GROUP POLICY - OPTIONS PPO CERTICATE OF COVERAGE
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UNITED HEALTH CARE INSURANCE COMPANY
P.O. Box 150450450 Columbus Blvd.
Hartford, CT 06115-0450
Call 1-800-526-2414 to obtain information about coverage or for
assistance in resolving complaints.
A STOCK COMPANY
ENROLLING GROUP
POLICY NUMBER
EFFECTIVE DATE
ANNIVERSARY DATE
City of Clearwater
82403
January 1, 2002
January 1, 2003
GROUP POLICY
("Policy")
This Policy is issued to the Enrolling Group by United HealthCare Insurance Company ("Company")
for the purpose of describing the terms and conditions for coverage of Health Services. The Policy includes
the Certificate of Coverage ("Certificate") attached as Attachment A. In the event of any conflict between
the body of the Policy and the Certificate, the body of the Policy shall govern.
Note.: . Coverage under the Policy is subiect to an annual deductible
prOVISIOn.
The Company has, by its President and Secretary, executed this Policy at its principal office in Hartford,
Connecticut.
UNITED HEALTHCARE INSURANCE COMPANY
UNITED HEAL THCARE INSURANCE CaMP ANY
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Ronald B. Colby, President and CEO
Matthew L. Friedman, Secretary
AN ACCIDENT AND HEALTH INSURANCE POLICY
Contact Customer Service at 1-800-526-2414 for benefit inquiries or
to file a complaint
FLCGrp30I(l/97)(Rev 12/98)
l~D
United Healthcare Insurance Company
Policy Number 82403
Approved as to form:
cc.
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CITY OF CLEARWATER, FLORIDA
By: ~~.~.,...~
IlIiam B. Horne II
City Manager
Attest:
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the grace period extend beyond the date the Policy terminates. The Emolling Group shall remain liable to
the Company for the payment of Premium due for any period in which the Policy is in force.
This Policy shall automatically terminate retroactive to the last paid date of Coverage if the grace period
expires and any Premium remains unpaid, or if Company receives written notice of termination from the
Emolling Group during the grace period.
ARTICLE 4 - ENROLLMENT AND ELIGIBILITY
4.1 Initial Eligibility Period. Eligible Persons and their Dependents may emoll in Company during their
Initial Eligibility Period (within 31 days of the date they first become Eligible Persons or Dependents). The
Eligible Employee must submit a signed and accurately completed emollment form. Eligible Employees
who fail to emoll during the Initial Eligibility Period shall be considered late emollees and must provide
proof of good health. Late emollments under this Policy must be accepted in writing by the Company in
order to be effective.
4.2 Eligibility Conditions. Eligibility conditions, in addition to those specified in Section 2 of the
Certificate, are listed in Attachment B.
4.3 Effective Date of Policy. This Policy becomes effective on the effective date shown above at 12:01
a.m standard time at the Emolling Group's address and may be continued in effect by the timely payment
of Premiums when due at such rates as may be determined by the Company in accordance with Article 3.
4.4 Anniversary Date of Policy. The first anniversary of this Policy shall be the anniversary date shown
above. Subsequent anniversaries shall be the same date each year thereafter. A first policy year is
determined from the effective date. Subsequent anniversaries are determined from the anniversary date of
this Policy.
4.5 Effective Date of Coverage. Coverage for properly emolled Eligible Employees and their Dependents
shall begin on the date specified in Attachment B.
ARTICLE 5 - POLICY TERMINATION
5.1 Termination of this Policy by the Enrolling Group. The Emolling Group may terminate this Policy
as of any Premium due date giving the Company at least 31 days prior written notice.
5.2 Termination of This Policy by the Company. This Policy and all Coverage under this Policy shall
automatically terminate on the earliest of the dates specified below:
A. As of any Premium due date if the Emolling Group has not paid the required Premium by the end of
the grace period.
B. On the date specified by the Company, after at least 90 days prior written notice to the Emolling
Group and participants that this Policy shall be terminated because the Company will no longer issue
this particular type of group health benefit plan within the applicable market.
C. On the date specified by the Company, after at least 180 days prior written notice to the applicable
state authority, the Emolling Group and participants that this Policy shall be terminated because the
Company will no longer issue any employer health benefit plan within the applicable market.
D. On the effective date of the Coverage, if the Emolling Group has performed an act or practice that
constitutes fraud or made a material misrepresentation of material fact under the terms of this Policy.
E. On the date specified by the Company, when the membership of an employer in a bona fide
association, on the basis of which coverage is provided, ceases.
5.3 Non-renewal of the Policy by the Company. The Company guarantees the Emolling Group the right
to renew this Policy each year, at the Emolling Group's option. However, the Company may refuse to
renew this Policy and all Coverage provided under this Policy if the Emolling Group has failed to comply
with a material provision of the Company which relates to rules for contributions or group participation.
FLCGrp301 (l/97)(Rev 12/98)
3
:VI
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administrator or named fiduciary of the welfare plan, other than as specifically identified by the plan
sponsor of the welfare plan, as those terms are used in ERlSA.
6.8 Clerical Error. Clerical error shall not deprive any individual of coverage under this Policy or create
a right to additional benefits. Failure by the Enrolling Group to report the termination of coverage shall not
continue such coverage beyond the date it is scheduled to terminate according to the terms of this Policy.
Upon discovery of a clerical error, any necessary appropriate adjustment in Premiums shall be made.
However, no such adjustment in Premiums or coverage shall be granted by Company to the Enrolling
Group for more than 60 days of coverage prior to the date Company received notification of such clerical
error.
6.9 Workers' Compensation Not Affected. The coverage provided under this Policy does not substitute
for and does not affect any requirements for coverage by Workers' Compensation Insurance.
6.10 Conformity with Statutes. Any provision of this Policy which, on its effective date, is in conflict
with the requirements of proper statutes or regulations of the jurisdiction in which it is delivered is hereby
amended to conform to the minimum requirements of such statutes and regulations.
6.11 Notice. Written notice given by Company to an authorized representative of the Enrolling Group
shall be deemed notice to all affected Covered Persons in the administration of this Policy, including
termination of this Policy. The Enrolling Group shall be responsible for conveying such notices to Covered
Persons.
6.12 Certification of Coverage Forms. As required by Florida law, the Company will produce
Certification of Coverage forms for Covered Persons who lose Coverage under the Policy on or after the
effective date of the Policy. The Enrolling Group agrees to provide all necessary eligibility and termination
data that the Enrolling Group provides to the Company's eligibility systems in accordance with the
Company's data specifications, and which is available in the Company's eligibility systems as of the date
the form is generated. The Certification of Coverage forms will only include periods of Coverage that the
Company administers under this Policy.
FLCGI1J301(l/97)(Rev 12/98)
5
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ATTACHMENT B
ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE
Board of Directors
Other:
l None
4.5 Effective Date of Coverage. Coverage for properly enrolled Eligible Persons and their Dependents
shall begin on:
_ The day following the last day of the required waiting period.
l The fIrst day of the month following the month in which the waiting period was completed.
_ The date the employee was hired.
FLCGrp301 (1/97)(Rev 12/98)
7
197716 - 01/09/2002
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UNITED HEALTHCARE INSURANCE
COMPANY
UNITED HEAL THCARE
OPTIONS PPO
CERTIFICATE OF COVERAGE
FOR
City of Clearwater
GROUP NUMBER: 82403
EFFECTIVE DATE: January 1,2002
Offered and Underwritten by
United HealthCare Insurance Company
UnitedHealthcare@
~ A UnitedHealth Group Company
United HealthCare Insurance Company
CERTIFICATE OF COVERAGE
This Certificate of Coverage ("Certificate") sets forth your rights and obligations as a Covered Person, It is
important that you READ YOUR CERTIFICATE CAREFULLY and familiarize yourself with its terms
and conditions.
The Policy may require that the Insured contribute to the required Premiums. Information regarding the
Premium and any portion of the Premium cost an Insured must pay can be obtained from the Enrolling
Group.
United HealthCare Insurance Company ("Company") agrees with the Enrolling Group to provide Coverage
for Health Services to Covered Persons, subject to the terms, conditions, exclusions and limitations of the
Policy. The Policy is issued on the basis of the Enrolling Group's application and payment of the required
Policy Charges. The Enrolling Group's application is made a part of the Policy.
The Company shall not be deemed or construed as an employer for any purpose with respect to the
administration or provision of benefits under the Enrolling Group's benefit plan. The Company shall not be
responsible for fulfilling any duties or obligations of an employer with respect to the Enrolling Group's
benefit plan.
