or Claims administrators to carry out certain
Plan duties and responsibilities. The Employer is responsible for formulating and carrying out all rules and
procedures necessary to administer the Plan. The Employer, as Plan Sponsor, has the discretionary authority to
(1) make decisions regarding the interpretation or application of Plan provisions (2) determine the rights,
eligibility, and benefits of Participants and beneficiaries under the Plan, and (3) review Claims under the Plan.
The Employer may delegate to a third party any or all such discretionary authority described above. Benefits
under the Plan will be paid only if the Employer, as Plan Sponsor, or its designee or delegate decides in its
discretion that the applicant is entitled to them.
The Plan may be amended at any time. Such amendments, for example, may (1) increase or otherwise change
the cost to you for coverage, (2) change the type of benefits provided under the Plan, the conditions of
participation and any other terms of the Plan, (3) require additional contributions from Participants, or (4)
terminate the Plan in whole or in part at any time. Plan provisions will be administered in accordance with any
appropriate collective bargaining agreement.
The Plan is not intended to and does not cover or provide any Medical Services or benefits that are not
Medically Necessary for the diagnosis and treatment of the Participant. The determination as to which services
are Medically Necessary shall be made by the Plan subject to the terms and conditions of the Plan. Claims for
benefits are to be sent to AvMed.
Notwithstanding any references for definitional purposes to the contrary,this Plan is not an HMO product and is
not subject to Chapter 641 of the Florida Statutes, nor is a Participant of the Plan afforded any individual rights
under Chapter 641 of the Florida Statutes. Premiums for employees and their families are paid in part by the
Employer as Plan Sponsor out of its general assets, and in part by employees' after-tax / before tax payroll
deductions.
1
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
The Medical and Hospital Services covered by the Plan shall be provided without regard to the race, color,
religion,physical handicap,or national origin of the Participant in the diagnosis and treatment of patients;in the
use of equipment and other facilities; or in the assignment of personnel to provide services, pursuant to the
provisions of Title VI of the Civil Rights Act of 1964, as amended, and the Americans with Disabilities Act of
1990.
II. DEFINITIONS
For further definitions, go to www.healthcare.gov/glossary to review the glossary provided as a result of the
Affordable Care Act.
As used in this SPD,each of the following terms shall have the meaning indicated:
2.01 Accidental Dental.Injury means an injury to Sound Natural Teeth caused by a sudden, unintentional,
and unexpected event or force. This term does not include injuries to the mouth, structures within the
oral cavity,or injuries to natural teeth caused by biting or chewing,surgery,or treatment for a disease or
illness. ,
2.02 Adverse Benefit Determination means 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 eligibility to
participate in the Plan, and including 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
Management Program, as well as a failure to cover an item or service for which benefits are otherwise
provided because it is determined to be Experimental and/or Investigational or not Medically Necessary;
and including a cancellation or discontinuance of coverage that has retroactive effect,unless attributable
to a failure to timely pay required premiums or contributions toward the cost of coverage.
2.03 Applied Behavior Analysis means the design, implementation, and evaluation of environmental
modifications, using behavioral stimuli and consequences, to produce socially significant improvement
in'human behavior, including, but not limited to,`the use of direct observation, measurement, and
functional analysis of the relations between environment and behavior. Applied Behavior Analysis
services shall be provided by an individual certified pursuant to Section 393.17,'Florida Statutes, or an
individual licensed under Chapter 490 or Chapter 491,Florida Statutes.
2.04 Attending Physician means the physician primarily responsible for the care of a Participant with
respect to any particular injury or illness.
2.05 Autism Spectrum Disorder means any of the following disorders as defined in the most recent edition
of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association:
2.05.01 Autistic disorder;
2.05.02 Asperger's syndrome;
2.05.03 Pervasive developmental disorder not otherwise specified.
2.06 AvMed Network means the providers and facilities that have contracted with AvMed to provide
covered services to Participants. Participants' Copayment, Deductible and/or Coinsurance
responsibilities are outlined in the Schedule of Benefits. Generally, Participants will have coverage at
the highest level of benefits when they use the AvMed Network.
2.07 Behavioral Health is the scientific study of the emotions, behaviors and biology relating to a person's
mental well-being, their ability to function in everyday life and their concept of self. Behavioral Health
is the preferred term to mental health. A person struggling with his or her Behavioral Health may face
stress,depression, anxiety,relationship problems, grief, addiction,ADHD or learning disabilities,mood
disorders, or other psychological concerns. Counselors therapists, life coaches, psychologists, nurse
practitioners or Physicians can help manage Behavioral Health concerns with treatments such as
therapy,counseling,or medication.
7
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
2.08 Benefit Level means:
2.08.01 For AvMed providers, the Copayment or percentage of the contracted rate shown in the
Schedule of Benefits after the applicable Deductible is met; or
2.08.02 For Non-Participating Providers, the Maximum Allowable Payment for covered services
shown in the Schedule of Benefits after the applicable Deductible.
2.08.03 The Deductible may not apply to all covered services..
2.09 Calendar Year means the twelve-month period beginning January 1 S`and ending December 31St
2.10 Claim means a request for benefits under the Plan made by a Participant in accordance with AvMed's
procedures for filing benefit Claims,including Pre-Service Claims and post-service Claims.
2.11 Claimant means a Participant or a Participant's authorized representative acting on behalf of the
Participant. AvMed may establish procedures for detei ining whether an individual is authorized to act
on behalf of the Participant. If the Claim is an Urgent Care or Pre-Service Claim, a Health Professional,
with knowledge of the Participant's medical Condition, shall be permitted to act as the Participant's
authorized representative and will be notified of all approvals on the Claimant's behalf. In the event of
an Adverse Benefit Determination,AvMed will notify both the Participant and the Heath Professional.
2.12 Coinsurance means the amount a Participant must pay once the Deductible has been met,if applicable,
and is expressed as a percentage of the contracted rate for the covered benefit.
2.13 Condition means a disease,illness,ailment,injury,or pregnancy.
2.14 Core Benefits means all benefits provided under Section VIII (SCHEDULE OF BASIC BENEFITS),
subject to the limitations of Section IX(LIMITATIONS OF BASIC BENEFITS)and the
Exclusions of Section X(EXCLUSIONS FROM BASIC BENEFITS).
2.15 Copayment means the portion of the cost, in addition to the prepaid premium amounts, which the
Participant is required to pay at the time certain health services are provided under the Plan. The
Copayment may be a specific dollar amount or a percentage of the cost. The Participant is responsible
for the payment of any Copayments directly to the provider of the health services at the time of service.
2.16 Covered Dependent means any dependent of a Covered Employee who meets all applicable
requirements of the Plan and is enrolled in the Plan.
2.17 Covered Employee means an employee who is permanently employed and paid a salary or earnings at
your Employer's place of business, or you as a former employee who is now a retiree who meets all of
the applicable requirements of the Plan and is enrolled in the Plan.
2.18 Covered Retiree means a former employee under the age of 65 who has retired from the City of Miami
Beach who meets all of the applicable requirements of the Plan and is enrolled in the Plan.
2.19 Custodial Care means services and supplies that are furnished mainly to train or assist in the activities
of daily living, such as bathing, feeding, dressing, walking and taking oral medications. `Custodial
Care' also means services and supplies that can be safely and adequately provided by persons other than
licensed Health Professionals, such as dressing changes and catheter care, or that ambulatory patients
customarily provide for themselves, such as ostomy care, administering insulin and measuring and
recording urine and blood sugar levels.
2.20 Deductible means the first payments up to a specified dollar amount that a Participant must make in the
applicable Calendar Year for covered benefits. The Deductible applies to each Participant, subject to
any family Deductible listed on the Schedule of Benefits. For purposes of the Deductible, `family'
means the Covered Employee and Covered Dependents. The Deductible must be satisfied once each
Calendar Year.
2.01.01 The Common Accident Provision: if the Deductible applies to accident expenses and if two
or more Participants of any family receive covered benefits because of disabilities resulting
3
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
from injuries sustained in any one accident, the Deductible will be applied only once with
respect to all covered benefits received as a result of the accident
2.21 Dental Care means dental x-rays, examinations and treatment of the teeth or any services, supplies or
charges directly related to:
2.21.01 the care,filling,removal or replacement of teeth,or
2.21.02 the treatment of injuries to or disease of the teeth, gums or structures directly supporting or
attached to the teeth, that are customarily provided by dentists (including orthodontics
reconstructive jaw surgery,casts,splints and services for dental malocclusion).
2.22 Domestic Partner means an unmarried adult who:
2.22.01 cohabits with the Covered Employee in an emotionally committed and affectional
relationship that is meant to be of lasting duration;
2.22.02 is not related by blood or marriage;
2.22.03 is at least eighteen years of age;
2.22.04 is mentally competent to consent to a contract;
2.22.05 has filed a domestic partnership agreement or registration with the Employer, if available, in
the state(and/or city)of residence;
2.22.06 has shared financial obligations including basic living expenses for the twelve month period
prior to enrollment in the Plan;
2.22.07 will provide documentation that will be satisfactory to the Employer as evidence of a
Domestic Partner relationship; and
2.22.08 meets the dependent eligibility requirements of the Employer's health benefit plan.
2.23 Durable Medical Equipment (DME). Durable Medical Equipment is any equipment that meets all of
the following requirements:
2.23.01 can withstand repeated use; and
2.23.02 is primarily and customarily used to serve a medical purpose; and
2.23.03 generally is not useful to a person in the absence of an illness or injury; and
2.23.04 is appropriate for use in the home.
2.24 Emergency Medical Condition means a medical Condition manifesting itself by acute symptoms of
sufficient severity such that the absence of immediate medical attention could reasonably be expected to
result in any of the following:
2.24.01 Serious jeopardy to the health of a patient,including a pregnant woman or fetus.
2.24.02 Serious impairment to bodily functions.
2.24.03 Serious dysfunction of any bodily organ or part.
2.24.04 With respect to a pregnant woman:
a. that there is inadequate time to effect safe transfer to another Hospital prior to delivery;
b. that a transfer may pose a threat to the health and safety of the patient or fetus;or
c. That there is evidence of the onset and persistence of uterine contractions or rupture of
the membranes.
2.24.05 Examples of Emergency Medical Conditions include, but are not limited to: heart attack,
stroke,massive internal or external bleeding, fractured limbs or severe trauma.
4
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
2.25 Emergency Medical Services and Care means medical screening, examination and evaluation by a
physician, or, to the extent permitted by applicable law, by other appropriate personnel under the
supervision of a physician to determine if an Emergency Medical Condition exists and, if it does, the
care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the
Emergency Medical Condition within the service capability of the Hospital.
2.25.01 In-area emergency does not include elective or routine care, care of minor illness or care
that can reasonably be sought and obtained from the Participant's physician. The
determination as to whether or not an illness or injury constitutes an emergency shall be
made by AvMed and may be made retrospectively based upon all information known at the
time the patient was present for treatment.
2.25.02 Out-of-area emergency does not include care for Conditions for which a Participant could
reasonably have foreseen the need of such care before leaving the Service Area or care that
could safely be delayed until prompt return to the Service Area. The determination as to
whether or not an illness or injury constitutes an emergency shall be made by AvMed and
may be made retrospectively based upon all information known at the time the patient was
present for treatment.
2.26 Essential Health Benefits has the meaning under section 1302(b) of the Federal Act and applicable
regulations.The ten categories of Essential Health Benefits are:
2.26.01 ambulatory patient services;
2.26.02 emergency services;
2.26.03 hospitalization;
2.26.04 laboratory services;
2.26.05 maternity and newborn care;
2.26.06 mental health and substance use disorder services (including behavioral health treatment);
2.26.07 pediatric services(including oral and vision care);
2.26.08 prescription drugs;
2.26.09 preventive and wellness services and chronic disease management;and
2.26.10 Rehabilitative and Habilitative Services and devices.
2.27 Exclusion means any provision of the Plan whereby coverage for a specific hazard or Condition is
entirely eliminated.
2.28 Experimental and/or Investigational. For the purposes of this Plan a medication, treatment, device,
surgery or procedure may be determined by AvMed in its discretion, to be Experimental and/or
Investigational if any of the following applies:
2.28.01 The FDA has not granted the approval for general use; or
2.28.02 There are insufficient outcomes data available from controlled clinical trials published in
peer-reviewed literature to substantiate its safety and effectiveness for the disease or injury
involved; or
2.28.03 There is no consensus among practicing physicians that the medication, treatment, therapy,
procedure or device is safe or effective for the treatment in question or such medication,
treatment, therapy, procedure or device is not the standard treatment, therapy, procedure or
device utilized by practicing physicians in treating other patients with the same or a similar
Condition; or
2.28.04 Such medication, treatment, procedure or device is the subject of an ongoing Phase I or
Phase II clinical investigation, or experimental or research arm of a Phase III clinical
investigation, or under study to determine: maximum tolerated dosage(s), toxicity, safety,
5
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the
condition in question. Notwithstanding the previous sentence, approved clinical trials, as
such term is defined by Section 2709 of the Public Health Service Act("PHSA")will not be
treated as Experimental and/or Investigational if the requirements of Section 2709 of the
PHSA are satisfied.
2.29 Full-Time Student or Part-Time Student means one who is attending a recognized and/or accredited
college,university,vocational,or secondary school and is carrying sufficient credits to qualify as a Full-
Time or Part-Time Student in accordance with the requirements of the school.
2.30 Group Health Insurance (for purposes of Section XI(COORDINATION OF BENEFITS))means that
form of health insurance covering groups of persons under a master Group Health Insurance policy
issued to any one of the groups listed in Sections 627.552 (employee groups), 627.553 (debtor groups),
627.554 (labor union and association groups), and 627.5565 (additional groups),Florida Statutes, or, if
applicable,equivalent or similar state law in another state.
2.30.01 The terms `amount of insurance' and `insurance' include the benefits provided under a plan
of self-insurance.
2.30.02 The term `insurer' includes any person,entity or governmental unit providing a plan of self-
insurance.
2.30.03 The terms `policy', `insurance policy', `health insurance policy' and `Group Health
Insurance policy' include plans of self-insurance providing health insurance benefits.
2.31 Habilitation Services are services that help a person keep, learn or improve skills and functioning for
daily living. Such services may be provided in order for a person to attain and maintain a skill or
function never learned or acquired due to a disabling Condition. They are services that are deemed
necessary to meet the needs of individuals with developmental disabilities in programs designed to
achieve objectives of improved health, welfare and the realization of individual's maximum physical,
social,psychological and vocational potential for useful and productive activities.
2.32 Health Professionals means physicians, osteopaths, podiatrists, chiropractors, physician assistants,
nurses, social workers, pharmacists, optometrists, clinical psychologists, nutritionists, occupational
therapists, physical therapists and other professionals engaged in the delivery of health care services,
who are licensed and practice under an institutional license, individual practice association or other
authority consistent with state law.
2.33 Home Health Care Services (Skilled Home Health Care) means services that are provided for a
Participant who does not require confinement in a Hospital or Other Health Care Facility. Such services
include,but are not limited to, the services of professional visiting nurses or other health care personnel
for services covered under the Plan.
2.34 Hospice means a public agency or private organization that is duly licensed by State of Florida to
provide Hospice services. Such licensed entity must be principally engaged in providing pain relief,
symptom management and supportive services to terminally ill Participants.
2.35 Hospital means any general acute care facility which is licensed under state law that offers services
which are more intensive than those required for room, board, personal services and general nursing
care; offers facilities and beds for use beyond 24 hours; and regularly makes available at least clinical
laboratory services, diagnostic x-ray services and treatment facilities for surgery or obstetrical care or
other definitive medical treatment of similar extent. The term Hospital does not include an Ambulatory
Surgery Center; Other Health Care Facility; stand-alone Birthing Center; convalescent, rest or nursing
home; or a facility which primarily provides custodial,educational or rehabilitative therapies.
2.36 Hospital Based Providers are defined as emergency room physicians, pathologists, radiologists and
anesthesiologists.
2.37 Hospital Services (except as expressly limited or excluded by the Plan) means those services for
registered bed patients that are:
6
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
2.37.01 generally and customarily provided by acute care general Hospitals in accordance with the
standards of acceptable community practice;
2.37.02 performed,prescribed or directed by an Attending Physician; and
2.37.03 Medically Necessary for Conditions which cannot be adequately treated in Other Health
Care Facilities or with Home Health Care Services or on an ambulatory basis.
2.38 Hospitalist/Admitting Panelist means a physician who specializes in treating inpatients and who may
coordinate a Participant's health care when the Participant has been admitted for a Medically Necessary
procedure or treatment at a Hospital.
2.39 Injectable Medication means a medication that is approved by the Food and Drug Administration
(FDA) for administration by one or more of the following routes: intramuscular injection, intravenous
injection, intravenous infusion, subcutaneous injection, intrathecal injection, intra-articular injection,
intracavernous injection or intraocular injection. Prior authorization is required for Injectable
Medications.
2.40 Limitation means any provision,other than an Exclusion,which restricts coverage under the Plan.
2.41 Maximum Allowable Payment means the maximum amount that AvMed will pay for any covered
service rendered by a Non-Participating Provider or supplier of services,medications or supplies.
2.42 Medically Necessary means the use of any appropriate medical treatment, service, equipment and/or
supply as provided by a Hospital, Skilled Nursing Facility, physician or other provider which is
necessary for the diagnosis,care and/or treatment of a Participant's illness or injury,and which is:
2.42.01 consistent with the symptom,diagnosis,and treatment of the Participant's Condition;
2.42.02 the most appropriate level of supply and/or service for the diagnosis and treatment of the
Participant's Condition;
2.42.03 in accordance with standards of acceptable community practice;
2.42.04 not primarily intended for the personal comfort or convenience of the Participant, the
Participant's family,the physician or other health care providers;
2.42.05 approved by the appropriate medical body or health care specialty involved as effective,
appropriate and essential for the care and treatment of the Participant's Condition;and
2.42.06 not Experimental or Investigational.
