1992-35 Adopts Employee Benefit Package for Group Health & Dental1
RESOLUTION 35-92
A RESOLUTION OF THE VILLAGE COUNCIL OF THE VILLAGE OF
NORTH PALM BEACH, FLORIDA, ADOPTING EMPLOYEE BENEFIT PACKAGE
FOR GROUP HEALTH INCLUDING DENTAL FOR THE VILLAGE OF NORTH
PALM BEACH EMPLOYEES.
NOW THEREFORE, BE IT RESOLVED BY THE VILLAGE COUNCIL OF
THE VILLAGE OF NORTH PALM BEACH, FLORIDA:
Section 1. The Employee Benefits Package for Group
Health including Dental for the Village of North Palm Beach
employees, attached hereto and by reference made a part
hereof, are hereby adopted.
Section 2. The Resolution shall take effect October
1, 1992.
PASSED AND ADOPTED THIS 24TH DAY OF SEPTEMBER, 1992.
Mayor
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ATTEST:
Village Clerk
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EMPLOYEE BENEFITS
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VILLAGE OF NORTH PALM BEACH
TABLE OF CONTENTS
Section One -Medical Expense Benefits
Schedule of Benefits ............................................... 1
Deductihle/(".oinsurance/Out-of-Pocket ................................. 2
Pre-Admission Certificate ............................................ 2
I're-Existing Conditions ............................................. 2
General Information ............................................... 3
Covered Expenses ................................................. 4
Maternity Expenses ................................................ 5
Newborn Child Coverage ............................................ 6
Well Baby Care ................................................... 6
Limitations and Exclusions ........................................... 7
Section 'Itvo -Dental
llental Schedule of Benefits (Non-PPO Plan) ............................ 10
Covered Dental Services (Non-PPO) .................................. 10
Schedule of Orthodontic Benefits ..................................... 11
' Covered Orthodontic Services ::::: : :::::::::: : ::::::::: : :::::::::::: 11
Dental Exclusions and Limitations 11
Advance Treatment Review 12
Non PPO Schedule ............................................... 13
PPO Dental Plan ................................................. 15
PPO Schedule ................................................... 16
Section Three -Eligibility
Employee Eligibility ............................................... 17
Dependent Eligibility .............................................. 17
Termination of Coverage ........................................... 18
Termination of the Plan ............................................ 19
Continuation of Coverage (COBRA) .................................. 20
Conversion Privileges ............................................... 23
Section Four -Benefit Provisions
Coordination of Benefits ........................................... 24
Subrogation ..................................................... 26
12ights of Recovery ................................................ 26
Claim Filing Procedures ............................................ 27
' Review Procedures ................................................ 26
Contract Provisions ~
Dcfinitions ...................................................... 29
VILLAGE OF NORTH PALM BEACH
SCHEDULE OF MEDICAL BENEFTI'S
' PPO NON-PPO
Medical Deductible -Per person $200.00 $200.00
Medical Deductible -Per family $600.00 $600.00
Out-of-Pocket Maximum $3,000.00 $3,000.00
Coinsurance 80% 70%'
Lifetime Maximum $1,000,000.00 $1,000,000.00
Number of Inpatient Days (per calendaz yeaz) 365 365
Physician Visits 80% 70%
Out-Patient (OP) Services (Including OP Surgery) 80% 70%
Inpatient Care/Hospital Confinement 80% 70%
Maternity 80% 70%
Prescription Drugs 80% 80%
' Chiropractic Care 80% 80%
Out of State Providers 80% 80%
Supplemental Accident 80% 70%
Second Surgical Opinion 80% 70%
Pre-Admission Testing 80% 70%
Emergency or Urgent Situations 80% 80%
SPECIAL BENEFTL' MAXIMUMS
PPO NON-PPO
Birthing Center Per delivery $1,000.00 $1,000.00
Convalescent Care Benefit 120 Days 120 Days
Home Health Care -per year 120 Visits 120 Visits
Eligible Pre-existing conditions
' for first 12 months Not Covered Not Covered
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Automatic Restoration per calendar yeaz
' Mental and Nervous Disorders
Inpatient hospital days (per calendaz yeaz)
Inpatient medical vistts (per calendar yeaz)
Our:atient benefits (per calendaz year)
Alcoholism and Dmg Dependency
Inpatient (lifetime maximum)
Outpatient (up to $35.00 per visit) Maximum visits (Lifetime)
Well Baby Caze
Dependents eligible
Maximum visit
$1,000.00
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31
$1,000.00
$2,000.00
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Birth to age 16
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Deductible
The Deductible is applied to the first covered eligible expenses received for payment in a
Calendar Yeaz. Covered eligible expenses occurring in the last quarter (October,
November and December) of a calendaz Yeaz needed to satisfy a Deductible, will carry-
over to the following calendaz Yeaz. After satisfying the stated full family Calendar
Year Deductible, the balance of other family members Covered Eligible Expenses will be
paid without a Deductible for the same calendaz Year.
Total Out-of-Pocket
' After your stated Deductible and Coinsurance have been met, the balance of Covered
Eligible Expenses in this section will be paid at 100% for the remainder of the Calendar
Year or to the Lifetime Maximum whichever comes first.
Pre-Admission Cert~cation
It will be necessary for you to have the doctor or the hospital obtain pre-admission
certification before a scheduled non-emergency admission, and the next business day for
a non-scheduled or emergency admission. Admissions not certified will be paid at 10%
less than the coinsurance which would have been paid, for a certified admission. This
option can be waived at the discretion of the Plan Administrator.
Pre-existing CondiKons
A pre-existing condition is an injury, sickness or pregnancy or any condition related to
that injury, sickness or pregnancy, where a diagnosis, treatment, medical advice or
expense was incurred within twelve (12) months prior to the effective date of this
coverage. Pre-existing condition will also include any tn~ury, sickness or pregnancy or
related condition that manifested itself twelve (12) months prior to the effective date of
this coverage. Pre-existing condition will also include the existence of symptoms which
would cause an ordinarily prudent person to seek diagnosis, care or treatment within
twelve (12) months prior to the effective date of this coverage.
No benefits aze payable for apre-existing condition until the end of twelve (12) months
of continuous coverage.
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GENERAL INFORMATION
Employer:
Name of the Plan:
Village of North Palm Beach
501 U.S. Highway #1
North Palm Beach, FL, 33408
Village of North Palm Beach
Employee Benefits Plan
Plan Adminisvator:
Claims Adminisvator:
Claims Adminisvator Phone Number:
Plan Number:
Plan Calendaz Yeaz
Village of North Palm Beach
McCreary Corporation
700 Central Pazkway
Stuart, FL, 34994
800/431-2221
407/287-7650
12005
January -December
Waiting Period: Coverage will become effective the first day of full time
employment, provided enrollment is made at that time, and the
employee is actively at work on that date.
Termination of Coverage Date: Coverage with this plan will terminate on the eazliest
of the following dates:
I. Upon termination of the Employee's employment (cessation of active full-time
work);
2. Upon termination of the Master Plan Document;
3. Upon no longer being eligible as defined by this Plan;
4. Upon date selected by Employee to enroll with any other Plan. Dependent coverage
will automatically terminate when the Employee's coverage ceases.
The requirements for being covered under this Plan, the provisions concerning termination
of coverage, a description of the Plan benefits (including any limitations and exclusions),
and the procedures to be followed in presenting claims for benefits and remedies available
for redress of claims denied are shown on the following pages of this booklet.
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Covered Expenses
' Covered expenses are limited to the Reasonable and Customary Charges for the Medically
Necessary care and treatment of a covered Illness or Injury that are prescribed by or given
by a Physician. Covered Expenses aze limited to the following items:
]. Hospital chazges for Room and Boazd and general nursing Gaze, not to exceed the
Semi-Private room rate;
2. Hospital charges for Intensive Care Unit when Medically Necessary;
3. Medically Necessary services and supplies furnished by a Hospital while confined
as an in-patient;
4. Hospital charges for services and supplies furnished by a Hospital while being
treated on an out-patient basis;
5. Charges for confinement in a Birthing Center which is licensed by a state
regulatory authority or aFree-Standing Surgical facility, these expenses are
payable as Hospital Expenses;
6. Charges incurred for services rendered by a Certified Nurse Midwife;
7. Charges for Medically Necessary transportation of the patient by professional
ambulance services to or from a Hospital or sanitarium equipped to furnish
treatment for the lllness;
' 8. Administration of anesthetics by a Physician and the charges for anesthetics;
9. Physician's fees for medical and surgical services;
10. Charges made by a licensed Physiotherapist;
I1. Charges made for diagnostic x-ray and laboratory services, excluding dental x-
rays;
12. Charges made for x-ray and radioactive therapy;
13. Chazges made by a Chiropractor;
14. Chazges made for drugs and medicines required by law to be prescribed by a
Physician and dispensed by a licensed pharmacist or Physician.