The Policy shall take effect on the date specified and will be continued in force by the timely payment of
the required Policy Charges when due, subject to termination of the Policy as provided. All Coverage under
the Policy shall begin at 12:01 a.m. and end at 12:00 midnight at the Enrolling Group's address.
The Policy is delivered in the State of Florida.
UNITED HEALTHCARE INSURANCE CaMP ANY
~13/
Ronald B. Colby, President and CEO
This policy certificate contains a deductible
Contact Customer Service at 800-526-2414 for benefit inquiries or to file a Complaint
2000-FL-UHI-LG
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Health Services Covered Under the Policy
In order for Health Services to be Covered as Network Benefits, you must obtain all Health Services
directly from or through a Network provider, with the exception of Emergency Health Services.
So that you will not be required to pay bills for non-Covered services, you must always verify the
participation status of a Physician, Hospital or other provider. From time to time, the participation status of
a provider may change. You can verify the participation status by calling the Company. If necessary, the
Company can provide assistance in referring you to Network providers.
Only Medically Necessary Health Services are Covered under the Policy. The fact that a Physician has
performed or prescribed a procedure or treatment or the fact that it may be the only available treatment for
an Injury, Sickness or Mental Illness does not mean that the procedure or treatment is a Covered Health
Service under the Policy.
The Company has sole and exclusive discretion in interpreting the benefits Covered under the Policy and
the other terms, conditions, limitations and exclusions set out in the Policy and in making factual
determinations related to the Policy and its benefits. The Company may, from time to time, delegate
discretionary authority to other persons or entities providing services in regard to the Policy.
The Company reserves the right to change, interpret, modify, withdraw or add benefits or terminate the
Policy, in its sole discretion, as permitted by law, without the approval of Covered Persons. No person or
entity has any authority to make any oral changes or amendments to the Policy.
The Company may, in certain circumstances for purposes of overall cost savings or efficiency and in its
. sole discretion, provide Coverage for services which would otherwise not be Covered. The fact that the
Company does so in any particular case shall not in any way be deemed to require it to do so in other
similar cases.
The Company may, in its sole discretion, arrange for various persons or entities to provide administrative
services in regard to the Policy, including claims processing and utilization management services. The
identity of the service providers and the nature of the services provided may be changed from time to time
in the Company's sole discretion and without prior notice to or approval by Covered Persons. You must
cooperate with those persons or entities in the performance of their responsibilities.
Similarly, the Company may, from time to time, require additional information from you to verify your
eligibility or your right to receive Coverage for services under the Policy. You are obligated to provide this
information. Failure to provide it may result in Coverage being delayed or denied.
Coupons and Incentives
At various times the Company may offer coupons or other incentives to encourage your participation in
various wellness programs or certain disease management programs. The decision about whether or not you
choose to participate is yours alone, but you are encouraged to discuss participating in such programs with
your Network Physician and to follow his or her advice. These incentives do not alter or affect the Health
Services Covered under the Policy. Contact the Company if you have any questions.
Important Note About Services
The Company does not provide Health Services or practice medicine. Rather the Company arranges for
providers of Health Services to participate in a Network. Network providers are independent practitioners
and are not employees of the Company. The Company, therefore, makes payment to Network providers
through various types of contractual arrangements. These arrangements may include financial incentives to
promote the delivery of health care in a cost efficient and effective manner. Such financial incentives are
not intended to impact your access to Health Services. Examples of financial incentives for Network
providers are:
· Bonuses for individual and/or aggregate performance based on factors which may include quality,
member satisfaction, and/or cost effectiveness.
2000-FL-UHI-LG
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Table of Contents
SECTION 1 - DEFINITIONS ..................................................................................................................... 1
SECTION 2 - ENROLLMENT AND EFFECTIVE DATE OF COVERAGE........................................... 7
SECTION 3 - TERMINATION OF COVERAGE .....................................................................................9
SECTION 4 - REIMBURSEMENT..........................................................................................................11
SECTION 5 - COMPLAINT PROCEDURES..........................................................................................13
SECTION 6 - GENERAL PROVISIONS.................................................................................................14
SECTION 7 - COORDINATION OF BENEFITS....................................................................................16
SECTION 8 - SUBROGATION AND REFUND OF EXPENSES ..........................................................20
SECTION 9 - CONTINUATION OF COVERAGE AND CONVERSION............................................. 22
SECTION 10 - PROCEDURES FOR OBTAINING BENEFITS ............................................................25
SECTION 11 - COVERED HEALTH SERVICES ..................................................................................28
SECTION 12 - GENERAL EXCLUSIONS .............................................................................................33
SECTION 13 - SCHEDULE OF BENEFITS ........................................................................................... 37
OUTPATIENT PRESCRIPTION DRUG PRODUCT RIDER ....................................................................43
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"Custodial Care" - services that:
A. Are non-health related services, such as assistance in activities of daily living (including but not
limited to feeding, dressing, bathing, transferring and ambulating);or
B. Are health-related services which do not seek to cure, or which are provided during periods when the
medical condition of the patient who requires the service is not changing; or
C. Do not require continued administration by trained medical personnel.
"Dependent" - (1) the Insured's legal spouse or (2) an unmarried dependent child of the Insured or the
Insured's spouse or (3) the newborn child of any covered dependent other than the Insured's spouse
(coverage terminates 18 months after the birth of the newborn child). The term "child" includes a natural
child, stepchild, a legally adopted child, a child placed for adoption, a foster child, and a child for whom
legal guardianship has been awarded to the Insured or the Insured's spouse.
The defmition of "Dependent" is subject to the following conditions and limitations:
· Dependent includes any unmarried dependent child under 25 years of age.
· A Dependent includes an unmarried dependent child who is 25 years of age or older, but less than 25
years of age only if you furnish evidence upon our request, satisfactory to us, of all the following
conditions:
1. The child must be primarily dependent upon the Insured for support and maintenance; and
2. The child is living with the Insured, or the child is a full-time or part-time student.
The Insured must reimburse Us for any Benefits that We pay for a child at a time when the child did not
satisfy these conditions.
We may agree with the Enrolling Group to increase these age limits, if it is specified in Article 4 of the
Policy and otherwise stated in Section 13, "Schedule of Benefits".
The term "Dependent" also includes a child for whom health care coverage is required through a 'Qualified
Medical Child Support Order' or other court or administrative order, even if the child does not reside within
the Company's geographical area. The Enrolling Group is responsible for determining if an order meets the
criteria of a Qualified Medical Child Support Order.
The term "Dependent" does not include anyone who is also enrolled as an Insured, nor can anyone be a
"Dependent" of more than one Insured.
"Designated Facility" - a Hospital, named by the Company as a Designated Facility, which has entered
into an agreement with or on behalf of the Company to render Covered Health Services for treatment of
specified diseases or conditions. A Designated Facility mayor may not be located within the Covered
Person's geographic area.
"Durable Medical Equipment" - medical equipment which: (1) can withstand repeated use; (2) is not
disposable; (3) is used to serve a medical purpose; (4) is generally not useful to a person in the absence of a
Sickness or Injury; and (5) is appropriate for use in the home.
"Eligible .Expenses" - Eligible Expenses for Covered Health Services, incurred while the Policy is in
effect, are determined as stated below:
1. For Network Benefits:
A. When Covered Health Services are received from Network providers, Eligible Expenses are the
Company's contracted fee(s) for the Health Service with that provider;
B. When Covered Health Services are received from non-Network providers as a result of an
Emergency or as otherwise arranged by the Company, Eligible Expenses are the fee(s)
negotiated between the Company and the non-Network provider.
2. For Non-Network Benefits:
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"Health Services" - the health care services and supplies Covered under the Policy, except to the extent
that such health care services and supplies are limited or excluded.
"Home Health Agency" - a program or entity which is (1) engaged in providing health care services in the
home; and (2) authorized as required by the law of jurisdiction in which treatment is received.
"Hospice Care" - an integrated program of palliative and support services provided through a properly
licensed or accredited hospice agency to terminally ill Covered Persons. Hospice Care may include
physical, psychological, social and spiritual care, and short-term bereavement counseling for immediate
family members of the Covered Person.
"Hospital" - an institution, operated as required by law, which: (1) is primarily engaged in providing
Health Services on an inpatient basis for the care and treatment of injured or sick individuals through
medical, diagnostic and surgical facilities by or under the supervision of a staff of Physicians; (2) has 24
hour nursing services; and (3) is accredited as a Hospital by the Joint Commission on Accreditation of
Healthcare Organizations or by the American Osteopathic Hospital Association. A Hospital is not primarily
a place for rest, custodial care or care of the aged and is not a nursing home, convalescent home or similar
institution.