2.43 Medical Office means any outpatient facility or physician's office.
2.44 Medical Services (except as limited or excluded by the Plan) means those professional services of
physicians and other Health Professionals, including medical, surgical, diagnostic, therapeutic and
preventive services that are:
2.44.01 generally and customarily provided in the geographic area;
2.44.02 performed,prescribed or directed by Health Professionals; and
2.44.03 Medically Necessary (except for preventive services as stated herein) for the diagnosis and
treatment of injury or illness.
2.45 Morbid Obesity (clinically severe obesity) means a body mass index (BMI), as determined by a
Participating Provider as of the date of service,of:
2.45.01 40 kilograms or greater per meter squared(kg/m2); or
2.45.02 35 kilograms or greater per meter squared (kg/m2) with an associated comorbid Condition
such as hypertension, type II diabetes, life-threatening cardiopulmonary Conditions; or joint
disease that is treatable,if not for the obesity.
7
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
•
•
2.46 Non-Participating Provider means any Health Professional or group of Health Professionals,Hospital,
Medical Office or Other Health Care Facility with whom AvMed has neither made arrangements nor
contracted to render the professional health services set forth herein as a Participating Provider. The
Point of Service Plan provides access to Non-Participating Providers as defined herein.
2A7 Other Health Care Facility(ies)means any licensed facility, other than acute care Hospitals and those
facilities providing services to ventilator de pendent patients, which provides inpatient services such as
skilled nursing care,Residential Treatment and Rehabilitation Services.
2.48 Out-of-Network Provider means any Health Professional (or group of Health Professionals),Hospital,
Medical Office or Other Health Care Facility who is not under contract with AvMed's Choice Network,
and not under contract with the PHCS Network outside of AvMed's Service Area.
2.49 Partial Hospitalization means treatment in which an individual receives at least seven hours of
institutional care during a portion of a 24-hour period and returns home or leaves the treatment facility
during any period in which treatment is not scheduled. A Hospital shall not be considered a"home"for
purposes of this definition.
2.50 Participant means any Covered Employee, Covered Retiree, or Covered Dependent as described in
Sections 2.16,2.17,and 2.18 of this SPD.
2.51 Participating Physician means any Participating.Provider licensed under Chapter 458 (physician), 459
(osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes, or, if applicable, equivalent or
similar state laws of another state.
2.52 Participating Provider means any Health Professional (or group of Health Professionals), Hospital,
Medical Office or Other Health Care Facility with whom AvMed has made arrangements or contracted
to render the professional health services set forth herein.
2.53 Plan means the City of Miami Beach Group Health Plan sponsored by the Employer to provide covered
Medical Services to Participants.
2.54 Plan Administrator means City of Miami Beach, 1700 Convention Center Drive, Miami Beach,
Florida 33139,ATTENTION TO: Sylvia Crespo-Tabak,Telephone number: 305-673-7524.
2.55 Plan Year means the period of 12 consecutive months commencing on the effective date of the Plan.
2.56 Pre-Service Claim means any Claim for benefits under the Plan for which (in whole or in part), a
Participant must obtain authorization from AvMed in advance of such services being provided to or
received by the Participant.
2.57 Primary Care Physician means any Participating Physician engaged in family practice, pediatrics,
internal medicine, obstetrics/gynecology, or any specialty physician from time to time designated by
AvMed as a `Primary Care Physician' in AvMed's current list of physicians and Hospitals.
2.58 Private Duty Nursing means services provided by registered nurses, licensed practical nurses, or any
other trained attendant whose services ordinarily are rendered to, and restricted to, a particular
Participant by arrangements between the Participant and the private=duty nurse or attendant. Such
persons are engaged or paid by an individual Participant or by someone acting on their behalf,including
a Hospital that initially incurs the costs and looks to the Participant for reimbursement for such services.
2.59 Rehabilitation Services are health care services that help a person keep,get back, or improve skills and
functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled.
These services may include physical and occupational therapies, speech-language pathology and
psychiatric Rehabilitation Services in a variety of inpatient and/or outpatient settings.
2.60 Relevant Document means any documentation that:
2.60.01 was relied upon in making a benefit determination;
- 2:60.02 - was-submitted, considered-or generated in the course of making a benefit determination,
without regard to whether it was relied upon in making the determination;
8
SF-City of Miami Beach-Basic POS-SPD-2015 -
SF-3661(10/15)
•i
2.60.03 demonstrates compliance with the Plan's administrative process;and
2.60.04 constitutes a statement of policy or guidance with respect to the Plan concerning the Adverse
Benefit Determination for the Claimant's diagnosis, without regard to whether such advice
or statement was relied upon in making the Adverse Benefit Determination.
2.61 Residential Treatment is a 24-hour intensive structured and supervised treatment program providing
an inpatient level of care but in a non-hospital environment, and is utilized for those disorders that
cannot be affectively treated in an outpatient or Partial Hospitalization environment.
2.62 Service Area means those counties in the State of Florida where AvMed has been approved to conduct
business by the Agency for Health Care Administration(AHCA).
2.63 Skilled Nursing Facility means an institution or part thereof which is licensed as a Skilled Nursing
Facility by the State of Florida,is accredited as a Skilled Nursing Facility by the Joint Commission or
recognized as a Skilled Nursing Facility by the Secretary of Health and Human Services of the United
States under Medicare,and with which AvMed has made arrangements or contracted for the provision
of appropriate services.
2.64 Sound Natural Tooth (or Teeth) means a tooth that is whole or properly restored (restoration with
amalgams only) and is not in need of the treatment provided for any reason other than an Accidental
Dental Injury. For purposes of this Plan, a tooth previously restored with a crown inlay, onlay or
porcelain restoration,or treated by endodontics,is not considered a Sound Natural Tooth.
2.65 Specialty Health Care Physician means any physician licensed under Chapter 458 (physician), 459
(osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes, or, if applicable, equivalent or
similar state laws of another state,other than the Participant's Primary Care Physician.
2.66 Total Disability means a totally disabling Condition resulting from an illness or injury which prevents
the Participant from engaging in any employment or occupation for which he may otherwise become
qualified by reason of education, training or experience, and for which the Participant is under the
regular care of a physician.
2.67 Urgent Care Center means a facility properly licensed to provide care for minor injuries and illnesses
that require immediate attention, but are not severe enough for a trip to the emergency room, including
cuts, sprains, eye injuries, colds, flu, fever, insect bites, and simple fractures. For purposes of this
contract, an Urgent Care Center is not a Hospital.
2.68 Urgent Care Claim means any Claim for medical care or treatment that could seriously jeopardize the
Participant's life or health or the Participant's ability to regain maximum function or,in the opinion of a
physician with knowledge of the Participant's medical Condition, would subject the Participant to
severe pain that cannot be adequately managed without the care or treatment requested. Generally, the
determination of whether a Claim is an Urgent Care-Claim shall be made by an individual acting on
behalf of AvMed applying the judgment of a prudent layperson that possesses an average knowledge of
health and medicine. However, if a physician with knowledge of the Participant's medical Condition
determines that the Claim is an Urgent Care Claim,it shall be deemed as such.
2.69 Urgent Medical Condition means a medical Condition manifesting itself by acute symptoms that are of
lesser severity than that recognized for an Emergency Medical Condition, such that a prudent layperson
who possesses an average knowledge of health and medicine could reasonably expect the illness or
injury to place the health or safety of the Participant or another individual in serious jeopardy, in the
absence of medical treatment within 24 hours. Examples of Urgent Medical Conditions include,but are
not limited to: high fever, dizziness, animal bites, sprains, severe pain, respiratory ailments and
infectious illnesses.
2.70 Urgent Medical Services and Care means medical screening, and evaluation in an
Urgent g,
ambulatory setting outside of a Hospital emergency department,including an Urgent Care Center,retail
clinic or PCP office after-hours, on a walk-in basis and usually without a scheduled appointment; and
the covered services for those Conditions which, although not life-threatening, could result in serious
injury or disability if left untreated.
9
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
•
•
2.71 Utilization Management Program means those comprehensive initiatives that are designed to validate
medical appropriateness and to coordinate covered services and supplies. These include, but are not
limited to:
2.71.01 concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, and
skilled nursing facilities,including on-site review when appropriate;
2.71.02 case management and discharge planning for all inpatients and those requiring continued
care in an alternative setting (such as home care or a Skilled Nursing Facility) and for
outpatients when deemed appropriate; and
2.71.03 the Benefit Coordination Program which is designed to conduct prospective reviews for
select Medical Services to ensure that services are covered and Medically Necessary. The
Benefit Coordination Program may also advocate alternative cost-effective settings for the
delivery of prescribed care and may identify other options for non-covered health care needs.
2.72 Ventilator Dependent Care Unit means any facility which provides services to ventilator dependent
patients other than an acute care Hospital setting, including all types of facilities known as sub-acute
care units, ventilator dependent units, alternative care units, sub-acute care centers and all other like
facilities, whether maintained in a free standing facility or maintained in a Hospital or Skilled Nursing
Facility setting.
III. ELIGIBILITY
3.01 To be eligible to enroll as a Covered Employee,a person must be:
3.01.01 an employee of the City of Miami Beach who works the required number of hours per week;
3.01.02 employed for the 90 day waiting period required for eligibility;
3.01.03 entitled on his own behalf to participate in the medical and Hospital care benefits provided
by the City of Miami Beach under the Plan. Coverage begins on the day immediately
following the waiting period; and
3.01.04 If you are a person with current employment status who is age 65 and over(or the dependent
spouse age 65 and over of an employee of any age), your coverage under this Plan will be
provided on the same terms and conditions as are applicable to employees (or dependent
spouses)who are under the age of 65.Your rights under this Plan do not change because you
(or your dependent spouse) are eligible for Medicare coverage on the basis of age,as long as
you have current employment status with your Employer.
3.01.05 You have the option to reject plan coverage offered by your Employer, as does any eligible
employee. If you reject coverage under your Employer's Plan, coverage is terminated and
your Employer is not permitted to offer you coverage that supplement Medicare covered
services.
3.01.06 If you are an early retiree in the Miami Beach Employees Retirement Plan (MBERP)with 5
years or more of continuous service and meet the age requirement,you may elect to continue
coverage for you and your eligible dependents provided such coverage was elected at the
time of your retirement. Please see your Employer for more details.
3.02 To be eligible to enroll as a Covered Dependent, a person must be:
3.02.01 the spouse of the Covered Employee (a new spouse must be enrolled within 31 days after
marriage in order to be covered);or
3.02.02 the Domestic Partner of the Covered Employee,as defined by the Plan; or
3.02.03 a child of the Covered Employee, a child of the Domestic Partner, a child of a Covered
Retiree,or a child of a Covered Dependent of the Covered Employee,provided that all of the
following conditions apply:
10
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
a. The child is under the age of 26;and
b. The natural child or stepchild of the Covered Employee; or
c. The natural child of a Domestic Partner; or
d. A legally adopted child in the custody of the Covered Employee from the time of
placement in the home(written evidence of adoption must be furnished to the Employer
upon request); or
e. A child for whom the Covered Employee has been appointed legal guardian pursuant to
a valid court order. In the event an eligible Dependent child does not reside with the
Covered Employee, coverage will be extended where the Covered Employee if
obligated to provide medical care by Qualified Medical Child Support Order
(QMCSO).You(or your beneficiaries)may obtain,without charge,copies of the Plan's
procedures governing QMCSOs and a sample QMCSO by contacting the Plan
Administrator;or
f. The newborn child of a Covered Dependent of the Covered Employee other than the
spouse of the Covered Employee(such coverage terminates 18 months after the birth of
the newborn child).
g. With respect to 3.02.03 a., coverage for a child of a Covered Employee will end at the
end of the year in which they reach age 26.
3.02.04 In the case of a newborn child, the Plan Administrator should be notified of the Covered
Employee's intention to enroll the newborn child not later than 31 days after the birth. If
notice is not provided within 60 days of the birth,the child may not be enrolled until the next
open enrollment period of the Plan.
3.02.05 All services applicable for Covered Dependent children under the Plan shall be provided to
an enrolled newborn child of the Covered Employee, to the enrolled newborn child of a
Covered Dependent of the Covered Employee or to the newborn adopted child of the
Covered Employee, provided that a written agreement to adopt such child has been entered
into (prior to the birth of the child) from the moment of birth (as provided in Section 8.21).
In the case of the newborn adopted child, coverage shall not be effective if the child is not
ultimately placed in the Covered Employee's residence,in compliance with Florida law.
3.02.06 In the event the Covered Employee or a covered Domestic Partner has a child who meets the
following requirements, extended coverage may be available for that child until the end of
the Plan Year in which the child reaches age 30:
a. The child is unmarried and does not have a dependent of his or her own;
b. The child is a resident of Florida or a Full-Time or Part-Time Student;and
c. The child is not provided coverage as a named Participant, insured, enrollee or
Participant under any other group, blanket or franchise health insurance policy or
individual health benefits plan, or is not entitled to benefits under Title XVIII of the
Social Security Act.
3.02.07 It is the Participant's responsibility to notify the Plan Administrator when the child no longer
meets the eligibility requirements of Section 3.02. Termination of coverage may be
retroactively applied if the Plan Administrator is not notified within 31 days. Participant
agrees to provide supporting documentation upon request by AvMed.
3.02.08 No person is eligible to enroll hereunder who has had his coverage previously terminated
under Section 7.01.02,except with the written approval of AvMed.
3.02.09 Attainment of the limiting age by a dependent child shall not operate to exclude from or
terminate the coverage of such child,while such child is and continues to be both:
11
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
-:i
a. incapable of self-sustaining employment by reason of mental retardation or physical
handicap; and
b. chiefly dependent upon the Participant for support and maintenance,provided proof of
such incapacity and dependency is furnished to the Employer by the Participant within
31 days of the child's attainment of the limiting age, and subsequently as may be
required by the Employer,but not more frequently than annually after the 2-year period
following the child's attainment of the limiting age.
3.03 During the Plan Year, no changes in the Plan's eligibility or requirements of participation shall be
permitted to effect eligibility or enrollment under the Plan unless such change is agreed to by AvMed.
3.04 If the child of a Covered Employee or a covered Domestic Partner was enrolled in the Plan on the basis
of being a student at a postsecondary educational institution immediately before the first day of a
Medically Necessary leave of absence,the Plan will not terminate the coverage of such child before the
earlier of(1) one year after the first day of the medically necessary leave of absence, or (2) the date on
which such coverage would otherwise terminate under the terms of the Plan. A "Medically Necessary
leave of absence" is a leave of absence (or any other change in enrollment), from a postsecondary
educational institution that (1) begins while the child is suffering from a severe illness or injury, (2) is
Medically Necessary, and (3) causes the child to lose student status under the terms of the Plan.
Certification by the child's Attending Physician must be submitted to the Plan stating that the child is
suffering from a severe illness or injury and that the leave of absence or other change of enrollment is
Medically Necessary. A child whose benefits are continued under this provision is entitled to the same
benefits as if(during the Medically Necessary leave of absence)the child continued to be enrolled at the
institution of higher education and was not on a Medically Necessary leave of absence.
IV. ENROLLMENT
4.01 Prior to the effective date of the Plan and at a proper time prior to each anniversary thereof, the
Employer may allow an open enrollment period of 31 days in which any eligible employee on behalf of
himself and his eligible dependents may elect to enroll in the Plan.
4.02 Except as provided for newborns, eligible employees and dependents who meet the eligibility
requirements of Section III (ELIGIBILITY), must enroll within 31 days after becoming eligible by
submitting application forms acceptable to or provided by AvMed; otherwise, the eligible employees
and dependents may not enroll until the next open enrollment period.of the Employer.
4.03 Special Enrollment Periods. Eligible employees and their eligible dependents may request to enroll in
the Plan outside of the initial enrollment period and annual open enrollment periods if that individual
loses other coverage or acquires a new dependent as outlined below.
4.03.01 If the eligible employee or dependent declined coverage under the Plan when it was first
offered because of other group health plan or insurance coverage, and such other coverage
has terminated as a result of:
•
a. exhaustion of COBRA continuation coverage;
b. termination of employment or reduction in hours of employment;
c. termination of employer contributions;
d. legal separation,divorce or annulment,or termination of domestic partnership;
e. change in dependent status;
f. death of the employee;
g. change in legal custody or legal guardianship; or
h. relocation out of an HMO service area.
12
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
•
'.i
4.03.02 If the eligible or Covered Employee acquires a new dependent as a result of:
a. marriage;
b. birth;or
c. adoption or placement for adoption.
4.03.03 In the event of Sections 4.03.01 or 4.03.02 above, a completed Enrollment or Status Change
Form (together with proof of continuous coverage under the other plan when applicable)
must be submitted within 31 days of the date of termination of other coverage; or within 31
days of the date the dependent becomes eligible; or within 60 days as required for newborns.
To enroll an eligible dependent, the eligible employee must also enroll or already be a
Participant.
4.03.04 Eligible employees and dependents who are not enrolled, shall be eligible to enroll for
coverage within 60 days following:
a. termination of coverage under Medicaid or Children's Health Insurance Plan (CHIP)
due to loss of eligibility;or
b. determination of eligibility for premium assistance under Medicaid or CHIP.
c. A completed Enrollment or Status Change Form must be submitted within 60 days of
the date of the termination of Medicaid or CHIP coverage; or within 60 days of the date
of determination of eligibility for premium assistance under Medicaid or CHIP. To
enroll an eligible dependent, the eligible employee must also enroll or already be a
Participant.
4.03.05 Termination resulting from failure to pay premiums on a timely basis or termination of
coverage for cause (due to fraud, intentional misrepresentation, etc.) will not provide a
special enrollment period.
4.04 The eligibility requirements set forth in Section III (ELIGIBILITY) shall at all times control and no
coverage contrary thereto shall be effective. Coverage shall not be implied due to clerical or
administrative errors if such coverage would be contrary to Section III(ELIGIBILITY).
