2015 Benefit Plan Booklet FH 20150615

PREPARED EXCLUSIVELY FOR THE FLORIDA DIVISION OF THE ADVENTIST

HEALTH SYSTEM

2015 Benefit Plan Booklet

Medical and Prescription Drug Benefits Florida Hospital and Affiliates- What Your Plan Covers and How Benefits Are Paid

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015 2

Preface The medical benefits plan described in this Benefit Plan Booklet and Schedule of Benefits is a benefit plan of the Employer - Adventist Health System (AHS). Please note that the medical benefits plan is a component plan of the Adventist Health Employee Benefit Plan (the "AHS Plan") and this Benefit Plan Booklet includes important information from the AHS plan. You are urged to read this Benefit Plan Booklet carefully. In the event of any ambiguity or any inconsistency between this Benefit Plan Booklet and any formal AHS Plan documents, the AHS Plan documents will control. Copies of the formal AHS Plan documents are on file at Adventist Health System and are available for inspection at a time and place mutually agreeable to You and the Adventist Health System. These benefits are not insured, but will be paid from the employer's funds. The Plan Administrator of the AHS Plan is the Adventist Health System Benefits Administration Committee (the Committee). In carrying out its duties to administer the AHS Plan, The Plan Administrator has discretionary authority to exercise all powers and to make all determinations, consistent with the terms of the AHS plan, in all matters entrusted to it. The Plan Administrators determinations shall be given deference and shall be final and binding on all interested parties. If you have questions about the overall AHS Plan, Please contact the Committee at the following address or phone number: Adventist Health Systems Benefits Administration Committee c/o Adventist Health System Sunbelt Healthcare Corporation 900 Hope Way Altamonte Springs, FL 32714 407-351-2043 The Administrators agree with the employer to provide administrative services in accordance with the conditions, rights, and privileges as set forth in this Benefit Plan Booklet. The employer selects the products and benefit levels under the Plan. The Benefit Plan Booklet describes Your rights and obligations, what the Plan covers, and how benefits are paid for that coverage. It is Your responsibility to understand the terms and conditions in this Benefit Plan Booklet. Your Benefit Plan Booklet includes the Schedule of Benefits and any amendments. This Benefit Plan Booklet replaces and supersedes all Benefit Plan Booklets describing coverage for the medical benefits plan described in this Benefit Plan Booklet that You may previously have received.


Employer: Adventist Health System Group: Florida Hospital Orlando Florida Hospital for Children Winter Park Memorial Hospital Florida Hospital East Orlando Florida Hospital Altamonte Florida Hospital Apopka Florida Hospital Kissimmee Florida Hospital Celebration Health Centra Care Florida Hospital Physicians Group Florida Radiology Imaging Hospice of the Comforter Effective Date: January 1, 2015


THIRD PARTY ADMINISTRATOR/PRESCRIPTON BENEFIT MANAGER ADMINISTRATORS) Health First Health Plans (HFHP) under the marketing name of Florida Hospital Care Advantage (FHCA) is a licensed Third Party Administrator designated by the employer to receive, process, and administer claims submitted by both contracted providers and other non-network providers, for covered medical benefits and make claim payments for such benefits on behalf of the PLAN. MedImpact Healthcare Systems, MedImpact is the Prescription Benefit Management organization designated by the employer to receive, process and administer claims for prescription drug benefits and make claim payments for such benefits on behalf of the PLAN for covered short and long term prescription drug needs. MedImpact contracts with retail pharmacies in which You and Your covered dependents have access to for short term prescription drug needs. Rx Plus is the organization designated by the employer as the exclusive Mail Order Pharmacy for long term prescription needs and specialty medications. Contact Information Medical Benefits Florida Hospital Care Advantage (FHCA)) Customer Service 844-522-5279 www.myFHCA.org

Prescription Drug Benefits MedImpact Healthcare Systems Customer Service 800.788.2949 www.medimpact.com AHS Rx Plus Pharmacy Maintenance Drugs 866.943.4535 www.myahsrx.com


TABLE OF CONTENTS WHO CAN BE COVERED .............................................................................................. 7

ELIGIBLE EMPLOYEES ........................................................................................................................... 7

PROBATIONARY PERIOD ...................................................................................................................... 7

ELIGIBLE DEPENDENTS ........................................................................................................................ 7

INELIGIBLE DEPENDENTS ..................................................................................................................... 8

ENROLLMENT ............................................................................................................... 9

COST FOR COVERAGE ................................................................................................ 9

EFFECTIVE DATES ..................................................................................................... 10

INITIAL ENROLLMENT .......................................................................................................................... 10

ANNUAL ENROLLMENT ........................................................................................................................ 10

HEALTH CARE SPECIAL ENROLLMENT, STATUS CHANGES OR OTHER QUALIFYING EVENTS PERMITTING A CHANGE OF ELECTION ............................................................................................. 10

HOW TO ENROLL ........................................................................................................ 10

DEPENDENT DATA REQUIREMENT ................................................................................................... 11

DOCUMENTATION OF DEPENDENT ELIGIBILITY ............................................................................. 11

FAILING TO ENROLL ............................................................................................................................ 12

CHANGING BENEFIT ELECTIONS ............................................................................. 12

STATUS CHANGES ............................................................................................................................... 12

QUALIFIED MEDICAL CHILD SUPPORT ORDERS ............................................................................. 16

SPECIAL ENROLLMENT RIGHTS UNDER CHIPRA ............................................................................ 16

HEALTH CARE SPECIAL ENROLLMENT ............................................................................................. 16

TEMPORARY CONTINUATION OF COVERAGE ....................................................... 18

LEAVE OF ABSENCE ............................................................................................................................ 19

HOW THE PLAN WORKS ............................................................................................ 20

COVERAGE PROVISIONS .......................................................................................... 22

UNDERSTANDING THE PLAN .............................................................................................................. 23

COPAYMENTS ....................................................................................................................................... 23

THE DEDUCTIBLE ................................................................................................................................. 23

THE COINSURANCE PERCENTAGE ................................................................................................... 24

ALLOWANCE GUIDELINES .................................................................................................................. 24

COVERED SERVICES ................................................................................................. 25

MEDICAL SERVICES ............................................................................................................................. 25

OUTPATIENT PRESCRIPTION DRUGS ............................................................................................... 48

AUTHORIZATION REQUIREMENTS ........................................................................... 49

PRE-CERTIFICATION AND AUTHORIZATION FOR COVERED MEDICAL SERVICES .................... 49

CONCURRENT CARE ........................................................................................................................... 50


REDUCED BENEFITS FOR FAILURE TO COMPLY ............................................................................ 51

CARE MANAGEMENT/HEALTH MANAGEMENT....................................................... 51

EXCLUSIONS ............................................................................................................... 51

MEDICAL PLAN EXCLUSIONS ............................................................................................................. 51

OUTPATIENT PRESCRIPTION DRUG EXCLUSIONS ......................................................................... 62

PLAN AND OTHER PAYMENT ARRANGEMENTS .................................................... 64

COORDINATION OF BENEFITS ........................................................................................................... 64

THIRD PARTY LIABILITY AND RIGHT OF RECOVERY ...................................................................... 66

RIGHT TO RECEIVE AND RELEASE INFORMATION ......................................................................... 67

FACILITY OF PAYMENT ........................................................................................................................ 67

RIGHT OF RECOVERY ......................................................................................................................... 68

NON-DUPLICATION OF GOVERNMENT PROGRAMS ....................................................................... 68

MEDICARE ELIGIBLES ......................................................................................................................... 68

CLAIM PROVISIONS .................................................................................................... 69

REIMBURSEMENT FOR NETWORK AND OUT-OF-NETWORK PROVIDER SERVICES .................. 69

POST SERVICE CLAIMS PROCEDURE ............................................................................................... 69

FRAUD .................................................................................................................................................... 70