"Initial Eligibility Period" - the initial period of time, determined by the Company and the Enrolling
Group, during which Eligible Persons may enroll themselves and Dependents under the Policy.
"Injury" - bodily damage other than Sickness, including all related conditions and recurrent symptoms.
"Inpatient Rehabilitation Facility" - a Hospital or a special unit of a Hospital designated as an Inpatient
Rehabilitation Facility which provides rehabilitation Health Services (physical therapy, occupational
therapy and/or speech therapy) on an inpatient basis as permitted by the law of jurisdiction in which
treatment is received.
"Insured" - an Eligible Person who is properly enrolled for Coverage under the Policy. The Insured is the
person (who is not a Dependent) on whose behalf the Policy is issued to the Enrolling Group.
"Maximum Policy Benefit" - the maximum amount paid for Non-Network Benefits Network and Non-
Network Benefits during the entire period of time that the Covered Person is Covered under the Policy or
any Policy, issued by the Company to the Enrolling Group, that replaces the Policy. The Maximum Policy
Benefit is stated in Section 13, Schedule of Benefits.
"Medically Necessary" - health care services and supplies which meet each of the following criteria:
A. It is supported by national medical standards of practice;
B. It is consistent with conclusions of prevailing medical research that:
1. Demonstrate that the health service has a beneficial effect on health outcomes; and
2. Is based on trials that meet either of the following designs:
a. Well-conducted randomized controlled trials. (Two or more treatments are compared to
each other, and the patient is not allowed to choose which treatment is received.)
b. Well-conducted cohort studies. (Patients who receive study treatment are compared to a
group of patients who receive standard therapy. The comparison group must be nearly
identical to the study treatment group.)
C. It is a cost-effective method and yields a similar or better outcome to other available alternatives.
D. It is a health care service or supply described in Section II as a Covered Health Service, which is not
excluded under Section 12.
All new teclmologies, procedures and treatments are decided based upon the language in B.2 above.
"Medicare" - Parts A, B and C of the insurance program established by Title XVIII, United States Social
Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended.
2000-FL-UHI-LG
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"Pregnancy" - includes prenatal and postnatal care, childbirth, and any complications associated with
Pregnancy.
"Premium" - the periodic fee required for each Insured and each Emolled Dependent in accordance with
the terms of the Policy.
"Reconstructive Surgery" - surgery which is incidental to an Injury, Sickness or Congenital Anomaly
when the primary purpose is to improve physiological functioning of the involved part of the body. The
fact that physical appearance may change or improve as a result of Reconstructive Surgery does not
classify such surgery as cosmetic when a physical impairment exists, and the surgery restores or improves
function.
"Rider" - any attached description of Health Services Covered under the Policy. Health Services provided
by a Rider may be subject to payment of additional Premiums. Riders are effective only when signed by the
Company and are subject to all conditions, limitations and exclusions of the Policy except for those that are
specifically amended.
"Semi-private Room" - a room with 2 or more beds. The difference in cost between a Semi-private Room
and a private room is Covered only when a private room is Medically Necessary or when a Semi-private
Room is not available.
"Sickness" - physical illness, disease or Pregnancy. The term "Sickness" as used in this Certificate does
not include Mental Illness or substance abuse, regardless of the cause or origin of the Mental Illness or
substance abuse.
"Skilled Care Services" - skilled nursing, skilled teaching, and skilled rehabilitation services which meet
all of the following criteria:
A. Must be delivered or supervised by licensed technical or professional medical personnel in order to
obtain the specified medical outcome, and provide for the safety ofthe patient;
B. Are ordered by a Physician; and
C. Are not Custodial Care.
Determination of Benefits for Skilled Care Services is made based on both the skilled nature of the service
and the need for Physician-directed medical management. A service will not be determined to be "skilled"
simply because there is not an available caregiver.
"Skilled Nursing Facility" - a Hospital or nursing facility which is licensed and operated in accordance
with the law of jurisdiction inwhich treatment is received.
"Sound Natural Tooth" - a virgin or umestored tooth, or a tooth which has no decay, no filling on more
than two surfaces, no gum disease associated with bone loss, no root canal therapy, is not a dental implant,
and functions normally in chewing and speech.
"Substance Abuse Services" - services and supplies Covered under the Policy for the diagnosis and
treatment of alcoholism and substance abuse disorders which are listed in the current Diagnostic and
Statistical Manual of the American Psychiatric Association, unless specifically excluded from Coverage
under the Policy. The fact that a disorder is listed in the Diagnostic and Statistical Manual of the American
Psychiatric Association does not mean that treatment of the disorder is Covered.
"Total Disability" or "Totally Disabled" - an Insured's inability to perform all of the substantial and
material duties of his or her regular employment or occupation; and a Dependent's inability to perform the
normal activities of a person oflike age and sex.
"Urgent Care Center" - a non-Hospital-based facility which provides Health Services which are required
in order to prevent serious deterioration of a Covered Person's health and that are required as a result of an
unforeseen Sickness, Injury, or onset of threatening symptoms.
2000-FL-UHI-LG
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conditions are met: (a) The Eligible Person and/or Dependent had existing health coverage under another
plan at the time of the Initial Eligibility Period or Open Enrollment Period; and (b) Coverage under the
prior plan was terminated as a result of loss of eligibility (including, without limitation, legal separation,
divorce or death), termination of employer contributions, or in the case of COBRA continuation coverage,
the coverage was exhausted. A special enrollment period is not available if coverage under the prior plan
was tenninated for cause or as a result of failure to pay premiums on a timely basis. Coverage under the
Policy is effective only if the Company receives any required Premium and a properly completed
enrollment form within 31 days of the date coverage under the prior plan terminated.
A special enrollment period is also available for an Eligible Person and for any Dependent whose status as
a Dependent is affected by a marriage, birth, placement for adoption or adoption, as required by federal
law. In such cases you must submit the required Premium and a properly completed enrollment form within
31 days. In the case of newborn and adopted dependents, if the Insured fails to enroll the new dependent
within the fIrst 31 days, but enrolls the new dependent within 60 days of the event, the Insured will be
required to pay an additional premium from the date of birth or placement. If written notice is given within
60 days of the date of birth or placement, Coverage will not be denied for failure to timely or to pre-enroll
the dependent. If written notice is not given within 60 days of birth or placement, the newborn or adopted
child may be enrolled during the next Open Enrollment Period.
2000-FL-UHI-LG
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year. Failure to provide such satisfactory proof at the request of the Company will result in the termination
of the Emolled Dependent's Coverage under the Policy.
Section 3.3 Extended Coverage for Total Disability. A temporary extension of Coverage, only for
treatment of the condition causing a Total Disability, will be granted to a Covered Person who is Totally
Disabled on the date the person's Coverage is terminated. Benefits will be Covered until (a) the Total
Disability ends; (b) twelve months from the date of Total Disability; or (c) the date the maximum benefits
available under the Policy have been provided, whichever occurs first. Such benefits are subject to the
terms and conditions of the Policy.
Section 3.4 Extended Coverage for Pregnancy. If a Covered Person is pregnant on the date the person's
Coverage terminates, benefits for the pregnancy will be extended to Cover Eligible Expenses related
directly to the pregnancy. Such benefits will be extended until the pregnancy ends, regardless of whether
the group policyholder or other entity secures replacement coverage from a new insurer or foregoes the
provision of coverage unless coverage by the succeeding plan is required by statute.
Section 3.5 Payment and Reimbursement Upon Termination. Termination of Coverage shall not affect
any request for reimbursement of Eligible Expenses for Health Services rendered prior to the effective date
of termination. Your request for reimbursement must be furnished as required in Section 4.
2000-FL-UHI-LG
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The Insured is responsible for the recovery of excess Copayments. The Insured must notify the Company in
writing that excess Copayments have been paid no later than 90 days after the end of the calendar year.
This notification must include proof satisfactory to the Company of the payment of Copayments.
Section 4.5 Limitation of Action for Reimbursement. You do not have the right to bring any legal
proceeding or action against the Company to recover reimbursement until 60 days after you have properly
submitted a request for reimbursement, as described above. If you bring such legal proceedings or actions
against the Company after the expiration of the applicable statute of limitations from the time written proof
ofloss is required to be given, you forfeit your rights to bring any action against the Company.
2000-FL-UHI-LG
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SECTION 6 - GENERAL PROVISIONS
Section 6.1 Entire Policy. The Policy issued to the Enrolling Group, including the Certificate of
Coverage as Attachment A, the Enrolling Group's application, Amendments and Riders, constitute the
entire Policy. All statements made by the Enrolling Group or by an Insured shall, in the absence of fraud,
be deemed representations and not warranties.