V. EFFECTIVE DATE OF COVERAGE
5.01 Subject to the payment of applicable monthly administrative fees, coverage under this Plan shall
become effective on the following dates:
5.01.01 Eligible employees and their eligible dependents who enroll during the open enrollment
period will become Participants a s of the effective date of this Plan or subsequent
anniversary thereof.
5.01.02 If a Participant acquires an eligible dependent through birth, adoption, placement for
adoption or marriage,such dependent shall be treated as covered under the Plan if,within 31
days (or 60 days as provided for newborns in Section III (ELIGIBILITY)) of acquiring the
new dependent,the Participant completes and submits an Enrollment Form on behalf of such
dependent. If the enrollment form is received by AvMed within the 31 day time period (or
60 days as provided for newborns),the enrollment for such dependent shall become effective
on the date of the birth, adoption or placement for adoption; or in the case of marriage, on
the date of marriage. During this period, eligible employees and their eligible dependents
may also enroll for medical coverage under the Plan,if not already covered. However, if an
enrollment request is not received by AvMed within the required time frame, the employee
and dependents will be required to wait until the next open enrollment period to apply for
coverage.
5.01.03 Coverage for the newborn child of a Covered Employee or the newborn child of a Covered
Dependent is effective at birth if Sections 3.02.04 and 5.01.02 are complied with.
13
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
5.01.04 • If an eligible employee or the employee's eligible dependents originally declined medical
coverage under the Plan due to other health coverage, and that coverage is subsequently
terminated as a result of either a loss of eligibility for such coverage or the termination of
any employer contributions for such coverage, or termination of the Plan, the employee and
the employee's dependents will be eligible to enroll in the Plan. To enroll, a completed
Enrollment Form must be submitted within 31 days of the date of termination of other
coverage. The effective date of any coverage provided under the Plan will be the first day of
the month following the date of enrollment. If the employee fails to enroll within 31 days
after the loss of other coverage,the employee and the employee's dependents must wait until
the next open enrollment period to apply for coverage, absent eligibility for a second special
enrollment period.
5.01.05 If an employee or the employee's dependents are eligible for coverage but not enrolled, and
experience a termination of coverage under Medicaid or CHIP due to loss of eligibility, or
are determined to be eligible for premium assistance under Medicaid or CHIP,the employee
and the employee's dependents will be eligible to enroll in the Plan. To enroll, a completed
Enrollment Form must be submitted within 60 days of the date of the termination of
coverage or the determination of eligibility for assistance.The effective date of any coverage
provided by AvMed will be the first day of the month following the date of enrollment. If
the employee fails to enroll within 60 days after the loss of such coverage or the
determination of such eligibility, the employee and the employee's dependents must wait
until the next open enrollment period to apply for coverage, absent eligibility for a second
special enrollment period.
VI. MONTHLY PAYMENTS AND COPAYMiENTS
6.01 Annual maximum out-of-pocket limits (as described in your Schedule of Benefits and Coverage).
Your Deductible, as well as any Coinsurance and Copayments you pay for covered benefits received
during any Plan Year are accumulated toward your annual maximum out-of-pocket limit. Amounts paid
for penalties do not count toward any Deductible or out-of-pocket limits. Once you meet your individual
or family annual maximum out-of-pocket limit in any Plan Year, the Plan will pay 100% of the
allowable charges for all covered services for the remainder of that Plan Year. It is the responsibility of
the Participant to retain receipts and to notify and document to the satisfaction of the Plan when the
annual maximum out-of-pocket limits have been reached.
6.02 Expenses that do not count toward the annual maximum out-of-pocket expense limit are (i) expenses
related to charges for services not covered including charges exceeding the Maximum Allowable
Payment, (ii) additional charges incurred for failure to.pre-authorize a service requiring prior
authorization, (iii) expenses that relate to services that exceed any specific treatment Limitations noted
in the Schedule of Benefits, (iv)_Brand Additional Charges for prescription,medications, (v) expenses
that relate to services not considered an Essential Health Benefit.
6.03 A Participant must pay any applicable Copayments or Coinsurance for covered benefits.
6.04 In the event of the retroactive termination of a Participant, neither the Plan nor AvMed shall be
responsible for medical expenses incurred by the Plan in providing benefits to the Participant under the
terms of the Plan after the effective date of termination.
VII. TERMINATION OF PARTICIPATION
7.01 Reasons for Termination. If your employer no longer offers a health plan, coverage will be terminated
on the last day of the month for which the monthly administrative fee was paid.
7.01.01 Loss of eligibility
14
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
•
a. Upon the loss of a Participant's eligibility, as defined in Section III (ELIGIBILITY),
including but not limited to permanent relocation outside AvMed's Service Area,
coverage will either(i)terminate immediately, if AvMed and/or the Employer so elect,
in their sole discretion, or (ii) automatically terminate on the last day of the month for
which the monthly administrative fee was paid and during which the Participant was
eligible for coverage if no elections is made under(i)above.
b. Upon a loss of the Covered Employee's eligibility, as defined in Section III
(ELIGIBILITY), coverage for all Covered Dependents will either (i) terminate
immediately if AvMed and/or the Employer so elects, in their sole discretion, or (ii)
automatically terminate on the last day of the month for which the monthly
administrative fee was paid, and during which the Covered Dependent was eligible for
coverage if no election is made under(i)above.
7.01.02 Termination of Participation for Cause. AvMed may terminate or cease to provide
services to any Participant immediately upon written notice for the following reasons which
lead to a loss of eligibility of the Participant:
a. Fraud, material misrepresentation or omission in applying for participation, benefits or
coverage under the Plan. However, relative to a misstatement in the Application, after
two years from the issue date, only fraudulent misstatements in the Application may be
used to void the policy or deny any Claim for a loss occurred or disability starting after
the two year period;
b. Misuse of the Plan's identification card furnished to the Participant;
c. Furnishing to the Plan or AvMed incorrect or incomplete information for the purpose of
obtaining participation,coverage or benefits under the Plan;or
d. Behavior which is disruptive, unruly, abusive or uncooperative to the extent that the
Participant's continuing coverage under the Plan seriously impairs AvMed's ability to
administer the Plan or to arrange for the delivery of health care services to the
Participant or other Participants after AvMed has attempted to resolve the Participant's
problem.
e. At the effective date of such termination, administrative service fee payments received
by AvMed on account of such termination shall be refunded on a pro rata basis, and
AvMed shall have no further liability or responsibility for the Participant(s) under the
Plan.
7.02 Notification requirements:
- 7.02.01 - Loss of-eligibility of Covered Employee. It is the-responsibility of the Employer to notify
AvMed in writing within 31 days from the effective date of termination regarding any
Covered Employee, Covered Retirees, and/or Covered Dependent who becomes ineligible to
participate in the Plan. Employer shall be liable for Claims incurred by Covered Employees,
Covered Retirees or Covered Dependents resulting from failure of Employer to provide such
timely notification.
7.02.02 Loss of eligibility of Covered Dependent. When a Covered Dependent becomes ineligible
for coverage, the Covered Employee, or Covered Retiree is required to notify the Plan
Administrator in writing within 31 days of the Covered Dependent becoming ineligible.
7.03 Continuation Coverage under COBRA. COBRA requires that most employers sponsoring group
health plans offer certain employees and former employees and their eligible dependents the opportunity
for a temporary extension of health coverage (called `continuation coverage') at group rates in certain
instances where coverage under the Plan would otherwise end. This section of the SPD is intended to
inform Participants, in a summary fashion, of their rights and obligations under the continuation
coverage provisions of the law.Participants should take the time to read this section carefully.
15
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
•
•
7.03.01 Eligibility. Covered Employees, Covered Spouses, or their Covered Dependents will
become eligible for continuation coverage under COBRA after any of the following
qualifying events result in the loss of Plan coverage:
a. Loss of benefits due to a reduction in the Covered Employee's hours of employment;
b. Termination of the Covered Employee's employment including retirement but
excluding termination for gross misconduct; or
c. Termination of employment following leave under the Family and Medical Leave Act
of 1993 (FMLA),in which case the qualifying event will occur on the earlier of the date
the Covered Employee indicates he will not return to work or the last day of the FMLA
leave.
d. Termination of retiree coverage when the former employer discontinues retiree
coverage within one year before or one year after filing for Chapter 11 bankruptcy.
e. In addition, Covered Dependents will become eligible for COBRA continuation
coverage after any of the following qualifying events occur to cause a loss of Plan
coverage:
i. The Covered Employee's death;
ii. Divorce, legal separation, or termination of domestic partnership from the Covered
Employee;
iii. The Covered Employee first becomes entitled to and enrolls in Medicare;.or
iv. The Covered Dependent child no longer qualifies as an eligible dependent under the
Plan.
f. A child who is born to (or placed for adoption) with a covered former employee during
the continuation coverage period has the same continuation coverage rights as an
eligible dependent child described above.
7.03.02 Notification. If a qualifying event other than divorce, legal separation, loss of eligible
dependent status or entitlement to Medicare occurs, the Employer will notify AvMed and its
COBRA Administration business partner of the qualifying event,who will send the Covered
Employee an election form. To continue Plan coverage, the completed election form must
be returned to AvMed's COBRA Administration business partner within 60 days after the
later of the date the form is received, or the date the Covered Employee's coverage ends due
to the qualifying event.
a. If divorce,legal separation, loss of eligible dependent status,loss of retiree benefits due
to bankruptcy or entitlement to Medicare under the Plan occurs, the Covered Employee
or Covered Dependent is responsible for notifying the Plan Administrator that a
qualifying event has occurred. Such notice must be received by the Plan Administrator
within 60 days after the later of the date of such event, or the date the Participant would
lose coverage on account of such event. Failure to timely notify the Plan Administrator
of these events will result in loss of the right of a Participant to continue coverage.
b. After receiving such notice, the Plan Administrator will notify AvMed and its COBRA
Administration business partner, who will send the Participant an election form within
14 days. If the Participant wishes to elect continuation coverage,the election form must
be returned completed to AvMed's COBRA Administration business partner within 60
days from the later of the date the form is received or the date coverage ends due to the
qualifying event.
7.03.03 Cost. If continuation coverage is elected, Participants must pay the entire cost of coverage
(the employer's contribution and the active employee portion of the contribution),plus a 2%
administrative fee for the duration of COBRA continuation coverage.
16 . .
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
•
a. If a Covered Employee or Covered Dependent is Social Security disabled (Social
Security disability status must occur as defined by Title II or Title XVI of the Social
Security Act),the Covered Employee may elect continuation coverage for the disabled
person only or for some or all COBRA eligible family members for up to 29 months if
the Covered Employee's employment is terminated or hours are reduced. The Covered
Employee must pay 102% of the cost of coverage for the first 18 months of COBRA
continuation coverage and 150% of the cost of coverage for the 19th through the 29th
months of coverage. The Social Security disability date must be determined to have
occurred within the first 60 days of loss of coverage due to termination of the Covered
Employee's employment or reduction in hours.
b. For COBRA coverage to remain in effect, payment must be received by the Plan
Administrator by the first day of the month for which the premium is due (the first
payment is due no later than 45 days after the election to continue coverage, and must
cover the period of time back to the first day of COBRA continuation coverage).
7.03.04 Duration. COBRA Continuation Coverage can be continued for up to:
a. 18 months if coverage ended due to a reduction in a Covered Employee's work hours
•
or termination of employment and the Covered Employee or one of his Covered
Dependents is not Social Security disabled within 60 days of the date of the loss of
coverage due to termination of employment or reduction in hours. If the Covered
Employee becomes entitled to Medicare during the course of this initial 18 months of
coverage, the Covered Dependents may elect to extend COBRA for an additional 18
months;or
b. 36 months for Covered Dependents, if the Covered Dependents lose eligibility for
medical coverage due to the Covered Employee, or Covered Retiree's death, divorce or
legal separation, or termination of domestic partnership from the Covered Employee,
the Covered Employee, or Covered Retiree's entitlement to Medicare after termination
or reduction in hours, or the Covered Employee's Covered Dependent child ceasing to
qualify as an eligible dependent under the Plan; or
c. 29 months if the Covered Employee's coverage is lost due to termination of
employment or reduction in hours and the Covered Employee or Covered Dependent is
disabled, as defined by Title II or Title XVI of the Social Security Act, within 60 days
of the original qualifying event. In this case, the Covered Employee may continue
coverage for an additional 11 months after the original 18-month period either for the
disabled person only or for one or all of the Covered Dependents.
i. : To be eligible for extended coverage due to Social Security disability, a Covered
Employee must notify the Plan Administrator of the disability before the end of the
initial 18 months of COBRA continuation coverage and within 60 days following
the date the Covered Employee or Covered Dependent is determined to be disabled
by the Social Security Administration. If the disabled individual should no longer
be considered to be disabled by the Social Security Administration, the Covered
Employee must notify the Plan Administrator within 30 days following the end of
the disability. Coverage that has exceeded the original 18-month continuation
period will end when the individual is no longer Social Security disabled;
d. If more than one qualifying event occurs, no more than 36 months total of COBRA
continuation coverage will be available. The COBRA beneficiary must experience the
second qualifying event during the first 18 months of COBRA continuation, and must
provide notice to the Plan Administrator within the required time period. COBRA
continuation coverage will end sooner if the Plan terminates and the employer does not
provide replacement medical coverage,or if a person covered under COBRA:
17
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
i. first becomes covered under another group health plan after the loss of coverage
due to a termination or reduction in hours, this Plan will be secondary for all
eligible health care expenses, provided contributions for COBRA coverage
continue to be paid. Coverage may only continue for the remainder of the original
COBRA period;
ii. fails to make required contributions when due;
iii. first becomes entitled to Medicare benefits after the initial COBRA qualifying
event; or
iv. is extending the 18-month coverage period because of disability and is no longer
disabled as defined by the Social Security Act.
7.04 Continuation Coverage during leaves of absence.
7.04.01 Family and Medical Leaves of Absence (FMLA). Under FMLA, a Covered Employee
may be entitled to up to a total of 12 weeks of unpaid job-protected leave during each Plan
Year for the following:
a. the birth of the Covered Employee's child, to care for the newborn child, or for
placement of a child in the Covered Employee's home for adoption or foster care;
b. to care for a spouse,child or parent with a serious health Condition; or
c. for the Covered Employee's own serious health Condition.
d. If the FMLA leave is paid, such pay will be reduced by the amount of the Covered
Employee's before-tax contributions as usual for the coverage level in effect on the date
FMLA leave begins. If FMLA leave is unpaid, the Covered Employee will be required
to pay contributions directly to the employer until returning to active pay status.
e. If the Covered Employee notifies the employer that he is terminating employment
during FMLA leave, coverage will end on the date of notification. If the Covered
Employee does not return to work on the expected FMLA return.date,and the employer
is not notified of the intent either to terminate employment or to extend the period of
leave,coverage will end on the date the Covered Employee was expected to return.
f. Plan elections may not be changed during FMLA leave unless an open enrollment
occurs or the Covered Employee has a change in status event or a special enrollment
event under The Health Insurance Portability and Accountability Act of 1996(HIPAA).
7.04.02 Military leaves of absence. If a Covered Employee is absent from work due to military
service, continuation coverage under the Plan (including coverage for enrolled dependents)
may be elected for up to 18 months from the first day of absence (or if earlier,until the day
after the date the Covered Employee is required to apply for or return to active employment
with the employer under the Uniformed Services Employment and Reemployment Rights
Act of 1994 (USERRA)). The Covered Employee's contributions for continued coverage
will be the same as for similarly situated active Participants in the Plan.
a. Whether or not coverage is continued during military service,a Covered Employee may
reinstate coverage under the Plan option elected on return to employment under
USERRA. The reinstatement will be without any waiting period otherwise required
under the Plan, except to the extent that any required waiting period was not completed
prior to the start of the military service.
18
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
VIII. SCHEDULE OF BASIC BENEFITS
The AvMed Choice product has several special features that can influence the level of coverage and how much
Participants pay out of pocket for medical care. A Participant's choice of Health Professional and/or facility
may result in lower or higher costs and Participants may be required to follow certain procedures to avoid
additional costs. A Participant's choice of Health Professional and/or facility, and wise use of these benefits,
can save you money.
Within the AvMed Service Area, Participants are entitled to receive the covered services and benefits through
the AvMed Network or from Out-of-Network Providers. Outside the Service Area, Participants are entitled to
receive the covered services and benefits through Out-of-Network Providers. The AvMed Point of Service Plan
creates two benefit payment levels; one for services provided by AvMed Network providers, and a second for
services provided by Out-of-Network Providers. The Benefit Level this Plan will pay depends on the Health
Professional and/or facility you select to provide covered health care services and where the services are
received:
• If the Health Professional and/or facility used is part of the AvMed Network,benefits for covered services
are payable at the Participating Provider high Benefit Level shown in the Schedule of Benefits.
• If the Health Professional and/or facility used is an Out-of-Network Provider,benefits for covered services
are payable at the low Benefit Level as specified in the Schedule of Benefits.
An important feature of this Point of Service Plan is that the amount of your out-of-pocket expense is
determined by your choice of provider at the time services are sought:
• Participants choosing AvMed Network providers will be responsible for paying lower Copayments and/or
Coinsurance.
• Participants choosing Out-of-Network Providers will pay the highest Deductibles and Coinsurance amounts
and will also be at risk for provider fees that are in excess of allowed amounts. In other words, a Participant
who chooses an Out-of-Network Provider may be responsible to pay the amount that exceeds the Maximum
Allowable Payment for the particular Medical Service involved,in addition to the applicable Deductible and
Coinsurance amounts. Also, fees that are in excess of allowed amounts are not a covered benefit and
therefore do not apply to your Deductible or annual out-of-pocket limit.
It is a Participant's responsibility when seeking benefits under this Plan to identify himself as a Participant and
to verify that the provider chosen is still a contracted provider of the selected network, if any. Participants
should confirm participation of a selected provider prior to seeking services.
Any Participant requiring medical, hospital, or ambulance services for emergencies (as described in Sections
2.24 and 2.25), while outside the Service Area or within the Service Area, but before they can reach a
Participating Provider,may receive the emergency benefits as specified in Section 8.14.