COMPLAINT & APPEAL PROCEDURES .................................................................... 71

INFORMAL COMPLAINT PROCEDURE ............................................................................................... 71

GRIEVANCE PROCEDURES ................................................................................................................ 71

APPEAL PROCEDURES ....................................................................................................................... 72

APPEAL PROCEDURE - First Level of Review ..................................................................................... 72

APPEAL PROCEDURE - Level Two Appeal .......................................................................................... 74

INDEPENDENT REVIEW PROCEDURE EXTERNAL REVIEW ........................................................ 74

APPEAL TO THE PLAN-Level Three ..................................................................................................... 75

GLOSSARY OF COVERAGE TERMS ......................................................................... 76

REQUIRED NOTICES ................................................................................................ 107

WOMENS HEALTH AND CANCER RIGHTS ACT OF 1998 .............................................................. 107

STATEMENT OF RIGHTS UNDER THE NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT108

CHILDREN'S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT OF 2009 (CHIPRA) ... 108


WHO CAN BE COVERED

Throughout this section you will find information on who can be covered under the plan, how to enroll and what to do when there is a change in your life that affects coverage. In this section, you means the employee. ELIGIBLE EMPLOYEES Regular full-time employees and part-time employees who work the minimum prescribed hours as defined by the employer; Employees who are classified as follows are NOT eligible to participate in the Plan:

Part-Time employees who are working less than the minimum prescribed hours;

Temporary employees;

Persons who are not classified by the employer as employees on both payroll and personnel records (such as leased employees, independent contractors, and other persons who are not classified as employees).

PROBATIONARY PERIOD Once you become eligible for coverage, you will need to complete a probationary period, as defined by the employer, before coverage under this plan begins. ELIGIBLE DEPENDENTS 1. Your spouse*

FHCA will rely upon your employer to determine whether or not a person meets the definition of a dependent for coverage under this Plan. This determination will be conclusive and binding upon all persons for the purposes of this Plan. *If you do not know if a relationship you have with another person constitutes a spousal relationship with the meaning of the Plan, please consult with Human Resources or the call center that administers your benefits.

2. Your married or unmarried children under age 26 who are:

your biological children;

your stepchildren;

children legally adopted by you or your spouse or placed with you or your spouse for adoption

your foster children;

any child for whom you are responsible under court order;

your grandchildren in your court-ordered custody; and

any other child with whom you have a parent-child relationship 3. Extended Coverage for Disabled Dependent Children: Coverage for an unmarried, enrolled dependent child (as defined above) who is incapable of self-support and is permanently and totally disabled (as defined below) will be continued beyond the maximum age limits as stated above, provided that:


The enrolled dependent child becomes disabled before reaching the limiting age; and

The enrolled dependent child is dependent upon you for support and maintenance; and

Required documentation is provided within 31 days of the date of request for such proof; and

Payment of any required contribution for the enrolled dependent child is continued.

If you are a new or an existing employee and you have an unmarried dependent child (as defined above) who is incapable of self-support and is permanently and totally disabled (as defined below), your child may be enrolled, provided that:

You provide proof that the child had continuous major medical coverage through a prior group health plan without a 63-day gap in coverage at the time you try to add the child to your coverage; and

The disabled child has incurred a loss of major medical coverage within the last 31 days prior to the time you try to add the child to your coverage; and

You satisfy the conditions in the four bullet points directly above for continuation of an enrolled disabled child.

An individual is permanently and totally disabled if he/she is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve (12) months. Coverage will be continued so long as the dependent child continues to be disabled and dependent upon the employee for support unless otherwise terminated from coverage in accordance with the terms of the Plan. INELIGIBLE DEPENDENTS Ineligible dependents include, but are not limited to, the following: 1. Dependents in the Military. Coverage is not available for any dependent on active duty in the uniformed services or armed forces of any country.

2. Dependent Parents. Coverage is not available for an employee's or employee's spouse's parents.

3. Former Spouses. A spouse from whom you are divorced (even if the divorce decree stipulates you will continue Health Care coverage for your ex-spouse) or legally separated.

4. Spouse and Children of Adult Children. Coverage is not available for an adult childs spouse or children. 5. Non US Citizen or National. Coverage is not available to dependents who are not a citizen or national of the United States unless he or she is a resident of the United States, Canada or Mexico. However, this provision will not apply to exclude your legally adopted child from being an eligible dependent, if that child is a member of your


household and resides in your home and you are a citizen or national of the United States. It is your responsibility to notify Human Resources or call center that administers your benefits, when a dependent no longer meets the eligible dependent status. The PLAN is not liable to provide coverage for ineligible dependents even if contributions have been received. You may not participate in the PLAN as an employee and as a dependent. In addition, a person may not participate in the PLAN as a dependent of more than one employee. RETIRED EMPLOYEES (varies by facility) Some early-retirees may be eligible to maintain their medical coverage to age 65 through a special early retiree benefit based on their age and length of service. Contact Human Resources for more information on this benefit.

ENROLLMENT

There are six time periods during which an eligible Employee and/or Dependent can enroll for coverage under the PLAN: 1. The Initial Enrollment Period is the period of time during which you or any dependent is first eligible to enroll.

A. If you are an eligible employee on the date of hire, your coverage eligibility date is the date you complete the probationary period.

B. If you enter an eligible class of employee after your date or hire, your coverage eligibility date is the date you complete the probationary period.

2. The Annual Enrollment Period is an annual period prior to the plans Anniversary Date, during which:

A. If the employer offers more than one health benefit option, you may change to one of the alternatives offered.

B. If you decided not to enroll for coverage during the Initial Enrollment Period, you may now enroll yourself and eligible Dependents.

3. A Health Care Special Enrollment Period of thirty days is provided for special circumstances described in the Special Enrollment Provisions section.

4. If you are reinstated or rehired within 30 days of your employment termination date.

5. Within thirty (30) days after a status change event or other qualifying event permitting a change of election.

6. Within sixty (60) days of losing eligibility for Medicaid or a Childrens Health Insurance Program (CHIP) or if they become eligible for premium assistance under Medicaid or CHIP.

COST FOR COVERAGE

Participation in the plan has a premium cost associated with it. The employer pays most of the cost of providing your health care benefits. You are required to contribute part of the cost for you and any dependents. Payroll deductions will depend on the number of hours you are regularly scheduled to work and the coverage category you have


selected. Premiums and payroll deductions may change from year-to-year. Enrollment materials will include additional information about the cost of coverage. When you elect health care benefits, including coverage for yourself and your dependents under the PLAN, the cost of your coverage is deducted from your pay before taxes are taken. This reduces your taxable income and, therefore, reduces the taxes you pay and increases your take-home pay. Since most Florida Hospital benefits are purchased with before-tax dollars, the plans and programs are governed by IRS regulations. The various provisions designed to comply with these regulations are noted within this booklet. Please note that pretax payroll deductions reduce your federal income tax and Social Security contributions, and could slightly reduce the income on which your Social Security retirement benefits are based. Generally, the current tax savings outweigh the slight reduction in Social Security benefits. Check with your tax advisor regarding your personal tax situation. Pretax payroll deductions have no effect on Medicare benefits.

EFFECTIVE DATES

INITIAL ENROLLMENT Generally becomes effective after the Probationary Period. . ANNUAL ENROLLMENT Generally, the elections made during Annual Enrollment take effect the following Jan. 1 and remain in effect for the entire plan year (Jan. 1 through Dec. 31). REHIRED OR REINSTATED EMPLOYEES - If you are rehired or reinstated within 30 days after termination, the benefits elected previously are reinstated effective on your rehire or reinstatement date. The Probationary Period is waived. If you are rehired or reinstated more than 30 days after termination, coverage will become effective following satisfaction of the Probationary Period. HEALTH CARE SPECIAL ENROLLMENT, STATUS CHANGES OR OTHER QUALIFYING EVENTS PERMITTING A CHANGE OF ELECTION Benefit changes will be effective on the dates specified in this Benefits Booklet. If enrollment is not timely, the next time to enroll will be during the next Annual Enrollment.

