HMO_Attachment G - Benefits Document_2022.pdf

I. INTRODUCTION

II. DEFINITIONS

III. ELIGIBILITY, ENROLLMENT AND EFFECTIVE DATE

IV. SCHEDULE OF BENEFITS

V. MEDICAL BENEFITS

VI. LIMITATIONS AND EXCLUSIONS

VII. SPECIAL HMO PLAN FEATURES

VIII. PRESCRIPTION DRUG PROGRAM

IX. HOW TO FILE A CLAIM

X. COORDINATION OF BENEFITS

XI. SUBROGATION AND RIGHT OF RECOVERY, RECOUP, AND SUE FOR LOSSES

XII. DISCLAIMER OF LIABILITY

XIII. APPEALS AND GRIEVANCE PROCEDURE

XIV. BUNDLED SERVICES AND PRICING TRANSPARENCY PROGRAMS

XV. MISCELLANEOUS

SUMMARY PLAN DESCRIPTION INFORMATION

2 State Employees' HMO Plan Group Health Insurance Plan Booklet and Benefits

Document (Summary Plan Description or "SPD")

I. INTRODUCTION

The descriptions contained in this document are intended to provide a summary explanation of your benefits.

Easy-to-read language has been used as much as possible to help you understand the terms of the Plan. Your insurance coverage is limited to the express written terms of this Summary Plan Description (SPD). Your coverage cannot be changed based upon statements or representations made to you by anyone, including employees of the Division of State Group Insurance (DSGI), Aetna, CVS Caremark, People First or your employer.

This SPD describes the benefits provided to you by the State of Florida under the State Employees’ HMO Plan (or

Plan), for Health Plan Members, as defined herein, who have selected Aetna as their Claims administrator. This

SPD is made available for your reference and is subject to various legal requirements, including the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Plan is further subject to federal and State of Florida laws and rules promulgated pursuant to law including, but not limited to, Chapter 60 of the Florida Administrative Code. In any instance of conflict, the provisions of this SPD shall take precedence over provisions of law so far as legally permitted. Any clause, section or part of this SPD that is held or declared invalid for any reason shall be eliminated, and the remaining portion or portions shall remain in full force and be valid as if such invalid clause or section had not been incorporated herein. Unless otherwise noted in this document, if the terms of this document and the terms of the Plan conflict, the SPD shall control.

The State of Florida may designate any third-party administrators or Claims administrators to carry out certain

Plan duties and responsibilities. The State of Florida is responsible for formulating and carrying out all rules and procedures necessary to administer the Plan. The State of Florida, as Plan Administrator, has the discretionary authority to (1) make decisions regarding the interpretation or application of Plan provisions (2) determine the rights, eligibility, and benefits of Health Plan Members and beneficiaries under the Plan, and (3) review Claims under the Plan. The State of Florida may delegate to a third party any or all such discretionary authority described above. Benefits under the Plan will be paid only if the State of Florida, as Plan Administrator, or its designee or delegate decides in its discretion that the Health Plan Member is entitled to them. Whether such

Third Party Administrators have been delegated any such discretionary authority shall be determined solely on the basis of the contract between them and the state, and no such delegation shall be assumed to have been made unless expressly stated in their contract.

The State of Florida contracts with Aetna to arrange for the provision of Medical Services which are Medically

Necessary for the diagnosis and treatment of Health Plan Members through a network of contracted independent physicians and Hospitals and other health care providers and to administer Claims in connection therewith. Aetna, in arranging for the delivery of Medical Services or benefits, does not directly provide these

Medical Services or administer the Plan.