15. Charges made for the initial placement of aztificial limbs and eyes surgical
dressings, casts, splints, trusses, braces and crutches;
16. Charges made for Rental of wheelchairs, Hospital beds and artificial respirators,
and other Durable Medical Equipment. Such items may be purchased at the
discretion of the Plan Administrator,
17. Charges made by a legally qualified Physician or qualified speech therapist for
restoratory or rehabilatory speech therapy for speech loss or impairntent due to an
Illness, other than a functional nervous disorder, or to surgery on account of an
Illness. If the speech loss or impairment is due to a congenital anomaly, surgery to
correct the anomaly must have been performed prior to the therapy;
' I8. Private duty nursing Gaze by a Registered Graduate Nurse (R.N J;
19. Charges made for insulin, needles and clinitest when ordered by a Physician for
the treatment of diabetes;
20. Expenses incurred for Managed Care Services in lieu of inpatient Hospital
Confinement, when such services aze agreed upon and approved in advance by the
attending Physician, the Claims Administrator and the Employer,
21. "Managed Care" means a reasonable and more appropriate course of medical
treatment for recuperation of relatively stable patients who require some medical
attention and supervision, but no longer require confinement in an acute Hospital
setting. Alternatives to Hospital settings may include:
a. a patient's home;
b. a rehabilitation center;
c. a Skilled Nursing Facility;
d. an Ambulatory Medical Center,
e. an urgent caze center;
f. a Physician's office;
g. an independent state approved x-ray facility, or the services of a qualified
independent practitioner such as a physical therapist.
' This benefit is available only with PRIOR APPROVAL from the Claims Administer. To
request approval, a written treatment plan must be submitted to the Claims Administrator
from the attending Physician, along with the patient's history and prognosis;
22. Charges made by a Physician for routine examinations, immunizations and
laboratory tests for a dependent child from birth to age sixteen (16);
23. Chazges made by a licensed Hospital or Physician for the out-patient treatment of
chemical dependency, dmg addiction and alcoholism, subject to limitations shown
in the Schedule of Benefits and the General Limitations portions of the Plan.
Malerni(y Expenses
Benefits will be available for expenses incurred due to the pregnancy of a female Covered
Employee or the Eligible spouse of an Employee on the same basis as for any other Illness
(e.g. Hospital expenses in the same manner as any other Hospital expenses, obstetrical
procedures as a surgical expense, etc.).
Benefits will not be provided for an elective induced abortion, unless carrying the fetus to
full term would seriously endanger the life of the mother. If complications arise after the
performance of an abortion, any eligible expenses incurred to treat those complications
will be considered, but the initial cost relating to the abortion will not be considered.
Recognized providers of maternity services are physicians (M.D.), Osteopaths (D.O.) and
nurse-midwives. A nurse -midwife is defined as a graduate registered nurse or a lay mid-
wife who is licensed to provide maternity care under the Florida law.
Newborn Child Coverage
A child bom to you (while covered for Dependents) or a covered Dependent while the
' Plan is in force will be covered from the moment of birth. Coverage for such newborn
child will consist of coverage for Injury or Illness, including Gaze or treatment of
congenital defects, birth abnormalities, or premature birth and usual and customary
transportation costs of the newborn child, not to exceed $1,000.00, to and from any
facility for treatment certified as necessary to protect the health and safety of the newborn
child. Coverage with respect to Plan benefits will be those applicable to children. A
newborn infant of a dependent child is eligible and shall be covered under the provisions
of this Plan but not to exceed eighteen (18) months.
Well73abv Care
Child Health Supervision Services will be considered eligible expenses when they aze
incurred by a covered dependent child from birth to age 16.
Services include eighteen (18) total visits at the following age intervals: birth, 2 months, 4
months, 6 months, 9 months, 12 months, IS months, 18 months, 2 yeazs, 3 years, 4 yeazs,
5 years, 6 years, 8 yeazs, 10 yeazs, 12 yeazs, 14 years, and 16 yeazs. Services to be
covered at each visit include a history, a physical examination, a developmental
assessment and anticipatory guidance, appropriate immunizations and laboratory tests, in
keeping with prevailing medical standazds.
Benefits shall be limited to one visit payable to one provider for all of the services
provided at each visit cited above. Chazges will be subject to covered eligible expenses.
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GENERAL LIMITATIONS
' No Pa ment will be made under an ortion of the Plan for ex enses incurred b a
Y YP P Y
Covered Person for:
1. Any services or supplies for which benefits are, or could be available if proper claim
were made, through any Worker's Compensation, Occupational Disease law or
similaz legislation;
2. Any Illness or Injury arising out of or in the course of any work for wage or profit, or
any employment;
3. Elective abortions unless the life of the mother would be in danger if pregnancy
continued.
4. Any services and supplies which are not medically necessary to treat an Illness,
Injury or Pregnancy;
5. Chazges which aze in excess of the Reasonable and Customary fee;
6. Any chazge the Plan member is not legally obligated to pay or for chazges which
would not have been made if no coverage had existed;
7. Marriage or family counseling;
8. Weight control counseling, or services primarily for weigh[ loss or control, unless
necessitated as the result of a specifically identifiable .and diagnosed medical
condition of disease etiology;
9. Hypnotism acupuncture, any goal-oriented therapy such as to quit smoking;
10. Dental work or treatment which includes hospital and/or professional charges in
connection with:
(a) operation or treatment in connection with the fitting or wearing of dentures;
(b) orthodontic caze or treatment of malocclusion; o
(c) dental caze for any operation on or treatment of or to the teeth or the supporting
tissues of the teeth (impacted or otherwise) except for:
(i) removal of malignant tumors; and
(ii) treatment of an Injury to sound natural teeth other than by eating or
chewing (including their replacement) due to an accident (a) occurring
while covered under the Plan; and (b) for expenses incurred within one yeaz
from the date of the accident.
11. Cosmetic surgery and related services, unless needed to repair a disfigurement
sustained as the result of an accident occurring while covered by the Plan, when
' treatment is begun within ninety (90) days of the date of the accident, or for the
correction of a congenital anomaly in a child born while covered by this Plan;
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12. Eye refractions, or the purchase or fitting of eyeglasses, contact lenses, hearing aids,
corrective shoes, or other corrective devices and appliances (except initial lens
purchase when prescribed as part of necessary post-operative treatment following
' catazact extractions);
13. Any routine physical examination (including related lab and x-ray work, check-ups
not incident to treatment of an Illness or Injury, except as stated for well baby and/or
child caze;
14. Any Illness or Injury due to waz, or act of waz, declared or undeclared, or any act of
armed aggression resisted by the armed forces of any country, combination of
countries, or international organization;
15. Any reversal surgery;
16. Any intentionally self-inflicted Illness or Injury;
17. Any service or supply not included as an eligible expense, or any chazge in excess of
the benefits specified;
18. Any elective surgical procedure, and related eligible expenses if the procedure is
performed more than twenty-four (24) hours after a scheduled admission to a
licensed Hospital specifically for the performance of such surgical procedure, unless
satisfactory medical evidence of complications, or a change in the patient's condition
are submitted to support a delay;
19. Chazges which aze determined by the Plan Administrator to be Experimental and/or
Investigational;
20. Charges which aze determined by the Plan Administrator not to be Medically
Necessary;
21. Charges incurred for services or supplies rendered by a member of the Covered
Person's immediate family;
22. Chazges incurred for personal hygiene and convenience items such as but not limited
to air conditioners, bathing/toilet accessories, and physical fitness equipment;
23. Charges incurred for telephone consultations, chazges for failure to keep scheduled
appointments, chazges for completion of claim forms; or charges for providing
medical information necessary to determine coverage;
24. Chazges incurred for custodial care, domiciliary care, rest cures or services that are
primarily educational in nature;
25. Charges related to treatment received as a result of and while committing or
attempting to commit an illegal act;
26. Treatment furnished by special facilities, maintenance counselors, therapists or
social workers other than a licensed Physician for chemical dependency, drug
addiction or alcoholism;
1 27. Fertility testing;
28. Artificial insemination or in vitro fertilization;
' 29. Education or training;
30. Food supplements;
31. Treatment or surgery to change gender or to improve or restore sexual function;
32. equipment or supplies made or used for physical fitness, athletic training or general
health up-keep;
33. Usual and normal home medical supplies or first aid items.
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VILLAGE OF NORTH PALM BEACH
SCHEDULE OF DENTAL BENEFITS
' NON-PPO DENTAL PLAN
Maximum per Calendar Year (per person) $1,000.00
Deductible (per person per calendaz yeaz) $100.00
Eligible Expenses aze paid according to a fee schedule of benefits. After the deductible
has been met, your Plan will pay the following coinsurance percentage of the Schedule of
Benefits. Please contact the Claims Administrator's office if you would like to know in
advance, the amount that will be paid.