Only services and benefits in conformity with Section II (DEFINITIONS), Section VIII (SCHEDULE OF
BASIC BENEFITS), Section IX (LIMITATIONS OF BASIC BENEFITS), Section X (EXCLUSIONS FROM
BASIC BENEFITS) and the Schedule of Benefits,which by reference is incorporated herein,are covered by the
Plan. It is the Participant's responsibility when seeking benefits under the Plan to identify himself as a Plan
Participant and to assure that the services received by the Participant are being rendered by Participating
Providers. Participants must understand that services will not be covered if they are not, in AvMed's opinion,
Medically Necessary. Any and all decisions made by AvMed in administering the provisions of this Contract,
including without limitation, the provisions of Section VIII (SCHEDULE OF BASIC BENEFITS), Section IX
(LIMITATIONS OF BASIC BENEFITS) and Section X(EXCLUSIONS FROM BASIC BENEFITS) are made
only to determine whether payment for any benefits will be made by the Plan.
Any and all decisions that pertain to the medical need for, or desirability of, the provision or non-provision of
Medical Services or benefits, including without limitation, the most appropriate level of such Medical Services
or benefits, must be made solely by the Participant and his physician in accordance with the normal
patient/physician relationship for purposes of determining what is in the best interest of the Participant. AvMed
does not have the right of control over the medical decisions made by the Participant's physician.or health care
19
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
providers. The ordering of a service by a physician,whether participating or Non-Participating,does not in itself
make such service Medically Necessary. The Employer and Participants acknowledge that it is possible that a
Participant and his physician may determine that such services or supplies are appropriate even though such
services or supplies are not covered and will not be arranged or paid for by the Plan. Any covered service for
which the Participant is seeking reimbursement,must be submitted to AvMed within one year from the date of
service to be considered.
Cost-Sharing Information
Deductible. In some instances, the annual Deductible specified in the Schedule of Benefits must be satisfied
before the Plan will begin paying expenses for services covered. The Deductible means the amount a
Participant must pay each Plan Year for covered services before the Plan will make payment for eligible
expenses. The individual Deductible or family Deductible must be satisfied each Plan Year before any payment
for certain services and medications will be made by the Plan for any Claim. The Deductible is accumulated
across all levels. Satisfaction of the Deductible under one Benefit Level will count toward satisfaction of the
Deductible under the other Benefit Level.
If two or more covered Participants of a family incur injury due to the same accident, the Deductible applies
only once for all such expenses. If during a Plan Year, the covered Participants of a family incur eligible
expenses for which no benefits are payable because of the Deductible requirements, and the amount of such
eligible expense equals the family Deductible limit, then no further Deductible will apply to the covered
Participants of the family during the remainder of such Plan Year.
Coinsurance. Once the Plan Year Deductible has been met,Participants are responsible for paying a percentage
of eligible expenses. The coverage percentage,hereinafter called `Coinsurance' is specified in the Schedule of
Benefits. Participants will be responsible for paying any charges not considered an eligible expense.
Participants should remember that services that are provided or received without advance authorization from
AvMed, or when the service is beyond the scope of practice authorized for that provider under applicable state
law, are not covered unless such services otherwise have been expressly authorized under the terms of the Plan
or when required to treat an Emergency Medical Condition.
Services that require prior authorization from AvMed include,but are not limited to:
• all non-emergency inpatient admissions (including but not limited to Hospital and observation stays, skilled
nursing facilities,Ventilator Dependent Care and/or acute rehabilitation);
• all Home Health Care Services;
• all medications administered in an outpatient Hospital or infusion therapy setting;
• care rendered by Non-Participating Providers(except for Emergency Medical Services and Care);
• dialysis services;
• select medications administered in a physician's office;
• surgical procedures or services performed in an outpatient Hospital, Hospital-affiliated ambulatory surgery
center or free-standing ambulatory surgery center;
• transplant services.
Services requiring prior authorization may change from time to time. For more information about which
services require prior authorization,contact AvMed at 1-877-535-1397,or visit www.avmed.org.
If a physician is an AvMed Network/Participating Provider, he or she will handle all authorizations,
notifications and utilization reviews with AvMed. If a physician is not an AvMed Participating Provider,
Participants are responsible for making sure the physician or Health Professional contacts AvMed to obtain prior
authorization for a covered service when it is required. Participants should refer to their Plan identification card
for the telephone number where authorization may be obtained,or have the physician call 1-800-443=4103.
20
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
Please remember that failure to obtain prior authorization of a service will result in a reduction in coverage as
shown in the Schedule of Benefits. This reduction will occur regardless of whether such services are deemed
Medically Necessary. If an inpatient admission is extended beyond the number of days approved without
authorization,benefits for the extra days will be denied.
AvMed encourages but does not require Participants to select a Primary Care Physician(PCP)upon enrollment.
For children, Participants may designate a pediatrician as the PCP. Participants have the right to designate any
PCP who participates in our network and who is available to accept you or your family members. Until you
make this designation, AvMed may designate one for you. For information on how to select a PCP, and for a
list of the participating PCPs, contact AvMed. The names and addresses of Participating Providers and
Hospitals are set forth in a separate booklet which,by reference, is made a part hereof. The list of Participating
Providers, which may change from time to time, will be provided to the Employer. The list of Participating
Providers may also be accessed from the AvMed Website at www.avmed.org. Notwithstanding the printed
booklet, the names and addresses of Participating Providers on file with AvMed at any given time shall
constitute the official and controlling list of Participating Providers.
The selection of a PCP can be changed at any time. Health Professionals may from time to time cease their
affiliation with AvMed. In such cases, Participants will be required to receive services from another
participating Health Professional,subject to continuity of care rules to the extent required by law.
PARTICIPANTS ARE RESPONSIBLE AND WILL BE LIABLE FOR APPLICABLE COPAYMENTS,
DEDUCTIBLES AND/OR COINSURANCE WHICH MUST BE PAID TO HEALTH CARE
PROVIDERS FOR CERTAIN SERVICES, AT THE TIME SERVICES ARE RENDERED, AS SET
FORTH IN THE SCHEDULE OF BENEFITS. THE SCHEDULE OF BENEFITS IS A SEPARATE
DOCUMENT AVAILABLE FROM THE PLAN ADMINISTRATOR OR AVMED'S MEMBER
SERVICES AND IS INTENDED TO ACCOMPANY THIS SPD IN EXPLAINING THE BENEFITS
AVAILABLE UNDER THE PLAN.
8.01 Accidental Dental Injury Services. Dental injury services are covered the same as any other
Condition including the initial extraction and replacement of Sound Natural Teeth due to injury.
8.02 Ambulance services as follows:
8.02.01 Local professional air/ground ambulance transport for emergency services to the nearest
emergency department appropriately staffed and equipped to treat a medical Condition;
8.02.02 Ground transportation to an alternative level of care when associated with an approved
Hospital confinement;and
8.02.03 Ground transportation to a Participant's home will be covered when associated with an
approved hospitalization or other confinement and the Participant's Condition requires the
skill of medically trained personnel. Transportation is not covered when the skill of
medically trained personnel is not required and the Participant can be safely transferred (or
transported)by other means.
8.02.04 , Air ambulance transportation is covered only when the point of pick-up is inaccessible by
land or when distance or other obstacles are involved in transporting the Participant to the
nearest emergency department equipped to adequately treat the medical Condition.
8.03 Cardiac Rehabilitation. Cardiac rehabilitation is covered for the following Conditions: acute
myocardial infarction,percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass
graft(CABG),repair or replacement of heart valves or heart transplant. See Section IX(LIMITATIONS
OF BASIC BENEFITS)for any applicable coverage limits.
8.04 Child Cleft Lip and Cleft Palate Treatment. Health Care Services for child cleft lip and cleft palate,
including medical, dental, speech therapy, audiology, and nutrition services, for treatment of a child
under the age of 18 who has cleft lip or cleft palate are covered. For information on coverage and
Limitations that apply to Speech Therapy see Section 8.30, and Section IX(LIMITATIONS OF BASIC
21 •
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
BENEFITS). In order for such services to be covered, the Participant's Attending Physician must
specifically prescribe such services and such services must be consequent to treatment of the cleft lip or
cleft palate.
8.05 Clinical Trials.
8.05.01 Routine patient care costs incurred during participation in a qualifying clinical trial for the
treatment of:
a. cancer or other life-threatening disease or Condition. For purposes of this benefit,a life-
threatening disease or Condition is one from which the likelihood of death is probable
unless the course of the disease or Condition is interrupted;
b. cardiovascular disease (cardiac/stroke) which is not life threatening, for which, as we
determine,a clinical trial meets the qualifying clinical trial criteria stated below;
c. surgical musculoskeletal disorders of the spine, hip and knees, which are not life-
threatening,for which, as we determine,a clinical trial meets the qualifying clinical trial
criteria stated below.
8.05.02 Benefits include the reasonable and necessary items and services used to prevent, diagnose
and treat complications arising from participation in a qualifying clinical trial. Benefits are
available only when the Participant is clinically eligible for participation in the qualifying
clinical trial as defined by the researcher. Participants are required to use a Participating
Provider for any clinical trials covered under this Summary Plan Description.
8.05.03 Routine patient care costs for qualifying clinical trials include:
a. covered Health Services for which benefits are typically provided absent a clinical trial;
b. covered Health Services required solely for the provision of the investigational item or
service,the clinically appropriate monitoring of the effects of the item or service,or the
prevention of complications;
c. covered Health Services needed for reasonable and necessary care arising from the
provision of an Investigational item or service.
8.05.04 Routine costs for clinical trials do not include:
a. the Experimental or Investigational service or item. The only exceptions to this are
certain Category B devices, certain promising interventions for patients with terminal
illnesses, other items and services that meet specified criteria in accordance with our
medical and drug policies;
b. items and services provided solely to satisfy data collection and analysis needs and that
are not used in the direct clinical management of the patient;
c. a service that is clearly inconsistent with widely accepted and established standards of
care for a particular diagnosis;
d. items and services provided by the research sponsors free of charge for any person
enrolled in the trial.
8.05.05 With respect to cancer or other life-threatening diseases or Conditions, a qualifying clinical
trial is a Phase I,Phase II,Phase III, or Phase IV clinical trial that is conducted in relation to
the prevention, detection, or treatment of cancer or other life-threatening disease or
Condition and which meets any of the following criteria in the list below. With respect to
cardiovascular disease or musculoskeletal disorders of the spine,hip and knees which are not
life threatening, a qualifying clinical trial is a Phase I, Phase II, or Phase III clinical trial that
is conducted in relation to the detection or treatment of such non-life-threatening disease or
disorder and which meets any of the following criteria in the list below.
22
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
a. Federally funded trials.The study or investigation is approved or funded by(which may
include funding through in-kind contributions)by one or more of the following:
i. National Institutes of Health(NIH). (Includes National Cancer Institute.)
ii. Centers for Disease Control and Prevention.
iii. Agency for Healthcare Research and Quality.
iv. Centers for Medicare and Medicaid Services.
v. A cooperative group or center of any of the entities described above or the
Department of Defense(DOD)or the Veteran's Administration.
vi. A qualified non-governmental research entity identified in the guidelines issued by
the NIH for center support grants.
vii. The Department of Veteran Affairs,the DOD, or the Department of Energy as long
as the study or investigation has been reviewed and approved through a system of
peer review that is deteiinined by the Secretary of Health and Human Services to
meet both of the following criteria:
(a) Comparable to the system of peer review of studies and investigations used by
the NIH.
(b) Ensures unbiased review of the highest scientific standard by qualified
individuals who have no interest in the outcome of the review.
b. The study or investigation is conducted under an investigational new drug application
reviewed by the U.S.Food and Drug Administration.
c. The study or investigation is a drug trial that is exempt from having such an
investigational new drug application.
d. The clinical trial must have a written protocol that describes a scientifically sound study
and have been approved by all relevant institutional review boards before Participants
are enrolled in the trial.We may,at any time,request documentation about the trial.
e. The subject or purpose of the trial must be the evaluation or an item or service that
meets the definition of a Covered Health Service and is not otherwise excluded under
the Plan.
8.06 Complications of Pregnancy. Health Care Services provided to you for the treatment of complications
of pregnancy are Covered Services and shall be treated the same as any other medical Condition.
Complications of pregnancy include,but are not limited to:
8.06.01 acute nephritis;
8.06.02 nephrosis;
8.06.03 cardiac decompensation;
8.06.04 eclampsia(toxemia with convulsions);
8.06.05 ectopic pregnancy;
8.06.06 uncontrolled vomiting requiring fluid replacement;
8.06.07 missed abortion(i.e., fetal death without spontaneous abortion);
8.06.08 therapeutic and missed abortion (i.e., termination of pregnancy before the time of fetal
viability due to medical danger to the pregnant woman or when the pregnancy would result
in the birth of an infant with grave malformation;
8.06.09 Conditions that may require other than a vaginal delivery, such as: uterine wound separation,
premature labor, unresponsive to tocolytic therapy, failed trial labor, dystocia (i.e.,
23
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
•
cephalopelvic disproportion, failure to progress, dysfunctional labor), fetal distress requiring
neonatal support/intervention, breech presentation where external version is unsuccessful,
active clinical herpes at delivery, placenta previa, transverse lie where external version is
unsuccessful,presence of fetal anomaly;
8.06.10 tubal pregnancy;
8.06.11 miscarriages;
8.06.12 medical and surgical Conditions of similar severity;and
8.06.13 Medically Necessary non-elective cesarean section.
8.07 Dermatological Services. AvMed will cover office visits to a participating dermatologist for Medically
Necessary covered services subject to Sections 2.42 and 2.71. No prior referral is required for these
services.
8.08 Diabetes outpatient self-management includes all Medically Necessary equipment, supplies, and
services to treat diabetes. This includes outpatient self-management training and educational services if
the Participant's Primary Care Physician or the physician to whom the Participant has been referred who
specializes in diabetes treatment certifies the equipment, supplies or services are Medically Necessary.
Diabetes outpatient self-management training and educational services must be provided under the
direct supervision of a certified diabetes educator or a board certified endocrinologist under contract
with AvMed.
8.09 Diabetic Supplies. Insulin and other covered anti-diabetic drugs and diabetic supplies, including
needles, syringes, lancets, lancet devices and test strips are covered under your Prescription Drug
benefits. Insulin pumps when Medically Necessary and accompanied by a prescription from your
Attending Physician are covered under your medical benefits. Please see Section 8.13 Durable Medical
Equipment.
8.10 Diagnosis and treatment of Autism Spectrum Disorder through speech therapy, occupational
therapy, physical therapy, and Applied Behavior Analysis services for an individual under 18 years of
age or an individual 18 years of age or older who is in high school who has been diagnosed as having a
developmental disability at 8 years of age or younger.
8.10.01 Coverage shall be limited to services that are prescribed by the treating physician in
accordance with a treatment plan. The treatment plan required shall include, but is not
limited to, a diagnosis, the proposed treatment by type, the frequency and duration of
treatment, the anticipated outcomes stated as goals, the frequency with which the treatment
plan will be updated, and the signature of the treating physician. See Section IX
(LIMITATIONS OF BASIC BENEFITS)for any applicable benefit maximums.
8.11 Diagnostic Imaging and Laboratory. All prescribed diagnostic imaging and laboratory tests and
services including diagnostic imaging, fluoroscopy, electrocardiograms, blood and urine and other
laboratory tests, and diagnostic clinical isotope services are covered when Medically Necessary and
ordered by a Participating Physician as part of the diagnosis and/or treatment of a covered illness or
injury or as preventive health care services.
8.12 Diagnostic Testing and Treatment Related to Attention Deficit Hyperactivity Disorder (ADHD).
Coverage is subject to applicable Copayments and coverage limitations as outlined on the Schedule of
Benefits. Covered services do not include those that are primarily educational or training in nature.
8.13 Durable Medical Equipment (DME). This Plan provides benefits, when Medically Necessary, for the
purchase or rental of such DME that:
8.13.01 can withstand repeated use(i.e. could normally be rented and used by successive patients);
8.13.02 is primarily and customarily used to serve a medical purpose;
8.13.03 generally is not useful to a person in the absence of illness or injury; and
24
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
8.13.04 is appropriate for use in a patient's home.
8.13.05 Some examples of DME are: hospital beds, crutches, canes, walkers, wheelchairs, oxygen,
respiratory equipment, apnea monitors and insulin pumps. It does not include hearing aids
or corrective lenses,or the professional fee for fitting same. It also does not include medical
supplies and devices,such as a corset,which do not require prescriptions. The Plan will pay
for rental of equipment up to the purchase price. Repair and/or replacements are not
covered.
8.13.06 Oxygen is covered when Medically Necessary pursuant to AvMed's coverage guidelines,
which are available free of charge upon request. The type of oxygen delivery system
covered(stationary,portable,ambulatory)is based on the Participant's activity status. Initial
coverage is contingent upon arterial blood gas results. Reassessment of oxygen needs
through pulse oximetry at rest and after exercise is required and must be performed by an
independent respiratory provider at three months after the initiation of therapy and then
yearly in order to re-qualify coverage of oxygen therapy.
8.13.07 The determination of whether a covered item will be paid under the DME, orthotics or
prosthetics benefits will be based upon its classification as defined by the Centers for
Medicare and Medicaid Services. See Section IX (LIMITATIONS OF BASIC BENEFITS)
for applicable coverage limitations.