HOW TO ENROLL

Newly hired employees will be provided with information regarding how to complete the benefit enrollment process. Employees with a status change or employment status change that impacts their benefits should immediately contact Human Resources and the Benefits Service Center for instructions regarding enrolling in benefits or making benefit changes. All benefit eligible employees will receive information regarding the annual benefits enrollment process.


DEPENDENT DATA REQUIREMENT Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) is a federal law that became effective January 1, 2009. This federal law requires AHS (and covered affiliates) to provide the Social Security number (SSN) for your covered dependents that are U.S. citizens. Newborn dependents are also included in this requirement. This information is reported to assist the Centers for Medicare and Medicaid Services (CMS) and health plans to properly coordinate payment of benefits among plans. Compliance is required in order to provide coverage for your dependents. When adding or enrolling a dependent, you will want to have that information available in order to complete the enrollment process. If you cannot provide your dependents SSN, you should contact Human Resources or the Benefits Service Center (if applicable):

If your dependent doesnt have a SSN because he/she is not a U.S. citizen. Providing a dependents Tax Identification number (TIN) in place of the SSN is not sufficient.

If your dependent is a newborn and you have not yet been issued a Social Security number for the child.

DOCUMENTATION OF DEPENDENT ELIGIBILITY Employees enrolling dependents will be required to provide documentation to verify the dependents eligibility. These cases include:

New employees;

Newly eligible employees;

Employees enrolling new dependents due to a qualifying Family Status Change or Health Care Special Enrollment;

Dependents not previously covered during Annual Enrollment; or

Dependents for which documentation has not been submitted.

Re-enrolled dependents that were not covered by the Plan immediately prior to being re-enrolled

Depending on the documentation submitted, employees may be asked to submit documentation on an annual basis. If you do not provide documentation or the documents you provide do not verify your dependents eligibility, that dependent will be removed from your coverage, and you may be responsible for any claims paid for that dependent from the PLAN. AHS reserves the right to recover any and all benefit payments made for services received by ineligible dependents. You will have the right to appeal the decision to remove a dependent(s) from coverage for failure to provide acceptable documentation. Eligible dependents that do not become covered in accordance with the provisions of the preceding paragraphs may be enrolled (subject to proof of eligibility) during the annual open enrollment period held in November of each year. Their coverage will


become effective on January 1 of the following year provided appropriate eligibility documentation is provided. FAILING TO ENROLL You are required to affirmatively make elections regarding coverage of dependents. You will not receive coverage for your dependents unless you affirmatively elect such coverage.

CHANGING BENEFIT ELECTIONS

The decisions you make during the Annual Enrollment period generally take effect the following Jan. 1 and remain in effect for the entire Plan Year. However, you may be eligible to change some of your benefit choices during the year if you have a change in your employment status or family status, qualify for a Health Care Special Enrollment or qualify for any other permitted election change. Because most benefits are purchased with before-tax dollars, the IRS limits changes during the year to those that are related to and consistent with a change in status and certain other permitted election a described below. In addition, you may qualify for a Health Care Special Enrollment if you have new dependents or if you or a dependent loses health coverage through another source. STATUS CHANGES IRS rules determine which events qualify to allow you to change your benefit elections during the plan year. Generally, you can change your benefit elections only if you experience a change in status and the election change you request satisfies a consistency rule. All requests for Status Changes are subject to approval by the employer. If you fail to submit your request timely, you will not be able to make changes until the next Annual Enrollment (changes are effective Jan. 1 of the following year) unless you have another qualifying Status Change. If your Status Change allows you to enroll your dependent(s) for coverage, you will be required to provide proof of each dependents eligibility. Failure to provide such proof may result in denial of your Status Change request. Some events may qualify as a Health Care Special Enrollment as described later. Eligible Status Change Events Following is a list of events that may qualify for a Status Change during the plan year.

A change in your legal marital status, including marriage, death of a spouse, divorce, legal separation or legal annulment;

A change in the number of your dependents, including birth, adoption, placement for adoption, death of a dependent, loss of custody of a dependent, or commencement or termination of legal guardianship;

A change in the employment status of you or your dependent, including: o termination or commencement of employment;

o commencement of or return from a strike or lockout;

o commencement of or return from an unpaid leave;

o a change in worksite;


o a change from part-time to full-time or full-time to part-time status; and

o any other change in employment status that affects benefit eligibility;

Your dependent satisfies or ceases to satisfy the eligibility requirements under the Plan;

Your dependent is entitled to make a change in his or her elections under his or her employer's plan due to a permitted election change recognized by that plan or, if his or her employer's plan has a plan year that is different than your plan, during his or her plan's annual enrollment period;

You or your dependent gains or loses eligibility for Medicare or Medicaid (this event does not apply to other state benefit programs);

You receive or obtain a Qualified Medical Child Support Order that requires you or your former spouse to provide Health Care coverage for a dependent child;

You change residence; or

You or your eligible dependent loses coverage under a group health plan sponsored by a governmental or educational institution.

Consistency Rule In addition to qualifying for a family Status Change, you can only change specific benefit elections if the requested change is on account of and corresponds with the change in your family status. This is called the Consistency Rule. Generally, to make a change to your Health Care coverage, the family Status Change must have affected you or your family member's eligibility for coverage for that benefit. You can change only your coverage level; you may not change your plan. For example, if you enroll in the PPO plan, you may not later elect HDHP plan due to a family Status Change. You may, however, change your plan at Annual Enrollment. However, please see the section below regarding changes of election because of changes in cost and coverage. In addition, certain family Status Changes have special Consistency Rules. These special Consistency Rules are:

Changes Due to Loss of Dependent Eligibility. If the family Status Change is divorce, legal annulment, death of a dependent, or a dependent ceasing to satisfy the eligibility requirements and you are enrolled in the plan, the only election change permitted is cancellation of coverage for that particular dependent. Coverage may not be cancelled for you or any other covered family member unless some other family Status Change applies.

Eligibility for Medicare, Medicaid or CHIP. If you or your dependent become(s) eligible for Medicare, Medicaid or CHIP, you may elect to cancel or decrease your coverage. If you or your dependent loses eligibility for Medicare, Medicaid or CHIP, you may elect to enroll in or increase your coverage.


Court-Mandated Coverage. If you are required by a Qualified Medical Child Support Order to provide coverage for a child, coverage will automatically be added for the child and you will be enrolled if necessary. If your spouse is required to provide coverage for a child covered by you under the plan, you may cancel coverage for that child, but you may not cancel coverage for yourself or any other covered dependents.

Change in Coverage of Your Dependent. If your dependent is entitled to make a change to his or her coverage under his or her employer's plan due to a permitted election change or during his or her plan's annual enrollment period (if his or her employer's plan has a plan year that is different than your plan, you may make an enrollment election change that corresponds with the change made by your dependent.

Because of the Consistency Rule, you may experience a family Status Change that does not let you change your benefit elections. Here are some examples of how these Consistency Rules apply: Example 1. Pat is married and has two children. Pat elects Family coverage (employee, spouse, plus children) under the PPO plan. One child turns age 26 and therefore loses eligibility under the plan. Although Pat's child has experienced a family Status Change, because Pat still has two remaining eligible dependents (spouse and one child), Pat is not permitted to make a benefit election change. Pat must notify the employer to terminate coverage for the dependent that turned age 26. Example 2. Facts are the same as example 1, except Pat has only one child. The child turns age 26 and, therefore, loses eligibility for coverage under the plan. Pat can change her election from the Family coverage level to Employee plus Spouse coverage. Pat could not, however, change from Family coverage to Employee Only coverage or no coverage. Example 3. Chris elects Employee Only coverage under the PPO plan. Chris marries. Before they were married, Chris' wife elected health coverage for herself only under her employer's health plan. After they are married, Chris may either cancel coverage under his plan, if he and his wife will be covered under her employer's plan, or change his election to Employee Plus Spouse, if his wife cancels her coverage under her employer's plan. Either change satisfies the Consistency Rule. Changes of Election Because of Changes in Cost or Coverage You may make certain changes, as described below, because of changes in cost or coverage of benefits available under the Plan. You must request such an election change within 30 days after your right to change your election arises (as determined by the Administrator, in its discretion). Generally, your new elections will take effect as soon as practicable after the date you complete and submit the Status Change Form and the Election Form, if required, and the election is approved by the Administrator, and will be effective until you change your election.