Section 6.2 Limitation of Action. You do not have the right to bring any legal proceeding or action
against the Company without first completing the complaint procedure specified in Section 5. If you bring
such legal proceedings or actions against the Company after the expiration of the applicable statute of
limitations from the time written proof of loss is required to be given, you forfeit your rights to bring any
action against the company.
The only exception to this limitation of action is that reimbursement of Eligible Expenses, as set forth in
Section 4 of this Certificate, is subject to the limitation of action provision of that section.
Section 6.3 Time Limit on Certain Defenses. No statement, except a fraudulent statement, made by the
Enrolling Group shall be used to void the Policy after it has been in force for a period of two years.
Section 6.4 Amendments and Alterations. Amendments to the Policy are effective upon 31 days written
notice to the Enrolling Group. Riders are effective on the date specified by the Company. No change will
be made to the Policy unless it is made by an Amendment or a Rider which is signed by an officer of the
Company. No agent has authority to change the Policy or to waive any of its provisions.
Section 6.5 Relationship Between Parties. The relationships between the Company and Network
providers and relationships between the Company and Enrolling Groups, are solely contractual
relationships between independent contractors. Network providers and Enrolling Groups are not agents or
employees of the Company, nor is the Company or any employee of the Company an agent or employee of
Network providers or Enrolling Groups.
The relationship between a Network provider and any Covered Person is that of provider and patient. The
Network provider is solely responsible for the services provided to any Covered Person.
The relationship between the Enrolling Group and Covered Persons is that of employer and employee,
Dependent or other Coverage classification as defined in the Policy. The Enrolling Group is solely
responsible for enrollment and Coverage classification changes (including termination of a Covered
Person's Coverage through the Company), for the timely payment of the Policy Charge to the Company,
and for notifying Covered Persons of the termination of the Policy.
Section 6.6 Records. You must furnish the Company with all information and proofs which it may
reasonably require regarding any matters pertaining to the Policy.
By accepting Coverage under the Policy, you authorize and direct any person or institution that has
provided services to you, to furnish the Company any and all information and records or copies of records
relating to the services provided to you. The Company has the right to request this information at any
reasonable time. This applies to all Covered Persons, including Enrolled Dependents whether or not they
have signed the Insured's enrollment form.
The Company agrees that such information and records will be considered confidential. The Company has
the right to release any and all records concerning health care services which are necessary to implement
and administer the terms of the Policy or for appropriate medical review or quality assessment.
The Company or its Network providers are permitted to charge you reasonable fees to cover costs for
completing requested medical abstracts or forms which you have requested.
In some cases, the Company will designate other persons or entities to request records or information from
or related to you and to release those records as necessary. The Company's designees have the same rights
to this information as does the Company.
2000-FL-UHI-LG
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SECTION 7 - COORDINATION OF BENEFITS
Section 7.1 Coordination of Benefits Applicability. This coordination of benefits (COB) provIsIon
applies when a person has health care coverage under more than one Coverage Plan. "Coverage Plan" is
defmed below.
The order of benefit determination rules below determine which Coverage Plan will pay as the primary
Coverage Plan. The primary Coverage Plan that pays first pays without regard to the possibility that
another Coverage Plan may cover some expenses. A secondary Coverage Plan pays after the primary
Coverage Plan and may reduce the benefits it pays so that payments from all group Coverage Plans do not
exceed 100% of the total allowable expense.
Section7.2 Definitions. For purposes of Section 7, terms are defined as follows:
A. A "Coverage Plan" is any of the following that provides benefits or services for medical or dental care
or treatment. However, if separate contracts are used to provide coordinated coverage for members of
a group, the separate contracts are considered parts of the same Coverage Plan and there is no COB
among those separate contracts.
1. "Plan" includes: group insurance, closed panel or other forms of group or group-type coverage
(whether insured or uninsured); medical care components of group long-term care contracts,
such as skilled nursing care; medical benefits under group or individual automobile contracts;
and Medicare or other governmental benefits, as permitted by law.
2. "Plan" does not include: individual or family insurance; closed panel or other individual
coverage (except for group-type coverage); school accident type coverage; benefits for non-
medical components of group long-term care policies; Medicare supplement policies, Medicaid
policies and coverage under other governmental plans, unless permitted by law.
Each contract for coverage under (1) or (2) is a separate Coverage Plan. If a Coverage Plan has two
parts and COB rules apply only to one of the two, each of the parts is treated as a separate Coverage
Plan.
B. The order of benefit determination rules determine whether this Coverage Plan is a "primary
Coverage Plan" or "secondary Coverage Plan" when compared to another Coverage Plan covering the
person.
When this Coverage Plan is primary, its benefits are determined before those of any other Coverage
Plan and without considering any other Coverage Plan's benefits. When this Coverage Plan is
secondary, its benefits are determined after those of another Coverage Plan and may be reduced
because of the primary Coverage Plan's benefits.
C. "Allowable expense" means a health care service or expense, including deductibles and copayments,
that is covered at least in part by any of the Coverage Plans covering the person. When a Coverage
Plan provides benefits in the form of services, (for example an HMO) the reasonable cash value of
each service will be considered an allowable expense and a benefit paid. An expense or service that is
not covered by any of the Coverage Plans is not an allowable expense. The following are examples of
expenses or services that are not allowable expenses:
1. If a covered person is confined in a private hospital room, the difference between the cost of a
semi-private room in the hospital and the private room, (unless the patient's stay in a private
hospital room is medically necessary in terms of generally accepted medical practice, or one of
the Coverage Plans routinely provides coverage for hospital private rooms) is not an allowable
expense.
2. If a person is covered by 2 or more Coverage Plans that compute their benefit payments on the
basis of usual and customary fees, any amount in excess of the highest of the usual and
customary fees for a specific benefit is not an allowable expense.
2000-FL-UHI-LG
16
11
a. The primary Coverage Plan is the Coverage Plan of the parent whose birthday is earlier in
the year if:
1) The parents are married;
2) The parents are not separated (whether or not they ever have been married); or
3) A court decree awards joint custody without specifying that one party has the
responsibility to provide health care coverage.
Ifboth parents have the same birthday, the Coverage Plan that covered either of the parents
longer is primary.
b. If the specific terms of a court decree state that one of the parents is responsible for the
child's health care expenses or health care coverage and the Coverage Plan of that parent
has actual knowledge of those terms, that Coverage Plan is primary. This rule applies to
claim determination periods or Coverage Plan years commencing after the Coverage Plan
is given notice of the court decree.
c. If the parents are not married, or are separated (whether or not they ever have been
married) or are divorced, the order of benefits is:
1) The Coverage Plan of the custodial parent;
2) The Coverage Plan of the spouse of the custodial parent;
3) The Coverage Plan of the noncustodial parent; and then
4) The Coverage Plan of the spouse of the noncustodial parent.
3. Active or inactive employee. The Coverage Plan that covers a person as an employee who is
neither laid off nor retired is primary. The same would hold true if a person is a dependent of a
person covered as a retiree and an employee. If the other Coverage Plan does not have this rule,
and if, as a result, the Coverage Plans do not agree on the order of benefits, this rule is ignored.
Coverage provided an individual as a retired worker and as a dependent of an actively working
spouse will be determined under the rule labeled D(I).
4. Continuation coverage. If a person whose coverage is provided under a right of continuation
provided by federal or state law also is covered under another Coverage Plan, the Coverage Plan
covering the person as an employee, member, subscriber. or retiree (or as that person's
dependent) is primary, and the continuation coverage is secondary. If the other Coverage Plan
does not have this rule, and if, as a result, the Coverage Plans do not agree on the order of
benefits, this rule is ignored.
5. Longer or shorter length of coverage. The Coverage Plan that covered the person as an
employee, member, subscriber or retiree longer is primary.
6. If a husband or wife is covered under this Coverage Plan as an Insured and as a Covered
Dependent, the dependent benefits will be coordinated as if they were provided under another
Coverage Plan, this means the person's Insured benefit will pay first.
Section 7.4 Effect on the Benefits of This Coverage Plan.
