GROUP POLICY #03040
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Group Policy
For
City of Clearwater
Group #03,040,
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UNITED HEALTHCARE OF FLORIDA, INC.
GROUP POLICY
City of Clearwater
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Copyright United Hea1thCare Corporation
April 1995
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GROUP POllCY
This Group Policy ("Policy") is entered into by and betw~ trnited HealthCare of Florida, Inc. ("PLAN"), a
Florida Health Maintenance Organization and City of Clearwater ("'Enrolling Unit").
Upon receipt of the Enrolling Unit's application and payment of the required Policy Charges, this Policy is
deemed executed. The PLAN agrees with the Enrolling Unit to provide Coverage for Health Services set forth
herein, subject to the terms, conditions, exclusions, and limitations of this Policy. The Enrolling Unit's
application is made a part of this Policy.
This Policy replaces and supersedes any previous agreements relating to the Coverage of Health Services between
the Enrolling Unit and the PLAN. The terms and conditions of this Policy shall in turn be superseded by those of
any subsequent agreements relating to the Coverage of Health Services between the Enrolling Unit and the PLAN.
This Policy shall become effective at 12:01 a.m. January 1,2002 Eastern Time and will be continued in force by
the timely payment of the required Policy Charges when due, subject to termination of this Policy as provided
herein. When the Policy is terminated, as provided for in Article 5, this Policy and. all Coverage under this
Policy will end at 12:00 midnight on the date of termination.
This Policy is. delivered in and governed by the laws of the State of Florida.
04/18/95 POLICY
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ARTICLE 1
DEFINITIONS
The terms used in this Policy have the same meaning given those terms in the Certificate of Coverage. unless
otherwise specifically defined in this Policy.
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ARTICLE i .
HEALm SERVICES
Subscribers and their Enrolled Dependents are entitled to Coverage for Health Services subject to the terms.
conditions. limitations and exclusions set forth in the Certificate of Coverage included in this Policy as
Attachment A. The Certificate describes the Covered Health Services including any optional Riders. required
Copayments. and the terms. conditions. limitations and exclusions related to Coverage.
ARTICLE 3
PREMIUM RATES AND POLICY CHARGE
3.1 Premiums. Monthly Premiums payable by or on behalf of Covered Persons are specified on Exhibit A to the
Policy entitled "Premiums".
The PLAN reserves the right to change the schedule of rates for Premiums on the first anniversary of the effective
date of the Policy specified in the application or on any monthly due date thereafter. or on any date the provisions
of the Policy are amended. The PLAN will provide written notice of any change in Premiums to the Enrolling
Unit at least 45 days prior to the effective date of the change.
3.2 Computation of Policy Charge. Each Policy Charge shall be calculated based on the number of Subscribers
in each Coverage classification the PLAN shows in its records at the time of calculation. at the Premiums then in
effect. A full calendar month's Premiums shall be charged for Covered Persons whose effective date of Coverage
falls on or before the 15th of that calendar month. No Premiums shall be charged for Covered Persons whose
effective date of Coverage falls after the 15th of that calendar month. A full calendar month's Premiums shall be
charged for Covered Persons whose Coverage is terminated after the 15th of that calendar month. No Premiums
shall be charged for Covered Persons whose Coverage is terminated on or before the 15th of that calendar month.
3.3 Acljustments to the Policy Charge. Retroactive adjustments may be made for any additions or terminations
of Subscribers or changes in Coverage classification not reflected in the PLAN's records at the time the Policy
Charge is calculated by the PLAN. However. no retroactive credit shall be granted for any change occurring
more than 60 days prior to the date the PLAN received notification of the change from the Enrolling Unit. nor
shall retroactive credit be granted for any calendar month in which a Subscriber has received Health Services.
The Enrolling Unit shall notify the PLAN in writing within 30 days of the effective date of enrollments,
terminations or other changes; provided. however. that the Enrolling Unit shall notify the PLAN in writing each
month of any changes in the Coverage classification of any Subscriber.
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3.4 Payment of the Pollcy Charge. The Policy Charge is payable in advance on a monthly basis by the
Enrolling Unit to the PLAN. The first Policy Charge is due and payable on the effective date of the Policy.
Subsequent Policy Charges are due and payable no later than the first day of each period thereafter that the Policy
is in effect.
A late payment charge will be assessed for any Policy Charge not received by the last day of the grace period. A
service charge will be assessed for any non-sufficient-fund check received in payment of the Policy Charge. All
Policy Charge payments shall be accompanied by supporting{ documentation which states the names of the
Covered Persons for whom payment is made. 1,
The PLAN reserves the right to collect attorney's fees and any other costs related to collecting delinquent Policy
Charges.
3.5 Grace Period. A grace period of 10 days shall be granted for the payment of any Policy Charge, during
which time the Policy shall continue in force. In no event shall the grace period extend beyond the date the Policy
terminates.