Changes in Cost - If the amount that you are required to pay for a benefit option significantly increases (as determined by the employer) while you are covered under that benefit, you may elect to revoke your election for that benefit and elect another similar benefit option, if one is available (as determined by the employer). If no similar benefit option is available, you may elect to drop your coverage because of the increased cost.

If the amount that you are required to pay for a benefit option significantly decreases (as determined by the employer) during the Plan Year (i.e., January 1st - December 31st), you may elect that benefit option for yourself or an eligible spouse or dependent. You may change your elections because of a significant cost change, as described above, regardless of the reason for the increase or decrease in your cost. It does not matter whether the change in cost results from an action taken by the employer or if it occurs because of something you do (such as switching from part-time to full-time employment if that changes the amount you have to pay for coverage).

Changes in Coverage - If your coverage changes under a benefit is significantly curtailed during the Plan Year, you may revoke your election of that benefit and elect another benefit option that offers similar coverage (as determined by the employer), if any. Coverage is significantly curtailed only if there is an overall reduction of the coverage provided to all participants (as determined by the employer). If your coverage under a benefit is significantly curtailed during the Plan Year (as determined by the employer), and the significant curtailment amounts to a complete loss of coverage (as determined by the employer), you may change your elections as described in the previous paragraph. In addition, if you experience a complete loss of coverage and no other benefit option that provides similar coverage is available, you may drop the coverage entirely. A loss of coverage includes, for example, the elimination of a benefit option, the loss of availability of an HMO option in the area where you or your dependent reside, or a loss of coverage for you or a dependent under a health plan option because your expenses exceed an annual limit. The employer, in its discretion, will determine when a curtailment of a benefit amounts to a complete loss of coverage. If the employer adds a new benefit option or if an existing benefit option is significantly improved during a Plan Year (as determined by the employer), you may change your elections to replace a benefit option that provides similar benefits with the new or improved benefit option, or, if you did not previously elect a similar benefit option, you may elect to begin participating in the new or improved benefit option.


QUALIFIED MEDICAL CHILD SUPPORT ORDERS A Qualified Medical Child Support Order (QMCSO) is any judgment, decree or order (including approval of a settlement agreement) for one parent to provide a child or children with reimbursement for health and/or dental care expenses. If the employer receives a QMCSO for your child or children, it will contact you concerning the procedures for such an order. Generally, if the employer receives an order that is determined to be a QMCSO, coverage for the child who is the subject of the QMCSO will become effective on the date specified in the QMCSO. In addition, the employer will deduct the appropriate charges from your pay beginning on the date the QMCSO becomes effective. If the request for coverage is not made within 31 days of the date of the QMCSO, coverage for the child will be subject to all of the terms of the plan, as applicable. SPECIAL ENROLLMENT RIGHTS UNDER CHIPRA CHIPRA is an acronym for the Childrens Health Insurance Program Reauthorization Act of 2009 and was signed into law on Feb. 9, 2009. It extends and expands the Childrens Health Insurance Program (CHIP, formerly known as the State Childrens Health Insurance Program or SCHIP). CHIPRA provides for the following: If you or your dependents Medicaid or CHIP coverage is terminated because you are no longer eligible, you qualify for a Health Care Special Enrollment which will allow you to enroll in the employers plan.

If you or your dependents become eligible for a premium assistance subsidy under Medicaid or CHIP, you qualify for a Health Care Special Enrollment which will allow you to enroll in the employers plan. HEALTH CARE SPECIAL ENROLLMENT You may qualify for a Health Care Special Enrollment if you have new dependents or you or a dependent loses existing health coverage through another source. If you want to request a Health Care Special Enrollment, you must contact the employer to make the change no later than 30 days after the date of your Health Care Special Enrollment event. If your Health Care Special Enrollment allows you to enroll your dependent(s) in Health Care coverage, you will be required to provide proof of each dependents eligibility. In addition, a copy of the certificate or other official paperwork showing the date of the event or proving loss of coverage may be required. Events that may qualify for a Health Care Special Enrollment during the Plan Year include the following situations:

loss of other coverage* for reasons such as: o divorce, legal separation, legal annulment;

o death;

o termination of employment;

o reduction in hours;

o ineligibility for Medicare, Medicaid or CHIP;

o exhaustion of your COBRA coverage (if you were enrolled in COBRA through another source); or

o termination of another employer's contribution toward the cost of coverage.


gaining a dependent due to: o marriage;

o birth, adoption, placement for adoption/legal guardianship

* Loss of coverage due to non-payment of premiums or termination for cause, such as making fraudulent claims or intentional misrepresentation, is not a qualifying event.

What You Can Change Events qualifying for Health Care Special Enrollment allow you to enroll in or make election changes to your Health Care coverage only. If you previously waived coverage, you may elect coverage for yourself and your eligible dependents; otherwise you may add dependents to your health plan. If you were previously enrolled you can only change your coverage level; you may not change your plan. How to Request a Status Change, Health Care Special Enrollment or Other Permitted Election Changes To request a Status Change, Health Care Special Enrollment or other Permitted Election Change, contact your employer to make the change no later than 30 days after your qualifying event. The representative will explain the process and the changes you can make. WHEN COVERAGE ENDS Your coverage under the PLAN will end when one of the following events first occurs. For you:

You terminate employment with the employer;

You retire (unless eligible as defined by the employer);

Upon attaining the age of 65 if eligible and covered as a retiree;

You die;

You no longer satisfy the eligibility requirements for participation (including Temporary Continuation of Coverage);

You fail to pay any required premiums in full by the required due date;

You request that coverage be terminated, as a result of, and consistent with, Annual Enrollment, a Status Change, Health Care Special Enrollment or Other Permitted Election Change;

You are on active duty military leave deployment for more than 6 weeks or other military training leave lasting more than 90 days (refer to USERRA in this section);

The PLAN or program is discontinued or amended so that you lose eligibility. In addition to the events listed above, coverage for your dependents will end due to:

Divorce or legal separation;

The dependent child reaches his/her 26th birthday;

The dependent no longer satisfying the dependent criteria for participation in the PLAN;


A decision by you to terminate coverage, as a result of, and consistent with, Annual Enrollment, a Status Change or Health Care Special Enrollment; or

You fail to provide requested documentation that proves your dependents eligibility for coverage or the documentation you provide does not verify your dependents eligibility for coverage.

If one of the events listed earlier occurs, your coverage will end on the date in which ineligibility occurs.

TEMPORARY CONTINUATION OF COVERAGE

In some cases, you and your dependents may have the option of continuing Health Care coverage when coverage would otherwise end. Due to the fact that the federal law considers the plan to be a "Church Plan" it is not subject to the continuation of coverage rules under the Consolidated Omnibus Budget Reconciliation Act (COBRA). While the PLAN is not required to comply with COBRA, it does provide you with the option of continuing their existing coverage for up to 12 months following:

The date your employment ends for any reason, other than gross misconduct, including death or disability, or

The date your eligibility to receive plan benefits ends due to a change in your job classification, or

Birth of a child(ren) for the remaining months following the initial event that caused coverage as an eligible employee or dependent to end, or

Your divorce if a covered dependent, or

With respect to a covered dependent, your retirement, if you continue benefits as an eligible retiree; or

With respect to a covered dependent child, the attainment of the age limits set forth in the Eligible Dependents section

You or the affected family member must complete a Temporary Continuation of Coverage form and make arrangements for premium payments within 30 days following the event that would otherwise cause coverage as an eligible employee or dependent to end. Temporary Continuation of Coverage will end on the earliest of the following:

The date requested at the time application is made or as modified in advance and in writing, or

The date that any required premium is not received as agreed at the time application is made, or

Twelve months following the initial event that caused coverage as an eligible employee or dependent to end

Temporary Continuation of Coverage forms are available from the employer. If the employee is pregnant at the time they lose eligibility and elect Temporary Continuation of Coverage, you may add the child(ren) at time of birth for the remaining months following the initial event that caused coverage as an eligible employee to end.