8.14 Emergency Services.The Plan will cover all necessary physician and Hospital Services for Emergency
Medical Services and Care. See Sections 2.23 and 2.25. In the event Hospital inpatient services are
provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital,
Participant or designee, within 24-hours of the inpatient admission if reasonably possible. AvMed may
elect to transfer the Participant to a Participating Provider after the Participant's condition has been
stabilized and as soon as it is medically appropriate to do so. For out-of-network Emergency Services,
AvMed will pay an amount equal to the greater of the three amounts specified below:
8.14.01 The median of the amount negotiated with in-network providers for the Emergency Service
furnished;
8.14.02 The amount for the Emergency Services calculated using AvMed's Maximum Allowable
Payment, which is the same method the Plan generally uses to determine payments for out-
of-network services,and applying in-network cost-sharing; or
8.14.03 The amount that would be paid under Medicare for the Emergency Service.
8.15 General anesthesia and hospitalization services to a Participant who is under 8 years of age and is
determined by a licensed dentist and the Participant's physician to require necessary dental treatment in
a Hospital or ambulatory surgical center due to a significantly complex dental Condition or a
developmental disability in which patient management in the dental office has proved to be ineffective;
or if the Participant has one or more medical Conditions that would create significant or undue medical
risk for the Participant in the course of delivery of any necessary dental treatment or surgery if not
rendered in a Hospital or ambulatory surgical center. Pre-authorization by AvMed is required. There is
no coverage for diagnosis or treatment of dental disease.
8.16 Habilitation Services. Covered services consist of physical therapy, speech therapy, and occupational
therapy that is provided for developmental speech or language disorder, developmental coordination
disorder and mixed developmental disorder. Therapy services must be performed by an appropriate
registered physical, occupational or speech-language therapist licensed by the appropriate state licensing
board and must be furnished under the direction and supervision of a physician or an advanced practice
nurse in accordance with a written treatment plan established or certified by the treating Attending
Physician or advanced practice nurse.
8.16.01 Covered services take place in a participating non-residential setting separate from the home
or facility in which the Participant lives.
25
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
• 8.16.02 , Services are covered up to the point where no further progress can be documented. Services
are not considered a covered benefit when measurable functional improvement is not
expected or progress has plateaued.
8.16.03 Covered Habilitation Services do not include activities or training to which the client may be
entitled under federal or state programs of public elementary or secondary education or
federally aided vocational rehabilitation. See Section IX (LIMITATIONS OF BASIC
BENEFITS)for any applicable benefit maximums.
8.17 Home Health Care Services (Skilled Home Health Care). Home Health Care Services (as defined in
Section 2.33) are covered when ordered by and under the direction of the Participant's Attending
Physician. Home Health Care Services that do not include a medical, diagnostic, therapeutic or
rehabilitative component or that do not require the skill of a registered nurse, licensed practical
(vocational) nurse or other healthcare personnel are not covered. Homemaker or other Custodial Care
services are not covered. See Section IX (LIMITATIONS OF BASIC BENEFITS) for any applicable
benefit maximums.
8.18 Hospital Care: Inpatient. All non-emergency Hospital inpatient services received at Participating
Hospitals for non-mental illness or injury are provided when prescribed by Participating Physicians and
pre-authorized by AvMed. Inpatient services include semi-private room and board, birthing rooms,
newborn nursery care,nursing care,meals and special diets when Medically Necessary,use of operating
rooms and related facilities, the intensive care unit and services, diagnostic imaging, laboratory and
other diagnostic tests, medications, biologicals, anesthesia and oxygen supplies, physical therapy,
radiation therapy, respiratory therapy, and administration of blood or blood plasma.- See Section 8.14
with regard to inpatient admission following Emergency Medical Services and Care.
8.18.01 Hospital Based Providers will be paid as follows.
a. For non-emergency services, the level of payment for Hospital Based Providers will be
determined subject to the following criteria:
i. If services are performed at an AvMed Choice Network Hospital and the admitting
physician is also part of the AvMed Choice Network, then the Hospital Based
Provider will be paid at the highest Benefit Level.
ii. If services are rendered at an AvMed Choice Network Hospital and the admitting
physician is not part of the AvMed Choice Network, then the Hospital Based
Provider will be paid at the middle Benefit Level.
iii. If services are rendered at a PHCS Hospital, then the Hospital Based Provider will
be paid at the middle Benefit Level.
iv. If services are rendered at an out-of-network Hospital, then the Hospital Based
Provider will be paid at the low Benefit Level.
8.19 Hospice Services. Services are available for a Participant whose Participating Physician has
determined the Participant's illness will result in a remaining life span of 6 months or less. See Section
IX(LIMITATIONS OF BASIC BENEFITS) for any applicable benefit maximums.
8.20 Mammograms are covered in accordance with Florida Statutes and the U.S. Preventive Services Task
Force (USPSTF) preventive services recommendations (Grade A and B). One baseline mammogram is
covered for female Participants between the ages of 35 and 39. A mammogram is available every two
years for female Participants between the ages of 40 and 49 and a mammogram is available every year
for female Participants aged 50 and older.
8.20.01 In addition, one or more mammograms a year are available when based upon a physician's
recommendation for any woman who is at risk for breast cancer because of a personal or
family history of breast cancer, because of having a history of biopsy-proven benign breast
disease, because of-having a mother, sister, or daughter who has had breast cancer, or
because a woman has not given birth before the age of 30.
26
SF-City of Miami Beach-Basic POS-SPD-2015 .
SF-3661(10/15)
8.21 Mastectomy Surgery. If you have had or are going to have a mastectomy, you may be entitled to
certain benefits under the Women's Health and Cancer Right's Act of 1988 (WHCRA). For individuals
receiving mastectomy-related benefits, coverage will be provided in a manner determined in
consultation with the Attending Physician and the patient,for:
8.21.01 all stages of reconstruction of the breast on which the mastectomy has been performed;
8.21.02 surgery and reconstruction on the other breast to produce a symmetrical appearance; and
8.21.03 prostheses and physical complications during all stages of mastectomy including
lymphedemas.
8.21.04 The length of stay will not be less than that determined by the Attending Physician to be
Medically Necessary in accordance with prevailing medical standards and after consultation
with the Participant. The Attending Physician, after consultation with the Participant, may
choose that the outpatient care be provided at the most medically appropriate setting, which
may include the Hospital, treating physician's office, outpatient center or home of the
Participant.
8.21.05 Coverage is subject to the same Copayments or Coinsurance applicable to other medical and
°-- surgical benefits provided under the Plan, and will require prior authorization of services as
applicable to other surgical procedures or hospitalizations under the Plan.
8.21.06 If you would like more information on WHCRA benefits,call AvMed at 1-877-535-1397.
8.22 Mental Health Services. Inpatient acute and intermediate, and outpatient mental health services are
covered when Medically Necessary, and may be covered when a Participant is admitted to a Hospital or
Other Health Care Facility.
8.22.01 Inpatient intermediate mental health services may be covered in conjunction with a 24-hour
intensive, structured and supervised treatment program providing an inpatient level of care
but in a non-Hospital environment,for those disorders that cannot be effectively treated in an
outpatient or Partial Hospitalization environment.
8.22.02 Partial Hospitalization may be covered under a structured program of active psychiatric
treatment provided in a Hospital outpatient setting or by a community mental health center,
that is more intense than the care received in a physician's or therapist's office, as an
alternative to inpatient hospitalization.
8.22.03 Outpatient and intensive outpatient treatment for mental health disorders may be covered
when provided by a state-licensed psychiatrist or other Physician, clinical psychologist,
clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or
other qualified mental health professional as allowed under applicable state law.
8.22.04 Prior notification is required for mental health services. Prior authorization is required for
mental health inpatient and Partial Hospitalization services. See Section IX (LIMITATIONS
OF BASIC BENEFITS)for any applicable benefit maximums.
8.23 Newborn Care. All services applicable for children under the Plan are covered for an enrolled
newborn child of the Covered Employee, or the enrolled newborn child of a Covered Dependent of the
Covered Employee, or the newborn adopted child of the Covered Employee (as described in Section
3.02.05, from the moment of birth, including the Medically Necessary care or treatment of medically
diagnosed congenital defects,birth abnormalities or prematurity, and transportation costs to the nearest
facility appropriately staffed and equipped to treat the newborn's Condition when such transportation is
Medically Necessary. Circumcisions are provided for up to one year from date of birth.
8.24 Nutrition Therapy. Nutritional supplements and low protein modified foods for use at home by a
Participant may be covered when prescribed or ordered by a Physician for the treatment of an inherited
metabolic disease, e.g., phenylketonuria (PKU). Coverage shall include food products modified to be
low protein for a Participant. See Section IX (LIMITATIONS OF BASIC BENEFITS) for any
applicable benefit maximums.
27
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
8.25 Obstetrical and Gynecological Care. An annual gynecological examination and Medically Necessary
follow-up care detected at that visit are available without the need for a prior referral from your Primary
Care Physician. You do not need prior authorization from the Plan or from any other person(including
a PCP) in order to obtain access to obstetrical or gynecological care from a Health Professional in the
Plan's network who specializes in obstetrics or gynecology. The Health Professional,however,may be
required to comply with certain procedures, including obtaining prior authorization for certain services,
following a pre-approved treatment plan, or procedures for making referrals. For a list of participating
Health Professionals who specialize in obstetrics or gynecology,please refer to your provider directory.
Obstetrical care benefits as specified herein are covered and include Hospital care, anesthesia,
diagnostic imaging and laboratory services for Conditions related to pregnancy. The length of maternity
stay in a Hospital will be that determined to be Medically Necessary in compliance with Florida law and
in accordance with the Newborns' and Mothers' Health Protection Act (NMHPA). Group health plans
and health insurance issuers generally may not, under Federal law (including the NMHPA), restrict
benefits for any hospital length of stay in connection with childbirth for the mother or newborn child
below certain levels. These levels are as follows:
8.25.01 Hospital stays of at least 48 hours following a normal vaginal delivery, or at least 96 hours
following a cesarean section (under Federal law, the Plan may not require that your provider
obtain authorization from the Plan for prescribing a length of stay not in excess of 48 or 96
hours,as appropriate);
8.25.02 The Attending Physician does not need to obtain authorization from AvMed to prescribe a
Hospital stay of this length;
8.25.03 The Plan will cover an extended stay, if Medically Necessary; however, the physician or
Hospital must pre-certify the extended stay.
8.25.04 Shorter Hospital stays are permitted if the Attending Physician, in consultation with the
mother,determines that to be best course of action. Coverage for maternity care is subject to
applicable Copayments and all other Plan limits and requirements.
8.26 Orthotic Appliances. Coverage for orthotic appliances is limited to..custom-made leg, arm, back and
neck braces when related to a surgical procedure or when used in an attempt to avoid surgery and when
necessary to carry out normal activities of daily living, excluding sports activities. Coverage includes
the initial purchase, fitting or adjustment. Replacements are covered only when Medically Necessary
due to a change in bodily configuration. Arch support and orthopedic shoes are covered if medically
necessary because of diabetes or hammertoe. All other orthotic appliances are not covered. The
determination of whether a covered item will be paid under the DME, orthotics or prosthetics benefits
will be based upon its classification as defined by the Centers for Medicare and Medicaid Services.
8.27 Osteoporosis diagnosis and treatment when Medically Necessary for high-risk individuals, including
but not limited to, estrogen-deficient individuals, individuals with vertebral abnormalities, individuals
on long-term glucocorticoid (steroid) therapy, individuals with primary hyperparathyroidism and
individuals with a family history of osteoporosis.
8.28 Other Health Care Facility(ies). All routine services of Other Health Care Facilities (see Section
2.47), including physician visits, physiotherapy, diagnostic imaging and laboratory work, may be
covered when a Participant is admitted to such a facility, following discharge from a Hospital, for a
Condition that cannot be adequately treated with Skilled Home Health Care Services or on an
ambulatory basis. See Section IX (LIMITATIONS OF BASIC BENEFITS) for any applicable benefit
maximums.
8.29 Outpatient therapeutic services. Covered health services for therapeutic treatments received on an
outpatient basis in the home, physician's office, Other Health Care Facility or Hospital, including
intravenous chemotherapy or other intravenous infusion therapy and Injectable Medications. Self-
Administered Injectable Medications are only a covered benefit when included in the supplemental
prescription medication benefits.
28
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15) -
8.30 Physical, Occupational, Speech and Cognitive Therapy. Short-term rehabilitative physical,
occupational, speech and cognitive therapy provided in an outpatient or home care setting is covered to
improve or restore physical functioning following disease, injury or loss of a body part. Habilitative
physical, occupational and speech therapy provided in an outpatient or home care setting is covered
when provided to help a person keep, learn or improve skills and functioning for daily living. Clinical
documentation or a treatment plan to support the need for therapy services or continuing therapy must
be submitted for review. See Section IX (LIMITATIONS OF BASIC BENEFITS) for any applicable
benefit maximums.
8.30.01 Continued therapy is only Medically Necessary when this care is prescribed by a physician
in order to significantly improve,develop or restore physical functions that have been lost or
impaired. Using additional diagnoses to obtain additional therapy for the same Condition is
not considered Medically Necessary. Once maximum therapeutic benefit has been achieved,
and there is no longer any progression, or a home exercise program could be used for any
further gains, continuing supervised therapy is not considered Medically Necessary.
Therapy in persons whose Condition is neither regressing nor improving is considered not
Medically Necessary.Therapy in asymptomatic persons or in persons without an identifiable
clinical Condition is considered not Medically Necessary.
8.30.02 Additional therapy can be considered for a new or separate Condition in a person who
previously received therapy for another indication. An exacerbation or flare-up of a chronic
illness is not considered a new incident of illness.
8.30.03 Home-Based Physical Therapy is Medically Necessary in selected cases based upon the
Participant's needs i.e., the Participant must be homebound. This may be considered
Medically Necessary in the transition of the Participant from Hospital to home, and may be
an extension of case management services.
8.31 Physician Care: Inpatient. All Medical Services rendered by physicians and other Health
Professionals when requested or directed by the Attending Physician, including surgical procedures,
anesthesia, consultation and treatment by Specialty Health Care Physicians, laboratory and diagnostic
imaging services, and physical therapy(see Section 8.30) are covered while the Participant is admitted
to a Hospital as a registered bed patient. When available and requested by the Participant, the Plan
covers the services of a certified nurse anesthetist licensed under Chapter 464,Florida Statutes.
29
SF-City of Miami Beach-Basic P0S-SPD-2015
SF-3661(10/15)
8.32 Physician Care: Outpatient
8.32.01 Diagnosis and Treatment. All Medical Services rendered by physicians and other Health
Professionals, are covered when Medically Necessary and when provided at Medical
Offices, including surgical procedures, routine hearing examinations and vision
examinations for glasses for children and adults (such examinations may be provided by
optometrists licensed pursuant to Chapter 463, Florida Statutes (or, where appropriate,
similar laws of another state) or by ophthalmologists licensed pursuant to Chapter 458 or
459,Florida Statutes (or where,appropriate, similar or analogous laws of another state),and
consultation and treatment by Specialty Health Care Physicians. Also included are non-
reusable materials and surgical supplies. These services and materials are subject to the
Limitations outlined in Section IX(LIMITATIONS OF BASIC BENEFITS).
8.32.02 Preventive and Health Maintenance Services. The services of physicians for illness
prevention and health maintenance,including items or services that have an A or B rating in
current recommendations of the U.S. Preventive Services Task Force (USPSTF);
immunizations recommended by the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention; evidence-informed preventive care and
screenings for infants, children, and adolescents as provided for in the comprehensive
guidelines supported by the Health Resources and Services Administration (HRSA); and
additional preventive care and screening(with respect to women)provided for in guidelines
supported by the Health Resources and Services Administration.
8.32.03 Hospital Based Providers who are considered Out-of-Network Providers because they do
not contract with AvMed, and who provide services in an outpatient setting, will be paid at
the mid-level.
8.33 Prescription Medication Benefits. Allergy serums and chemotherapy for cancer patients are covered
under the Plan's medical benefits. Coverage for insulin and other diabetic supplies is described in
Section 8.09. Other retail prescription medications are a covered benefit only when the Plan includes
supplemental prescription medication benefits; coverage is subject to the Copayment/Coinsurance
provisions outlined therein. See the form entitled Prescription Medication Benefits for a description of
other prescription medication coverage.
8.34 Prosthetic Devices. This Plan provides benefits, when Medically Necessary, for prosthetic devices
designed to restore bodily function or replace a physical portion of the body. Coverage for prosthetic
devices is limited to artificial limbs, artificial joints, ocular prostheses and cochlear implants. Coverage
includes the initial purchase, fitting or adjustment. Replacement is covered only when Medically
Necessary due to a change in bodily configuration. The initial prosthetic device following a covered
mastectomy is also covered. Replacement of intraocular lenses is covered only if there is a change in
prescription that cannot be accommodated by eyeglasses. All other prosthetic devices are not covered,
including prosthetic devices for Deluxe, Myo-electric and electronic prosthetic devices. The
determination of whether a covered item will be paid under the DME, orthotics or prosthetics benefits
will be based upon its classification as defined by the Centers for Medicare and Medicaid Services.
8.35 Second Medical Opinions. The Participant is entitled to a second medical opinion when he disputes
the appropriateness or necessity of a surgical procedure or is subject to a serious injury or illness.
8.35.01 The Participant may obtain a second medical opinion from any participating or Non-
Participating physician, chosen by the Participant. If a Participating Physician is chosen,
there is no cost to the Participant other than any applicable Copayment or Coinsurance. If
the Participant chooses an Out-of-Network Provider, the Participant will be responsible for
40% of the amount of the Maximum Allowable Payment associated with the consultation.
8.35.02 Once a second medical opinion has been rendered, AvMed shall review and determine the
treatment obligations of the Plan, and that judgment is controlling, subject to the Plan's
appeals process. Any treatment the Participant obtains that is not authorized by AvMed shall
be at the Participant's expense.
30
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
8.35.03 The Plan may limit second medical opinions in connection with a particular diagnosis or
treatment to three per Plan Year, if additional opinions are deemed to be an unreasonable
over-utilization by the Participant.
8.36 Sexual dysfunction/impotence is covered the same as any other Condition subject to Medical
Necessity and Utilization Management guidelines as noted in sections 2.42 and 2.71.
8.37 Spinal manipulations will be covered only when Medically Necessary, subject to Sections 2.42 and
2.71. No prior referral is required. See Section IX (LIMITATIONS OF BASIC BENEFITS) for any
applicable benefit maximums.