This benefit plan is designed to cover most major medical expenses for a covered illness or injury, including

Hospital, physician services and prescription drugs. However, you will be responsible for any:

1. Deductibles (HDHP Option only);

2. Coinsurance (HDHP Option only);

3. Copayments;

4. Hospital admission fees;

5. Non-covered services;

6. Amounts above or beyond the Plan’s Limitations;

3 State Employees' HMO Plan Group Health Insurance Plan Booklet and Benefits Document

(Summary Plan Description or "SPD")

7. Non-emergency services in a Non-Network Hospital, facility, or office (i.e., anesthesiology, nurse anesthetists, radiology, pathology, laboratory, emergency room physician services and so forth) unless authorized in advance by Aetna, not the Primary Care Physician; and

8. Any other services identified in this SPD as excluded.

This SPD describes enrollment and eligibility, Covered Services and Supplies, the amount the Plan pays for

Covered Services and Supplies, amounts that are your responsibility, and services and supplies that are not covered.

You Must Enroll to Receive Benefits

You must affirmatively enroll to receive benefits under the Plan, as explained in the section within this document titled “Eligibility, Enrollment and Effective Date.” If you do not take the actions outlined in this document to affirmatively enroll to receive benefits, you will not be entitled to any benefits of any kind under this Plan.

The Medical Services and Hospital Services covered by the Plan shall be provided without regard to the race, color, religion, physical handicap, or national origin of the Health Plan Member in the diagnosis and treatment of patients; in the use of equipment and other facilities; or in the assignment of personnel to provide services, pursuant to the provisions of Title VI of the Civil Rights Act of 1964, as amended, and the Americans with

Disabilities Act of 1990.

If you have questions about your coverage after reading this booklet, you may call any of the telephone numbers listed on the WHO TO CALL section at the beginning of this document and talk with a member service representative.

Medical Claims

The Plan is not intended to and does not cover or provide any Medical Services or benefits that are not

Medically Necessary for the diagnosis and treatment of the Health Plan Member. Aetna determines whether the services are Medically Necessary on the basis of the terms, conditions, and criteria established by the Plan as interpreted by the state, and as set forth in the medical guidelines. The State’s interpretations of the Plan shall be communicated to Aetna by such means as may be agreed upon between them including, but not limited to, the appeals process set forth in Section XIII below and the final determination of DSGI on behalf of the Plan.

Claims for benefits are to be sent to Aetna. Sometimes medical providers make a mistake and over charge for the service. Please report any suspected billing errors to Aetna.

Patient Auditor Program

Sometimes providers make a mistake and overcharge a patient. This may result in an overpayment of the claim by this Plan. If you discover an overpayment for any of the following, you may receive 50 percent of any

4 State Employees' HMO Plan Group Health Insurance Plan Booklet and Benefits Document amount the State recovers, up to a maximum of $1,000 per claim:

1. A charge for Covered Services or Supplies that the covered person did not receive;

2. A charge higher than the amount previously agreed to in writing by the provider in a pretreatment estimate, other than charges for complications or procedures that were not anticipated; or

3. A charge that is part of an arithmetic billing error.

Contact DSGI at (850) 921-4600 to request a form to file a Patient Auditor claim. Report any suspected overcharges to DSGI.

Prescription Drug Claims

When you use a participating pharmacy, you do not need to file a Claim. The Claim will be submitted electronically to CVS Caremark. You will be responsible for your Copayment or Coinsurance, subject to the calendar year Deductible, if applicable to your Plan.

Rights to Employment

The existence of this Plan does not affect the employment rights of any employee or the rights of the state to discharge an employee.

Rights to Amend or Terminate the Plan

The State has arranged to sponsor this Plan indefinitely, but reserves the right to amend, suspend, or terminate it for any reason. Plan fee schedules, allowed amounts, allowances, physician and pharmacy network participation status, medical policy guidelines, prescription preferred drug list, prescription specialty drug program guidelines and premium rates are subject to change at any time without the consent of Health

Plan Members. You will be given notice of any changes that affect your benefit levels as soon as administratively possible.

Primary Care Physician

We strongly encourage you to select a participating Primary Care Physician (PCP) who is responsible for providing and managing all of your primary health care. You may change PCPs anytime by calling Aetna in advance. Your PCP does not need to refer you when you need to see a Specialist. Go to Aetna’s website listed in this document’s contact section to access the most current list of Participating Providers and

Hospitals.