LEAVE OF ABSENCE Family Medical Leave of Absence (FMLA) This continuation of coverage section applies only for the period of any approved family or medical leave (approved FMLA leave) required by Family and Medical Leave Act of 1993 (FMLA). If your employer grants you an approved FMLA leave for a period in excess of the period required by FMLA, any continuation of coverage during that excess period will be determined by your employer. If your employer grants you an approved FMLA leave in accordance with FMLA, you may, during the continuance of such approved FMLA leave, continue Health Expense Benefits for you and your eligible dependents. At the time you request the leave, you must agree to make any contributions required by your employer to continue coverage. If any coverage your employer allows you to continue has reduction rules applicable by reason of age or retirement, the coverage will be subject to such rules while you are on FMLA leave. Coverage will not be continued beyond the first to occur of: The date you are required to make any contribution and you fail to do so. The date your employer determines your approved FMLA leave is terminated. The date the coverage involved discontinues as to your eligible class. However, coverage for health expenses may be available to you under another plan sponsored by your employer. Any coverage being continued for a dependent will not be continued beyond the date it would otherwise terminate. If Health Expense Benefits terminate because your approved FMLA leave is deemed terminated by your employer, you may, on the date of such termination, be eligible for Continuation Under Federal Law on the same terms as though your employment terminated, other than for gross misconduct, on such date. If this Plan provides any other continuation of coverage (for example, upon termination of employment, death, divorce or ceasing to be a defined dependent), you (or your eligible dependents) may be eligible for such continuation on the date your employer determines your approved FMLA leave is terminated or the date of the event for which the continuation is available. If you acquire a new dependent while your coverage is continued during an approved FMLA leave, the dependent will be eligible for the continued coverage on the same terms as would be applicable if you were actively at work, not on an approved FMLA leave. If you return to work for your employer following the date your employer determines the approved FMLA leave is terminated, your coverage under this Plan will be in force as though you had continued in active employment rather than going on an approved FMLA leave provided you make request for such coverage within 31 days of the date


your employer determines the approved FMLA leave to be terminated. If you do not make such request within 31 days, coverage will again be effective under this Plan only if and when this Plan gives its written consent. If any coverage being continued terminates because your employer determines the approved FMLA leave is terminated, any Conversion Privilege will be available on the same terms as though your employment had terminated on the date your employer determines the approved FMLA leave is terminated. UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) USERRA generally allows you to leave work for military service and continue coverage for yourself and your covered dependents under an employment-based group health plan. Temporary Continuation of Coverage provides for 12 months of coverage. USERRA provides for 24 months of coverage. If military service is for 30 or fewer days, you and your family can continue coverage at the same cost as before your short service. If military service is longer, you and your family may be required to pay the full premium for coverage. This complies with the benefit provisions of the Uniformed Services Employment and Reemployment Rights Act (USERRA). The uniformed services are:

the Armed Forces, the Army National Guard and the Air National Guard (when engaged in active duty for training, inactive duty training, or full-time National Guard duty);

the Commissioned Corps of the Public Health Service; and

any other category of persons designated by the President of the United States in time of war or emergency.

If you were previously eligible to enroll, but opted not to, you may (if eligible) elect to enroll during the Annual Enrollment Period. Your new coverage will become effective January 1 of the following year. Contact Human Resources for details.

HOW THE PLAN WORKS

It is important that you have the information and useful resources to help you get the most out of your medical plan. This Benefit Plan Booklet explains: Definitions You need to know;

How to access care, including procedures You need to follow;

What expenses for services and supplies are covered and what limits may apply;

What expenses for services and supplies are not covered by the plan;

How You share the cost of Your covered services and supplies; and

Other important information such as eligibility, complaints and appeals, termination, continuation of coverage, and general administration of the plan.

Important Notes

Unless otherwise indicated, You refers to You and Your covered dependents.


Your health plan pays benefits only for services and supplies described in this Benefit Plan Booklet as covered expenses that are medically necessary.

This Benefit Plan Booklet applies to coverage only and does not restrict Your ability to receive health care services that are not or might not be covered benefits under this health plan.

Store this Benefit Plan Booklet in a safe place for future reference. Common Terms Many terms throughout this Benefit Plan Booklet are defined in the Glossary section at the back of this document. Understanding these terms will also help you understand how your plan works and provide you with useful information regarding Your coverage. Network Providers When You or Your eligible dependents become covered under this plan, You have access to a unique network of Primary Care Physicians, specialists and health care facilities. You will receive the Plans maximum level of coverage when You receive care from a participating Florida Hospital Healthcare System (FHHS) provider. This type of provider is referred to as Tier 1. Care provided by a physician in the customized MultiPlan/PHCS network is covered as Tier 2. All other non-contracted providers are covered as Tier 3. NOTE: Your share of the cost will be higher for services rendered by Tier 2 or Tier 3 providers. Network providers (Tier 1 and Tier 2) have agreed not to balance bill You for the difference in their billed charge and the negotiated fees. Read Your Schedule of Benefits carefully to understand the cost sharing charges applicable to You.

Note on Network Providers If Your provider is contracted with both FHHS and MultiPlan/PHCS, claims for covered services rendered will be processed per the FHHS Provider Network contract.

Open Access You can choose to see any physician in the contracted networks without a referral, including specialists. The PLAN does not require You to select a Primary Care Physician (PCP), but its still important to establish a relationship with a doctor for Your preventive and primary care needs and to coordinate any specialty care You may need. The list of Network Providers is subject to change. You are responsible for verifying the participation status of the Physician, Hospital, Pharmacy or other providers prior to receiving Covered Services. When a provider on the list no longer has a contract with their respective ADMINISTRATOR, You must choose among remaining Network Providers to continue to maximize the highest benefit level. Tier 1

Medical- Florida Hospital Health System (FHHS) Provider Network You may search online for the most current list of participating providers in Your area by using the online provider directory at www.myFHCA.org. FHHS contracts with physicians, hospitals and other healthcare practitioners at negotiated discounts throughout Orange, Osceola, Seminole, Lake, Flagler, Volusia,


Highlands, Hardee, Hillsborough, Pasco, Pinellas and Polk counties. Since some of the benefits may require You to share in the cost for covered services (coinsurance), Your share of the cost will be calculated off the negotiated discounted fee.

Prescription Drug

o MedImpact Contracted Retail Pharmacies includes both national chains (such as Walgreens, CVS, Publix, Winn Dixie, Target, Walmart, K-Mart, and many more) and independent pharmacies

o RX Plus Mail Service Pharmacy Tier 2

MultiPlan/PHCS contracted Physicians and most Facilities All physicians, ancillary providers and most facilities contracted in the MultiPlan/PHCS network. You may search online for the most current list of participating providers through a link on myFHCA.org.

Tier 3

Out-of-Network Providers With the exception of Out-of-Network pharmacies, You may choose to receive covered medical services from any Out-of-Network Provider for covered medical and mental health/substance abuse services. However, in almost all cases Your out-of-pocket expenses are higher if You use Out-of-Network Providers. The Plan only pays a portion of any charges for Out-of-Network Providers. It is Your responsibility to pay the remainder. In addition, You will be responsible for any charges in excess of the Out-of-Network Fee Schedule the provider may bill. This is referred to as balance billing. The amount that You may be balance billed can be significant and does not count towards the Out-of-Pocket Maximum Expense Limit. To avoid any surprises, ask Your Out-of-Network Provider about their billed charges before You receive care.