A. When this Coverage Plan is secondary, it may reduce its benefits so that the total benefits paid or
provided by all Coverage Plans during a claim determination period are not more than 100 percent of
total allowable expenses. The difference between the benefit payments that this Coverage Plan would
have paid had it been the primary Coverage Plan, and the benefit payments that it actually paid or
provided shall be recorded as a benefit reserve for the covered person and used by this Coverage Plan
to pay any allowable expenses, not otherwise paid during the claim determination period. As each
claim is submitted, this Coverage Plan will:
1. Determine its obligation to payor provide benefits under its contract;
2. Determine whether a benefit reserve has been recorded for the covered person; and
2000- FL-UHI - LG
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SECTION 8 - SUBROGATION AND REFUND OF EXPENSES
Subrogation is the substitution of one person or entity in the place of another with reference to a lawful
claim, demand or right. The Company shall be subrogated to and shall succeed to all rights of recovery,
under any legal theory of any type, for the reasonable value of services and benefits provided by the
Company to you from: (i) third parties, including any person alleged to have caused you to suffer injuries
or damages; (ii) your employer; or (iii) any person or entity obligated to provide benefits or payments to
Covered Persons, including benefits or payments for underinsured or uninsured motorist protection (these
third parties and persons or entities are collectively referred to as "Third Parties"). You agree to assign to
the Company all rights of recovery against Third Parties, to the extent of the reasonable value of services
and benefits provided by the Company, plus reasonable costs of collection.
Y oushall cooperate with the Company in protecting the Company's legal rights to subrogation and
reimbursement, and acknowledge that the Company's rights shall be considered as the first priority claim
against Third Parties, to be paid before any other claims by you are paid. You shall do nothing to prejudice
the Company's rights under this provision, either before or after the need for services or benefits under the
Policy. The Company may, at its option, take necessary and appropriate action to preserve its rights under
these subrogation provisions, including filing suit in your name. For the reasonable value of services
provided under the Policy, the Company may collect, at its option, amounts from the proceeds of any
settlement (whether before or after any determination of liability) or judgment that may be recovered by
you or your legal representative, regardless of whether or not you have been fully compensated. You shall
hold in trust any proceeds of settlement or judgment for the benefit of the Company under these
subrogation provisions and the Company shall be entitled to recover reasonable attorney fees from you
incurred in collecting proceeds held by you. You shall not accept any settlement that does not fully
compensate or reimburse the Company without the written.approval of the Company. You agree to execute
and deliver such documents (including a written confirmation of assignment, and consent to release
medical records), and provide such help (including responding to requests for infonnation about any
accident or injuries and making court appearances) as may be reasonably requested by the Company.
Refund of Overpayments. If the Company pays benefits for expenses incurred on account of a Covered
Person, that Covered Person or any other person or organization that was paid must make a refund to the
Company if:
A. All or some of the expenses were not paid by the Covered Person or did not legally have to be paid by
the Covered Person, or
B. All or some of the payment made by the Company exceeded the benefits under the Policy.
The refund equals the amount the Company paid in excess of the amount it should have paid under the
Policy.
If the refund is due from another person or organization, the Covered Person agrees to help the Company
get the refund when requested.
If the Covered Person, or any other person or organization that was paid, does not promptly refund the full
amount, the Company may reduce the amount of any future benefits that are payable under the Policy. The
Company may also reduce future benefits under any other group benefits plan administered by the
Company for the Emolling Group. The reductions will equal the amount of the required refund. The
Company may have other rights in addition to the right to reduce future benefits.
Reimbursement of Benefits Paid. If the Company pays benefits for expenses incurred on account of a
Covered Person, the Insured or any other person or organization that was paid must make a refund to the
Company if all or some of the expenses were recovered from or paid by a source other than the Policy as a
result of claims against a third party for negligence, wrongful acts or omissions. The refund equals the
amount of the recovery or payment, up to the amount the Company paid.
2000-FL-UHI-LG
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XI
SECTION 9 - CONTINUATION OF COVERAGE AND CONVERSION
Section 9.1 Continuation Coverage. A Covered Person whose Coverage ends under the Policy may be
entitled to elect continuation Coverage in accordance with federal law (under COBRA) and as outlined in
Sections 9.2 through 9.4 below.
Continuation Coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act) shall apply only
to Enrolling Groups which are subject to the provisions of COBRA. Covered Persons should contact the
Enrolling Group's plan administrator to determine if he or she is entitled to continue Coverage under
COBRA. For the pwpose of continuation Coverage under COBRA, a newborn child of an Insured or a
child placed for adoption with the Insured during the period of continuation coverage shall be considered
on the same basis as an Insured.
Continuation Coverage for Covered Persons who selected continuation coverage under a prior plan which
was replaced by Coverage under the Policy shall terminate as scheduled under the prior plan or in
accordance with the terminating events set forth in Section 9.4 below, whichever is earlier.
In no event shall the Company be obligated to provide continuation Coverage to a Covered Person if the
Enrolling Group or its designated plan administrator fails to perform its responsibilities under federal law.
These responsibilities include but are not limited to notifying the Covered Person in a timely manner of the
right to elect continuation Coverage and notifying the Company in a timely manner of the Covered Person's
election of continuation Coverage.
It is the Insured's responsibility to notify the Enrolling Group within 60 days of the date an Enrolled
Dependent loses eligibility due to divorce or due to an Enrolled Dependent child losing eligibility (i.e.
reaching the limiting age or failing to meet the criteria of a Full-time Student.) If you fail to notify the
Enrolling Group of these events within the. 60 day period, the Enrolling Group and its designated plan
administrator are not obligated to provide continuation Coverage for that Enrolled Dependent.
The Company is not the Enrolling Group's designated Plan Administrator and does not assume any
responsibilities of a Plan Administrator pursuant to federal law .
A Covered Person whose Coverage would otherwise end under the Policy may be entitled to elect
continuation Coverage in accordance with federal law, as outlined in Sections 9.2 through 9.4 below.
Section 9.2 Qualifying Events for Continuation Coverage Under Federal Law. If the Covered
Person's Coverage terminated due to one of the following qualifying events, he or she is entitled to continue
Coverage. The Covered Person may elect the same Coverage that he or she had at the time of the qualifying
event.
A. Termination of the Insured from employment with the Enrolling Group or reduction of hours, for any
reason other than gross misconduct; or
B. Death of the Insured; or
C. Divorce or legal separation of the Insured; or
D. Loss of eligibility by an Enrolled Dependent who is a child; or
E. Entitlement of the Insured to Medicare benefits; or
F. The Enrolling Group filing for bankruptcy, under Title XI, United States Code, on or after July 1,
1986, but only for a retired Insured and his or her Enrolled Dependents. This is also a qualifying event
for any retired Insured and his or her Enrolled Dependents if there is a substantial elimination of
coverage within one year before or after the date the bankruptcy was filed.
Section 9.3 Notification Requirements and Election Period for Continuation Coverage Under
Federal Law. The Covered Person must notify the Enrolling Group's designated plan administrator within
60 days of his or her divorce, legal separation or loss of eligibility as an Enrolled Dependent. A Covered
2000-FL-UHI- LG
22
M
.
Continuation Coverage for Enrolled Dependents of an Insured whose continuation Coverage terminates
because the Insured becomes entitled to Medicare may be extended for an additional period of time. Such
Covered Persons should contact the Enrolling Group's designated plan administrator for information
regarding the continuation period.
Section 9.5 Conversion. If your Coverage terminates for one of the reasons described below, you may
make application to the Company for coverage under a conversion contract without furnishing evidence of
insurability.
Reasons for termination:
A. The Insured is retired or pensioned; or
B. Because you cease to be eligible as an Insured or Enrolled Dependent; or
c.' Because continuation Coverage expires; or
D. The entire Policy terminates and is not replaced.
Application and payment of the initial Premium must be made within 63 days after termination of
Coverage under the Policy. A conversion contract shall be issued in accordance with the terms and
conditions in effect at the time of application and may be substantially different from Coverage provided
under the Policy.
Section 9.6 Conversion Exceptions. Conversion is not available if:
A. Coverage ended due to Your failure to make timely required Premium payments.
B. Any discontinued group coverage is replaced by a succeeding carrier within 31 days.
C. The person was not continuously Covered under the Policy (and a prior plan for which the Policy
replaced) for a period of at least 3 months, ending with the date of termination.
2000- FL-UHI - LG
24
'1
-
When you notify the Company, we can work with you to implement the Care Coordination™ process. We
will provide you information about additional services such as disease management programs, health
education, pre-admission counseling and patient advocacy.
A. Admission to a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility. Notification is
not required for an admission for inpatient maternity services related to delivery when Confinement is
limited to 48 hours for a mother and newborn for any delivery other than a cesarean section, and 96
hours for a cesarean section delivery.
. Notify us five business days before an elective admission, and within one business day or the
same day of admission for non-elective admissions. For Emergency admissions,. notify us within
one business day or the same day (or as soon as reasonably possible.)
. If you don't notify us, Coverage will be reduced as described in 10.2.
B. Admission to a Hospital for maternity services that extend beyond the minimum stay requirements
listed in Section 11.10 or which are not related to delivery.