This Policy shall automatically terminate retroactive to the last paid date of Coverage if the grace period expires
and any Policy Charge remains unpaid, or if the PLAN receives written notice of termination from the Enrolling
Unit during the grace period.
ARTICLE 4
ENROLLMENT AND ELIGIBILITY
4.1 Initial Eligibility Period. Eligible Persons and their Dependents may enroll for Coverage under the Policy
during the Initial Eligibility Period. The Initial Eligibility Period shall begin on December I, 2001 and shall end
on January 31, 2002. Eligible Persons and Dependents who do not submit an application for enrollment to the
Enrolling Unit during the Initial Eligibility Period may not apply for Coverage under this Policy until the
Enrolling Unit holds an <>pen Enrollment Period.
4.2 Open Enrollment. The Enrolling Unit shall provide an annual Open Enrollment Period of 30 days, in
accordance with state law. during which Eligible Persons may enroll for Coverage under the Policy.
4.3 Eligibility Conditions. The following conditions are in addition to those specified in Section 2 of the
Certificate:
(a) The term "Dependent" shall not include any unmarried dependent child 19 years of age or older
unless the unmarried dependent child is19 years of age or older and less than 25 years of age and
meets the criteria described in Section 1 of the Certificate, the definition of "Dependent, "
items 2.a. through 2.c.
(b) Waiting or probationary period for newly Eligible Persons shall be as follows:
Effective first of the month follo~ date of hire
(c) Excluded persons, if any:
Part-time, Seasonal, and Temporary
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(d) Coverage classifications other than employee. if any:
(e) Other:
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4.4 Effective Date of Coverage. Coverage for properly enrolled Eligible Persons and their Dependents shall
begin on:
o The day following the last day of the required waiting period.
[8J The first day of the month following the month in which the waiting period was completed.
o The date the Eligible Person joins the Enrolling Unit.
o Other:
ARTICLE 5
POUCY TERMINATION
5.1 Conditions for Termination of This Entire Poney. This Policy and all Coverage under this Policy shall
automatically terminate on the earliest of the dates specified below:
(a) At the PLAN's option. retroactive to the last paid date of Coverage. if the grace period expires
and any Policy Charge remains unpaid.
(b) On the date specified by the Enrolling Unit. after at least 45 days prior written notice to the
PLAN that this Policy shall be terminated.
(c) On the date specified by the PLAN. after at least 45 days prior written notice to the Enrolling
Unit that this Policy shall be terminated. except for (d) below.
(d) On the date specified by the PLAN in written notice to the Enrolling Unit that this Policy shall
be terminated because the Enrolling Unit provided the PLAN with false information material to
the execution of this Policy or to the provision of Coverage under this Policy. The PLAN has
the right to rescind this Policy back to the effective date.
5.2 Payment and Reimbursement Upon Termination. Upon any termination of this Policy. the Enrolling Unit
shall be and shall remain liable to the PLAN for the payment of any and all Premiums which are unpaid at the
time of termination.
04118/95 POLICY
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ARTICLE 6
GENERAL PROVISIONS
6.1 Entire Policy. The group Policy, including the Certificate of Coverage as Attachment A, the application of
the Enrolling Unit, any individual SubscnDer applications, Amendments and Riders shall constitute the entire
Policy between parties. All statements made by the Enrolling Unit or by a Subscriber shall, in the absence of
fraud, be deemed representations and not warranties. No suchhatement shall void or reduce Coverage under this
Policy or be used in defense of a legal action unless it is conlliined in a written application.
6.2 Dispute Resolution. No legal proceeding or action may be brought without first completing the complaint
procedure specified in Section S of the Certificate. H the Enrolling Unit wishes to seek further review of the
decision or the complaint or dispute, it shall submit the complaint or dispute to binding arbitration pursuant to the
rules of the American Arbitration Association. This is the only right the Enrolling Unit has for further
consideration. The matter must be submitted to binding arbitration within 1 year of the date the final decision was
furnished to the Enrolling Unit, as described in Section S. The arbitrators shall have no power to award any
punitive or exemplary damages or to vary or ignore the provisions of the Policy, and shall be bound by controlling
law.
6.3 Time Limit on Certain Defenses. No statement made by the Enrolling Unit, except a fraudulent statement,
shall be used to void this Policy after it has been in force for a period of 2 years.
6.4 Amendments and Alterations. Amendments to this Policy are effective 4S days after PLAN sends written
notice to the Enrolling Unit. No change will be made to this Policy unless made by an Amendment or a Rider
which is signed by an executive officer of the PLAN. No agent has authority to change this Policy or to waive
any of its provisions.
6.5 Relationship Between Parties. The relationships between the PLAN and Participating providers and
relationships between the PLAN and Enrolling Units, are solely contractual relationships between independent
contractors. Participating .providers and Enrolling Units are not agents or employees of the PLAN, nor is the
PLAN or any employee of the PLAN an agent or employee of Participating providers or Enrolling Units.