Remember that while You may self-refer to any Provider, the care You receive may need to be authorized in advance for medical necessity regardless of whether or not the Health Care Provider is a Network Provider or an Out-of-Network Provider. The Pharmacy Network is contracted and maintained by MedImpact and includes the MedImpact's contracted retail pharmacies for short term prescription drug benefits and Rx Plus Mail Service Pharmacy for long term and specialty drug benefits. There are no benefits for prescription drugs filled by Out-of-Network pharmacies.

COVERAGE PROVISIONS

This section provides important information on the coverage provided under the PLAN, explaining: 1. How Deductibles, Coinsurance Percentages, Copayments and Maximum Out-Of-Pocket Expense Limits all impact what the Plan will pay;

2. The services that are covered under the Plan;


3. The Pre-Certification and Authorization procedures that must be followed, and rules related to Emergency Care Services;

4. The services that are not covered under the Plan. UNDERSTANDING THE PLAN The Plan either pays the Health Care Provider directly for Covered Services or pays you directly when you have incurred expenses related to Covered Services that have been provided. In general, the determination of coverage for expenses under the Plan can be understood as follows: 1. The deductible must be satisfied. (See the Deductible provision.)

2. You pay a percentage share of the Allowance. (See the Coinsurance Percentage and Allowance Guideline provisions.)

3. You may pay a Copayment for specified services at the time the service is rendered.

4. When out-of-pocket expenses reach a specified limit amount, the Plan pays 100% of the Covered Services. (See the Maximum Out-of-Pocket Expense Limit Provision.)

5. All services rendered must be Medically Necessary as defined in the Plan and must not be specifically excluded, limited, or restricted in the Plan. (See the Medically Necessary and the Exclusions and Limitations provisions).

6. The level of benefits is determined by whether the Covered Service is rendered by Network or Out-of-Network Providers. Covered services rendered by Network Providers may be paid at Tier 1or Tier 2 benefits depending upon the network provider. Covered services rendered by Out-of-Network Providers are paid at the Tier 3 benefit level and generally mean more out-of-pocket cost. Exceptions to process Tier 3 Provider claims at the Tier 2 Benefit Level. There are two exceptions where claims for covered services rendered by a Tier 3 provider will be processed at the Tier 2 benefit level:

a. Emergency Services rendered in an Out-of-Network hospital until the patient is stable to be transferred to a Network facility. If you elect to remain at the Out-of-Network hospital once stable, then at that point, the continued claims will be processed at the Tier 3 benefit level.

b. If you require care from a Tier 3 facility because services are not offered at a Tier 1 or Tier 2 facility, and such care has been authorized by FHCA in advance, the Plan payment for Covered Services will be at the Tier 2 benefit level.

Refer to the Schedule of Benefits for specific details for each Benefit Tier. COPAYMENTS For some services, You are responsible for paying a portion of the cost of Covered Services. Usually, this portion is a flat dollar amount referred to as a Copayment. Copayments may be due at the time of service. The Copayment requirements are set forth in the Schedule of Benefits. THE DEDUCTIBLE Before the Plan will begin paying expenses for most Covered Services, You must satisfy the Deductible. This deductible is a flat dollar amount as specified in the


Schedule of Benefits, and must be satisfied each Calendar Year. Once the Deductible amount specified in the Schedule of Benefits is reached, the Deductible will be considered satisfied. THE COINSURANCE PERCENTAGE You are responsible for paying a percentage of Covered Services in addition to the deductible each calendar year. The percentage You are responsible for is called the Coinsurance Percentage. The Coinsurance Percentage is shown in the Schedule of Benefits. ALLOWANCE GUIDELINES Once the Deductible is satisfied, the PLAN will pay a percentage of the eligible expenses for Covered Services (see Coinsurance Percentage provision above). With most expenses, the ADMINISTRATOR will first determine if the Provider is a contracted in the Network or is Out-of-Network.

Network Provider Allowance When covered services are rendered by Network Providers, the ADMINISTRATOR calculates all coinsurance amounts by applying the Coinsurance Percentage to the amount the Network Provider has agreed to accept for that service or supply in the negotiated fee schedule. If the Providers charges exceed the negotiated fee Schedule, the provider agrees not to balance bill You the excess. Out-of-Network Allowance In the event You receive covered services from a provider who is not contracted in the Network, the benefit will be calculated using an Out-of-Network Fee Schedule. If the Out-of-Network Providers charges exceed the Out-of-Network Fee Schedule, the excess amount will not be paid by the PLAN. This difference can be substantial. This excess amount will be Your responsibility and should be discussed with the Health Care Provider. For Example: An Out-of-Network Provider charges $500 for a covered service. The Out-of-Network Fee Schedule for this service is $400. The difference is $100. You will be responsible for the $100 difference. The PLAN will only consider $400 when applying deductibles and coinsurance. The $100 difference You are responsible for is in addition to any deductible and coinsurance. And this difference does not count towards the PLANs Out-of-Pocket Maximum Expense Limit.

MAXIMUM OUT-OF-POCKET EXPENSE LIMIT The Maximum Out-of-Pocket Expense Limit is the maximum amount You pay out-of-pocket each calendar year before the PLAN pays Covered Services at 100% of the Allowance determination for the remainder of that calendar year. The Maximum Out-of-Pocket Expense Limit is shown in the Schedule of Benefits.


COVERED SERVICES

The PLAN covers certain treatments for illness, injury, and pregnancy. Coverage is not necessarily limited to services and supplies described in this section, but do not assume that an unlisted service is covered. If You have questions about coverage, call the ADMINISTRATOR. Covered Services must be Medically Necessary except for covered Preventive Services. Medically necessary means a medical service or supply that is required for the identification, treatment, or management of a Condition is medically necessary if, in the opinion of the ADMINISTRATOR, it is: 1. Consistent with the symptom, diagnosis, and treatment of Your Condition;

2. Widely accepted by the practitioners' peer group as efficacious and reasonably safe based upon scientific evidence;

3. Universally accepted in clinical use such that omission of the service or supply in these circumstances raises questions regarding the accuracy of diagnosis or the appropriateness of the treatment;

4. Not Experimental, Investigational, or Unproven;

5. Not for cosmetic purposes;

6. Not primarily for the convenience of the Covered Person, the Covered Person's family, the Physician, or other Provider, and

7. The most appropriate level of service, care, or supply which can safely be provided to You. Pre-certification and authorization is required for certain services in order for them to be covered. See the Authorization Requirements section for more information. If the safety and the efficacy of all alternatives are equal, The PLAN will provide coverage for the least costly alternative. When applied to inpatient care, Medically Necessary further means that the services cannot be safely provided to You in an alternative setting. MEDICAL SERVICES Ambulance Services Covered expenses include charges made by a professional ambulance, as follows:

Ground Ambulance - Covered expenses include charges for transportation:

To the first hospital where treatment is given in a medical emergency.

From one hospital to another hospital in a medical emergency when the first hospital does not have the required services or facilities to treat Your condition.

From hospital to home or to another facility when other means of transportation would be considered unsafe due to Your medical condition.

From home to hospital for covered inpatient or outpatient treatment when other means of transportation would be considered unsafe due to Your medical condition. Transport is limited to 100 miles.


When during a covered inpatient stay at a hospital, skilled nursing facility or acute rehabilitation hospital, an ambulance is required to safely and adequately transport You to or from inpatient or outpatient medically necessary treatment.

Air or Water Ambulance - Covered expenses include charges for transportation to a hospital by air or water ambulance when:

Ground ambulance transportation is not available; and

Your condition is unstable, and requires medical supervision and rapid transport; and

In a medical emergency, transportation from one hospital to another hospital; when the first hospital does not have the required services or facilities to treat Your condition and You need to be transported to another hospital; and the two conditions above are met.