. Notify us as soon as possible.
. If you don't notify us, Coverage will be reduced as described in 10.2.
C. Reconstructive Surgery. (Notify us to verify that the service is Reconstructive, rather than a cosmetic
procedure. Cosmetic procedures are excluded)
. Notify us five business days before receiving services.
. If you don't notify us, Coverage will be reduced as described in 10.2.
D. Home Health Care Services. .Nursing, physical Therapy, Occupational Therapy, Speech Therapy,
Respiratory Therapy, Infusion Service and Hospice.
. Notify us five business days before receiving services.
. If you don't notify us, Coverage will be reduced as described in 10.2.
E. Accident-related dental services.
. Notify us five business days before receiving services
. If you don't notify us, Coverage will be reduced as described in 10.2.
F. Rental or purchase of Durable Medical Equipment that costs more than $1,000 (either purchase price
or cumulative rental for a single item.)
. Notify us five business days before rental or purchase.
. If you don't notify us, you will be responsible for paying all charges and no benefits will be paid.
G. Purchase ofa prosthetic that costs more than $1,000.
. Notify us five business days before purchase.
. If you don't notify us, you will be responsible for paying all charges and no benefits will be paid.
H. Transplants.
. Notify us five business days before receiving services.
. If you don't notify us, Coverage will be reduced as described in 10.2.
I. End Stage Renal Disease Services
. Notify us five business days before receiving services.
. If you don't notify us, you will be responsible for paying all charges and no benefits will be paid.
2000-FL-UHl-LG
26
..rrJ
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SECTION 11 - COVERED HEALTH SERVICES
Health Services described in this section are Covered when such services are:
A. Medically Necessary (refer to definition in Section I);
B. provided by or under the direction of a Physician or other appropriate provider as specifically
described; and
C. not excluded as described in Section 12, General Exclusions.
Network Benefits are subject to satisfaction of the Annual Deductible and the payment of any Copayment
and payment of the percentage of Eligible Expenses listed under the "Network Copayment or Coinsurance"
column in Section 13. Covered Health Services must be provided by or directed by a Network Physician.
Network Benefits include Emergency Health Services and referral Health Services received from non-
Network providers as described in Section 10.
Non-Network Benefits are subject to satisfaction of the Annual Deductible and payment of Copayments
and payment of the percentage Eligible Expenses listed under the "Non-Network Copayment or
Coinsurance" column in Section 13. Covered Health Services must be obtained from non-Network
providers.
Covered Health Services are subject to satisfaction of Annual Deductible and Copayments or Coinsurance
as described in Section 13, Schedule of Benefits.
Section 11.1 Medical Services in a Physician's Office. Health Services provided by or through a
Physician in the Physician's office. Covered Health Services includes preventive medical care such as well-
baby and well-child care including Child Health SuperVision Services in accordance with state law, routine
physical examinations, vision and hearing screenings, voluntary family planning and immunizations.
Section 11.2 Eye Examinations. Eye examinations provided by a provider in the provider's office.
Refractive eye examinations are limited to one every two calendar years.
Section 11.3 Allergy Services in a Physician's Office. Allergy Health Services provided by or through a
Physician. Health Services must be provided in the Physician's office.
Section 11.4 Professional Fees for Surgical and Medical Services. Professional fees for surgical
services and other medical care provided by or through a Physician. Health Services must be provided in a
Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility or Alternate Facility.
Section 11.5 Inpatient Hospital and Related Health Services. Commement, including room and board,
and services and supplies provided during Confinement (in a Semi-private Room) in a Hospital. Health
Services must be provided by or through a Physician. Certain Health Services rendered during a Covered
Person's Confinement are subject to separate benefit restrictions and/or Copayments as described elsewhere
in this Certificate.
Section 11.6 Transplantation Health Services. Health Services for transplants when ordered by a
Network Physician provided at or arranged by a Designated Facility for transplants. Transplantation Health
Services must be rendered in accordance with the Company's policies for transplantation Health Services.
Coverage is provided for cornea, kidney, kidney/pancreas, liver, heart, lung, and heart/lung transplants.
Coverage is also provided for bone marrow transplants (either from the Covered Person or a compatible
donor) and peripheral Stem Cell transplants, with or without high dose chemotherapy, rendered in
accordance with the Company's policies for transplantation Health Services. The reasonable costs of
searching for the donor may be limited to immediate family members and the National Bone Marrow
Donor Program.
Contact the Company for information about the Company's policies on transplantation Health Services,
including benefits that may be available for travel and lodging.
2000-FL-UHI-LG
28
.10
one home care visit. Federal law does not prohibit the mother's or newborn's attending Physician, after
consulting with the mother, from discharging the mother or her newborn child earlier than 48 hours (or 96
hours, as applicable).
You should notify the Company as soon as reasonably possible in the event that Confmement for the
mother and/or the newborn will extend beyond these minimum time frames. The purpose of the notification
is to coordinate with the Company to ensure that all Health Services related to the extended Confmement
will be Covered. Limitations will not be placed on any Maternity Services Covered under this section that
have been determined to be Medically Necessary.
Section 11.12 Outpatient Mental Health and Substance Abuse Services. Coverage for mental health,
substance abuse and chemical dependency evaluations and referral services, short-term individual, family
and/or group outpatient therapeutic services (including intensive outpatient therapy) and crisis intervention.
Health Services must be provided by or under the direction of the Mental Health/Substance Abuse
Designee. Contact the Mental Health/Substance Abuse Designee at the telephone number on your ID card.
Coverage is limited as stated in Section 13, Schedule of Benefits.
Section 11.13 Inpatient Mental Health and Substance Abuse Services. Coverage for Mental Health
and/or Substance Abuse Services provided on an inpatient or intermediate care basis, as determined to be
Medically Necessary by the Mental Health/Substance Abuse Designee. Confinement is provided only on a
Semi-private Room basis. At the discretion of the Mental Health/Substance Abuse Designee, two sessions
of intermediate care (e.g. partial hospitalization) may be substituted for one inpatient day. Coverage is
limited as stated in Section 13, Schedule of Benefits.
Coverage includes detoxification from abusive chemicals or substances and is limited to physical
detoxification when necessary to protect the physical health and well-being of the Covered Person.
Referrals to a Network provider shall in all cases be at the sole discretion of the Mental Health/Substance
Abuse Designee. ..
Section 11.14 Home Health Agency Services. Part-time, intermittent Health Services of a Home Health
Agency, when provided under the direction of a Physician. Home Health Agency services are Covered only
when Skilled Care Services are required. Home Health Agency Services must be provided in your home,
by or under the supervision of a registered nurse. Coverage is limited as stated in Section 13, Schedule of
Benefits.
Section 11.15 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services. Confmement (in a
Semi-private Room), including medical services and supplies, when provided under the direction of a
Physician. Health Services must be provided in a Skilled Nursing Facility or Inpatient Rehabilitation
Facility and are Covered only for the care and treatment of an Injury or Siclrness which otherwise would
require Confmement in a Hospital. Coverage is limited as stated in Section 13, Schedule of Benefits.
Section 11.16 Hospice Care. Coverage for Hospice Care which is recommended by a Physician, and
provided through a provider designated by the Company. Contact the Company for information about the
Company's policies for Hospice Care. Coverage is limited as stated in Section 13, Schedule of Benefits.
Section 11.17 Ambulance Services. Emergency ambulance transportation by a licensed ambulance
service to the nearest Hospital where Emergency Health Services can be rendered including transportation
costs of a newborn to and from the nearest appropriate facility to treat the newborn's condition. Such
transportation must be certified by the attending Physician as Medically Necessary to protect the health and
safety of the newborn child.
Section 11.18 Accident-related Dental Services. Services performed by a Doctor of Dental Surgery,
"D.D.S.," or Doctor of Medical Dentistry, "D.M.D." for the treatment of any Sound Natural Tooth made
necessary as a result of accident related damage. Coverage is provided only when services are required due
to an external trauma that results in dental damage to a Sound Natural Tooth. The dental damage must be of
sufficient significance that initial contact for evaluation must occur within 72 hours of the accident and
completed within 12 months of the accident. No Coverage is provided unless the dentist certifies to the
Company that the tooth was a Sound Natural Tooth that was injured as a result of an accident. (Incidents
2000-FL-UHI-LG
30
/~
Rehabilitation services must be performed in a Hospital or Skilled Nursing Facility or through a Home
Health Agency or other provider and provided under the direction of a Physician.
Section 11.22 Infertility Services. Health Services for the diagnosis and treatment of infertility when
provided by or under the direction of a Physician. Coverage is limited as stated in Section 13, Schedule of
Benefits.