The relationship between a Participating provider and any Covered Person is that of provider and patient. The
Participating provider is solely responsible for the services provided by it to any Covered Person. The
relationship between any Enrolling Unit and any Covered Person is that of employer and employee, Dependent, or
other Coverage classification as defined in this Policy. The Enrolling Unit is solely responsible for enrollment
and Coverage classification changes (including termination of a Covered Person's Coverage through the PLAN)
and for the timely payment of the Policy Charge.
6.6 Records. The Enrolling Unit shall furnish the PLAN with all information and proofs which the PLAN may
reasonably require with regard to any matters pertaining to this Policy. PLAN may at any reasonable time inspect
all documents furnished to the Enrolling Unit by an individual in connection with the Coverage, and the Enrolling
Unit's payroll, and any other records pertinent to the Coverage under this Policy.
By accepting Coverage under this Policy, each Covered Person, including Enrolled Dependents, whether or not
such Enrolled Dependents have signed the application of the Subscriber, authorizes and directs any person or
institution that has provided services to the Covered Person, to furnish the PLAN or any of the PLAN's designees
at any reasonable time, upon its request, any and all information and records or copies of records relating to the
services provided to the Covered Person. The PLAN agrees that such information and records will be considered
confidential. The PLAN and any of the PLAN's designees shall have the right to release any and all records
concerning health care services which are necessary to implement and administer the terms of this Policy or for
appropriate medical review or quality assessment.
04118/95 POLICY
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6.7 Administrative Services. The services necessary to administer this Policy and the Coverage provided under
it will be provided in accordance with the PLAN's or its designee's standard administrative procedures. If the
Enrolling Unit requests that such administrative services be provided in a manner other than in accordance with
these standard procedures. including requests for non-standard reports. the Enrolling Unit shall pay for such
services or reports at the PLAN's or its designee's then-current charges for such services or reports. .
6.8 ERISA. When this Policy is purchased by the Enrolling Unit to provide benefits under a welfare plan
governed by the Employee Retirement Income Security Act 2!(U.S.C. ~1001 et seq.. the PLAN shall not be
named as and shall not be the Plan Administrator or named fiduciary of the welfare plan. as those terms are used
in ERISA.
6.9 Examination of Covered Persons. In the event of a question or dispute concerning Coverage for Health
Services. the PLAN may reasonably require that a Covered Person be examined at the PLAN's expense by a
Participating Physician acceptable to the PLAN.
6.10 Clerical Error. Clerical error shall not deprive any individual of Coverage under this Policy or create a
right to additional benefits. Failure 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 the PLAN to the Enrolling Unit for more than 60 days of Coverage
prior to the date the PLAN received notification of such clerical error.
6.11 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.
6.12 Conformity with Statutes. Any provision of this Policy which. on its effective date. is in conflict with the
requirements of 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.
6.13 Notice. Written noti~egivenby the PLAN to an authorized representative of the Enrolling Unit is deemed
notice to all affected Subscribers and their Enrolled Dependents in the administration of this Policy. including
termination of this Policy. The Enrolling Unit is responsible for giving notice to Covered Persons.
Any notice sent to PLAN under this Policy shall be addressed to:
United Hea1thCare of Florida. Inc.
4350 W. Cypress St.
Tampa. FL 33607
Any notice sent to Enrolling Unit under this Policy shall be addressed to:
City of Clearwater
100 S Myrtle Ave
Clearwater. FL 33756
04/18/95 POLICY
6.14 Continuation Coverage. The PLAN agrees to provide Coverage under the Policy for those Covered
Persons who are eligible to continue Coverage under federal or state law. as described in Section 8 of Attachment
A. Certificate of Coverage.
The PLAN will not provide any administrative duties with respect to the Enrolling Unit's compliance with federal
or state law. All duties of the plan sponsor or plan admini!ltrator. including but not limited to notification of
COBRA and state law continuation rights. and billing and collection of Premium. remain the sole responsibility of
the Enrolling Unit. I
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EXIllBIT A
PREMIUMS
Monthly Premiums payable by or on behalf of Covered Persons are specified below:
Class I
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Class' 2
Class 3
Class 4
Premium POS
$900.01
Enrolling Unit Contribution
Subscriber Contribution
04/18/95 POLICY
$320.12
50% Single
50% Single
$555.61
$
0% Dependent
100% Dependent
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CONTRACT TERMINATION AMENDMENT
United HealthCare of Florida, Inc.
The Contract is modified to comply with the provisions of the federal law referred to as the Health Insurance
Portability and Accountability Act of 1996. The conditions under which the Contract may be terminated are
changed. This Amendment replaces Article 5 of the Contract with the following:
5.1 Termination of this Contract by the Enrolling Unit. ~ Enrolling Unit may terminate this Contract as of
any Premium due date giving the PLAN at least 31 days priofWritten notice.