Limitations Not covered under this benefit are charges incurred to transport You: - If an ambulance service is not required by Your physical condition; or

- If the type of ambulance service provided is not required for Your physical condition; or

- By any form of transportation other than a professional ambulance service. Allergy Testing and Treatment Services include allergy testing, desensitization therapy and allergy immunotherapy, including hypo sensitization serum. Ambulatory Surgical Center or Other Outpatient Medical Treatment Facility Services

Use of operating room and recovery rooms;

Respiratory and inhalation therapy (e.g., oxygen);

Drugs and medicines administered (except for take home drugs) at the Ambulatory Surgical Center or other Outpatient Medical Treatment Facility;

Intravenous solutions;

Dressings, including ordinary casts, splints, or trusses;

Anesthetics and their administration;

Transfusion supplies and equipment;

Diagnostic services, including radiology, ultrasound, laboratory, pathology and approved machine testing (e.g., electrocardiogram (EKG);

Imaging services, including CT Scans, Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET) Scans, Nuclear Cardiology Studies;

Chemotherapy treatment for proven malignant disease; and

Other Medically Necessary services and supplies. Anesthesia Services Performed by an anesthesiologist or certified registered nurse anesthetist in connection with a surgical procedure.


Applied Behavioral Analysis Medically necessary services for children with Autism Spectrum Disorders. Applied Behavioral Analysis includes the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including, but not limited to, the use of direct observation, measurement and functional analysis of the relations between environment and behavior. Autism Services Treatment of Autism is limited to treatment that is prescribed by the treating Physician in accordance with an approved Treatment Plan. Benefits apply to children under 18 years of age or in high school who have been diagnosed as having a developmental disability at 8 years of age or younger: Covers the following spectrum of disorders:

Autistic disorder;

Aspergers syndrome; and

Pervasive developmental disorder not otherwise specified

Well-baby and well-child screening for diagnosing the presence of autism

Treatment of autism through speech therapy, occupational therapy, physical therapy, and applied behavior analysis provided by certified behavior analysts, psychologists, clinical social workers, and others

Bariatric Surgery Bariatric surgery will be covered by the PLAN, subject to the member cost share and limitations as set forth in the Schedule of Benefits, if the following is met for adult members (18 years of age or older): You have been an active member of the PLAN continuously for the 2-year period prior to receiving surgery; and

1. have been severely obese with a BMI of at least 40 or at least 35 with one or more comorbidities (see definition) for at least five years immediately prior to the procedure;

2. have been evaluated by an appropriate behavioral health professional, addressing components such as behavioral, cognitive, emotional, developmental, current life situation, motivation, and expectations;

3. have undergone a preoperative psychological evaluation by a psychiatrist or psychologist if a history of a psychiatric or psychological disorder exists, or if the member is currently under the care of a psychologist/psychiatrist or on psychotropic medications;

4. Have been previously unsuccessful with medical treatment for obesity, meaning: a. The patient has been provided with knowledge and tools needed to

achieve such lifelong lifestyle changes, exhibits understanding of the needed changes and has demonstrated to clinicians involved in his or her care to be capable and willing to undergo the changes;


b. The patient has made a diligent effort to achieve healthy body weight with such efforts described in the medical record and certified by the operating surgeon;

c. The patient has failed to maintain a healthy weight despite adequate participation in a structured weight loss program overseen by one of the following:

i. Physician (MD or DO) ii. Registered dietician (RD) iii. Board certified specialist in pediatric nutrition (CSP) iv. Board certified specialist in renal nutrition (CSR) v. Fellow of the American Dietetic Association (FADA)

5. Must have participated in and complied with a physiciansupervised weight 6. loss program for three consecutive months within twelve months prior to the

requested procedure. The weightloss program must include the following: a. Nutritional counseling;

b. Lowcalorie diet; c. Physical activity; d. Behavior modification services supervised by an appropriate behavioral

health specialist;. e. At least monthly documented visits to a physician with progress noted in

the physicians official medical record. A physicians summary letter will not suffice; and

f. Consideration of weight loss drug therapy NOTE: Coverage is limited to services rendered at Florida Hospital Celebration only. Birthing Center Covered expenses include charges made by a Birthing Center for services and supplies related to Your care in a Birthing Center for:

Prenatal care;

Delivery; and

Postpartum care within 48 hours after a vaginal delivery Durable Medical Equipment and Supplies (DME) Durable Medical Equipment and supplies are covered if each of the following criteria is met: - Ordered, prescribed, or provided by a physician for the outpatient use for the patients condition; and

- Used for medical purposes for a covered medical condition; and

- Equipment, appliances, and devices cannot be consumable or disposable; and

- Are not available over the counter. Covered Durable Medical Equipment includes those items covered by Medicare unless excluded in the Exclusions section of this Plan.


If more than one piece of durable medical equipment can meet Your functional needs, benefits are available for the most cost-effective piece of equipment, as determined by FHCA. At FHCAs option, the cost of either renting or purchasing will be covered. If the cost of renting is more than its purchase price, only the cost of the purchase is considered a Covered Service. The plan limits coverage to one item of equipment, for the same or similar purpose and the accessories needed to operate the item. You are responsible for the entire cost of any additional pieces of the same or similar equipment You purchase or rent for personal convenience or mobility. Covered expenses include charges by a DME supplier for the rental of equipment or, in lieu of rental: The initial purchase of DME if: - Long term care is planned; and

- The equipment cannot be rented or is likely to cost less to purchase than to rent. Repair of purchased equipment. Maintenance and repairs needed due to misuse or abuse are not covered. Replacement of purchased equipment if: - The replacement is needed because of a change in Your physical condition; and

- It is likely to cost less to replace the item than to repair the existing item or rent a similar item. Emergency Care Services Coverage will be provided for medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists. If it is determined that an emergency medical condition exists, the care, treatment, or surgery necessary to relieve or eliminate the emergency medical condition, within the service capability of a hospital, is covered. In the event of an emergency medical condition, You or Your family should notify FHCA within 24 hours or as soon as reasonably possible. Only the initial treatment as described above is covered without authorization and all follow-up care must be coordinated to ensure proper coverage under this PLAN. Covered expenses include charges made by a hospital or a physician for services provided in an emergency room to evaluate and treat an emergency medical condition. The emergency care benefit covers:

Use of the emergency room facilities;

Emergency room physicians services;

Hospital nursing staff services; and

Radiologist and pathologists services.


Family Planning Services - Other Than Services in Preventive Services Section Covered expenses include charges for certain family planning services, even though not provided to treat an illness or injury.

Voluntary sterilization for males Foot Care

Services associated with foot care, that are recommended by a physician as result of infection;

Routine foot care for diabetics who are prone to peripheral vascular disease;

Treatment of any condition resulting from weak, strained, flat, unstable or unbalanced feet, when surgery is performed;

Treatment of corns, calluses and toenails, when at least part of the nail root is removed for diabetics;

Physician office visit for diagnosis of bunions. Treatment of bunions when an open cutting operation or arthroscopy is performed;

Genetic Testing Testing that uses a proven testing method for the identification of genetically-linked inheritable disease. Genetic testing is covered only if:

It has been determined that the member is at risk of carrier status (as supported by existing peer-reviewed, evidence-based, scientific literature) for the presence of a genetically-linked inheritable disease, and

The purpose of the testing is to possibly identify a specific genetic mutation that has been demonstrated in the existing peer-reviewed, evidence-based, scientific literature to impact clinical outcome, the results of which are necessary to subsequently direct the immediate choice of available treatment options of a physical condition

Genetic testing when linked to amniocentesis Hearing Services Audiometric hearing exams are covered (one for any 24-month period) if performed by a physician certified as an otolaryngologist or otologist or an audiologist (who is legally qualified, certified and at the written direction of an otolaryngologist or otologist. Preventive hearing exams performed by a Primary Care Physician as required by the Affordable Care Act. Home Health and Home Infusion Services Covered expenses include charges for home health care services when ordered by a physician as part of a home health plan and provided You are:

Transitioning from a hospital or other inpatient facility, and the services are in lieu of a continued inpatient stay; or

Homebound Covered expenses include only the following:


Skilled nursing services that require medical training of, and are provided by, a licensed nursing professional within the scope of his or her license.