NOTICE: as prohibited by the terms of the Plan, the following acts will be treated as fraud or misrepresentation of material fact:

• Falsifying dependent information;

• Falsely certifying ineligible persons as eligible;

• Falsifying dependent documentation;

• Falsely enrolling ineligible persons in Coverage;

• Falsifying the occurrence of Qualifying Status Change ("QSC") Events; or

• Falsifying QSC Event documentation.

5 State Employees' HMO Plan Group Health Insurance Plan Booklet and Benefits Document

Such acts will require you to reimburse the Plan for any fraudulent Claims incurred, or if still within the

COBRA election window, for paying COBRA premiums for any months ineligible persons were covered.

6 State Employees' HMO Plan Group Health Insurance Plan Booklet and Benefits Document

II. DEFINITIONS

As used in this SPD, each of the following terms are capitalized throughout this document shall have the meaning indicated:

Accidental Dental Injury - An injury to sound natural teeth caused by a sudden, unintentional, and unexpected event or force. This term does not include injuries to the mouth, structures within the oral cavity, or injuries to natural teeth caused by biting or chewing, surgery, or treatment for a disease or illness.

Adverse Benefit Determination - A denial, reduction, termination of, or a failure to provide or make payment

(in whole or in part) for, a benefit, including any such action that is based on a determination of a Health Plan

Member’s eligibility to participate in the Plan; the application of any Utilization Management Program; the failure to cover an item or service for which benefits are otherwise provided because it is determined to be

Experimental and/or Investigational or not Medically Necessary; a cancellation or discontinuance of coverage that has retroactive effect, unless attributable to a failure to timely pay required premiums or contributions toward the cost of coverage; and the requirements of the Shared Savings Program.

Applied Behavior Analysis - The design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including, but not limited to, the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. Applied Behavior Analysis services shall be provided by an individual certified pursuant to Section 393.17, Florida Statutes, or an individual licensed under Chapter 490 or Chapter 491, Florida

Statutes.

Autism Spectrum Disorder - Any of the following disorders as defined in the most recent edition of the

Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association:

• Autistic disorder;

• Asperger’s syndrome;

• Pervasive developmental disorder not otherwise specified.

Claim - A request for benefits under the Plan made by a Health Plan Member in accordance with Aetna’s procedures for filing benefit Claims, including Pre-Service Claims and Post-Service Claims.

Coinsurance - The amount a Health Plan Member must pay once the Deductible has been met, if applicable, and is expressed as a percentage of the fee for the covered benefit.

Copayment - The portion of the cost, in addition to the prepaid premium amounts, which the Health Plan

Member is required to pay at the time certain health services are provided under the Plan. The Copayment may be a specific dollar amount or a percentage of the cost. The Health Plan Member is responsible for the payment of any Copayments directly to the provider of the health services at the time of service.

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Covered Service or Covered Services and Supplies – Health care services and supplies, including pharmaceuticals as described in Section VIII, for which reimbursement is covered under this Plan. The

Division of State Group Insurance (DSGI) has final authority to determine if a service or supply is covered, limited, or excluded by the Plan.

Deductible - The first payments up to a specified dollar amount which a Health Plan Member must make in the applicable calendar year for covered benefits. The Deductible applies to each Health Plan

Member, subject to any family Deductible listed on the Schedule of Benefits. For purposes of the

Deductible, “family” means the Enrollee and Health Plan Members. The Deductible must be satisfied once each calendar year.

Dental Care - Dental x-rays, examinations and treatment of the teeth or any services, supplies or charges directly related to:

• The care, filling, removal, or replacement of teeth, or

• The treatment of injuries to or disease of the teeth, gums or structures directly supporting or attached to the teeth, that are customarily provided by dentists (including orthodontics reconstructive jaw surgery, casts, splints, and services for dental malocclusion).

Developmental Disability – A disorder or syndrome that is: 1) attributable to an intellectual disability, cerebral palsy, autism, spina bifida, or Prader-Willi syndrome, 2) manifests before the age of 18, and 3) constitutes a substantial handicap that can reasonably be expected to continue indefinitely.