5.2 Termination of this Contract by the PLAN. This Contract and all Coverage under this Contract shall
automatically terminate on the earliest of the dates specified below:
(a) As of any Premium due date if the Enrolling Unit has not paid the required Policy Charges by the end of
the grace period.
(b) On the date specified by the PLAN, after at least 90 days prior written notice to the Enrolling Unit and
participants that this contract shall be terminated because the PLAN will no longer renew or issue this
group health benefit PLAN.
(c)
On the date specified by the PLAN, after at least 180 days prior written notice to the applicable state
authority, the Enrolling Unit and participants that this Contract shall be terminated because the PLAN will
not longer renew or issue any employer health benefit PLAN within the applicable market.
(d)
On the effective date of the Coverage, if the Enrolling Unit has performed an act or practice that
constitutes fraud or made an intentional misrepresentation of material fact under the terms of the Contract.
(e)
On the date specified by the PLAN, when there are no Subscribers who reside or are employed in the
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Service Area.
(f)
On the date specified by the PLAN, when the membership of an employer in a bona fide association, on
the basis of which the coverage is provided, ceases.
5.3 Non-renewal of the Contract by the PLAN. The PLAN guarantees the Enrolling Unit the right to renew
this Contract each year, at the Enrolling Unit's option. However, the PLAN may refuse to renew this Contract and
all Coverage provided under this Contract if the Enrolling Unit has failed to comply with a material provision of
the PLAN which relates to rules for contributions or group participation. The PLAN will give the Enrolling Unit
4S days notice in writing, of its intent to refuse renewal of this Contract.
5.4 Payment and Reimbursement Upon Termination. Upon any termination of this Contract, the Enrolling
Unit shall be and shall remain liable to the PLAN for the payment of any and all Premiums which are unpaid at
the time of termination.
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Gary L. Schultz
President
United HealthCare of Florida, Inc.
HIP AA/POL (8/97)
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UNITED HEAL THCARE INSURANCE COMPANY
Administrative Office: 5901 Lincoln Drive Edina, Minnesota 55436
Call 1-800-216-0017 to obtain information about coverage
or for assistance in resolving complaints.
A STOCK COM,ANY
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ENROLLING UNIT City of Clearwater
POLICY NUMBER 03040
EFFECTIVE DATE January 1, 2002
ANNIVERSARY DATE Each year, beginning January 1, 2003.
GROUP POLICY
("Policy")
This Policy is issued to the Enrolling Unit 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 subject to an annual
deductible provision.
The Company has, by its President and Secretary, executed this Policy at its
principal office in Hartford, Connecticut.
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Secretary
AN ACCIDENT AND HEALTH INSURANCE POLICY
FLCGrp301 (1/97)
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ARTICLE 1
DEFINITIONS
Certain terms used in this Policy are defined in the Certificate, attached in Attachment
A, unless otherwise specifically defined in this Policy.
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ARTICLE 2
HEALTH SERVICES
Covered Persons are eligible for coverage for Health Services as described in this
Policy, including the Certificate. The Certificate will be provided to each Insured by the
Company.
ARTICLE 3
PREMIUM RATES
The Enrolling Unit is solely responsible for enrollment and coverage classification
changes (including termination of a Covered Person's coverage through Company) and
for the timely payment of this Premium to Company.
3.1 Premium Rates. Monthly Premium rates payable by or on behalf of Covered
Persons. Company reserves the right in its sole discretion to change the schedule of
Premium rates effective on. the first renewal date specified in the application or on any
monthly due date thereafter, or on any date the provisions of the Policy are amended.
Written notice of any change in Premium rates shall be given by Company to the
Enrolling Unit at least 45 days prior to the effective date of the change.
3.2 Computation of Premiums. Premiums shall be calculated based on the number
of Insureds in each coverage classification Company shows in its records at the time of
calculation, at the Premiums then in effect. A full calendar month's Premiums shall be
charged for Covered Persons whose effective date of coverage falls on or before the
15th of that calendar month. No Premiums shall be charged for Covered Persons
whose effective date of coverage falls after the 15th of that calendar month. A full
calendar month's Premiums shall be charged for Covered Persons whose coverage is
terminated effective after the 15th of that calendar month. No Premiums shall be
charged for Covered Persons whose coverage is terminated effective on or before the
15th of that calendar month.
FLCGrp301 (1/97)
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3.3 Adjustments to Premiums. Retroactive adjustments may be made for any
additions of Insureds and changes in coverage classification not reflected in Company's
records at the time the Premium is calculated by Company. However, no retroactive
credit shall be granted for any change with an effective date occurring more than 60
days prior to the date Company received notification of the change from the Enrolling
Unit, nor shall retroactive credit be granted for any calendar month in which an Insured
has received Health Services covered by this P()lrc~.
The Enrolling Unit shall notify Company in writing within 30 days of the effective date of
enrollments, terminations or other changes relating to a Covered Person, including any
change in the coverage classification of the Insured.