8.38 Substance Abuse Services. Inpatient,intermediate and outpatient substance abuse services are covered
when Medically Necessary, and may be covered when a Participant is admitted to a Hospital or Other
Health Care Facility.
8.38.01 Inpatient intermediate substance abuse services may be covered in conjunction with a 24-
hour intensive, structured and supervised treatment program providing an inpatient level of
care but in a non-Hospital environment,for those disorders that cannot be effectively treated
in an outpatient or Partial Hospitalization environment.
8.38.02 Partial Hospitalization may be covered under a structured program of active psychiatric
treatment provided in a Hospital outpatient setting or by a community mental health center,
that is more intense than the care received in a physician's or therapist's office, as an
alternative to inpatient hospitalization.
8.38.03 Outpatient and intensive outpatient treatment for substance use disorders may be covered
when provided by a state-licensed psychiatrist or other physician, clinical psychologist,
clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or
other qualified substance abuse professional as allowed under applicable state law.
8.38.04 Prior notification is required for substance abuse services. Prior authorization is required for
substance abuse inpatient and Partial Hospitalization services. See Section IX
(LIMITATIONS OF BASIC BENEFITS)for any applicable benefit maximums.
8.39 Supplies. Ostomy,urostomy and wound care supplies are covered when Medically Necessary. Wound
care supplies are covered as part of an approved treatment plan,when the wound is caused by or treated
by a surgical procedure, or requires debridement. Items which are not medical supplies or which could
be used by the Participant or a family member for purposes other than ostomy care are not covered.
8.40 Temporomandibular Joint Dysfunction(TMJ). Includes Medically Necessary treatment for jaw joint
problems including temporomandibular joint disorder, craniomaxillary, craniomandibular disorder or
other conditions of the joint linking the jaw bone and skull and treatment of the facial muscles used in
expression and mastication functions, for symptoms including but not limited to, headaches. These
expenses do not include charges for orthodontic services.
8.41 Transgender Reassignment Services. All medically necessary Transgender Reassignment services are
covered, including gender reassignment services (surgical and facility fees) hormone therapy, mental
health services,lab,x-rays,and diagnostic testing.
8.42 Transplant services, limited to the procedures listed below, are covered when performed at an AvMed
contracted transplant facility, subject to the Conditions and Limitations described below. Transplant
services are subject to Prior Authorization. Transplant includes pre-transplant, transplant and post-
discharge services,and treatment of complications after transplantation.
8.42.01 The Plan will pay benefits only for services, care and treatment received or provided in
connection with:
a. a Bone Marrow Transplant, which is specifically listed in Rule 59B-12.001, Florida
Administrative Code, or any successor or similar rule or covered by Medicare as
described in the most recently published Medicare Coverage Issues Manual issued by
the Centers for Medicare and Medicaid Services. The Plan will cover the expenses
31
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15) .•
•
incurred for the donation of bone marrow by a donor to the same extent such expenses
would be covered for the Participant and will be subject to the same Limitations and
Exclusions as would be applicable to the Participant. Coverage for reasonable expenses
of searching for the donor will be limited to a search among immediate family members
and donors identified through the National Bone Marrow Donor Program.
v. Bone Marrow Transplant means human blood precursor cells administered to a
patient to restore normal hematological and immunological functions following
ablative therapy. Human blood precursor cells may be obtained for the patient in an
autologous transplant, or an allogeneic transplant from a medically acceptable
related or unrelated donor, and may be derived from bone marrow, the circulating
blood, or a combination of bone marrow and circulating blood. If chemotherapy is
an integral part of the treatment involving bone marrow transplantation, the term
`Bone Marrow Transplant',includes the transplantation as well as the administration
of chemotherapy and the chemotherapy medications. The term `Bone Marrow
Transplant' also includes any services or supplies relating to any treatment or
therapy involving the use of high dose or intensive dose chemotherapy and human
blood precursor cells and includes any and all Hospital, physician or other health
care provider services which are rendered in order to treat the effects of, or
complications arising from, the use of high dose or intensive dose chemotherapy or
human blood precursor cells(e.g.,Hospital room and board and ancillary services);
b. corneal transplant;
c. heart transplant (including a ventricular assist device, if indicated, when used as a
bridge to heart transplantation);
d. heart-lung combination transplant;
e. liver transplant
f. kidney transplant;
g. pancreas only transplant;
h. pancreas transplant performed simultaneously with a kidney transplant; or
i. lung-whole single or whole bilateral
8.42.02 The Plan will cover donor costs and acquisition for transplants, other than Bone Marrow
Transplants, provided such costs are not covered in whole or in part by any other carrier,
organization or person other than the donor's family or estate.
8.43 Urgent Care Services. All necessary and covered services received in Urgent or Immediate Care
Centers, retail clinics or a Primary Care Physician's office after-hours for Conditions as described in
Section 2.69 will be covered by the Plan. In addition, any Participant requests for reimbursement (of
payment made by the Participant for services rendered) must be filed within 90 days after the
emergency or as soon as reasonably possible but not later than one year unless the Claimant was legally
incapacitated.
8.44 Ventilator Dependent Care. With prior authorization by AvMed, Ventilator Dependent Care is
covered. (See Section 2.72).
8.45 Wigs are covered for cancer patients with hair loss resulting from chemotherapy and/or radiation
therapy.
32
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15).`
IX. LIMITATIONS OF BASIC BENEFITS
The rights of Participants and obligations of Participating Providers hereunder are subject to the following
Limitations:
9.01 Accidental Dental Injury Services. Treatment must begin within 90 days from the date of injury and
must be completed within twelve months from date of injury.
9.02 Chiropractic services including spinal manipulations are limited to 20 visits per Plan Year included
in rehabilitative therapies maximum.
9.03 Cosmetic Surgery. Cosmetic surgery requires prior authorization beginning 10/1/15. Services will
only be considered if due to bodily injury or illness and functional impairment is present.
9.04 Diabetic Shoe Supports. Arch support and orthopedic shoes are covered only if medically necessary
because of diabetes or hammertoe.
9.05 Habilitative physical, occupational & speech therapies are limited to a combined maximum of 100
visits per Plan Year for the treatment of Autism Spectrum Disorder.
9.06 Home Health Care Services(Skilled Home Health Care)visits are limited to a period of two hours or
less per visit and 40 visits per Plan Year,including 40 hours of part-time services at 8 hours per day.
9.07 Hyperbaric oxygen treatments are limited to 40 treatments per Condition as appropriate, pursuant to
the Centers for Medicare and Medicaid Services(CMS) guidelines, subject to applicable Copayments as
listed for physical,occupational and speech therapies.
9.08 Nutrition therapy is covered for diabetes treatment only.
9.01 Mental health and substance abuse services in a Inpatient Intermediate Care Facility are limited to a
combined maximum of 60 post-hospitalization days per Plan Year.
9.02 Nutrition Therapy. Coverage for enteral,parenteral, or oral nutrition and any related supplies is subject
to a Calendar Year maximum of$2,500.
9.09 Orthotic Appliances. Coverage for orthotic appliances is limited to custom-made braces for the leg,
arm, back and neck when related to a surgical procedure or when used in an attempt to avoid surgery
and when necessary to carry out normal activities of daily living,excluding sports activities.
9.10 Other Health Care Facility(ies). All routine inpatient services of Other Health Care Facilities and
Skilled Nursing Facilities (see Section 2.47), including physician visits, physiotherapy, diagnostic
imaging and laboratory work, are covered for a maximum of 30 days per Plan Year, excluding mental
health and substance abuse services.
9.11 Preventive care services for adult is covered, limiting to one visit per Participant per Calendar Year
for routine care exam,and one visit per Participant per Calendar Year for routine well woman exam.
9.12 Private Duty Nursing provided inpatient only.
9.13 Prosthetic Devices. Coverage for prosthetic devices is limited to artificial limbs, artificial joints, ocular
prostheses and cochlear implants.
9.14 Rehabilitative Physical, Occupational, Speech and Cognitive Therapies. Coverage of outpatient
physical, occupational, speech and cognitive therapy is limited to a combined total of 60 visits per Plan
Year including evaluations.
9.15 Routine Eye-Care. Routine eye-care is covered,excluding refractions.
9.16 Second Medical Opinions. AvMed may limit second medical opinions in connection with a particular
diagnosis or treatment to three per Plan Year, if AvMed deems additional opinions to be an
unreasonable over-utilization by the Participant.
33
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
9.17 Skilled Nursing Facilities and Rehabilitation Centers. Routine services are covered up to a
combined maximum of 60 days post-hospitalization days per Plan Year.
9.18 Supplies. Provision of ostomy and urostomy supplies is limited to a one-month supply every 30 days,
and a maximum of$2,500 per Plan Year.
9.19 Transportation for Major Organ Transplant services. Transportation for transplant services is
administered through Optum Health,an AvMed third party partner.Benefits are limited to$200 per day
up to $10,000 lifetime maximum for a companion to accompany the Participant (or two companions
when the patient is a minor) and the Participant has to travel greater than a 50 miles radius to receive the
transplant This is a benefit available only when the transplant is authorized at one of AvMed's
contracted transplant facilities nationwide.
9.20 Ventilator Dependent Care. The total benefit for ventilator dependent care is limited to a lifetime
maximum of 100 calendar days.
X. EXCLUSIONS FROM BASIC BENEFITS
Medical Services and benefits for the following classifications and Conditions are not covered and are excluded
from the Schedule of Basic Benefits provided under this Plan:
10.01 Acupuncture is not covered.
10.02 Aids or devices that assist with nonverbal communications, including but not limited to
communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal
Digital Assistants (PDAs)Braille typewriters,visual alert systems for the deaf and memory books.
10.03 Armed forces service-connected medical care for both sickness and injury.
10.04 Autopsy or postmortem examinations and associated services.
10.05 Breast reduction or augmentation. Surgery for the reduction or augmentation of the size of the breasts
except as required for the comprehensive treatment of breast cancer.
10.06 Complementary or alternative medicine including but not limited to aromatherapy, Ayurvedic
medicine such as lifestyle modifications, purification and massage therapies; behavioral training,
biofield therapies; bioelectromagnetic applications and medicine; biofeedback; chelation therapy;
cognitive therapy; environmental medicine including the field of clinical ecology; herbal therapies;
homeopathic medicine and counseling; hypnotherapy; mind-body interactions such as meditation,
imagery, yoga, dance, and art therapy; manual healing methods such as the Alexander technique,
massage therapy including but not limited to:, craniosacral balancing, Feldenkrais method, Hellerwork,
reflexology, Rolfing, shiatsu, traditional Chinese massage, Trager therapy, trigger-point myotherapy,
and polarity therapy; naturopathic medicine; prayer and mental healing; Reichian therapy, Reiki, self-
care and self-help training; sex therapy, SHEN therapy, sleep therapy,therapeutic touch; thermography;
traditional Chinese medicine including acupuncture and vocational rehabilitation. NOTE: Acupuncture
may be covered in lieu of generally accepted anesthesia if a Participant is referred to the acupuncturist
by a Physician, treatment is deemed medically necessary, and provided within the scope of the
acupuncturist's license.
10.07 Complications of any non-covered service,including the evaluation or treatment of any Condition that
arises as a complication of a non-covered service.
10.08 Cosmetic, surgical or non-surgical procedures which are undertaken primarily to improve or
otherwise modify the Participant's external appearance are excluded, except for reconstructive surgery
to correct and repair a functional disorder as a result of a disease, injury, or congenital defect or initial
implanted prosthesis and reconstructive surgery incident to a mastectomy for cancer of the breast. Also
excluded are surgical excision or reformation of any sagging skin of any part of the body, including,but
not limited to: the eyelids, face, neck, abdomen, arms, legs or buttocks; any services performed in
connection with the enlargement, reduction, implantation or change in appearance of a portion of the
34
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
body, including, but not limited to: the face, lips,jaw, chin, nose, ears, breasts or genitals (including
circumcision, except newborns for up to one year from date of birth (see Section 8.21); hair
transplantation,chemical face peels or abrasion of the skin,electrolysis depilation,removal of tattooing;
or any other surgical or non-surgical procedures which are primarily for cosmetic purposes or to create
body symmetry. Additionally, all medical complications as a result of cosmetic, surgical or non-
surgical procedures are excluded. Plastic (Reconstructive/Cosmetic) are only covered if Medically
Necessary and if they comply with AvMed's medical coverage policies.
10.09 Cosmetics,Dietary Supplements,Health or Beauty Aids.
10.10 Custodial Care as defined in Section 2.18.
10.11 Dental Care,as defined in Section 2.21,for any Condition except:
10.11.01 services, supplies or appliances for Dental Care necessary to promptly repair (but not
replace), sound natural teeth required as a result of and directly related to an accidental
injury sustained while covered under the Plan. Treatment must begin within 90 days from
date of injury and must be completed within 12 months from date of injury;
ctive jaw surgery for the treatment of deformities that are present and apparent at
10.11.02 reconstru � su g ry p pp
birth;or
10.11.03 services for the treatment of tumors or full mouth extraction when required before radiation
therapy.
10.12 Diagnostic testing and treatment extended beyond the period necessary for evaluation and diagnosis
of learning and behavioral disabilities or for mental retardation.
10.13 Durable Medical Equipment (DME) items that are not covered include, but are not limited to the
following:
10.13.01 bed related items: bed trays, over the bed tables, bed wedges, pillows, custom bedroom
equipment,mattresses,including non-power mattresses, custom mattresses and posturepedic
mattresses;
10.13.02 bath related items: bath lifts, non-portable whirlpools,bathtub rails, toilet rails, raised toilet
seats,bath benches,bath stools,hand held showers,paraffin baths,bath mats,and spas;
10.13.03 chairs, lifts and standing devices: computerized or gyroscopic mobility systems, roll about
chairs, geriatric chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts
(mechanical or motorized — manual hydraulic lifts are covered if patient is 2-person
transfer),and auto tilt chairs;
10.13.04 electric or powered scooters;non-standard customized wheelchairs,motorized or manual;
10.13.05 fixtures to real property: ceiling lifts and wheelchair ramps;
10.13.06 car/van modifications;
10.13.07 air quality items: air conditioners, room humidifiers, vaporizers, air purifiers and
electrostatic machines;
10.13.08 blood/injection related items: blood pressure cuffs, centrifuges, nova pens and needleless
injectors; and
10.13.09 other equipment: heat lamps, heating pads, cryounits, cryotherapy machines, electronic-
controlled therapy units, ultraviolet cabinets, sheepskin pads and boots, postural drainage
board, AC/DC adaptors, enuresis alarms, magnetic equipment, scales (baby and adult), stair
gliders, elevators, saunas, any exercise equipment, emergency alert equipment and
diathermy machines.
10.13.10 The replacement of Durable Medical Equipment solely because it is old or used is excluded.
10.14 Emergency Room Services for Non-Emergency Purposes. See Sections 2.24 and 2.25.
35
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
10.15 Exercise programs, gym memberships, or exercise equipment of any kind, including, but not limited
to: exercise bicycles, treadmills, stairmasters, rowing machines, free weights or resistance equipment.
Also excluded are massage devices, portable whirlpool pumps, hot tubs, jacuzzis, sauna baths,
swimming pools and similar equipment.
10.16 Experimental and/or Investigational procedures, except for bone marrow transplants, as approved
per Section 59B-12.001, Florida Administrative Code, and cancer clinical trials as set forth in the
Florida Clinical Trials Agreement, effective July 1,2010(see Section 8.05).
10.17 Eye care including:
10.17.01 eye examinations for the purpose of determining vision refraction;
10.17.02 training or orthoptics,including eye exercises;or
10.17.03 radial keratotomy, refractory keratoplasty, Lasik surgery or any other corneal surgical
procedure to correct refractive error.
10.18 Foot supports are not covered, except for diabetes and hammertoe. These including orthopedic or
specialty shoes, shoe build-ups, shoe orthotics, shoe braces,and shoe supports. Also excluded is routine
foot care,including trimming of corns,calluses, and nails.
10.19 Habilitation Services. Non-covered Habilitation Services include, but are not limited to: home-based
Habilitation Services, institutional based Habilitation Services, personal assistance/ attendant care
services; errand services; transportation to and from training facilities unless provided by training
facility; family education and training, family support services;prevocational services designed to assist
a Participant in acquiring basic work skills; supportive employment habilitation; respite care/ camps/
hotel respite, room and board; services that are purely educational in nature, personal training or life
coaching; Custodial Care (care that is provided primarily to assist in the activities of daily living, such
as bathing, dressing, eating, and maintaining personal hygiene and safety and could be provided by
people without professional skills or training).
10.20 Hearing aids (external or implantable) and services related to the fitting or provision of hearing aids,
including tinnitus maskers,batteries,and the cost of repairs.
10.21 Home monitoring devices and measuring devices (other than apnea monitors), and any other
equipment or devices for use outside the Hospital.
10.22 Hospital Services that are associated with Excluded Surgery or Excluded Dental Care.
10.23 Infertility diagnosis, treatment, and supplies, including infertility testing, treatment of infertility,
diagnostic procedures and artificial insemination, to determine or correct the cause or reason for
infertility or inability to achieve conception. This includes artificial insemination, in-vitro fertilization,
ovum or embryo placement or transfer, gamete intra-fallopian tube transfer, or cryogenic or other
preservation techniques used in such or similar procedures. Medications for the treatment of infertility
are not covered.
10.24 Immunizations and medications for the purpose of foreign travel or employment.
10.25 Mandibular and maxillary osteotomies except when Medically Necessary to treat Conditions caused
by congenital or developmental deformity,disease, or injury.
10.26 Medical supplies including, but not limited to: pre-fabricated splints, Thromboemboletic/Support hose
and all other bandages,except as provided in Sections 8.13 and 8.39.