Down Syndrome –A chromosomal disorder caused by an error in cell division which results in the presence of an extra whole or partial copy of chromosome 21.

Emergency Medical Condition - A medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

• Serious jeopardy to the health of a patient, including a pregnant woman or fetus.

• Serious impairment to bodily functions.

• Serious dysfunction of any bodily organ or part.

With respect to a pregnant woman:

• That there is inadequate time to effect safe transfer to another Hospital prior to delivery;

• That a transfer may pose a threat to the health and safety of the patient or fetus; or

• That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes.

Examples of Emergency Medical Conditions include, but are not limited to, heart attack, stroke, massive internal or external bleeding, fractured limbs, or severe trauma.

• Emergency (In-area) - Does not include elective or routine care, care of minor illness or care that can

8 State Employees' HMO Plan Group Health Insurance Plan Booklet and Benefits Document reasonably be sought and obtained from the Health Plan Member’s Primary Care Physician. The initial determination as to whether or not an illness or injury constitutes an emergency shall be made by Aetna and may be made retrospectively based upon all information known at the time the patient was present for treatment, subject to the appeals process set forth in Section XIII below and the final determination of DSGI on behalf of the Plan.

• Emergency (Out-of-area) - Does not include care for conditions for which a Health Plan Member could reasonably have foreseen the need of such care before leaving the Service Area or care that could safely be delayed until prompt return to the Service Area. The initial determination as to whether or not an illness or injury constitutes an emergency shall be made by Aetna and may be made retrospectively based upon all information known at the time the patient was present for treatment; such initial determinations are subject to the appeals process set forth in Section XIII below and the final determination of DSGI on behalf of the Plan.

Emergency Medical Services and Care - A medical screening, examination and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician to determine if an Emergency Medical Condition exists and, if it does, the care, treatment, or surgery for a Covered

Service by a physician necessary to relieve or eliminate the Emergency Medical Condition within the service capability of the Hospital.

Enrollee - All state officers and employees, Retired State Officers or Employees, Surviving Spouses of deceased state officers and employees, and terminated employees or individuals with continuation coverage who are enrolled in an insurance plan offered by the State Group Insurance Program. “Enrollee” includes all state university officers and employees, retired state university officers and employees, Surviving Spouses of deceased state university officers and employees, and terminated state university employees or individuals with continuation coverage who are enrolled in an insurance plan offered by the State Group Insurance Program.

Exclusion - Any provision of the Plan whereby coverage for a specific hazard or condition is entirely eliminated.

Experimental and/or Investigational - For the purposes of this Plan a medication, treatment, device, surgery, or procedure may initially be determined by Aetna to be Experimental and/or Investigational if any of the following applies:

• The FDA has not granted the approval for general use; or

• There are insufficient outcomes data available from controlled clinical trials published in peer-reviewed literature to substantiate its safety and effectiveness for the disease or injury involved; or

• There is no consensus among practicing physicians that the medication, treatment, therapy, procedure or device is safe or effective for the treatment in question or such medication, treatment, therapy, procedure or device is not the standard treatment, therapy, procedure or device utilized by practicing physicians in treating other patients with the same or a similar condition; or

• Such medication, treatment, procedure or device is the subject of an ongoing Phase I or Phase II clinical investigation, or Experimental or research arm of a Phase III clinical investigation, or under study to determine: maximum tolerated dosage(s), toxicity, safety, efficacy, or efficacy as compared with the standard for treatment or diagnosis of the condition in question.

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Such initial determination shall be subject to the appeals process set forth in Section XIII below and the final determination of DSGI on behalf of the Plan.

Health Maintenance Organization or “HMO” - An entity certified under part I of chapter 641.

Health Plan Member - Any person participating in a State Group Health Insurance Plan or a Health Maintenance

Organization plan under the State Group Insurance Program, including Enrollees and other covered Health Plan

Members.

Health Professionals - Physicians, osteopaths, podiatrists, manipulative services providers, physician assistants, nurses, social workers, pharmacists, optometrists, clinical psychologists, nutritionists, occupational therapists, physical therapists and other professionals engaged in the delivery of health care services, who are licensed and practice under an institutional license, individual practice association or other authority consistent with State law.