In the event there is any increase in premium tax, guarantee or uninsured fund
assessments or other governmental charges relating to or calculated in regard to
Premium, such increase shall be automatically added to Premium.
3.4 Payment of Premium. Premium is payable in advance on a monthly basis by the
Enrolling Unit to Company at its offices. The first payment is due and payable before
the effective date of the Policy. Subsequent payments of Premium are due and
payable no later than the first day of each month that the Policy is in effect.
A service charge in the maximum allowable amount will be assessed for any non-
sufficient-fund check received in payment of Premium. All Premium payments shall be
accompanied by supporting documentation which states the names of the Covered
Persons for whom payment is made.
3.5 Grace Period. A grace period of 31 days after the due date shall be granted for
the payment of any Premium due after the first Premium, during which time the Policy
shall continue in force. In no event shall the grace period extend beyond the date the
Policy terminates. The Enrolling Unit shall remain liable to the Company for the
payment of Premium due for any period in which the Policy is in force.
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period expires and any Premium remains unpaid, or if Company receives written notice
of termination from the Enrolling Unit during the grace period.
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ARTICLE 4
ENROLLMENT AND ELIGIBILITY
4.1 Initial Eligibility Period. Eligible Persons and their Dependents may enroll 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 enrollment form. Eligib(e Employees who fail to enroll during
the Initial Eligibility Period shall be considered late ~nrollees and must provide proof of
good health. Late enrollments 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 Enrolling Unit'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 ~f Coverage. Coverage for properly enrolled Eligible Employees
and their Dependents shall begin on the date specified in Attachment B.
ARTICLE 5
POLICY TERMINATION
5.1 Conditions for Termination of This Entire Policy. This Policy and all coverage
under this Policy shall automatically terminate on the earliest of the dates specified
below:
(a) Last day for which Premium was paid or the grace period expires.
(b) On the date specified by the Enrolling Unit, after at least 45 days prior
written notice to Company that this Policy shall be terminated.
(c) On the date specified by Company, after at least 45 days prior written
notice to the Enrolling Unit that this Policy shall be terminated.
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5.2 Payment Upon Termination. Upon any termination of this Policy, the Enrolling
Unit shall be and shall remain liable to Company for the payment of any and all
Premiums which are unpaid at the time of termination, including for any period this
Policy was in force during the grace period, if any, preceding the termination.
ARTICLE 6
GENERAL PROV1610NS
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6.1 Entire Agreement and Policy. This Policy, including the Certificate attached as
Attachment A, the application of the Enrolling Unit, any individual applications shall
constitute the entire agreement between parties. Amendments to this Policy shall be
effective upon 45 days prior written notice by the Company to the Enrolling Unit. This
Policy may be amended only by a written amendment or a rider which is signed by an
executive officer of the Company.
No agent or person, other than an executive officer of the Company, has authority
to change or amend this Policy or to waive or modify any of its provisions,
including this provision.
6.2 Limitation of Action. No legal proceeding or action may be brought unless such
proceeding or action is brought within five years from the date the cause of action first
arose.
6.3 Time Limit on Certain Defenses. No statement, except a fraudulent statement or
omission, made by the Enrolling Unit shall be used to rescind this Policy after it has
been in force for a period of two years. All statements made by the Enrolling Unit or by
an Insured shall, in the absence of fraud, be deemed representations and not
warranties. No such statement shall void or reduce coverage under this Policy or be
used in defense of a legal action unless it is contained in a written application or was
omitted when required to be included in a written application and a copy of which has
been furnished to the Enrolling Unit.
6.4 Relationship Between Parties. The relationships between Company and
Providers and relationships between Company and Enrolling Units, are solely
contractual relationships between independent contractors. Providers and Enrolling
Units are not agents or employees of Company, nor is Company or any employee of
Company an agent or employee of Providers or Enrolling Units.
FLCGrp301 (1/97)
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The relationship between a Provider and any Covered Person is that of provider and
patient. The Provider is solely responsible for the services provided by it to any
Covered Person. The relationship between any Enrolling Unit and any Covered Person
is that of employer and employee, Dependent or other Coverage classification as
defined in this Policy. The Enrolling Unit is solely responsible for enrollment and
coverage classification changes (including termination of a Covered Person's coverage
through Company) and for the timely payment ofihe Premium.
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6.5 Records. The Enrolling Unit shall maintain adequate records relating to its
responsibilities and coverage under this Policy and shall allow Company to inspect and
copy such records upon reasonable notice.
By accepting coverage under this Policy, each Covered Person, including Dependents,
whether or not such Dependents have signed the application of the Insured,authorizes
and directs any person or institution that has provided services to the Covered Person,
to furnish Company or any of Company's designees at any reasonable time, upon its
request, any and all information and records or copies of records relating to the services
provided to the Covered Person. Company agrees that such information and records
will be considered confidential. Company and any of Company's designees shall have
the right to release any and all records concerning health care services which are
necessary to implement and administer the terms of this Policy or for appropriate
medical review or quality assessment.