10.27 Mental Health Services shall not be covered if treatment is:
10.27.01 rendered in connection with a Condition not classified in the Diagnostic and Statistical
Manual of Mental Disorders of the American Psychiatric Association; or
10.27.02 extended beyond the period necessary for diagnosis of learning and behavioral disabilities or
for mental retardation;or
36
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
•
•
10.27.03 for marriage counseling; or
10.27.04 court ordered care or testing, or required as a Condition of probation or parole;or
10.27.05 testing for aptitude,ability,intelligence,or interest.
10.28 Morbid Obesity is not covered.
10.29
10.30 Nutrition Therapy. Vitamins, dietary supplements, and dietary formulas; except formulas, nutritional
supplements or low protein modified food products for the treatment of an inherited metabolic disease,
e.g.phenylketonuria(PKU)through age 24.
10.31 Organ Donor Treatment and Services. The Medical Services and Hospital Services for a donor or
prospective donor who is a Plan Participant when the recipient of an organ transplant is not a Plan
Participant. Coverage is provided for costs associated with the bone marrow donor-patients to the same
extent as the insured recipient. The reasonable costs of searching for the bone marrow donor are limited
to a Participant's family members and the National Bone Marrow Donor Program. Post-transplant
donor complications will not be covered.
10.32 Over-the-counter medications, and prescription medications not otherwise covered as required by
applicable State or federal law,or under this Summary Plan Description.
10.33 Personal comfort items not Medically Necessary for proper medical care as part of the therapeutic plan
to treat or arrest the progression of an illness or injury. This Exclusion includes, but is not limited to:
personal care kits, guest meals and accommodations, maid services, televisions/radios, telephone
charges,photographs, complimentary meals,birth announcements, take home supplies,travel expenses
(other than Medically Necessary ambulance services that are provided for in Section 8.02, or as
described in 9.18),air conditioners,humidifiers,dehumidifiers,and air purifiers or filters.
10.34 Physical examinations or tests, such as premarital blood tests or tests for continuing employment,
education,licensing,or insurance or that are otherwise required by a third party.
10.35 Physical,occupational, speech and all other therapies for chronic Conditions.Non-covered services
include: services that involve non-diagnostic, non-therapeutic, routine, or repetitive procedures to
maintain general welfare and do not require the skilled assistance of a licensed therapist; services such
as general exercise programs to promote overall fitness and endurance, for diversion or for general
motivation.. Maintenance therapy is not covered. Maintenance therapy begins when the therapeutic
goals of a treatment plan have been met and/or no further functional progress is expected. Speech
therapy for non-organic or functional disorders is not covered, except for the initial evaluation to
determine the root cause. Examples include attention deficit disorder, mental retardation, and Down's
syndrome. Abnormal speech pathology, including but not limited to lisping and stuttering, is not
covered.Physical therapy modalities that are considered investigational and not covered include,but are
not limited to: Interactive Metronome Program, Augmented Soft Tissue Mobilization, Kinesio
Taping/Taping,MEDEK Therapy,Hands-Free Ultrasound and Low-Frequency Sound(Infrasound), and
Hivamat Therapy(Deep Oscillation Therapy).
10.36 Private duty nursing services except when Medically Necessary in relationship to a covered inpatient
stay.
10.37 Rehabilitation Programs. Vocational rehabilitation, long term rehabilitation, or any other
rehabilitation program.
10.38 Removal of benign skin lesions including, but not limited to,warts,moles, skin tags, lipomas,keloids
and scars is not covered,even with a recommendation or prescription by a physician.
10.39 Reversal of Sterilization Procedures.
10.40 Sports-related devices, services and medications used to affect performance primarily in sports-
related activities; all expenses related to physical conditioning programs such as athletic training,
bodybuilding,exercise,fitness,flexibility,and diversion or general motivation.
37
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
10.41 Surgically implanted devices and any associated external devices, except for cardiac pacemakers,
intraocular lenses, cochlear implants, ventricular assist devices (when used as a bridge to heart
transplant),artificial joints,orthopedic hardware and vascular grafts. Dental appliances, other corrective
lenses and hearing aids,including the professional fee for fitting them, are not covered.
10.42 Termination of pregnancy unless deemed Medically Necessary by the Medical Director, subject to
applicable State and Federal laws or as specified in the Elective Termination of Pregnancy amendment
to the SPD.
10.43 Travel expenses except in accordance with Section 8.02, or as described in Section 9.19. Ambulance
services including expenses for ambulance services to and from a physician or Hospital are not covered
when the skill of medically trained personnel is not required and the Participant can be safely
transported by other means.
10.44 Training and educational programs or materials including, but not limited to, programs or materials
for Pain Management and vocational rehabilitation,except as provided under Section 8.08.
10.45 Treatment of a Condition resulting from:
10.45.01 participation in a riot or rebellion;
10.45.02 engagement in an illegal occupation;
10.45.03 participation in, or commission of, any act punishable by law as a felony whether or not the
individual is charged or convicted.
a. Coverage for such injuries will be available for situations in which the Participant
demonstrates that the injury resulted from an act of domestic violence or from a medical
Condition (including both physical and mental health Conditions), whether or not the
Condition has been diagnosed before the occurrence of the injury.
10.46 Weight control services including,but not limited to,any service or treatment to lose,gain,or maintain
weight, including and without limitation,any weight control/loss program,appetite suppressants;dietary
regimens; food or food supplements; exercise programs or equipment; whether or not it is part of a
treatment plan for a Condition.
10.47 Workers' Compensation Benefits. Any sickness or injury for which the Participant is paid benefits, or
may be paid benefits if claimed, if the Participant is covered or required to be covered by Workers'
Compensation. In addition,if the Participant enters into a settlement giving up rights to recover past or
future medical benefits under a Workers' Compensation law, the Plan shall not cover past or future
Medical Services that are the subject of or related to that settlement. Furthermore, if the Participant is
covered by a Worker's Compensation program that limits benefits if other than specified health care
providers are used and the Participant receives care or services from a health care provider not specified
by the program,the Plan shall not cover the balance of any costs remaining after the program has paid.
XI. COORDINATION OF BENEFITS
11.01 The services and benefits provided under this Plan are not intended to and do not duplicate any benefit
to which Participants are entitled under any other Group Health Insurance, HMO, personal injury
protection and medical payments under the automobile insurance laws of this or any other jurisdiction,
governmental organization, agency, or any other entity providing health or accident benefits to a
Participant, including but not limited to: Medicare, Worker's Compensation, Public Health Service,
CHAMPUS, Maritime Health Benefits, or similar state programs as permitted by contract, policy, or
law. Plan coverage will be primary to Medicaid and Children's Health Insurance Program (CHIP)
benefits.
11.02 If any Participant is eligible for services or benefits under two or more plans as set forth in Section
11.01, the coverage under those plans will be coordinated so that up to but not more than 100% of any
eligible expense will be paid for or provided by all such plans combined. The Participant shall execute
and deliver such instruments and papers as may be required and do whatever else is necessary to secure
38
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
such rights to the Plan. Failure to do so will result in nonpayment of Claims. Requested information
should be provided to AvMed within 30 days of request or Participant will be responsible for payment
of the Claim. Information received after one year from date of service will not be considered.
11.03 The standards governing the coordination of benefits are the following, in accordance with the
provisions of Chapter 627.4235,Florida Statutes:
11.01.01 The benefits of a policy or plan that covers the person as an employee, Participant, or
Covered Employee, other than as a dependent, are determined before those of the policy or
plan which covers the person as a dependent.
11.03.01 Except as stated in Section 11.03.02, when two or more policies or plans cover the same
child as a dependent of different parents:
a. The benefits of the policy or plan of the parent whose birthday, excluding year of birth,
falls earlier in a year are deter mined before the benefits of the policy or plan of the
parent whose birthday,excluding year of birth,falls later in the year;but
b. If both parents have the same birthday, the benefits of the policy or plan which covered
the parent for a longer period of time are determined before those of the policy or plan
which covered the parent for a shorter period of time.
c. However, if a policy or plan subject to the rule based on the birthday of the parents as
stated above coordinates with an out-of-state policy or plan which contains provisions
under which the benefits of a policy or plan which covers a person as a dependent of a
male are determined before those of a policy or plan which covers the person as a
dependent of a female and if, as a result, the policies or plans do not agree on the order
of benefits, the provisions of the other policy or plan shall determine the order of
benefits.
11.03.02 If two or more policies or plans cover a dependent child of divorced or separated parents,
benefits for the child are determined in this order:
a. First,the policy or plan of the parent with custody of the child;
b. Second,the policy or plan of the spouse of the parent with custody of the child; and
c. Third,the policy or plan of the parent not having custody of the child.
d. However, if the specific terms of a court order state that one of the parents is
responsible for the health care expenses of the child and if the entity obliged to pay or
provide the benefits of the policy or plan of that parent has actual knowledge of those
terms, the benefits of that policy or plan are determined first. This does not apply with
respect to any Claim determination period or plan or policy year during which any
benefits are actually paid or provided before that entity has that actual knowledge.
11.03.03 The benefits of a policy or plan which covers a person as an employee who is neither laid off
nor retired, or as that employee's dependent, are determined before those of a policy or plan
which covers that person as a laid off or retired employee or as that employee's dependent.
If the other policy or plan is not subject to this rule, and if, as a result, the policies or plans
do not agree on the order of benefits,this Section shall not apply.
11.03.04 If none of the rules in Sections 11.01.01 through 11.03.03 determine the order of benefits,
the benefits of the policy or plan which covered an employee, Participant or Covered
Employee for a longer period of time are determined before those of the policy or plan
which covered that person for the shorter period of time.
11.03.05 Coordination of benefits shall not be permitted against an indemnity-type policy, an excess
insurance policy as defined in Chapter 627.635, Florida Statutes, a policy with coverage
limited to specified illnesses or accidents, or a Medicare supplement policy. However,if the
person is also a Medicare beneficiary, and if the rule established under the Social Security
39
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
Act of 1965, as amended, makes Medicare secondary to the plan covering the person as a
dependent of an active employee,the order of benefit determination is:
a. First, benefits of a plan covering a person as an employee, Participant, or Covered
Employee.
b. Second,benefits of a plan of an active worker covering a person as a dependent.
c. Third,Medicare benefits.
11.03.06 Medicare shall be considered the secondary plan and this Plan shall be 'considered the
primary plan with respect to the following Participants entitled to Medicare:
a. For Medicare entitlement due to age,active employees and their spouses;
b. For Medicare entitlement due to disability, employees under this Plan due to current
employment status and their family Members;
c. For Medicare entitlement due to end-stage renal disease,all Participants during the first
30 months of Medicare entitlements.
11.03.07 If an individual is covered under COBRA continuation coverage and also under another
group plan,the following order of benefits applies:
a. First,the plan covering the person as an employee or as the employee's dependent.
b. Second, the coverage purchased under the plan covering the person as a former
employee, or as the former employee's dependent provided according to the provisions
of COBRA.
11.04 For the purpose of determining the applicability and implementing the terms of the Coordination of
Benefits provision of the Plan,AvMed may,without the consent of or notice to any person,release to or
obtain from any other insurance company, organizations or person, any information,with respect to any
Participant,or applicant for participation,which AvMed deems to be necessary for such purposes.
11.05 Whenever payments which should have been made under this Plan in accordance with this provision
have been made under any other plans, the Plan shall have the right, exercisable alone and in its sole
discretion, to pay over to any organizations making such other payments any amounts the Plan shall
determine to be warranted in order to satisfy the intent of this provision, and amounts so paid shall be
deemed to be benefits paid under this Plan.
11.06 All treatments must be Medically Necessary and comply with all terms, conditions, Limitations, and
Exclusions of this Plan even if this Plan is secondary to other coverage and the treatment is covered
under the other coverage.
11.07 If the amount of the payments made by the Plan is more than it should have paid under the provisions of
this Section XI,it may recover the excess from one or more of the persons it has paid or for whom it has
paid; or any other person or organization that may be responsible for the benefits or services provided
for the Participant. The `amount of the payments made' includes the reasonable cash value of any
benefits provided in the form of services.
11.08 In the event the Employer offers Health Reimbursement Arrangements (HRA) in connection with this
Plan, the HRA is intended to pay solely for otherwise un-reimbursed medical expenses. Accordingly, it
shall not be considered a group health plan for coordination of benefits purposes, and its benefits shall
not be taken into account when determining benefits payable under any other plan.
XII. SUBROGATION AND RIGHT OF RECOVERY
12.01 If the Plan provides health care benefits to a Participant for injuries or illness for which another party is
or may be responsible, then the Plan retains the right to repayment of the full cost of all benefits
provided by the Plan on behalf of the Participant that are associated with the injury or illness for which
another party is or may be responsible.. The Plan's rights of recovery apply to any recoveries made by
40
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
•
or on behalf of the Participant from the following third-party sources, as allowed by law, including but
not limited to: payments made by a third-party tortfeasor or any insurance company on behalf of the
third-party tortfeasor; any payments or awards under an uninsured or underinsured motorist coverage
policy; any worker's compensation or disability award or settlement; medical payments coverage under
any automobile policy, premises or homeowners medical payments coverage or premises or
homeowners insurance coverage; any other payments from a source intended to compensate a
Participant for injuries resulting from an accident or alleged negligence. For purposes of this SPD, a
tortfeasor is any party who has committed injury, or wrongful act done willingly, negligently or in
circumstances involving strict liability,but not including breach of contract for which a civil suit can be
brought.
12.02 Participant specifically acknowledges the Plan's right of subrogation. When the Plan provides health
care benefits for injuries or illnesses for which a third party is or may be responsible, the Plan shall be
subrogated to the Participant's rights of recovery against any party to the extent of the full cost of all
benefits provided by the Plan,to the fullest extent permitted by law. The Plan may proceed against any
party with or without the Participant's consent.
12.03 Participant also specifically acknowledges the Plan's right of reimbursement. This right of
reimbursement attaches, to the fullest extent permitted by law, when the Plan has provided health care
benefits for injuries or illness for which another party is or may be responsible and the Participant
and/or the Participant's representative has recovered any amounts from the third party or any party
making payments on the third party's behalf. By providing any benefit under this SPD, the Plan is
granted an assignment of the proceeds of any settlement,judgment or other payment received by the
Participant to the extent of the full cost of all benefits provided by the Plan. The Plan's right of
reimbursement is cumulative with and not exclusive of the Plan's subrogation right and the Plan may
choose to exercise either or both rights of recovery.
12.04 Participant and the Participant's representatives further agree to:
12.04.01 notify the Plan promptly and in writing when notice is given to any third party of the
intention to investigate or pursue a Claim to recover damages or obtain compensation due to
injuries or illness sustained by the Participant that may be the legal responsibility of a third
party;and
12.04.02 cooperate with the Plan and do whatever is necessary to secure the Plan's rights of
subrogation and/or reimbursement under this SPD; and
12.04.03 give the Plan a first-priority lien on any recovery, settlement or judgment or other source of
compensation which may be had from a third party to the extent of the full cost of all
benefits associated with injuries or illness provided by the Plan for which a third party is or
may be responsible (regardless of whether specifically set forth in the recovery, settlement,
judgment or compensation agreement); and
12.04.04 pay, as the first priority, from any recovery, settlement or judgment or other source of
compensation, any and all amounts due the Plan as reimbursement for the full cost of all
benefits associated with injuries or illness provided by the Plan for which a third party is or
may be responsible (regardless of whether specifically set forth in the recovery, settlement,
judgment or compensation agreement), unless otherwise agreed to by the Plan in writing;
and
12.04.05 do nothing to prejudice the Plan's rights as set forth above. This includes, but is not limited
to,refraining from making any settlement or recovery,which specifically attempts to reduce
or exclude the full cost of all benefits,provided by the Plan.
12.05 The Plan may recover the full cost of all benefits provided by the Plan under this SPD without regard to
any Claim of fault on the part of the Participant, whether by comparative negligence or otherwise. No
court costs or attorney fees may be deducted from the Plan's recovery without the prior express written
consent of the Plan. In the event the Participant or the Participant's representative fails to cooperate
41
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
with the Plan, the Participant shall be responsible for all benefits paid by the Plan in addition to costs
and attorney's fees incurred by the Plan in obtaining repayment.
XIII. DISCLAIMER OF LIABILITY
13.01 Neither AvMed nor the Plan directly employs any practicing physicians nor any Hospital personnel or
physicians.These health care providers are independent contractors and are not the agents or employees
of AvMed. AvMed shall be deemed not to be a health care provider with respect to any services
performed or rendered by any such independent contractors. Participating Providers maintain the
physician/patient relationship with Participants and are solely responsible for all Medical Services
which Participating Providers render to Participants. Therefore, neither AvMed nor the Plan shall be
liable for any negligent act or omission committed by any independent practicing physicians,nurses or
medical personnel, nor any Hospital or health care facility, its personnel, other Health Professionals or
any of their employees or agents who may, from time to time,provide Medical Services to a Participant.
Furthermore, neither AvMed nor the Plan shall be vicariously liable for any negligent act or omission of
any of these independent Health Professionals who treat a Participant of the Plan.
13.01 Certain Participants may, for personal reasons, refuse to accept procedures or treatment recommended
by Participating Physicians. Participating Physicians may regard such refusal to accept their
recommendations as incompatible with the continuance of the physician/patient relationship and as
obstructing the provision of proper medical care. If a Participant refuses to accept the medical treatment
or procedure recommended by the Participating Physician and if, in the judgment of the Participating
Physician, no professionally acceptable alternative exists or if an alternative treatment does exist but is
not recommended by the Participating Physician, the Participant shall-be so advised. If the Participant
continues to refuse the recommended treatment or procedure, the Employer may terminate the
Participant's coverage under this Plan as set forth in Section 7.01.02.
XIV. REVIEW PROCEDURE
14.01 Complaints. Participants have the right to a review of any complaint regarding the services or benefits
covered under the Plan. If a Participant has a complaint regarding Plan services, including quality of
service,office wait time,physician behavior and other concerns,the Participant or someone he names to
act on his behalf(an authorized representative) may call AvMed's Member Services Department at 1-
800-882-8633. AvMed encourages the informal resolution of complaints relating to Plan services, and
Member Services Representatives will work with complainants to resolve any such issues over the
telephone. If a complainant asks for a written response, or if a complaint is related to quality of care,
AvMed will respond in writing. The Member Services Department can also advise how to name an
authorized representative.