This Plan will pay 100% for:
• Oral examinations
• Dental X-rays
• Fluoride application
This Plan will pay 80% for:
• Prophylaxis (cleaning)
• Emergency treatment for pain
• Space maintainers
• Biopsies of oral tissue
' Pulp vitality tests
Fillings
• Extractions
• Oral surgery
• Endodondcs
• Periodontics
This Plan will pay 50% for:
• Inlays,onlays
• Crowns
• Bridges, denttu+es
• Orthodontics
COVERED DENTAL SERVICES
1. Examinations and recall services including check-ups and cleaning of teeth.
One each six (ti) months.
2. Sodium or stannous fluoride for children under 15 yeazs of age.
3. Temporary treatment of pain
4. Space maintainers
' S. X-rays -one set of bite-wings each six (6) months; a full mouth series each
three (3) years
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7. Periodontal treatment
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S. Normal extraction of teeth
9. Fillings, crowns, jackets
10. Fixed bridges and removable bridges, dentures
11. Adjustments and repairs
SCHEDULE OF ORTHODONTIC BENEFITS
Lifetime maximum (per person)
Lifetime deductible (per person)
Covered eligible expenses are payable after the deductible at
COVERED ORTHODONTIC SERVICES
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1. Diagnostic procedures
2. Appliances for tooth guidance and control of harmful habits.
3. Retention appliances
$1,000.00
$100.00
50%
4. Comprehensive treatment with fixed and removable appliances for correction
of malocclusion in permanent, primary and mixed dentition.
DENTAL EXCLUSIONS & LIMITATIONS
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Benefits will not be paid for chazges for:
1. expenses incurred after the date coverage under the Plan ceases for you or your
Dependents for any reason. This is true even though the expenses relate to a
condition which began while you or your Dependents were covered.
2. fixed bridgework or dentures to replace teeth that were missing prior to the date
you or your Dependents became covered under this Plan.
3. treatment from anyone other than a Dentist or Physician. (Roufine cleaning of
teeth and fluoride application when performed by a licensed dental hygienist under
the direct supervision of, and billed by, the Dentist or Physician will be covered).
4, facings, veneers or similar material placed on molar crowns or pontics. ('T'eeth or
spaces to the reaz of the second bicuspid).
5. services or supplies that aze partially or wholly cosmetic in nature, or directed
towazd a cosmetic end.
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6. any service or supply incurred; installed or delivered before you or your Dependent
become eligible for benefits or after coverage terminates.
' 7. replacing a lost, missing or stolen prosthetic appliance.
8. a broken appointment.
9. any service that is not necessazy or is not normally performed for proper dental
care of the condition or any service that is not approved by the attending Dentist.
10. services or supplies that do not meet accepted standards of dental practice
including experimental services or supplies.
11. services or supplies received as a result of dental disease, defect, or injury due to
an act of waz, declazed or undeclazed.
12. any duplicate prosthetic appliance except as specifically provided under Covered
Expenses.
13. claim form completion.
14. sealants, oral hygiene or dietary instruction, or plaque control programs.
15. any implant.
16. wiring or bonding teeth or crowns to act as a splint for any reason.
' 17. an injury arising from any employment or occupation.
18. an illness covered by Workers' Compensation.
19. services or supplies for which you aze not required to pay.
20. expenses incurred outside the United States or Canada, unless .you or your
Dependent are a resident of one or the other and the charges are incurred while
traveling on business or for pleasure.
21. appliances, restoration, or any procedure to alter vertical dimension or restore
occlusion, except as stated in the Orthodontic Schedule of Benefits.
22. any service or supply which is covered in whole or in part by a plan provided, or
sponsored, by the Employer.
23. services or supplies not specifically listed under covered Dental expenses.
Advance Treatment Review
If a course of treatment will exceed $200.00, the treatment plan should be submitted for
review before the work starts. You and the Dentist or Physician will be advised of the
estimated benefits payable under this dental plan, subject to Eligibility, Coordination of
Dental Benefits, Maximum Benefits and all Limitations and Exclusions. In order to
' review the treatment plan, a description of each service and chazge should be submitted
along with all supporting aids such as pre-operative x-rays.
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NON-PPO SCHEDULE
Pxce~ure Code j2G.5criotion of Service FSg ~L11frf11
' Ora] Examination
0110 Initial Oral Examination 15.00 100%
0120 Periodic Oral Examination 10.00 100%
Radioeraphs
0210 Intraoral X-ray complete series 35.00 100%
0220 Intraoral Periapical single 1st film 6.00 100%
0230 Intraoral Periapical each additional 3.00 100%
0270 Bitewing -single film 7.00 100%
0272 Bitewing - two films 10.00 100%
0273 Bitewing -three films 12.00 100%
0274 Bitewing -four films 15.00 100°h
0330 Panoramic x-ray 30.00 100%
0340 Cepholometric,x-ray 30.00 100%
T st aboratory Ex min narions
0470 Diagnostic Casts 25.00 100%
Dental Prophylaxis
1110 Prophylaxis -Adult 30.00 80%
1120 Prophylaxis -Child 2A.00 80%
Fluoride
1220 Topical application of Fluoride 10.00 100°k
S alan c
1350 Topical application of Sealants
Per quadrant 17.00 50%
Amalgam Restorations
2110 Amalgam One surface decidicous 25.00 80%
2120 Amalgam Two surface deeidicous 35.00 80%
2130 Amalgam Three surface decidicous 44.00 80%
2131 Amalgam Four surfacedecidicous 53.00 80°k
2140 Amalgam One surface permanent 25.00 80%
2150 Amalgam Two surface permanent 37.00 80%
2160 Amalgam Three surface permanent 48.00 80%
2161 Amalgam Four or more surface permanent 55.00 80%
' $oot n 1 Therapv
3310 Anterior Root Canal Therapy 178.00 80%
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3320 Bicuspid Root Canal Therapy 219.00 80%
3330 Molar Root Canal Therapy 293.00 80%
Extractions
7110 Extraction single tooth 29:00 80%
7120 Hxtraction, each additional
l E
t
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i
i 24.00 80%
7210 ca
ract
¢
x
ons
Extraction of tooth errupted
44.00
80%
7220 Extraction of tooth sofr tissue impaction 75.00 80%
7230 Extraction of tooth partial bony impaction 103.00 80%
7240 Extraction of tooth complete bony impattior 115.00 80%
7250 Root recovery (surgical removal of residual: 48.00 80%
Crowns
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2710 Crown, plastic 55.00 50%
2711 Crown plastic -prefabricated 80.00 50%
2740 Crown porcelain 299.00 50%
2750 Crown porcelain w/gold 305.00 50%
2751 Crown porcelain w/non precious metal 316.04 50%
2752 Crown porcelain w/semi precious metal 334.00 509b
2790 Crown gold (full cast) 351.00 50%
2791 Crown non-precious metal (full cast) 276.00 50%
2792 Crown semi-precious metal (full cast) 293.00 50°k
2810 Crown (gold) 316.00 50%
2830 Crown prefabricated deciduous stainless ste< 69.00 50%
2891 Cast post & core in addition to crown 98.00 50%
2892 Prefabricated post & core in addition to erov 81.00 50%
5110 Complete denture- upper 385.00 50%
5120 Complete denture -lower 385.00 50%
5130 Ltvnediate dentureupper 368.00 50°h
5140 Immediate dentttre lower 368.00 50%
5216 Upper partial w/2 cast chrome clasps with re 345.00
5218 Lower partial w/2 cast chrome clasps 345.00
5237 Lower partial w/cast chrome 443.00
5241 lower partial w/cast chrome lengual baz and two
clasps w/cast base 460.00
5251 Upper partial w/cast chrome palatal bar and
two clasps acrylic bast 431.00
5261 Upper partial w/cas[ chrome palatal baz and
two clasps cast base 480.00
50%
50%
50°!0
50%
50%
50%
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PPO nrrrru, PLAN
' Maximum per Calendar Year (per person) Unlimited
Deductible (per person per calendar yeaz) .00
If yotl use one of the Preferred Dental Providers, you will only be responsible for the
a111ounts listed in the PPO Schedule. You will not have to pay a deductible for these
services.