6.6 Administrative Services. The services necessary to administer this Policy and
the coverage provided under it will be provided in accordance with Company's or its
designee's standard 'administrative procedures. If the Enrolling Unit requests that such
administrative services be provided in a manner other than in accordance with these
standard procedures, including requests for non-standard reports, the Enrolling Unit
shall pay for such services or reports at Company's or its designee's then-current
charges for such services or reports.
6.7 ERISA. The Enrolling Unit and Company acknowledge that this Policy may be
purchased by the Enrolling Unit to provide benefits under a welfare plan governed by
the Employee Retirement Income Security Act 29 U.S.C. 31001 et seq. Company shall
not be named as and shall not be the plan 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 ERISA.
FLCGrp301 (1/97)
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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 Unit 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 coyerage shall be granted by Company
to the Enrolling Unit for more than 60 days of to.verage prior to the date Company
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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 Unit shall be deemed notice to all affected Covered Persons in the
administration of this Policy, including termination of this Policy. The Enrolling Unit shall ,
be responsible for conveying such notices to Covered Persons.
FLCGrp301 (1/97)
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ATTACHMENT A
CERTIFICATE OF COVERAGE
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ATTACHMENT B
ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE
These provisions of this Policy are modified as follows:
1.- ,.
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4.2 Eligibility Conditions. The following conditions are in addition to those specified
in Section 2 of the Certificate:
(a) Waiting or probationary period for newly Eligible Persons shall be as
follows:
Effective first of the month following date of hire
(b) Excluded classes of persons, if any:
Part Timerremp/Seasonal
(c) Coverage classifications other than employee, if any:
Retirees
Board of Directors
Other:
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.
X 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)
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UNITED HEAL THCARE INSURANCE COMPANY
GRACE PERIOD AMENDMENT
The Policy is amended by the attachment of this Amendment. Effective July 1,
1998, the Grace Period is changed to 1 0 day~ and the corresponding provision
in Article 3 is replaced by the following: .. i
3.5 Grace Period. A grace period of 10 days after the due date shall
be granted for the payment of any Premium due after the first Premium,
during which time this Policy shall continue in force. In no event shall the
grace period extend beyond the date this Policy terminates.
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
the Company receives written notice of termination from the Enrolling Unit
during the grace period.
This Amendment does not affect any terms other than the above.
J-.LA
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Ronald B. Colby
President
United HealthCare Insurance Company
98UHIGrace-1O
.' Schedule of Benefits
UnitedHealthcare Choice Plus
Plan 653T
MH/SA Carve Out
Health Maintenance Organization - Certificate of Coverage
Section 10 - Schedule of Benefits
Section 10.1
Medical Services in a Physician's Office.
$0 per visit for preventive medical care such as well-baby care, child health supervision
services, routine physical examinations, voluntary family planning, mammography, pre-natal care
and immunizations,
$15 per visit at a primary care Physician's office.
$15 per visit at a specialist Physician's office.
Section 10.2 Routine Eye Examinations.
$15 per visit,
Section 10.3 Professional Fees for Surgical and Medical Services
$0 per visit.
Section 10.4 Allergy Services.
$15 per visit.
Section 10.5 Infertility Services.
$15 per visit,
Section 10.6 Inpatient Hospital and Related Services.
$500 per Confmement.
Section 10.7 Transplantation Health Services.
$500 per Confmement.
Section 10.8 Emergency Outpatient and Related Services.
(a) $50 per visit for Emergency Health Services rendered by a Participating Hospital, except the
Copayments specified in Section 10.6 and Section 10.17 shall apply when Confmement occurs for the
same condition within 24 hours; OR
(b) $25 per visit for Emergency Health Services rendered by a Participating Alternate Facility.
Section 10.9 Facility Charges for Outpatient Surgery.
$0 per visit.
Section 10.10 Facility Charges for Outpatient Diagnostic and Therapeutic Services.
$0 per visit.
Section 10.11 Maternity Services.
Same as Sections 10.1,10.3,10.6,10.9, and 10.10
Section 10.12 Detoxification Services.
Same as any other Sickness.
Section 10.13 Home Health Agency Services.
$0 per visit.
Section 10.14 Hospice Care.
$0 per visit.
4/18/95 OPEN ACCESS HMO CERT
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. Section 10.15 Skilled Nursing Facility Services.
No Charge (up to 90 days per calendar year).
Section 10.16 Ambulance Services.
(a) $50 per trip.
(b) $50 per trip.
Section 10.17 Accident-related Dental Services.
$15 per visit.
Section 10.18 Prosthetic Devices and Durable Medical Equipment.
(a) $50 per item.
(b) $50 per item.
Section 10.19 Short-Term Rehabilitation Services.