Home Health Care Services (Skilled Home Health Care) - Services that are provided for a Health Plan Member who does not require confinement in a Hospital or Other Health Care Facility. Such services include, but are not limited to, the services of professional visiting nurses or other health care personnel for services covered under the Plan. A visit is limited to a period of two hours or less.

Hospice - A public agency or private organization that is duly licensed by the state to provide Hospice services.

Such licensed entity must be principally engaged in providing pain relief, symptom management and supportive services to terminally ill Health Plan Members.

Hospital - Any general acute care facility which is licensed by the state.

Hospital Services - Except as expressly limited or excluded by the Plan, means those services for registered bed patients that are:

i.) Generally and customarily provided by acute care general Hospitals in accordance with the standards of acceptable community practice;

ii.) Performed, prescribed, or directed by Participating Providers; and iii.) Medically Necessary for conditions which cannot be adequately treated in Other Health Care Facilities or with Home Health Care Services or on an outpatient or ambulatory basis.

Limitation - Any provision, other than an Exclusion, which restricts coverage under the Plan.

Medically Necessary - The use of any appropriate medical treatment, service, equipment and/or supply as provided by a Hospital, skilled nursing facility, physician or other provider which is necessary for the diagnosis, care and/or treatment of a Health Plan Member’s illness or injury, and which is:

• Consistent with the symptom, diagnosis, and treatment of the Health Plan Member’s condition;

• The most appropriate level of supply and/or service for the diagnosis and treatment of the Health Plan

Member’s condition;

• In accordance with standards of acceptable community practice;

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• Not primarily intended for the personal comfort or convenience of the Health Plan Member, the Health

Plan Member’s family, the physician or other health care providers;

• Approved by the appropriate medical body or health care specialty involved as effective, appropriate, and essential for the care and treatment of the Health Plan Member’s condition; and

• Not Experimental or investigational.

Medical Office - Any outpatient facility or physician’s office.

Medical Services - Except as limited or excluded by the Plan, means those professional services of physicians and other Health Professionals, including medical, surgical, diagnostic, therapeutic and preventive services, and pharmaceuticals as described in the Prescription Drug Program section that are:

• Generally and customarily provided in the Service Area;

• Performed, prescribed, or directed by Participating Providers; and

• Medically Necessary (except for preventive services as stated herein) for the diagnosis and treatment of injury or illness.

• Division of State Group Insurance has final authority to determine if a service or supply is covered, limited, or excluded under the Plan.

Mental and Nervous Disorder - Any disorder listed in the diagnostic categories of the International Classification of Disease (ICD-9 CM or ICD10-CM), or their equivalents in the most recently published version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, regardless of the underlying cause or effect of the disorder.

Network - The providers and facilities that have contracted with Aetna to provide Covered Services and Supplies to Health Plan Members. The Health Plan Members’ Copayment, Deductible and/or Coinsurance responsibilities are outlined in Section V - Medical Benefits within this document. Sometimes referred to as “Participating Provider.”

Non-participating Provider - Any Health Professional or group of Health Professionals, Hospital, Medical Office, or Other Health Care Facility with whom Aetna has neither made arrangements nor contracted to render the professional health services set forth herein as a Participating Provider. Sometimes referred to as “Non- Network.”

Other Health Care Facility - Any licensed facility, other than acute care Hospitals and those facilities providing services to ventilator dependent patients, which provides inpatient services such as skilled nursing care and rehabilitative services.

Participating Physician - Any Participating Provider licensed under Chapter 458 (physician), 459 (osteopath), 460

(chiropractor) or 461 (podiatrist), Florida Statutes.

Participating Provider - Any Health Professional (or group of), Hospital, Medical Office, or Other Health Care

Facility with whom Aetna has made arrangements or contracted to render the professional health services set forth herein.

Plan Administrator - State of Florida, Division of State Group Insurance, P.O. Box 5450, Tallahassee, FL 32314-

5450.