PPO SCHEDULE
(Subject to Change)
Code Pef<nl Charge Code Pntient Chnrne
DIAG<;OS7'IC/PRF,VEMrIVE CROWN AND BRIDGE (Cont'd)
9310 Consultation ...................... No Charge 2791-92 Crown, Full Cast (Per Unit, 1 to 5 UNI"I'S-
0110 Oral Examination (Initial) ............ No Charge Replacement Limit 1 Every 5 Years) .. 5230.00
0120 Oral Examination (Periodic) .......... No Charge 2830 Crown, Stainless Stccl - Pedodontic .... 540.00
0210 X-Rays -Complete Scrics (14 or Mor< 2891 Cast Past ..... ................... 590.00
Films or Panoramic Plus IIitewings - 2892/2950 Pre-fab Post end/or Crown Buildup
Limit 1 Every 3 Vea rs) ............. No Charge (Including Pins) .................. 580.00
0220 X-Rays (Single) .................... No Charge 2910 Recement Inlays .................. No Charge
0230 X-Rays (Each Additional) ............ No Charge 2920 Recement Crowns ...... No Charge
0272/0274 X-Rays (IIitcwing) No Charge 6241-42 Pontic, Porcelain Pused To Metal
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0330 .
X-Rays (Panoramic) No Charge (Per Unit, Replacement Limit 1
0470 ......... ' .. , . '
..
Diagnostic Casts
No Charge .. .. .
Every 5 Yeas for Each Unit)
5230.00
1110 Prophylaxis -Adult (Every Siz Months) .. No Charge 675]-52~ Crown, Abutment, Porcelain Puud
1231 Prophylaxis with Fluoride -Child to Metal (Per Unil, Repiacemcnt
(Every Six Months) ................ No Charge Limit 1 Every 5 Years for Pach
1210 Topical Application of Fluoride - Up to Unit)
......................... 5230.00
Age 19 (Limit 1 Per Year) ........... No Charge 6930 Ruement Bridge ..:............... No Charge
1310 Preventive Care Training ............. No Charge .... REHABILTI'A710N
]350 Sealant (Per Tooth) ................. 55.00 ~ (6 or More Units of Crown and bridge in
1510/ISIS Space Maintainer -Fixed Band ........ 565.00 Same Treatment Plan Requires Compicz
Rehabilitation and Additional Charge
RESTOR477VE (Fillings) ~ Per Unit)
2110 Amalgam - 1 Surface (Primary) ........ No Charge
2120 Amalgam - 2 Surfaces (Primary) ....... No Charge ENDOI)ONTICS (Roof Canal Therapy, Excluding Final Restorations)
2130 Amalgam - 3 Surfaces (Primary) ....... No Charge ,,,- Endodontic Consultation ............ No Charge
2140 Amalgam - 1 Surface (Permanent) ...... No Charge 3310 Anterior Rool Canal (Permanent Tooth) 560.00
2150 Amalgam - 2 Surfaces (Permanent) ..... No Charge 3320 Bicuspid Rool Gnal ............... 5125.00
2160 Amalgam - 3 Surfaces (Permanent) ..... No Charge 3330 Molar Root Canal (Permanent Tooth) .. S16S.00
2161 Amalgam - 4 Surfaces (PermanenQ ..... No Charge - 3340 Molar Root Canal (Pour or Mor< Canals
2330 Composite - 1 Surface (Anterior) ...... No Charge and/or Morc Complicated Procedures) 5235.00
2331 Composite - 2 Surfaces (Anterior) ...... No Charge 3110 Pul Ca
P P ........................ No Cha e
rg
2332 Composite - 3 Surfaces (Anterior) ...... No Charge 3220 'nterepeutic Pulpotomy ............. 340.00
2335 Composite Resin, Involving Incisal Angie . 560.00 3410 Apicoectomy ..................... SIOS.00
2940 Sedative Filling .................... No Charge
2190/2334 Pin Retention Exclusive of Restoration PERIODONTTCS
(Per Tooth) ...................... 510.00 „-- Periodontal Consultation ............ No Charge
CROWN ANU BRIDGE (Including Temporaries) .... Periodontal Evaluation and Treatment
2510.30
inla Onla
Y/ Y .......................
5165.00
.... Plan ..........................
Nonsurgical Progrem 540.00
2711 Crown, Plastic (Prc-fab Pedodontic) ..... 540.00 0410 Microscopic Evaluation 56.00
2740 Crown, Porcelain (Per Unit, 1 to 5 UNITS 8341 Scaling and Root Planing (Per Quadrant)
Rcplaccmcnt Limit 1 Every S Years) ..
5230.00 ' ..' .. .
(Limit 4/Year)
555.00
2751-52 Crown, Porcelain Fused to Metal (Per 4345 Periodontal Scaling in the Presence of
Unit, 1 to 5 UNITS - Rcplaccmcnt Gingival InOammation (Full Mouth) 555.00
Limit 1 Every 5 Yca rs) ............. 5230.00
IS
PPO SCTIEUDLE
Code Patent Charge Code Palfent Charge
PF:RIOIlON17CS (Confd) DENTURE RELINING (Confd)
9630 Medicinal Irrigation/Application 5760 Rdine or Rebau Upper or lower
(Per Quadrant) .................. 530.00 Partial Denture -Laboratory
4999 Homc Care Instructions for Periodontal (Limit 7 Every 36 Months) ......... 560.00
Managcm<nt .................... No Charge
.... Post-7hcrepcutic Evaluation ......... 530.00 ORAL SURGERY
4910 Prophylads - Pcrio Analysis, Post Surgical .... Orzl Surgery Consultation ........... No Charge
(Limit 2 Within 12 Months After 7110 Extraction (Single Tooth) ........... No Charge
Surgery) .. . .................... . 535.00 7120 Extraction (Each Additional Tooth) .... No Charge
4210 Gingivectomy or Gingivoplasty 7210 Surgical Extroaion Ervpted Tooth ..... 530.00
(PCr Quadrent) ................... 2110.00 .... Surgical Removal of Impacted Teeth
4211 Gingivcctomy (Per Tooth) ............ 545.00 (Covered Benefit Only When Evidence
.... Oss<ous Surgery (Per Tooth) .......... 1100.00 0( Pathology Exists)
42CA Osseous Surgery (Per Quadrant) ....... _ 5250.00 7220 -Solt Tissue Impaction ........... 530.00
4271 Gingival Graft (Per Procedure) ........ 5185.00 7230 -Partial Bony Impaction .......... 565.00
4330 Occlusal Adjustment/Limited ......... 530.00 7b10-4] -Pull Bony Impaction ........... , 585.00
4331 Occlusal Equilibration/Complete ....... 560.00 7250 Surgical Removal Root Tip -
4320.21 Provisional Splint (2-6 T«th) ......... 2125.00 ~ Root Recovery .................. 540.00
4305 Night Guard (Soft Acrylic) ..........: 545.00 7310 Ah~eoloplasty (Per Quadrant) ........ 545.00
4360 Night Guard (hard Aerylit) ........... 2185.00 7450.57 Surgical Excision of Cyst No Charge
7470 Removal of Exostosis .: .......... No Charge
PROSTIIEPICS (Removable Tooth Replacement • Dentures) 7510 Surginl Incision and Drainage -
5211 Partial Upper-Without Clasps' ....... $60,00 Intreorel ....................... No Charge
5212 Partial Lower -Without Clasps' ....... 560.00 7960 Frcnectomy .:.................... No Charge
' 5213/5216 Partial Upper - 2•Chrome Clasps,.... • .. 7270 Tooth Replantation ::::::::::...::: No Charge
With Rests' 5240.00 7280 Su cal
5214 5231 Partial I.owcr • 2 Chrome Clas Bt Exposure of Impacted or Un-
/ ps, ervpted Tooth for Orthodontic
With Rests' 5240.00 Reasons .. No Charge
...