Medical social services, when provided in conjunction with skilled nursing care, by a qualified social worker.

Benefits for home health care visits are payable up to the Home Health Care Maximum. Coverage for Home Health Care services is not determined by the availability of caregivers to perform them. The absence of a person to perform a non-skilled or custodial care service does not cause the service to become covered. If the covered person is a minor or an adult who is dependent upon others for non-skilled care (e.g. bathing, eating, toileting), coverage for home health services will only be provided during times when there is a family member or caregiver present in the home to meet the persons non-skilled needs. Note: Home short-term physical, speech, or occupational therapy is covered when the above home health care criteria are met. Services are subject to the conditions and limitations listed in the Short Term Rehabilitation Therapies section of the Schedule of Benefits. Limitations Unless specified above, not covered under this benefit are charges for:

Services or supplies that are not a part of the Home Health Care Plan.

Services of a person who usually lives with You, or who is a member of Your or Your spouses family.

Services of a certified or licensed social worker.

Services of a Home Health Aide

Services for physical, occupational and speech therapy. Refer to Short Term Rehabilitation Therapies section for coverage information.

Transportation.

Services or supplies provided to a minor or dependent adult when a family member or caregiver is not present.

Services that are custodial care. Important Reminders The plan does not cover custodial care, even if care is provided by a nursing professional, and family member or other caretakers cannot provide the necessary care. Hospice Services If You are diagnosed as having a terminal illness with a life expectancy of one year or less, You may elect hospice care for such illness instead of the traditional services covered under this PLAN. To qualify for coverage, the attending Physician must certify that You are not expected to live more than one year on a life expectancy certification and submit a written hospice care plan or program. Under these circumstances, the following services are covered:


1. Physician services and part-time or intermittent nursing care by a registered nurse or licensed practical nurse;

2. Home health aides;

3. Inhalation (respiratory) therapy;

4. Medical social services;

5. Medical supplies, drugs and appliances;

6. Medical counseling for the terminally ill; and

7. Physical, Occupational and Speech Therapy, if approved by FHCA as appropriate for special circumstances.

8. Inpatient hospice care in a hospice facility, Hospital or Skilled Nursing Facility, including care for pain control or acute chronic symptom management. Covered hospice services do not include bereavement counseling, pastoral counseling, financial or legal counseling, or custodial care. Hospice Care Covered expenses include charges made by the following furnished to You for hospice care when given as part of a hospice care program. Facility Expenses - the charges made by a hospital, hospice or skilled nursing facility for:

Room and Board and other services and supplies furnished during a stay for pain control and other acute and chronic symptom management; and

Services and supplies furnished to You on an outpatient basis. Outpatient Hospice Expenses - Covered expenses include charges made on an outpatient basis by a Hospice Care Agency for:

Part-time or intermittent nursing care by a R.N. or L.P.N. for up to eight hours a day;

Part-time or intermittent home health aide services to care for You up to eight hours a day.

Medical social services under the direction of a physician. These include but are not limited to:

o Assessment of Your social, emotional and medical needs, and Your home and family situation;

o Identification of available community resources; and

o Assistance provided to You to obtain resources to meet Your assessed needs.

Physical and occupational therapy; and

Medical supplies;

Prescription drugs;

Dietary counseling; and

Psychological counseling.


Charges made by the providers below if they are not an employee of a Hospice Care Agency; and such Agency retains responsibility for Your care:

A physical or occupational therapist;

o A home health care agency for: o Physical and occupational therapy;

o Part time or intermittent home health aide services for Your care up to eight hours a day;

o Medical supplies;

o Prescription drugs;

o Psychological counseling; and

o Dietary counseling.

Limitations Unless specified above, not covered under this benefit are charges for: - Daily room and board charges over the semi-private room rate.

- Funeral arrangements.

- Pastoral counseling.

- Financial or legal counseling. This includes estate planning and the drafting of a will.

- Homemaker or caretaker services. These are services which are not solely related to Your care. These include, but are not limited to: sitter or companion services for either You or other family members; transportation; maintenance of the house.

Infertility Covered expenses include charges made by a physician to diagnose and to surgically treat the underlying medical cause of infertility. Inpatient Hospital Services Expenses for the services and supplies listed below shall be considered Covered Services when furnished at a Hospital on an inpatient basis.

Room and board for semi-private accommodations, unless the patient must be isolated from others for documented clinical reasons;

Confinement in an intensive care unit including cardiac, progressive, and neonatal care;

Miscellaneous hospital services;

Routine nursery care for a newborn child;

Drugs and medicines administered by the Hospital;

Respiratory, pulmonary, or inhalation therapy (e.g., oxygen);

Rehabilitative services, when hospitalization is not primarily for rehabilitation;

Use of operating room and recovery rooms;

Cost for and administration of blood and blood products..

Use of emergency rooms;

Intravenous solutions;


Dressings, including ordinary casts, splints and trusses;

Anesthetics and their administration;

Transfusion supplies and equipment;

Diagnostic services, including radiology, ultrasound, laboratory, pathology and approved machine testing (e.g., electrocardiogram (EKG);

Imaging services, including CT Scans, Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET) Scans, Nuclear Cardiology Studies;

Other Medically Necessary services and supplies. Jaw Joint Disorder Treatment The plan covers charges made by a physician, hospital or surgery center for the diagnosis and treatment of jaw joint disorder. A jaw joint disorder is defined as a painful condition:

Of the jaw joint itself, such as temporomandibular joint dysfunction (TMJ) syndrome; or

Involving the relationship between the jaw joint and related muscles and nerves such as myofacial pain dysfunction (MPD).

Benefits are payable up to the jaw joint disorder maximum shown in the Schedule of Benefits. Mental Health Services Covered expenses include charges made for the treatment of mental disorders by behavioral health providers. In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:

There is a written treatment plan supervised by a physician or licensed provider; and

The Plan is for a condition that can favorably be changed. Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility or behavioral health provider's office for the treatment of mental disorders as follows:

Inpatient Treatment - Covered expenses include charges for room and board at the semi-private room rate, and other services and supplies provided during Your stay in a hospital, psychiatric hospital or residential treatment facility. Inpatient benefits are payable only if Your condition requires services that are only available in an inpatient setting.

Partial Confinement Treatment - Covered expenses include charges made for partial confinement treatment provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of a mental disorder. Such benefits are payable if Your condition requires services that are only available in a partial confinement treatment setting.


Outpatient Treatment - Covered expenses include charges for treatment rendered while not confined as a full-time inpatient in a hospital, psychiatric hospital or residential treatment facility.

The plan covers partial hospitalization services (more than 4 hours, but less than 24 hours per day) provided in a facility or program for the intermediate short-term or medically-directed intensive treatment. The partial hospitalization will only be covered if You would need inpatient care if You were not admitted to this type of facility.

Nutritional Services

Charges made for nutritional evaluation and counseling when diet is part of the medical management of, including but not limited to, a documented organic disease, high cholesterol and triglyceride level, high blood pressure, digestive disorders, cancer, and food allergies

Charges made for nutritional evaluation and counseling for child 0-17 years of age for treatment of obesity or as required by the Affordable Care Act

Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth) Covered expenses include charges made by a physician, a dentist and hospital for:

Non-surgical treatment of infectio

2015 Benefit Plan Booklet FH 20150615

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Transcript of 2015 Benefit Plan Booklet FH 20150615