Section 11.23 Reconstructive Surgery. Coverage for Reconstructive Surgery when provided by a
Physician in the Physician's office, at a Hospital or Alternate Facility.
Specifically Covered are:
A. The surgical repair of a Congenital Anomaly or syndrome if the Congenital Anomaly or syndrome is
listed in a recognized atlas of congenital anomalies or syndromes.
B. Breast reconstruction following mastectomy, including reconstruction of the non-affected breast to
achieve symmetry. (Other services required by the Women's Health and Cancer Rights Act of 1998,
including breast prosthesis and treatment of complications, are Covered in the same manner and at the
same level as any other Health Service.)
Section 11.24 Cleft Lip and Cleft Palate Treatment. Treatment of cleft lip and cleft palate for any
Covered Person under the age of 18 includes medical, dental, speech therapy, audiology and nutritional
Health Services. All Health Services must be Medically Necessary and under the direction of a Physician.
Section 11.25 Bones or Joints of the Jaw and Facial Region. Medically Necessary Health Services for
diagnostic and surgical procedures involving bones or joints of the jaw and facial region to treat conditions
caused by congenital or developmental defonnity, Sickness or Injury. Note: Covered Health Services do
not include care or treatment of the teeth or gums, intraoral prosthetic devices or surgical procedures for
cosmetic purposes.
Section 11.26 Diabetes Treatment. Coverage for Medically Necessary diabetes equipment, supplies and
diabetes self-management training and educational programs when provided by or under the direction of a
Physician. Diabetes self-management training includes training provided to a Covered Person after the
initial diagnosis in the care and management of that condition, including nutritional counseling and proper
use of diabetes equipment and supplies.
Section 11.27 Certain Prescription and Non-prescription Enteral Formulas. Including low protein
food products for home use when prescribed by a Physician as Medically Necessary for the treatment of
inherited diseases of amino acid, organic acid, carbohydrate, or fat metabolism as well as malabsorption
originating from congenital defects present at birth or acquired during the neonatal period. Coverage for
inherited diseases of amino acids and organic acids includes food products modified to be low protein for
Covered Persons through the age of24. Coverage is limited as stated in Section 13, Schedule of Benefits.
Section 11.28 Osteoporosis diagnosis, treatment and management. Health Services for high-risk
individuals, including, but not limited to: (a) estrogen-deficient individuals who are clinically at risk for
osteoporosis; (b) individuals who have vertebral abnonnalities; (c) individuals who are receiving long-term
glucocorticoid (steroid) therapy; (d) individual who have primary hyperparathyroidism, and (e) individuals
who have a family history of osteoporosis. Such Health Services must be provided under the direction of a
Physician.
2000-FL-UHI-LG
32
of)
Coverage under the Policy. Health Services and associated expenses for transplants involving
mechanical or animal organs.
J. Health Services and associated expenses for organ or tissue transplants are excluded, except those
specified as Covered in Section 11 and in the Company's policies for transplantation Health Services.
Any solid organ transplant otherwise Covered under the Policy that is performed as a treatment for
cancer.
K. Health Services and associated expenses for megavitamin therapy; psychosurgery; nutritional-based
therapy.
L. Services and supplies for smoking cessation programs and the treatment of nicotine addiction are
excluded.
M.. Surrogate parenting. Non-Medically Necessary amniocentesis. Health Services and associated
expenses for sex transformation operations and for reversal of voluntary sterilizations.
N. Repair or replacement for any otherwise Covered implant. Penile implants for the treatment of
impotence having a non-organic origin. Implants for the purpose of contraception more often than
once every 4 years.
O. Except when necessitated due to a change in medical condition - such that the present prosthesis no
longer functions adequately, the repair, replacement or duplicate prosthetic or Durable Medical
Equipment is excluded. Replacement of prosthetics or Durable Medical Equipment due to breakage or
malfunction is excluded. Replacement of prosthetics or Durable Medical Equipment for the sole
purpose of technical modification or enhancement is excluded.
P. Orthotic appliances (including shoe orthotics) are excluded. Personal comfort items, including air
conditioners and humidifiers,. eVen though prescribed by a Physician are excluded.
Q. Growth hormone therapy except as may be provided as a prescription drug benefit for a documented
growth hormone deficiency, Turner's Syndrome, growth delay due to cranial radiation, or chronic
renal disease.
R. Travel or transportation expenses, even though prescribed by a Physician. (Ambulance and Transplant
travel services are Covered as described in Section 11.)
S. Health Services for treatment of military service-related disabilities, when the Covered Person is
legally entitled to other coverage and facilities are reasonably available to the Covered Person.
T. Mental Health and/or Substance Abuse Services rendered in connection with conditions not classified
in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric
Association. Mental Health and/or Substance Abuse Services, when such services extend beyond the
period necessary for short-term evaluation, diagnosis, treatment or crisis intervention. Specifically
excluded are Mental Health/Substance Abuse Services for the treatment of insomnia and other sleep
disorders, dementia, neurological disorders and other disorders with a known physical basis.
U. Mental Health Services for the treatment of Mental Illnesses which will not substantially improve
beyond the current level of functioning, or for conditions not subject to favorable modification or
management according to generally accepted standards of psychiatric care, as determined by the
Mental Health/Substance Abuse Designee, including, but not limited to, conduct and impulse control
disorders; personality disorders; and paraphilias.
V. Mental Health and/or Substance Abuse Services for the following: (1) services utilizing methadone
treatment as maintenance, L.A.A.M. (l-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents;
and (2) services and treatment provided in connection with or to comply with involuntary
commitments, police detentions and other similar arrangements, unless coordinated with the Mental
Health/Substance Abuse Designee.
2000-FL-UHI-LG
34
/7.'J
n. Health Services and associated expenses for in vitro fertilization; gamete intrafallopian transfer (GIFT)
procedures; zygote intrafallopian transfer (ZIFf) procedures; embryo transport; surrogate parenting;
donor semen and related costs including collection and preparation; and drugs for the treatment of
infertility .
KK. Charges incurred in connection with the provision or fitting of hearing aids, eye glasses or contact
lenses. Optometric therapy is excluded.
LL. In the event that a non-Network provider routinely waives Copayments and/or the Annual Deductible
for a particular Health Service, the Health Service for which the Copayments and/or Annual
Deductible are waived is not Covered.
MM. Medical and surgical treatment of excessive sweating (hyperhidrosis).
NN. Medical and surgical treatments for snoring, except when provided as a part of treatment for
documented obstructive sleep apnea. Oral appliances for snoring.
00. Routine foot care, including the cutting or removal of corns and calluses; the trimming cutting,
clipping or debriding of nails; and other hygienic and preventive maintenance care, such as cleaning
and soaking the feet, the use of skin creams to maintain skin tone and any other service performed in
the absence of localized illness, injury or symptoms involving the foot. Treatment involving otherwise
covered services such as diagnosis and treatment of ulcers, wounds or infections, treatment of warts on
the foot and treatment required because of metabolic, neurologic or peripheral vascular disease is
covered. Treatment of flat foot. Treatment of subluxation of the foot.
PP. Nutritional counseling and related services for either individuals or groups.
QQ. Wigs
2000-FL-UHI-LG
36
.-a?
SECTION - BENEFIT NETWORK COPAYMENT NON-NETWORK
DESCRIPTION OR COINSURANCE COPAYMENTOR
COINSURANCE
11.6 Transplantation Health *10% of Eligible Expenses. *30% of Eligible Expenses.
Services
11.7 Outpatient Emergency $50 per visit. Covered as a Network Benefit.
Health Services Copayment waived if Confined
within 24 hours for the same
condition.
Does not apply to Out-of-Pocket
Maximum.
11.8 Urgent Care Center $35 per visit. 30% of Eligible Expenses.
Does not apply to Out-of-Pocket
Maximum.
11.9 Outpatient Surgery, *10% of Eligible Expenses. *30% of Eligible Expenses.
Diagnostic and
Therapeutic Services
11.10 Mammography No Copayment. Covered as a Network Benefit.
11,11 Maternity Services Same as 11.1, 11.4, 11.5, and Same as. 11.1, 11.4, 11.5, and
11.9. 11.9.
11.12 Outpatient Mental Health $15 per individual visit; 30% of Eligible Expenses.
and Substance Abuse $10 per group visit.
Services
Limited to 20 visits per
calendar year. Visits are
combined for In-Network
and Non-Network
benefits.
Must be coordinated
through the Mental
Health/Substance Abuse
Designee.
Does not apply to Out-of-
Pocket Maximum.
2000-FL-UHI-LG
38
(Y.)