$20 per visit.
Section 10.20 Mammography Screening.
Same as Section 10.1 and 10.10
04/18/95 CERTIFICATE
Managed Major Medical - Certificate of Coverage
Section 6 - Outline of Coverage
Major Medical Coverage
Annual Deductible
$500 per Covered Person and not more than
$1,000 per family each calendar year.
Covered Percentage
70% of Eligible Expenses, unless otherwise specified.
Out-of-Pocket Limit
$3000 per Covered Person and not more than
$6000 per family each calendar year.
FLC320 (1/97)
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OUTPATIENT PRESCRIPTION DRUG PRODUCT RIDER
United HealthCare of Florida, Inc.
The Contract is modified by the attachment of this Rider to provide Coverage for outpatient Prescription Drug Products.
I. Defined Terms. For purposes of this Rider, the following terms have the meaning given below:
"Brand-name" - a Prescription Drug Product which is (I) manufactured and marketed under a trademark or name by a specific drug
manufacturer; and (2) identified as a Brand-name product by the PLAN.
"Dual Marketed Drug" - patented Prescription Drug Products which are chemically and therapeutically identical, but produced and
marketed by different manufacturers under different brand names.
"Generic" - a Prescription Drug Product thatis: (I) chemically equivalent to a Brand-name drug; and (2) identified as a Generic product
by the PLAN.
"Network Pharmacy" - a pharmacy which has: (1) entered into an agreement with the PLAN or its designee to provide Prescription Drug
Products to Covered Persons; (2) agreed to accept specified reimbursement rates for dispensing Prescription Drug Products; and (3) been
designated by the PLAN as a Network Pharmacy. A Network Pharmacy can be eithera retail or a mail service pharmacy.
"Preferred Drug List" - a list that identifies those Prescription Drug Products which are preferred by the PLAN for dispensing to
Covered Persons when appropriate. This list is subject to periodic (at least quarterly) review and modification by the PLAN. You may
obtain a copy of the current Preferred Drug List by contacting the PLAN at the telephone number on your ID card.
"Prescription Drug Product" - a medication, product or device that has been approved by the Food and Drug Administration (FDA) and
that can, under federal or state law, be dispensed only pursuant to a Prescription Order or Refill. For the purpose of Coverage under the
Contract, this defmition includes inhalers (with spacers), insulin and the following diabetic supplies: insulin syringes with needles; blood
testing strips - glucose; urine testing strips - glucose;ketone testing strips and tablets; lancets and lancet devices; glucose monitors.
"Prescription Order or Refill" - the directive to dispense a Prescription Drug Product issued by a duly licensed health care provider
whose scope of practice permits issuing such a directive.
2. Covera~e for Outpatient Prescription Dru~ Products at Network Pharmacies. The PLAN provides Coverage under the Contract
for outpatient Prescription Drug Products, designated as Covered at the time the Prescription Order or Refill is dispensed, when
obtained from a Network Pharmacy. Refer to exclusions in your Certificate of Coverage and as listed at the end of this Rider under
item 10.
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 PLAN or its designee. (Prior
authorization is the process of obtaining approval for certain Prescription Drug Products, prior to dispensing, using guidelines approved by
the PLAN.) Prior authorization is to be obtained from the PLAN by the prescribing provider or the pharmacist. The list of Prescription
Drug Products and the Coverage criteria requiring prior authorization are subject to periodic review and modification by the PLAN. A
current list of Prescription Drug Products requiring prior authorization is available by contacting the PLAN at the telephone number on
your ID card.
If prior authorization is not obtained prior to dispensing the Prescription Drug Product, you can ask the PLAN to consider reimbursement.
The Prescription Drug Product may not be authorized for Coverage after the PLAN reviews the documentation provided. If Coverage is
authorized after the PLAN reviews the documentation, you will pay more than if authorization is obtained prior to the Prescription Drug
Product being dispensed.
3. Supply 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 PLAN. 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 PLAN. The
list is subject to periodic review and modification by the PLAN.
For a single Copayment you may receive a Prescription Drug Product up to the supply limit stated.
99FLNET (1199)
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Retail Network Pharmacy
If the Prescription Drug Product is dispensedby a retail Network Pharmacy, the following limits apply:
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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.
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A one cycle supply of an oral contraceptive. Up to three cycles can be purchased at one time if lCopayment is paid for each
cycle supplied.
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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.
4. What You Must Pay. You are responsible for paying the applicable Copayment described below. The amount you pay in
Copayments or for any non-Covered drug product will not be included in calculating the annual maximunCopayment charge stated
in the Certificate. You are responsible for paying 100% of the cost of any non-Covered drug product and thcPLAN's contracted rates
will not be available to you.
Your Copayment will not exceed the amount the Network Pharmacy normally charges, including any sales tax, when a contracted rate
does not apply.
There is no Coverage for Prescription Drug Products dispensed at a non-Network Pharmacy.