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Post-Service Claim - Any Claim for benefits under the Plan that is not a Pre-Service Claim.

Pre-Service Claim - Any Claim for benefits under the Plan for which (in whole or in part), a Health Plan Member must obtain authorization from Aetna in advance of such services being provided to or received by the Health

Plan Member.

Primary Care Physician - Any Participating Physician engaged in general or family practice, pediatrics, geriatrics, internal medicine, obstetrics/gynecology, or any specialty physician from time to time designated by Aetna as a

“Primary Care Physician” in Aetna’s current list of physicians and Hospitals.

Private Duty Nursing - Services provided by registered nurses, licensed practical nurses, or any other trained attendant whose services ordinarily are rendered to, and restricted to, a particular Health Plan Member by arrangements between the Health Plan Member and the private-duty nurse or attendant. Such persons are engaged or paid by an individual Health Plan Member or by someone acting on their behalf, including a

Hospital that initially incurs the costs and looks to the Health Plan Member for reimbursement for such services.

Retired State Officer or Employee or “Retiree” - Any state or state university officer or employee who retires under a state retirement system or a state optional annuity or retirement program or is placed on disability retirement, and who was insured under the State Group Insurance Program at the time of retirement, and who begins receiving retirement benefits immediately after retirement from state or state university office or employment. The term also includes any state officer or state employee who retires under the Florida

Retirement System Investment Plan established under part II of chapter 121 if he or she:

o Meets the age and service requirements to qualify for normal retirement as set forth in s. 121.021(29);

or o Has attained the age specified by s. 72(t)(2)(A)(i) of the Internal Revenue Code and has six years of creditable service.

Service Area - Those counties in the State of Florida where Aetna has been approved to conduct business by the

State of Florida Agency for Health Care Administration.

Sound Natural Tooth - A tooth that is whole or properly restored (restoration with amalgams only) and is not in need of the treatment provided for any reason other than an Accidental Dental Injury. For purposes of this Plan, a tooth previously restored with a crown inlay, inlay, or porcelain restoration, or treated by endodontics, is not considered a sound natural tooth.

Specialist - Any Participating Physician licensed under Chapter 458 (physician), 459 (osteopath), 460

(chiropractor) or 461 (podiatrist), Florida Statutes, other than the Health Plan Member’s Primary Care Physician.

State Group Health Insurance Plan or Plans or “state plan or plans” - The state self-insured health insurance plan or plans offered to state officers and employees, Retired State Officers or Employees, and Surviving

Spouses of deceased state officers and employees pursuant to this section.

State Group Insurance Program or “programs” - The package of insurance plans offered to state officers and employees, Retired State Officers or Employees, and Surviving Spouses of deceased state officers and employees pursuant to this section, including the State Group Health Insurance Plan or plans, Health

Maintenance Organization plans, and other plans required or authorized by law.

Substance Abuse - A condition where a person’s alcohol or drug use injures his or her health; interferes with his or her social or economic functioning; or causes the individual to lose self-control.

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Summary Plan Description (SPD) - This document which describes the Plan benefits, Exclusions, cost-share amounts, Claim administration procedures and other Plan features. Also called “Plan Booklet and Benefits

Document.”

Surviving Spouse - The widow or widower of a deceased state officer, full-time state employee, part-time state employee, or Retiree if such widow or widower was covered as a dependent under the State Group Health

Insurance Plan or a Health Maintenance Organization plan established pursuant to this section at the time of the death of the deceased officer, employee, or Retiree. “Surviving Spouse” also means any widow or widower who is receiving or eligible to receive a monthly state warrant from a state retirement system as the beneficiary of a state officer, full-time state employee, or Retiree who died prior to July 1, 1979. For the purposes of this section, any such widow or widower shall cease to be a Surviving Spouse upon his or her remarriage.