SECTION - BENEFIT NETWORK COPAYMENT NON-NETWORK
DESCRIPTION OR COINSURANCE COPAYMENTOR
COINSURANCE
11.20 Prosthetic Devices and * 1 0% of Eligible Expenses. *30% of Eligible Expenses.
Durable Medical Prior authorization required when Prior authorization required
Equipment the cost exceeds $1,000. when the cost exceeds $1,000.
Network and Non-
Network Benefits for
Durable Medical
Equipment are subject to
the combined limit of
$2,500 per calendar year.
All Coverage for Durable
Medical Equipment is
limited to $50,000 during
the entire period of time a
Covered Person is
enrolled for Coverage
under the Policy.
11.21 Outpatient Rehabilitation 10% of Eligible Expenses. 30% of Eligible Expenses.
Services
(Physical therapy,
occupational therapy, '.
speech therapy, and
cardiac/pulmonary
rehabilitation. )
Network and Non-
Network Benefits are
subject to combined
limits as follows:
20 visits of physical
therapy per calendar year.
20 visits of occupational
therapy per calendar year.
20 visits of speech
therapy per calendar year.
36 visits of
cardiac/pulmonary
rehabilitation per calendar
year.
11.22 Infertility Services 10% of Eligible Expenses. 30% of Eligible Expenses.
Limited to $2,000 per
calendar year.
11.23 Reconstructive Surgery *10% of Eligible Expenses. *30% of Eligible Expenses.
11.24 Cleft Lip and Cleft palate Same as 11.1, 11.4, 11.5, 11.9, Same as 11.1, 11.4, 11.5, 11.9,
Treatment 11.21. 11.21.
2000-FL-UHI-LG
40
0-11
SECTION - ELIGIBILITY DESCRIPTION
1. Initial Eligibility Period.
The Initial Eligibility Period shall begin on the date determined by the Enrolling Group and the
Company and shall end on the date determined by the Enrolling Group and the Company.
2. "Eligibility.
The following conditions are in addition to those specified in Section 2 of the Certificate:
Waiting or probationary period for newly Eligible Persons shall be as follows: None.
. Excluded classes of persons, if any: Part-time, and Temporary.
Coverage classifications other than employee, if any: None.
Other: None.
3. Effective Date.
The first day of the month following the month in which the waiting period was completed.
4. Minimum Participation Requirement.
The minimum participation requirements are:
2 Eligible Persons and;
Eligible Persons enrolled for Coverage under this Policy.
2000-FL-UHI-LG
42
/:;A}
exclusions in your Certificate of Coverage and as listed at the end of this Rider in the section entitled
"Exclusions" .
Outpatient Prescription Drug Products must be:
· Medically Necessary;
· or prescribed to prevent conception; and
· the preferred version of a Dual-Marketed drug.
Prior Authorization. Certain Prescription Drug Products require prior authorization from the
Company or its designee. (Prior authorization is the process of obtaining approval for certain
Prescription Drug Products, prior to dispensing, using guidelines approved by the Company.) Prior
authorization is to be obtained from the Company by the prescribing provider or the pharmacist when
Prescription Drug Products are dispensed at a Network Phannacy.
When Prescription Drug Products are dispensed at a non-Network Pharmacy, you are responsible for
obtaining the required prior authorization. The list of Prescription Drug Products and the Coverage
criteria requiring prior authorization are subject to periodic review and modification by the Company.
A current list of Prescription Drug Products requiring prior authorization is available by contacting
the Company at the telephone number on your ill card.
If prior authorization is not obtained prior to the pharmacy dispensing the Prescription Drug Product,
you can ask the Company to consider reimbursement after you have obtained your Prescription Drug
Product. However, the Prescription Drug Product may not be authorized for Coverage after the
Company reviews the documentation provided. If Coverage is authorized after the Company reviews
the documentation, you will pay more than if authorization is obtained prior to the Prescription Drug
Product being dispensed.at a Network Pharmacy. This is because when you obtain the prescription
without prior authorization, you will be required to pay for the Prescription Drug Product at the
phannacy. The Company's contracted pharmacy reimbursement rates will not be available to you.
When you seek reimbursement from the Company as described in the Certificate of Coverage, the
amount of reimbursement will be based on the Predominant Reimbursement Rate. When you submit a
claim on this basis, you will pay more because you failed to verify your eligibility when the
Prescription Drug Product was dispensed.
3. Supplv Limits. Coverage of Prescription Drug Products is subject to the supply limits shown below.
Note: Some products may be subject to additional supply limits based on Coverage criteria developed
by the Company. The limit may restrict either the amount dispensed per Prescription Order or Refill,
or the amount dispensed per month's supply. A current quantity level list of Prescription Drug
Products that have been assigned maximum quantity levels for dispensing may be obtained from the
Company. The list is subject to periodic review and modification by the Company.
For a single Copayment you may receive a Prescription Drug Product up to the supply limit stated.
Retail Network or Retail Non-Network Pharmacy
If the Prescription Drug Product is dispensed by a retail Network or non-Network Phannacy, the
following limits apply:
· As written by the provider, up to a consecutive 31 day supply of a Prescription Drug Product,
unless adjusted based on the drug manufacturer's packaging size.
· A one cycle supply of an oral contraceptive. Up to three cycles can be purchased at one time if a
Copayment is paid for each cycle supplied.
Mail Service Network Pharmacy
If the Prescription Drug Product is dispensed by a mail service Network Pharmacy, the supply limit is
as written by the provider, up to a consecutive 90 day supply of a Prescription Drug Product, unless
adjusted based on the drug manufacturer's packaging size.
UHI-RX-FL
44
~
and Therapeutics Committee objectively evaluates drugs for therapeutic treatment, safety and cost in
order to establish Coverage policies and guidelines which promote quality and cost-effective drug
therapy. The evaluation includes, but is not limited to: 1) medical appropriateness; 2) Medical
Necessity; 3) safety and efficacy; 4) needs for specific indications; 5) supply limits; 6) prior
authorization; and 7) Copayment levels. Even after a drug is included on the Preferred Drug List, this
evaluation continues at least annually or as new information becomes available.
7. Coupons and Incentives. At various times the Company may offer coupons or other incentives for
certain drugs on the Preferred Drug List. Only your doctor can determine whether a change in your
Prescription Order or Refill is appropriate for your medical condition.
8. Exclusions. Exclusions from Coverage listed in the Certificate apply also to this Rider. In addition,
the following exclusions from Coverage under this Rider include but are not limited to:
(a.) Coverage for Prescription Drug Products for the amount dispensed (days supply or quantity
limit) which exceeds the supply limit.
(6.) Drugs which are prescribed, dispensed or intended for use while you are Confined in a Hospital,
Skilled Nursing Facility, or Alternate Facility.
(c.) Experimental, Investigational or Unproven Services and medications; medications used for
experimental indications and/or dosage regimens determined by the Company to be
experimental. "Experimental" does not include pharmacological regimens for the treatment of
cancer if such drugs are recognized as acceptable treatment in one of the standard reference
compendia, but have not been approved by the FDA. Contact the Company for details.
(d.) Prescription Drug Products furnished by the local, state or federal government. Any Prescription
Drug Product to the extent payment or benefits are provided or available from the local, state or
. . federal government (for example, Medicare) whether or not payment or benefits are received,
except as otherwise provided by law.
(e.) Prescription Drug Products for any condition, Injury, Sickness or Mental Illness arising out of,
or in the course of, employment for which benefits are available under any workers'
compensation law or other similar laws, whether or not a claim for such benefits is made or
payment or benefits are received.
(f.) Any product dispensed for the purpose of appetite suppression and other weight loss products.
(g.) Compounded drugs not containing at least one ingredient requiring a Prescription Order or
Refill.
(h.) Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or
state law before being dispensed. Any drug that is therapeutically equivalent to an over-the-
counter drug.
(i.) Injectable drugs, except when the drug can be self-administered, as defined by the Company.
(j.) Durable Medical Equipment. Prescribed and non-prescribed outpatient supplies, other than the
diabetic supplies and inhaler spacers specifically stated as Covered.
(k.) General and injectable vitamins, except the following which require a Prescription Order or
Refill: prenatal vitamins, vitamins with fluoride, and single entity vitamins.
(1.) Unit dose packaging of Prescription Drug Products.
(m.) Medications for cosmetic purposes only.
(n.) Prescription Drug Products that are newly approved by the FDA until they are reviewed by the
Company or its designee. This exclusion does not pertain if the newly approved FDA drug is
pertinent to a Covered Persons condition and all other known approved FDA drugs have proven
to be non-effective in treating such Covered Person's condition.
UHI-RX-FL 46
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