5291-94 Partial Denture Designed -Chrome, Specific .... Postoperative Treatment ......... No Charge
Design, Any Number of Clasps' ...... 5345.00
5110 Complete Upper Denture (Standard)' ... S7A0.00 ORTF{ODONTICS
5120 Complete Lower Denture (Standard)' ... 5240.00 .... Orthodontic Consultation ........... No Charge
5130-00 Immediate Dcnturc (Does Not Include 8010 Orthodontic Evaluation ............. 535.00
Reline Charge)' .................. 22A0.00 8020 Orthodontia Treatment Plan end Records 2220.00
.... Characterized Denture -Upper or Lower' 1345.00 8030 Orthodontic Therapy. The Orthodontic Fcc
for a Normal 2A-Month Band<d Cau for.
•Rcplac<ment Limit 1 EveryS Years Children (Up to 19th Birthday) ... 5100.00
Adults ...................... 52,050.00
RF,1'AIRS TO PR05771 EI7CS 8750 Cost of Retention Additional
5610 Repair Brokcn Complete or Partial
Dcnturc (No T<eth Damage) ........ 530.00 MISCELLANEOUS/01'FIER SERVICES
5620 Repair Brokcn Complete or Partial 9110 Emergenty Visit -Palliative Treatment
Dcnturc and Replace One Broken During Regularly Scheduled Office
Tooth .......................... 535.00 Hours ......................... No Charge
5630 Replace Additional Teeth (Each Tooth) . 530.00 9440 Emergenty Visit -Palliative Treatment
5640 Rcplacc One Tooth on Denture Alter Regularly Scheduled Office
(No Other Repairs) ................ 530.00 Hourc ......................... 525.00
SG50 Add Tooth to Partial Denture .... Broken Appointment -Per 15-Minute
to Replace Extracted Tooth .......... 235.00 Appointment .................... 510.00
(Maximum 540.00)
DENNRF; RF.LININC
5730 Reline Upp<r or Lower Complete DMturc NOTE: This broken appointment fee will not be charged if CD31
- O(f¢e (Limit 1 Every 36 Months) .... 535.00 determines that the Covered Person was unable to provide
5740 Rclinc Upper or Lower Partial Denture 24-hourc' notice through no fault of his or her own.
' • O(ficc (Limit 1 Every 36 Months) :::: 535.00
5750 Rclinc or Rcbau Upper or Lower
Compl<te Dcnturc - Laboratory
(Limit 1 Every 36 Months) 560.00
16
ELIGIBILITY & TERMINATION OF COVERAGE
' Is/./G76ILITY: The following persons will be eligible to be covered under the Plan:
Isr»ployees: All full-time employees in Active Service at their customazy place of
employment who work at least 30 hours per week.
An employee who does not apply for coverage within thirty-one (31) clays of the date he
becomes eligible, but who applies for coverage at a subsequent date, must submit at his
own expense Evidence of Good Health provided through the Claims Administrator's
office.
You are also in an eligible class if you aze retiring from the Florida Retirement System.
You must apply in writing to your Employer prior to retiring and the retiree will be
responsible for all payments of premiums.
Dependents: The lawful spouse of the Eligible Employee and each unmarried child
between the ages indicated in the definition of an Eligible Dependent. An Eligible
Employee who has Dependents. will be eligible for Dependent coverage on whichever
of the following dates is first to occur:
1. The date the Eligible Employee is eligible for coverage, if on that date he has such
dependents;
' 2. The date the Eligible Employee gains a dependent.
In the event a husband and wife aze both eligible to be covered by the Plan as Covered
Employees, only one spouse will be eligible to cover any dependent children they might
have. All other persons aze excluded.
An employee who does not apply for Dependent coverage within thirty-one (31) days of
the date he becomes eligible, but who applies for Dependent coverage at a subsequent
date, must submit at his own expense Evidence of Good Health, with respect to his
Dependents, provided through the Claims Administrator's office.
EFFECTIVE DATES OF COVERAGE
Gffeetive Date of ErnplQyee Coveraee
Coverage will become effective for an Eligible Employee on the fast day of full time
employment.
An employee who makes application for individual coverage more than thirty-one (31)
days after the date eligible, shall be covered on the date the Claims Administrator is
satisfied with the Evidence of Good Health the employee is required to submit, with
respect to himself.
Effective Dafe of Dependent Coverage
The Effective date of Coverage for each Eligible Dependent will be the date on which the
' Eligible Employee becomes covered.
17
An employee who snakes application for dependent coverage more than thirty-one (31)
days after the date eligible, shall be covered for Dependent coverage on the date the
Claims Administrator is satisfied with the evidence of good health the Employee is
' required to submit, with respect to his dependents.
If you do not have family coverage and you (or your spouse) become pregnant, and you
want to cover the child, you may apply for family coverage and the application for family
coverage must be received by the Claims Administrator within three (3) months of the
birth of the child. Otherwise an evidence of insurability statement will be required and
coverage will not be effective unless and until approved by the Claims Administrator. We
strongly recommend that you apply and pay for family coverage from the time that you
first know you are (or your spouse is) pregnant. coverage will be effective on the fast day
of the month after approval by the Claims Administrator.
If you do not have family coverage and you are going to adopt a child, you should apply
for family coverage within three (3) months of the date of adoption or the date that the
child is actually placed in your home with the intent that the child will remain there
permanently.
TIsRMINATION OF COVERAGE
Termination oJEmplovee Coverage
Your coverage will cease on the sooner of:
(a) the date the Plan ceases;
(b) the date the Plan ceases for the class of Employees to which you belong;
(c) the last day of the calendar month during which you are no longer a member of
' the class eligible;
(d) the date ending the period for which your last contribution is made, if you are
required to pay a part of the cost of the Plan;
(e) the last day of the calendar month during which your active employment with
the Employer Participant ceases.
Terrninalion oJDependent Coverage
Your coverage with respect to Dependents will cease on the sooner of:
(a) the date ending the period for which your last contribution is made, if you aze
required to pay a part of the cost of the Plan;
(b) the date your coverage ceases;
(c) the last day of the calendar month during which a Dependent ceases to be
eligible as a Dependent, except as provided for under Handicapped Children;
(d) the last day of the calendaz month during which the adoption proceedings are
discontinued provided that such proceedings do not result in fmalization of the
adoption.
Iandicapped Children
Medical caze benefits may be continued for a Dependent child who is mentally retazded or
physically handicapped and unable to earn a living and who is dependent upon you for
support. You must:
(a) furnish proof of the Dependent's handicap; and
(b) agree to make any required contribution;
' within 31 days after the Dependent attains the age limit.
18
Any coverage continued for such dependent child will end on the sooner of:
' (a) the date ending the period for which your last contribution is made, if you are
required to pay a part of the cost of the Plan;
(b) the date your coverage ceases;
(c) when the handicap ceases; or
(d) at the end of the 31 day period after any required proof is not furnished (after 2
years from the date the Dependent attains the age limit, proof may not be
required more often than once each calendaz year).
~'ermination of the Plan
The Employer shall have the right, at any time, to tem~irtate the Plan.
The termination of the Plan shall not affect any right of a Covered Person to benefits under
the Plan for expenses incurred prior to such termination.
1
19
CONTINUATION OF COVERAGE
(COBRA)
' A Covered Person whose coverage has been temunated for any qualifying event
enumerated below has the right to continue coverage for all benefits of This Plan if
covered for such benefits on the day immediately preceding the termination date. The
Plan Administrator is required by federal law to provide this option.
The tune period for which the continuation is available is indicated below in conjunction
with the corresponding qualifying event. An election to continue or decline coverage
must be made within sixty (60) days of the qualifying event or the date of loss of coverage
as a result of a qualifying event or sixty (60) days from the notice made by the Plan
Administrator of the right to continue coverage.
If Continuation of Benefits is elected, coverage will continue as though termination of
employment or loss of eligible status had not occurred. Any accumulation of deductibles
or benefits paid prior to termination or loss of eligibility, which had been credited towazd
any deductible or maximum benefit of This Plan, will be retained. Also, no new or
additional waiting periods, pre-existing condition limitations or evidence of good health
requirements will apply. If any mod cations are made to the coverage for employees in
Active Service, the coverage provided to individuals under this continuation provision will
be similazly modified.
Oual(fving Events
An eighteen (18) month continuation shall be available to Covered Employees and/or
' Covered Dependents in the event of any one of the following qualifying events:
1. A Covered Employee's termination of employment for any reason except gross
misconduct;
2. A Covered Employee's loss of eligibility to participate in This Plan due to reduced
work hours.