Urgent - A medical condition manifesting itself by acute symptoms that are of lesser severity than that recognized for an Emergency Medical Condition, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the illness or injury to place the health or safety of the Health Plan Member or another individual in serious jeopardy, in the absence of medical treatment within

24 hours. Examples of Urgent medical conditions include, but are not limited to: high fever, dizziness, animal bites, sprains, severe pain, respiratory ailments, and infectious illnesses.

Urgent Care - Medical screening, examination and evaluation in an ambulatory setting outside of a Hospital emergency department, including an Urgent Care center, retail clinic or PCP office after-hours, on a walk-in basis and usually without a scheduled appointment, and the Covered Services and Supplies for those conditions which, although not life-threatening, could result in serious injury or disability if left untreated.

Utilization Management Program - Those comprehensive initiatives that are designed to validate medical appropriateness and to coordinate Covered Services and Supplies. These include, but are not limited to:

• Concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, and skilled nursing facilities, including on-site review when appropriate;

• Case management and discharge planning for all inpatients and those requiring continued care in an alternative setting (such as home care or a skilled nursing facility) and for outpatients when deemed appropriate; and

• The benefit coordination program which is designed to conduct prospective reviews for select Medical

Services to ensure that services are covered and Medically Necessary. The benefit coordination program may also advocate alternative cost-effective settings for the delivery of prescribed care and may identify other options for non-covered health care needs.

• Concurrent care or review means an ongoing course of treatment to be provided over a period of time or number of treatments that was previously approved by Aetna.

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III. ELIGIBILITY, ENROLLMENT AND EFFECTIVE DATE

You and your eligible dependents may only be covered under one State of Florida health plan.

Active Employees

To be eligible to participate in the Plan, you must be a full-time or a part-time employee as defined in s.

110.123(2)(c) and (f), Florida Statutes.

Plan eligibility is determined by whether an employee’s position is salaried career service, select exempt service

(SES), or senior management service (SMS); and, in the case of an other personnel services (OPS) position, the expected hours of service of the employee.

Full-time state employees are eligible to participate in the Plan. These employees are salaried career service, SES, and SMS employees; and OPS employees expected to work an average of 30 or more hours per week.

Part-time state employees are eligible to participate in the Plan. These employees are salaried career service, SES, and SMS employees who work less than 30 hours per week. Employees in these positions are eligible to participate in the Plan but pay a pro-rated share of the employer premium.

OPS employees expected to work less than 30 hours per week on average are not eligible to participate in the

Plan.

Seasonal workers in OPS positions are not eligible to participate in the Plan. These employees hold positions for which the customary annual employment is six months or less and begins each year at approximately the same part of the year, such as summer or winter.

Plan eligibility is initially determined at the point of hire. For OPS employees who are not reasonably expected to work 30 or more hours per week, eligibility for subsequent plan years is determined using a look-back measurement method.

The 12-month look-back measurement method involves three different periods:

1. Measurement period – counts hours of service to determine Plan eligibility.

a. Initial Measurement Period – If you are an OPS employee who is not reasonably expected to work at least 30 hours per week at the point of hire, your hours of service from the first day of the month following your date of hire to the last day of the twelfth (12) month of employment will be measured.

An example: Assume you are hired October 5, 2017. Your initial measurement period will run from November 1, 2017 through October 31, 2018. If your hours worked during the initial measurement period average 30 hours or more per week, you are eligible to enroll in the Plan with an effective date of December 1, 2018.

If you are an OPS employee and become reasonably expected to work 30 hours or more per week during the initial measurement period, you become eligible to participate in the Plan at that time.

b. Open enrollment measurement period –If you have been employed long enough to work through a full measurement period, you are considered an ongoing employee. Your hours of service are measured during the open enrollment measurement period. This period runs from

14 State Employees' HMO Plan Group Health Insurance Plan Booklet and Benefits Document

October 3 through the following October 2 of each year and will determine Plan eligibility for the plan year that follows the measurement period.

If you are an employee who is reasonably expected to work an average of 30 hours or more per week upon hire you are eligible to enroll in the Plan. Plan eligibility will continue until your hours are measured during the next or second (depending on date of hire) open enrollment measurement period to determine Plan eligibility for the next plan year. If you were a non-full-time OPS employee at the time of your initial hire but become reasonably expected to work 30 hours or more per week during the open enrollment measurement period, you become eligible to participate in the Plan at that time.