14.02 Grievances. A grievance is any complaint other than one that involves a request(Claim) for benefits,or
a request for review of an Adverse Benefit Determination. If a complaint cannot be resolved informally
over the telephone,the Participant or his authorized representative may submit the complaint to AvMed,
in writing. This is referred to as `filing a grievance'. The written grievance will be processed through
AvMed's formal grievance procedures.
14.02.01 Grievances must be filed within one year from the date of the event or action that led to the
grievance. AvMed will acknowledge and investigate the grievance, and provide a written
response advising of the disposition within 60 days after receipt of the grievance. A
grievance may be submitted in writing to:
AvMed Member Services—North AvMed Member Services—South
P.O.Box 823 P.O.Box 569008
Gainesville,Florida 32602-0823 Miami,Florida 33156-9906
Telephone: 1-877-535-1397 Telephone: 1-877-535-1397
Fax: (352) 337-8612 Fax: (305) 671-4736
• 42
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
14.03 Claims for benefits. The Employer has delegated to AvMed the discretionary authority to interpret the
Plan and to make initial Claim determinations. The Employer has delegated to AvMed the discretionary
authority to make final internal Claim review decisions on appeal.The Employer retains the authority to
determine whether employees and their dependents are eligible to enroll for or continue coverage under
the Plan.
14.03.01 Pre-Service Claims
a. Initial Claim. A Pre-Service Claim for benefits will be deemed to have been filed on
the date received by AvMed, on the Plan's behalf. AvMed shall notify the Claimant of
the benefit determination (whether adverse or not) within a reasonable period of time,
appropriate to the medical circumstances, but not later than 15 days after receipt of the
Pre-Service Claim.
i. AvMed may extend this period one time for up to 15 additional days,provided that
it determines such an extension is necessary due to matters beyond AvMed's
control, and notifies the Claimant before the expiration of the initial 15-day period,
of the circumstances requiring the extension of time and the date by which it
expects to render a decision. If such an extension is necessary because the
Claimant failed to provide sufficient information to decide the Claim, the notice of
extension will specifically describe the required information and the Claimant will
be afforded at least 45 days from receipt of the notice to provide the specified
information.
ii. In the case of a failure by a Claimant to follow AvMed's procedures for filing a Pre-
Service Claim, the Claimant shall be notified of the failure and the proper
procedures to follow in filing a Claim for benefits, not later than five days
following such failure.
iii. AvMed's period for making the benefit determination will be tolled from the date
the notification of the extension is sent to the Claimant,until the date the Claimant
responds to the request for the required information. If the Claimant fails to supply
the requested information within the 45-day period,the Claim will be denied.
b. Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to a
Pre-Service Claim within 180 days of receiving notification of such determination. The
Claimant will be notified, in accordance with Section 14.03.07, of the Plan's
determination on review within a reasonable period of time, but not later than 30 days
after receipt of the appeal. An appeal may be submitted to:
AvMed Member Relations
P.O.Box 749
Gainesville,FL 32602-0749
Fax#352-337-8794
i. If a Claimant wishes AvMed to review a denial prior to filing an appeal, he may
call AvMed's Member Services Department at 1-877-535-1397 or submit the
request in writing to:
AvMed Member Relations
P.O.Box 749
Gainesville,FL 32602-0749
(a) Additional information may be provided to clarify or support the Claim.
Persons who were not involved in the initial determination will conduct an
internal review. A decision will be made within 30 working days and written
notification will be provided to the Claimant. However, this process in no way
extends the 180 day appeal period.
•
43
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
•
14.03.02 Urgent Care Claims .
a. Initial Claim. An Urgent Care Claim for benefits,either oral or written,will be deemed
to have been filed on the date it is received by AvMed on the Plan's behalf.AvMed will
notify the Claimant of the benefit determination (whether adverse or not) as soon as
possible, taking into account the medical exigencies, but not later than 72 hours after
receipt of the Urgent Care Claim.
i. If the Claimant fails to provide sufficient information to determine whether or to
what extent benefits are covered or payable under the Plan, AvMed will notify the
Claimant as soon as possible,but not later than 24 hours after receipt of the Claim,
of the specific information required to complete the Claim. The Claimant will be
afforded a reasonable amount of time,taking into account the circumstances but not
less than 48 hours,to provide the specified information.
ii. AvMed will notify the Claimant of the benefit determination as soon as possible,
but in no case later than 48 hours after the earlier of AvMed's receipt of the
specified information or the end of the period afforded the Claimant to provide the
specified information.
iii. If the Claimant fails to supply the specified information within the 48-hour period,
the Claim will be denied. AvMed will notify the Claimant of the benefit
determination orally or in writing. If the notification is provided orally,a written or
electronic notification meeting the requirements of Section 14.03.05 will be
provided to the Claimant no later than three days after the oral notification.
b. Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to an
Urgent Care Claim within 180 days of receiving notification of such determination.
The Claimant will be notified, in accordance with Section 14.03.07, of the Plan's
determination on review as soon as possible, taking into account the medical
exigencies, but not later than 72 hours after receipt of the Claimant's appeal. The
address for submitting an appeal is provided in Section b.
14.03.03 Concurrent Care Claims
a. Any reduction or termination of Concurrent Care by AvMed before the end of an
approved period of time or number of treatments (other than by Plan amendment or
termination), will constitute an Adverse Benefit Determination. AvMed will notify the
Claimant,in accordance with Section 14.03.05,of the Adverse Benefit Determination at
a time sufficiently in advance of the reduction or termination to allow the Claimant to
appeal and obtain a final determination on review (including external review), before
the benefit is reduced or terminated.
b. With respect to an Urgent Care Claim, any request by a Claimant to extend a course of
treatment beyond a previously approved period of time or number of treatments will be
decided as soon as possible, taking into account the medical exigencies, and AvMed
will notify the Claimant of the benefit.determination (whether adverse or not)within 24
hours after receipt of the Claim, provided that any such Claim is made to AvMed at
least 24 hours before the expiration of the previously approved period of time or
number of treatments. Notification and appeal of any Adverse Benefit Determination
with respect to a request to extend a course of treatment, whether involving an Urgent
Care Claim or not, will be made in accordance with Sections 14.03.05 through
14.03.07.
14.03.04 Post Service Claims
a. Initial Claim. A Post-Service Claim for benefits will be deemed to have been filed on
the date it is received by AvMed. AvMed will notify the Claimant in accordance with
44
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
Section 14.03.05, of the benefit determination, within a reasonable period of time but
not later than 30 days after receipt of the Post-Service Claim.
i. AvMed may extend this period one time for up to 15 days, provided that it
determines such an extension is necessary due to matters beyond AvMed's control,
and notifies the Claimant before the expiration of the initial 30-day period, of the
circumstances requiring the extension of time and the date by which it expects to
render a decision. If such an extension is necessary because the Claimant failed to
provide sufficient information to decide the Claim, the notice of extension will
specifically describe the required information, and the Claimant will be afforded at
least 45 days from receipt of the notice to provide the specified information.
ii. AvMed's period for making the benefit determination will be tolled from the date
the notification of the extension is sent to the Claimant,until the date the Claimant
responds to the request for the required information. If the Claimant fails to supply
the requested information within the 45-day period,the Claim will be denied.
b. Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to a
Post-Service Claim within 180 days of receiving notification of such determination.
The Claimant will be notified, in accordance with Section 14.03.07, of the Plan's
determination on review within a reasonable period of time, but not later than 60 days
after receipt of the Claimant's appeal. The address for submitting an appeal is provided
in Section b.
14.03.05 Manner and Content of Initial Claims Determination Notification. AvMed will provide
a Claimant with written notification of any Adverse Benefit Determination. The notification
will set forth,in a manner calculated to be understood by the Claimant,the following:
a. Sufficient information to identify the Claim, including (as applicable) the date of
service,health care provider,and Claim amount,as well as notice that the diagnosis and
treatment codes along with the corresponding meaning are available upon request and
free of charge.
b. The specific reason for the Adverse Benefit Determination including the denial code
and its corresponding meaning;
c. A description of the specific benefit provision, guideline, protocol or other similar
criterion on which the denial decision is based, and a statement that a copy of such
provision, guideline, protocol or other similar criterion will be provided free of charge
to the Claimant upon request;
d. 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 Claimant's Claim for benefits;
e. If the denial decision is based on whether the treatment or service is Experimental
and/or Investigational or not Medically Necessary, an explanation of the scientific or
clinical judgment for the determination applying the terms of the Plan to the Claimant's
medical circumstances;
f. 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;
g. A description of appeal rights and AvMed's review procedures and the time limits
applicable to such procedures following an Adverse Benefit Determination on final
review.
h. In the case of an Adverse Benefit Determination involving an Urgent Care Claim, a
description of the expedited review process applicable to such Claim.
45
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
14.03.06 Review Procedure Upon Appeal. To provide Claimants a full and fair review, AvMed's
review process will include the following substantive procedures and safeguards:
a. Claimants may present evidence and testimony, and may submit written comments,
documents,records and other information relating to the Claim.
b. Upon request and free of charge,Claimants will have reasonable access to and copies of
documents, records, and other information relevant to the Claim, and will be permitted
to review the Claim file.
c. The review will take into account all comments, documents, records and other
information the Claimant submitted relating to the Claim, without regard to whether
such information was submitted or considered in the initial Adverse Benefit
Determination.
d. The review will be conducted by an appropriate..named fiduciary of AvMed who is
neither the individual nor a subordinate of the individual who made the initial Adverse
Benefit Determination. Such person will not be subject to promotion, raises, bonuses,
etc. based on whether they approve or deny any Claim. Such person will not defer to
the initial Adverse Benefit Determination.
e. Review by the appropriate named fiduciary, of any Adverse Benefit Determination
based in whole or in part on a medical judgment,including determination as to whether
a particular treatment, medication, or other item is Experimental and/or Investigational
or not Medically Necessary, will include consultation with a Health Professional who
has appropriate training and experience in the field of medicine relevant to the medical
judgment.
f. Review will provide for the identification of medical or vocational experts whose
advice was obtained on behalf of AvMed in connection with a Claimant's Adverse
Benefit Determination,without regard to whether the advice was relied upon in making
the Adverse Benefit Determination.
g. The review will provide that the Health Professional engaged for purposes of a
consultation as referenced in Section 14.03.06e will be an individual who is neither the
individual nor a subordinate of the individual who was consulted in connection with the
initial Adverse Benefit Determination that is the subject of the appeal.
h. In the case of an Urgent Care Claim,there will be an expedited review process available
pursuant to which:
i. Request for an expedited review of an Adverse Benefit Determination may be
submitted orally or in writing by the Claimant; and
ii. All necessary information, including AvMed's benefit determination on review,
will be transmitted between AvMed and the Claimant by telephone, facsimile or
other available similarly expeditious methods.
i. If any new or additional evidence considered, relied upon, or generated by or at the
direction of the Plan in connection with a Claim results in a final internal Adverse
Benefit Determination, Claimants will be provided free of charge with such new or
additional evidence as soon as possible, and sufficiently in advance of the due date for
the notice, so that Claimants have a reasonable opportunity to respond prior to the due
date.
j. If a new or additional rationale in connection with a Claim results in a final internal
Adverse Benefit Determination, Claimants will be provided free of charge with such
new or additional rationale as soon as possible, and sufficiently in advance of the due
date for the notice, so that Claimants have a reasonable opportunity to respond prior to
the due date.
46
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
14.03.07 Manner and Content of Final Internal Review Notification. AvMed will provide a
Claimant with written notification of its benefit determination upon review.
a. In the case of a final internal Adverse Benefit Determination, the notification will set
forth, in a manner calculated to be understood by the Claimant, all of the following as
appropriate:
b. Sufficient information to identify the Claim, including (as applicable) the date of
service,health care provider,and Claim amount, as well as notice that the diagnosis and
treatment codes along with the corresponding meaning, are available upon request and
free of charge.
c. The specific reason for the Adverse Benefit Determination including the denial code
and its corresponding meaning;
d. A description of the specific benefit provision, guideline, protocol or other similar
criterion on which the denial decision is based and a discussion of such benefit
provision,guideline,protocol or other similar criterion. '
e. 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 Claimant's Claim for benefits;
f. If the denial decision is based on whether the treatment or service is Experimental
and/or Investigational or not Medically Necessary, an explanation of the scientific or
clinical judgment for the determination applying the terms of the Plan to the Claimant's
medical circumstances.
g. A statement describing any voluntary appeal procedures offered by AvMed and the
Claimant's right to obtain the information about such procedures.
14.03.08 In the event of an Adverse Benefit Determination with respect to a cancellation or
discontinuation of coverage that has retroactive effect, other than one that is attributable to a
failure to timely pay required premiums or contributions toward the cost of coverage,
Participants may appeal such a determination by submitting a written request for review to
AvMed.The address for submission of such an appeal is provided in Section 14.03.01b.
14.04 External Review. In the event of a final internal Adverse Benefit Determination with respect to a Claim
for benefits, a Claimant may be entitled to an external review of the Claim. This request must be
submitted in writing on an External Review Request form, within 120 days of receipt of the Adverse
Benefit Determination.The external reviewer will render a recommendation within a reasonable period
of time after receipt of the Claim, not to exceed 45 calendar days unless the request meets expedited
criteria, in which case it will be resolved as soon as administratively possible, but not later than 72
hours. The external reviewer's recommendation will be binding. The external reviewer will notify the
Claimant of its decision in writing, and the Plan will take action as appropriate to comply with such
recommendation. For detailed information about the external review process, please contact AvMed's
Member Services Department.
14.05 Remedies if Process "Deemed Exhausted." If we continue to deny the payment, coverage, or service
requested or you do not receive a timely decision,you may be able to request an external review of your
Claim by an independent 3rd party, who will review the denial and issue a final decision. You may
contact AvMed Member Services at 1-877-535-1397 with any questions on your rights to external
review. Please understand that if you want to be informed about the legal remedies that may be
available to you and whether they are a better option for you than seeking independent external review,
you should consult a lawyer of your choice. AvMed cannot provide you with legal advice. We can only
explain the procedures for obtaining independent external review.
47
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10115)
XV. MISCELLANEOUS
15.01 Agent for Service of Legal Process.The name of the person designated as the agent for service of legal
process on behalf of the Plan is Raul Aquila, City of Miami Beach, 1700 Convention Center Drive,
Miami,Florida 33139. Additionally,service of legal process may be made on the Plan Administrator.
15.02 Clerical Errors. Clerical errors shall neither deprive any individual Participant of any benefits or
coverage provided under the Plan nor shall such error(s) act as authorization of benefits or coverage for
the Participant that is not otherwise validly in force. Retroactive adjustments in coverage, for clerical
errors or otherwise will only be done for up to a 60 day period from the date of notification. Refunds of
administrative service fees are done for up to a 60 day period from the date of notification. Refunds of
administrative service fees are limited to a total of 60 days from the date of notification of the event,
provided there are no Claims incurred subsequent to the effective date of such event.
15.03 Collective Bargaining Agreement. If the coverage under the Plan is intended to satisfy a benefit
obligation under an applicable collective bargaining agreement,please note that the Plan will govern all
benefit determinations and all other determinations under the Plan. The collective bargaining agreement
does not influence or control, and is not to be considered to be incorporated with, the Plan in any
fashion.
15.04 Gender. Whenever used, the singular shall include the plural and the plural the singular and the use of
any gender shall include all genders.
15.05 Identification Cards. Cards issued by AvMed to Participants pursuant to the Plan are for purposes of
identification only. Possession of an identification card confers no right to health services or other
benefits under the Plan. To be entitled to such services or benefits the holder of the card must, in fact,
be a Participant on whose behalf all applicable charges under the Plan have actually been paid and
accepted by the Plan.
15.06 Individual Information. Participants or other individuals shall complete and submit to the Plan such
applications, forms or statements as the Plan may reasonably request. If the Participant or other
individual fails to provide accurate information that the Plan deems material to providing coverage for
such individual, upon ten days written notice, the Plan may deny coverage and/or participation in the
Plan to such individual
15.07 Non-Waiver. The failure of the Plan to enforce any of the provisions of the Plan or to exercise any
options herein provided or to require timely performance by any Participant or the Employer of any of
the provisions herein, shall not be construed to be a waiver of such provisions nor shall it affect the
validity of the Plan or any part thereof or the right of the Plan to thereafter enforce each and every such
provision.
15.08 Plan Administration. The Employer may from time to time adopt reasonable policies, procedures,
rules and interpretations to promote the orderly and efficient administration of the Plan.
15.09 Waiver. A Claim that has not been timely filed with the Plan within one year of date of service shall be
considered waived.
48
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
SUMMARY PLAN DESCRIPTION INFORMATION
Official Plan Name: City of Miami Beach Group Health Plan
Plan Sponsor: City of Miami Beach
1700 Convention Center Drive
Miami,Florida 33139
Telephone: 305-673-7524
Plan Administrator: City of Miami Beach
1700 Convention Center Drive
Miami,Florida 33139
Telephone: 305-673-7524
Claims Administrator: AvMed,Inc.
Plan Year: 10/01/2015—09/30/2016
Effective Date of the Plan: 10/01/2015
Employer Identification No.: 5-6000372
Plan Type: Self-insured welfare benefit plan
Source of Funding for the Plan: The Company has elected to create a self-insured group
health plan. The Company has purchased individual stop-
loss coverage through Symetra.
Sources of Contribution: Company and Employees
Plan No.: Not Applicable
Agent for Service of Legal Process: Jose Smith
1700 Convention Center Drive
Miami,Florida 33139
Telephone: 305-673-7524
Organization that Provides the Benefit: Benefits under the Plan are provided through an
Administrative Services Agreement with AvMed,Inc.
49
SF-City of Miami Beach-Basic POS-SPD-2015
SF-3661(10/15)
•
•