A twenty-nine (29) month continuation shall be available to Covered Employees and/or
Covered Dependents in the event of the following event:
1. A Covered Person is disabled on the date of the Covered Employee's termination
of employment or reduction in work hours;
The Covered person must provide the Plan Adtninistrator with notice of the disability
within sixty (60) days of the determination of disability. The Covered Person must notify
the Plan Administrator of a detemunation that the individual is no longer disabled within
thirty (30) days of such determination.
A thirty-six (36) month continuation shall be available to a Covered Dependent spouse
and/or child in the event of any one of the following qualifying events:
1. A Covered Employee's death;
2. Divorce or legal separation from a covered Employee;
3. A Covered Dependent child's loss of eligibility to participate in this Plan due to
' age, marriage or a change in student status;
20
4. A Covered Dependent's loss of eligibility to participate in this Plan due to the
Covered Employee becoming entitled to Medicare as a result of Total Disability.
' A lifetime continuation shall be available to a covered retiree or the Covered Dependent of
a retiree in the event of the following qualifying event:
1. The Employet's filing of a bankruptcy proceeding under Title 11 of United States
Code;
Continued coverage must be offered when coverage is substantially reduced within one
year before or after the filling for bankruptcy. Retirees and widows or widowers of
retirees who died before the bankruptcy filing aze also entitled to lifetime continuation
coverage. Surviving spouses and dependent children of retirees who die after the
bankruptcy filing may elect an additional thirty-six (36) months of continuation coverage.
Individuals may be covered under multiple qualifying events, but in no case (except
bankruptcy) will coverage be continued for more than thirty-six (36) months.
If an employee becomes entitled to Medicaze, but no loss of coverage results for the
employee or the Covered Dependents, and a subsequent qualifying event occurs, the
duration of coverage for all qualified beneficiaries other than the Covered Employee must
be at least thirty-six (36) months from the date on which the employee became entitled to
Medicare.
Notice ojContinuation
A Covered Person has at least sixty (60) days from the date of a qualifying event or the
date of loss of coverage as a result of a qualifying event or sixty (60) days from the date of
notification of the rights pursuant to a qualifying event to elect coverage. No payment of
pretnium is required until the forty-fifth (45th) day after the election, to pay for the first
month of coverage. All payments are subject to a thirty (30) day graced period.
The Covered Person is required to notify the Plan Administrator within sixty (60) days of
any qualifying event of which it would not otherwise be awaze, such as divorce, legal
separation, or loss of dependent status by a dependent child. The Plan Administrator shall
notify Covered Persons of their right to continuation of coverage within fourteen (14) days
of (a) the qualifying event or (b) the notice made to the Plan Administrator of the
qualifying event.
The Covered Person is also required to provide the Plan Administrator with all
information needed to meet its obligation of providing notice and continuing coverage.
Cost of Continuation
The full cost of providing such coverage, plus a 2% administrative fee, may be chazged to
any person continuing in This Plan. This cost shall be determined at the beginning of each
Plan Year and shall remain in effect for the remainder of such Plan Yeaz.
If a Covered Person is entitled to continuation of coverage due to disability, the full cost of
providing such coverage, plus a 50% administrative fee, may be chazged for the eleven
(11) months in excess of the initial eighteen (18) months of continuation coverage.
' Contact the Etnployer for details regarding the cost of continuation.
21
Continuation of Coverage shall not be provided beyond whichever of the following dates
is first to occur:
' 1. The date the maximum continuation period expires for the corresponding
qualifying event;
2. The date Thrs Plan is termntated;
3. The date the Covered Person fails to make the contribution to continue
coverage;
4. The date the Covered Person becomes covered under any other group health
plan which does not contain any exclusion or limitation with respect to any
pre-existing condition;
5. The date the Covered Person becomes entitled to Medicare;
6. In the month that begins more than thirty (30) days after a final deternunadon has
been made that a Covered Person is no longer disabled.
1
1
22
•••CONVERSION PRTi'ILEGES•••
' Conversion privileges aze limited benefits and you should check cost and coverages
available from other sources before deciding. The primary advantage of conversion is that
you (and your dependents) do not need to provide medical evidence of insurability in
order to become instued. You may also be eligible for coverage under the provisions of
COBRA described in this booklet.
Individual's Termination of Coverage
Termination of the employee's coverage will be effective at the end of the month in which
employment terminates. The Conversion privilege entitles an employee to apply for
individual coverage of a similaz type. Application must be made and the conversion
premium paid within 31 days of the date group coverage terminates. This also applies to
aninsured spouse or insured dependent when his or her insurance ends because:
1. the insured person dies;
2. of divorce, annulment, or legal separation;
3. an insured child's dependent status ends; or
4. the dependent ceases to qualify as a family member for any reason while
the employee is still covered;
5. Coverage under COBRA terminates.
The exceptions listed below also apply to an insured spouse or dependent.
When the Conversion Privilege does not apply
The conversion privilege will not apply if:
' 1. a person is eligible for Medicare;
2. a person is insured for similar benefits under:
a. another health expense policy;
b. a hospital or medical service subscriber contract;
c. a medical practice or other prepay plan;
d. any group type plan; or
e. any governmental law oi'regulation;
3. the group termitates and is not replaced within thirty (30) days; or
4. the insured person chooses to stop his/her premium payments.
l_.J
23
COORDINATION OF BENEFITS
' If a Covered Person is covered under this Plan and one or more other Plans, as defined
below, the benefits payable with respect to him under this Plan will be either its regulaz
benefits or reduced benefits which, when added to the benefits of the other Plan, will equal
100% of the Allowable Expenses, also defined below:
"Plan" means any Plan under which medical or dental benefits or services aze provided by:
1. Group, blanket or franchise insurance coverage or any other arrangement to cover
people in a group, whether on an insured, self insured or uninsured or other basis;
2. a hospital service plan, medical service plan, group practice plan, or other
prepayment coverage;
3. labor-management trusteed plans, union welfaze plans, employer plans, or employee
benefit plans;
4. goventment programs or coverage provided or required bylaw; or
5. any medical or hospital coverage provided in accordance with a Motor Vehicles
Accident Repazations Act or similaz law.
"Allowable Expenses" means any Medically Necessary, Reasonable and Customary item
' of expense incurred by a Covered Person which is covered at least in part under any of the
Plans involved.
This Plan will not consider as an allowable expense any chazge which would have been
covered by an HMO had a Covered Person for whom the HMO would be primary payer,
availed himself of the services of an HMO Participating Provider. Nor will this Plan
consider any chazge in excess of what an HMO provider has agreed to accept as payment
in full.
When a claim is made, the primary Plan pays its benefits without regard to any other
Plans. The secondary Plan adjusts its benefits so that the total benefits available will not
exceed the Allowable Expenses. No Plan pays more than it would without the
Coordination of Benefits Provision.
A Plan without a Coordination of Benefits provision is always the primary Plan. If all
Plans have such a provision, the plan covering the patient directly, rather than as a
dependent, is primary.
For dependents covered under two plans the benefits of a plan which covers the person (on
whose expenses the claim is based) as a dependent of a person whose MONTH and DATE
of birth occurs eazlier in a calendaz yeaz shall be determined as primary over such person
as a dependent of a person whose MONTH and DATE of birth occurs later in the calendar
yeaz.
' Claims for a dependent child whose pazents are sepazated or divorced, the following shall
apply for determining primary responsibility:
24
1. Court issued decree specifying the responsible pazent.
' 2. the parent with custody and not remarried.
3. the parent with custody and remarried making the child a dependent of the step-
pazent.
1'he primazy plan pays benefits without regard to other plans. The secondary plan(s)
adjust their benefits so payments from all plans do not exceed total eligible expenses.
"Eligible Expense" means a necessary, reasonable and customary expense that is: (1)
incurred while you are eligible for benefits under this plan; and (2) covered in part or in
full by one of the plans coordinated with this plan.
All terms and conditions of this plan not in conflict with this section (COB) apply.