Retail Pharmacy Copayment:
$10 per Prescription Order or Refill for a Generic Prescription Drug Product;
$20 per Prescription Order or Refill for a Brand-name Prescription Drug Product on the Preferred Drug List;
$30 per Prescription Order or Refill for aBrand-name Prescription Drug Product which is not on the Preferred Drug List.
Mail Service Pharmacy Copayment:
$20 per Prescription Order or Refill for a Generic Prescription Drug Product;
$40 per Prescription Order or Refill for a Brand-name Prescription Drug Product on the Preferred Drug List;
$60 per Prescription Order or Refill for aBrand-name Prescription Drug Product which is not on the Preferred Drug List.
5. Identification Card. You must either show your identification card at the time you obtain your Prescription Drug Product or provide the
Network Pharmacy with identifying information that can be verified by thePLAN during regular business hours. If you fail to do so, you
will be required to pay for the Prescription Drug Product at the pharmacy. ThePLAN's contracted pharmacy reimbursement rates will not
be available to you. You may seek reimbursement from the PLAN as described in the Certificate of Coverage. The amount of
reimbursement will be based on the predominant pharmacy reimbursement rate applicable at most Network Pharmacies utilized by the
PLAN. 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.
6. Covera~e Policies and Guidelines. TIle PLAN's Pharmacy and Therapeutics Committee is the national committee that reviews all FDA
newly approved drugs. The Pharmacy and Therapeutics Committee evaluates the use of the newly approved prescription drug and
determines whether or not the drug is Covered under the currently filed and approved benefit plan. The Pharmacy 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. TIle evaluation includes, but is not limited to I) 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 evaluationcontinues at least annually or as new information becomes
available.
7. Limitation on Selection of Providers If the PLAN invokes the "Limitation on Selection of Providers" provision described in the
Certificate, you are also required to select a single Network Pharmacy for the provision and coordination of all future pharmacy services.
8. Rebates and Other Payments to the PLAN. The PLAN may receive rebates for certain Brand-name drugs included on thePLAN's
Preferred Drug List. Rebates are not considered in the calculation of any Copayments. The PLAN is not required to, and does nq1pass
on to you amounts payable to the PLAN under rebate programs or other such discounts.
9. Coupons and Incentives. At various times the PLAN 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.
99FLNET (1/99)
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10. 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 Prescrirtion Drug Products for the amount dispensed (days supply or quantity limit) which exceeds the supply
limit.
(b) Drugs which are prescribed, dispensed or intended for use while you are Confined in a Hospital, Skilled Nursing Facility, or
A1temate Facility.
(c) Experimental, Investigational or Unproven Services and ~dication~ medications used for experimental indications and/or
dosage regimens determined by the PLAN to be experim,nt'aI. "Experimental" does not include pharmacological regimens for
the treatment of cancer if such drugs are recognized as aCceptfwle treatment in one of the standard reference compendia, but
have not been approved by the FDA. Contact the PLAN 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 I1Iness arising out of, or in the course of, employment
for which benefits have been paid under any workers' compensation law or other similar laws.
(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 PLAN.
G) Durable Medical Equipment. Prescribed and non-prescribed outpatient supplies, other than the diabetic supplies and inhaler
spacers specifically stated as Covered.
(k) Replacement Prescription Drug Products resulting from a lost, stolen, broken or destroyed Prescription Order or Rfill.
(I) General and injectable vitamins, except the following which require a Prescription Order or Refill prenatal vitamins, vitamins
with fluoride, and single entity vitamins.
(m) Prescription Drug Products for smoking cessation.
(n) Unit dose packaging of Prescription Drug Products.
(0) Medications for cosmetic purposes only.
(P) New Prescription Drug Products until they are reviewed by the PLAN or its designee.
(q) Any Prescription Drug Product, including allergy serum, that is dispensed in ~rovider's office.
(r) Prescription Drug Products obtained from a non-Network Pharmacy, except due to an Emergency.
(s) Prescription Drug Products when prescribed to treat infertility.
(t) At the discretion of the PLAN, any new Prescription Drug Product released during the current contract period.
NOTE: The Coordination of Benefits provision in the Certificate does not apply to Prescription Drug Products Covered through this Rider.
Prescription Drug Product benefits will not be coordinated with those of any other health coverage plan.
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Gary L. Schultz
President
United HealthCare of Florida, Inc.
99FLNET (1/99)
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Signature page for United Healthcare of Florida, Inc. Group Policy
UNITED HEAL THCARE OF FLORIDA, INC.
By: ~I.f ~
~S~arez
Regional Vice President, Sales and Marketing
Countersig ned:
CITY OF CLEARWATER, FLORIDA
By: ~'''f~~..44.- "It
Iliam B. Horne II
City Manager
Approved as to form:
Attest:
Leslie K. Dougall- s
Assistant City Attorney
P<1
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