1
1
25
Subroeotion
In the event any benefits are paid to an Employee under this Pjan, the Plan, to the extent
' permitted by law, shall be subrogated and succeed to the Employcc's right of rccovery for
medical expenses incurred against any third party, and the Employee shall pay over to the
I3tnployer all sums recovered, by suit, settlement or otherwise, on account of such medical
expenses incurred, but not to exceed the amount of benefits paid under this Plan. As a
condition to paying any benefits under this Plan, the Employer may require the Employee
to assign to it any such recovery or right thereto from any third party to the extent that
benefits are payable under this Plan. For purposes of this provision, a recovery which
does not specify the matters covered thereby shall be deemed to include a recovery for
medical expenses incurred to the extent of any actual loss due to the disability involved.
The Employee shall take such action, furnish such information and assistance, and execute
such assignments and other instruments as the Plan Administrator may require to facilitate
enforcement of their rights and interests hereunder. The Employee shall also take no
action prejudicing such rights and interests.
Rights ojRecovery
In the event of any over payment of benefits by this Plan, the Plan will have the right to
recover the overpayment. If an Employee is paid a benefit greater than allowed in
accordance with the provisions of the Plan, the Employee will be requested to refund the
overpayment. If the refund is not received from the Employee, the amount of the
overpayment will be deducted from future benefits. Similazly, if payment is made on the
Employee's behalf to a Hospital, Physician, or other provider of health care, and that
payment is found to be an overpayment, the Plan will request a refund of the overpayment
from the provider.
Review Procedures
You may designate a representative to act for you in the review procedure provided that
you have given that person a written statement designating him/her to represent you in
review of your claim.
We are required to give you a written decision within 60 days after we receive your
request for review. That written decision will indicate the reasons for the decision and
refer to the section or sections of your contract on which the decision is based.
In unusual situations, we may need additional time to make a decision. In that case,
before the 60 day period has expired, we will send you a written notice that more time is
necessary, extending our time for a written decision to a total of 120 days from the date we
received your request for review. We aze precluded from delaying the decision beyond
the
120 day period even at your request.
You also have 60 days to submit issues and comments and any pertinent, additional
medical information.
In unusual situations where you aze unable to submit written issues and comments within
60 days and you advise us that you need more time, we will grant the request provided we
have sufficient time to give you the extension notice.
' If you feel you have been treated unfairly, please contact the Plan Administrator.
26
TO EXPEDITE CLAIMS PAYMENT
' 13e sure the bills submitted include all of ll:e following:
1. Employee's name, social security number and home address.
2. If claim is made for dependent, his/her name, age and name of employer.
(Employer is other than the Village of North Palm Beach).
3. Employer's Name: Village of North Palm Beach; Plan Number: 12005
4. Name and address of the Physician or Hospital.
5. Physician's diagnosis.
6. Itemized Chazges - Do not send canceled checks or "balance due statements".
7. Date of the Injury or when an Illness began.
8. Drug bills (not cash register receipts) showing RX number, name of drug, date
prescribed, and name of person for whom the dmg is prescribed.
These items are required in order to accurately pay your claims. Certain claims may
require additional information before being processed.
' All payments will be issued directly to the provider of the service unless receipted bills
showing payment has been made are submitted.
PLEASE DIRECT ANY QUESTIONS REGARDING CLAIMS TO:
McCreary Corporation
700 Central Parkway
Stuart, FL 34994
407/287-7650 or 800/431-2221
Should you have any questions, please call the Claims Administrator at the above
number.
Every attempt will be made to assist you in understanding your benefits; however, any
statement made by an employee of the Claims Administrator or the Employer, will be
deemed a representation not a warranty. Actual benefit payment can only be determined
at the time the claim is submitted and all facts aze presented in writing. All benefit
payments are governed by the provisions of the Master Plan Document.
If you require a definite answer to a specific question, please submit a written request,
including all pertinent information, and a statement from your Physician (if applicable),
and you will receive a written reply, which will be kept on file.
1
27
CONTRACT PROVISIONS
' This booklet and the Summary Plan Document (Master Contract to which it pertains) is
specifically intended to comply with all applicable Statutes as currently written or as may
be amended by the legislature, court decisions, or state Department of Insurance rules and
regulations. Where the contract is in conflict with the above, the statutory language will
prevail. Where the statute, court decision, or rule/regulation set forth a minimum
standazd and this contract is (1) silent on the issue; (2) in conflict; or (3) for any other
reason not in compliance, the minimum statutory provisions/requirements aze hereby
incorporated into this contract by reference and will in all instances prevail.
This Plan of Benefits is provided by your employer for the sole purpose of furnishing to
you and your dependents a convenient and economical plan of employment benefits. The
decision to participate in this Plan is willingly and voluntarily made by each employee.
The Claims Administrator is designated to manage and supervise the execution of this
Plan. The employee agrees, as evidenced by their participation in this Plan, that they will
accept and be bound by the decisions of the Plan Administrator as respects the execution
of this Plan. Benefits aze provided by the employer as the employer determines to be in
the best interest of the employer and the eligible employees and their dependents.
This booklet is intended only to provide a general description of the benefits provided
through your plan. In every instance, the terms of the Master Policy, Reinsurance
Contract, or Plan Document (by whatever name known) shall take precedence and control
the final adjudication of all services rendered and benefits paid under this plan.
1
28
DEFINITIONS
' "Accident" -Means an unforeseeable, unintentional and unplanned event resulting in a
traumatic injury to an individual occurring while this Plan is in force and resulting
directly and independently of all other causes in loss covered by this Plan. The acts of
bending, stooping, lifting, stretching or standing are covered as a sickness as defined
herein.
"Ancillary service" -means hospital in-patient services available to a patient other
than room and boazd.
"Active at Work" -means working full time or, on a day not required to work, able to
work full time at the regulaz place of employment, on one's regulaz job.
"Benefits or coverage" -means those hospital, medical, surgical and authorized
related expenses as hereinafter provided, for which payment shall be made to, or, on
behalf of, an individual. Also includes dental, disability and other covered expenses if
described in the Benefit Sections of this S.P.D.
"Birthing Center"- means a licensed facility that is equipped and provides prenatal
care, delivery, immediate postpartum Gaze of a child born at the facility, has a
physician or nurse midwife present at all births and immediate postpaztum period,
provides full-time nursing services directed by a registered nurse or nurse midwife and
keeps medical records on each patient and child.
' "Calendar year"- means the period of twelve (12) consecutive months, commencing
on January 1 and ending December 31 of the same year. For individuals enrolling
during a calendaz yeaz, the "Calendar Yeaz" begins on the effective date of their
enrollment and ends on December 31 of that same yeaz.
"Claims Administrator"-means McCYeary Corporation.
"Coinsurance" -After the deductible is paid, each covered person must pay a
percentage of covered eligible expenses up to a certain dollar amount. The percentage
and the dollar amount (as shown in the Schedule of Benefits) are considered
coinsurance.
"Contract" -means this agreement, personnel policies, official actions, State and
Federal Statutes by virtue of which the Employer, its eligible employees and their
dependents, become participants and by which the Plan is Administered shall include
the participation agreement of the employer, the rules, regulations and resolutions
adopted by the Employer, the attached endorsements and riders, if any, the individual
applications of the employees and the identification cards issued to employees
indicating their participation in the coverage provided hereunder.
"Convalescent Facility" - means a legally operating institution or a distinct part of one
which: (a) is supervised by a resident Physician or a resident registered graduate nurse;
(b) requires that the health care of each patient be under the supervision of a Physician;
(c) requires that a Physician be available to furnish necessary medical care in
' emergencies; (d) provides 24 hour nursing service; (e) provides facilities for the full-
time caze of 5 or more patients; and (f) keeps clinical records on all patients.
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"Conversion privilege" -means the right given the insured to change his group
insurance to some form of individual insurance, without medical examination.
' "Covered eligible expense" -means eligible expenses. for a covered condition as
defined in the contract and subject to reasonable and customary chazges as determined
by the Plan Administrator.
"Custodial Care Services" means room and boazd, or supplies provided to a person
which consists primarily of that basic Gaze given to maintain life and/or comfort with
no reasonable expectation of cure or improvement of the Injury or Illness.
"Deductible" - A deductible is the amount that each covered person must pay for
covered eligible expenses each calendaz year before the plan pays any benefits. No
amount will be considered for the deductible that is the result of a penalty, or that is
not included in a covered eligible expense. Refer to the Schedule of Benefits for
individual deductible, and family deductible if applicable.
"Dependent" -means the legal married spouse of an employee and/or eligible legal
unmarried (never married) dependent child (children) as defined herein. "Dependent"
means your spouse, or your unmarried child from birth until the end of the yeaz in
which they reach 19 years of age, excluding anyone who resides outside the United
States or Canada, is in the armed forces of any country, or has coverage under this
Group Plan as an employee or as a dependent of another person. The term "child"
includes an employee's adopted child, and his step child and child under legal
guazdianship if such child depends primarily on the employee for support and
maintenance and lives with the employee in a regular pazent-child relationship. In
. addition, your unmarried dependent children enrolled as full-time students at an
accredited school or college are eligible until they reach age 25.
"Durable Medical Equipment" -means medical equipment designated for repeated
use and which is medically necessary to improve the functioning of a malformed body
member, or to prevent further deterioration of the patient's medical condition.
"Employee" -means an officer or employee of the employer or any class or classes of
such employees, regulazly working thirty (30) or more hours a week, who is eligible
for coverage hereunder, who has been so designated by the employer and who holds a
valid social security number. This defmition shall include retired employees who meet
the retirement requirements of the employer, elected officials, and any other employees
who meet the "Full Time Employee" requirements as defined by the employer.
"Employer" -.shall mean any governmental entity, person, partnership, joint venture,
corporation, company, or unincorporated organization whose name appeazs on the
Schedule of Benefits of this Plan.
"Experimental and/or Investigational Services" -Services which have not been
clinically proven to be safe and effective based upon available professional
assessments. The Plan Administrator reserves the right to make the final
deterntination in case a dispute should arise.
"Grace period"- means a period of thirty days past your group's usual premium due
. date and your insurance coverage continues in force with no penalty imposed for late
payment.
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"hospice Care" - means an organization which has 24 hour hospice Gaze available,
meets licensing and certification standazds, provides skilled nursing services, medical
' social services, psychological and dietary counseling, provides physician services,
physical therapy, part-time home health aide services and inpatient Gaze, keeps medical
records and has afull-time administrator.
"Hospital" -means an institution which is operated in accordance with the laws of the
jurisdiction in which it is located pertaining to institutions identified as hospitals
primarily engaged in famishing for compensation diagnostic and therapeutic facilities
for the surgical and medical diagnosis, treatment, and care of the inured and sick
persons, by or under the supervision of a staff of physicians who are duly licensed to
practice medicine, and which continuously provides twenty-four (24) hour a day
nursing service by registered graduate nurses, and which is not other than incidentally
a convalescent home, custodial institution, sanitarium, nursing home, a place for rest,
the aged, drug addicts, alcoholics, except no claim for treatment, care or services in a
licensed hospital which is accredited by the Joint Commission on the Accreditation of
Hospitals, American Osteopathic Association, or the Commission on the Accreditation
of Rehabilitative Facilities shall be denied solely because such hospital lacks major
surgical facilities and is primarily of a rehabilitative nature, if such rehabilitation is
specifically for treatment of a physical disability. "Hospital" also means an institution
which is an ambulatory surgical center as defined and licensed under Florida Statutes.
"Iospital Services" -means and includes receiving an individual into a hospital for
services set forth in Part and outlined on the hospital bill and subject to the rules and
regulations of the hospital, for and during such time only as the individual is
necessarily treated on an inpatient or outpatient basis in the hospital, under the
' treatment and care of a physician for any conditions covered hereunder.
"Individual" -means an employee and/or dependent with respect to whom an
employee is or may become covered.
"Inpatient" - means a patient who has been admitted upon order of a physician as a
bed patient for treatment in a hospital for an anticipated stay of at least six (6)
continuous hours.
"Intensive Care Unit" - means a section, wazd or wing, within a hospital which is
sepazated from other hospital facilities and is operated exclusively for the purpose of
providing professional medical treatment for critically ill patients, has special supplies
and equipment necessary for such medical treatment available on a stand-by basis for
immediate use, and provides constant observation and treatment by registered nurses
(R.N.) or other highly trained hospital personnel. A hospital facility maintained for the
purpose of providing normal post-operative recovery treatment or services is not
considered an intensive care unit.
"Lifetime Maximum" -means the maximum liability of the Plan subject to the
covered benefits with respect to each individual covered under this Plan, during the
entire period such individual is covered hereunder.
"Medically Necessary" -means treatment, care or services that are consistent with the
diagnosis, complies with acceptable medical standards, is not primarily for the
individual's convenience or the convenience of any doctor, hospital, other provider or
patient's family and is the most appropriate level of service which can be safely
provided. When applied to hospital inpatient Gaze, it means that care cannot be safely
31
provided on an outpatient basis. In addition, care which has not received federal
approval will not be considered medically necessary.
' "Medicare" -means the medical benefits provided by Title XVIII of the Social
Security Act (as now in effect or as later amended).
"Newborn Transportation Charges" -for the transportation of a newborn child to
and from the neazest available facility appropriately staffed and equipped to treat the
newborn child's condition, when the attending physician certifies that such
transportation is necessary to protect the health and safety of the newborn child.
However, the coverage of such transportation cost shall not exceed $1,000.
"Outpatient"- means a patient not admitted to a hospital as an inpatient.
"Penalty" - An additional amount of deductible. or coinsurance that applies to a
particular expense because the person did not follow the cost containment provisions
of the policy. These provisions include but are not limited to pre-admission
certification, outpatient surgery, second surgical opinions, and the like. A penalty
always applies and never can be used to satisfy total out of pocket requirements.
"Physician" - means a duly licensed doctor of medicine (M.D.) or doctor of osteopathy
(D.O.) that is legally qualified and licensed to practice medicine and to perform
surgery at the time and place the service is rendered. For other services covered under
this contract, doctors of dental surgery (D.D.S.), doctors of surgical chiropody
(D.S.C.), Podiatrists, Chiropractors and Optometrists are considered physicians when
acting within the scope of their licenses.
' "Plan" -means this Master Plan of Benefits including any Benefits/Schedule of
Benefits, endorsements, or amendments attached hereto.
"Plan Administrator" -The term Plan Administrator means the Employer, Village of
North Palm Beach, Florida.
"Reasonable fee" -reasonable fee, reasonable and customary Usual and customary
chazges -means the allowance determined by the Plan Administrator for all covered
services. Allowances aze based on Medical Data Research (MDR), CRVS; H.I.A.A.
studies and other schedules.
"Registered Nurse (R.N.)" or Licensed Practical Nurse (L.P.N.) - means a nurse duly
licensed by the state to render nursing skills within the scope of their license.
"Registered Physical Therapist (R.P.T.)" - means a person licensed by the state to
perform physical therapy and is a member of the American Registry of Physical
Therapists.
"Retiree"- is a former employee of the employer who is retired under a retirement
system established by Chapters-121, 122, 123, 238 and 321 of the Florida Statutes;
who has terminated employment and is receiving benefits from the system in which he
(she) was a member. This term also includes a person who retired and is receiving
benefits under Section 112, Florida Statutes. The dependents of a Retiree are also
eligible. The premiums for a Retiree and their dependents are to be paid by the Retiree.
' "Service Provider" - means a person or organization providing services for covered
eligible expenses.
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"Sickness" -The state of being unwell, by disease or having illness.
' "TMJ" -Non surgical caze connected with the detection or correction of jaw joint
problems, including temporomandibulazjomt and craniomandibular disorders, or other
conditions of the joints linking the jawbone and skull, including the complex of
muscles, nerves and other tissues related to that joint. TMJ and Related Care does not
include dental work; such as, but not limited to orthodontics, fixed or removable
bridgework/dentures, inlays, onlays, crowns or equilibrations, whether done for dental
or medical reasons.
"Total Disability" - means a medically determinable physical or mental impairment
which renders a participant so incapacitated as to be unable, within the range of his
normal ability, and taking into consideration his education, training and work
experience, to engage in any gainful occupation. With respect to a dependent,
disability may also prevent the dependent from engaging in any and all of his/her usual
activities - or from performing those activities normal to a person of like age.
"Total Out-of-Pocket" -When the covered eligible expenses of one person, or on a
family basis, the family amount reach(s) the amount specified in the Schedule of
Benefits for the deductible and coinsurance provisions; all further covered eligible
expenses for that calendaz year will be paid at 100% up to the plan lifetime maximum.
Any benefit for mental/nervous/alcohol/drug or any benefit limited to a lesser
coinsurance rate or any penalty amount is ineligible for calculation of this provision.
"Usual and Customary Charge" -means for any service or supply, the Usual and
Customary Chage will not exceed the lesser of: (a) the amount customarily charged by
' the provider for the service; or (b) the chazge for the service or supply made by
providers of compazable services or supplies in the same locality.
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