An example: Assume you are hired January 5, 2017, in an OPS position and are expected to work an average of at least 30 hours per week. You are eligible to enroll in the Plan at your point of hire and will continue Plan eligibility through December 31, 2018. You will then be measured on October 3, 2018, by looking back at the previous 12-month period to determine if you worked at least 30 hours per week. Your eligibility for the 2021 plan year will depend on whether you worked an average of 30 hours or more per week during the 12-month measurement period or whether your employer reasonably expects you to work 30 or more hours per week.

2. Stability Period –follows a measurement period. If you are an OPS employee, the hours of service during the measurement period determines whether you are a full-time employee who is eligible for coverage during the stability period. If you are a full-time employee in the stability period, your eligibility is

“locked in” for the stability period, regardless of how many hours you work during the stability period, as long as you remain an employee of the State of Florida. However, if you were a non-full-time OPS employee but become reasonably expected to work 30 hours or more per week during the stability period, you become eligible to participate in the Plan at that time. For ongoing employees, the stability period lasts 12 consecutive months.

3. Administrative Period –the time between the measurement period and the stability period when administrative tasks, such as determining eligibility for coverage and facilitating Plan enrollment, are performed. If you are determined to be eligible, a benefits package showing your available options, costs, and effective dates will be mailed to your mailing address in People First, the system of record.

The rules for the look-back measurement method are complex, and this is a general overview of how the rules work. More complex rules may apply to your situation. The State of Florida intends to follow applicable IRS final regulations (including any future guidance issued by the IRS) when administering the look-back measurement method. If you have any questions about this measurement method and how it applies to you, call the People

First Service Center at (866) 663-4735 weekdays from 8 a.m. to 6 p.m. Eastern time.

Retirees

1. Retire under a State of Florida retirement system, pension plan, a state optional annuity, state retirement program or go on disability retirement under the State of Florida retirement system, as long as you were covered under health and life insurance at the time of your retirement and you begin receiving retirement benefits immediately after you retire; or

2. Retire under the Florida Retirement System Investment Plan, and you

• Meet the age and service requirements to qualify for normal retirement as set forth in s.

121.021(29), Florida Statutes; or have attained the age specified by s. 72(t)(2)(A)(i), Internal Revenue Code, and you have 6 years of creditable service; and

• Take an immediate distribution; and

20 State Employees' HMO Plan Group Health Insurance Plan Booklet and Benefits Document

Coverage begins on the first day of the month after the month in which the state deducts (or People First receives) a full month’s premium. Coverage always begins on the first day of a month and continues for the rest of the calendar year, as long as you pay premiums on time and remain eligible.

For example, you are hired July 20. If People First receives the enrollment information before August 1, coverage begins September 1, after the state deducts one full month’s premium from the paycheck. For health insurance only, new employees can elect an early effective date, provided they submit the full month’s employee share by check. For example, if an employee is hired July 20, health insurance can start on August 1 if the employee sends a check for the full month’s employee premium to People First and makes the election before August 1.

For OPS/variable hour employees, the earliest health coverage will start is the first day of the third month of employment. For example, employees hired in March will begin coverage in May.

Option 2 –QSC Event

To make an enrollment change based on a QSC event, federal law requires that the event result in a gain or loss of eligibility for coverage, and elections must meet general consistency rules. For example, if you have individual health insurance coverage and get married, you may change from individual to family coverage and enroll your spouse in coverage. However, you cannot change health insurance plans because the QSC event only changes the level of coverage eligibility. In this case, changing plans is not consistent with the nature of the QSC event.

QSC events allow you 60 days (unless otherwise noted) from the date of the event to make allowable changes to your health insurance. Depending on the type of QSC event, changes may include enrolling or cancelling, increasing, or decreasing coverage, or adding or removing dependents. You may be asked to submit all required documentation to People First within 60 days of the change. The complete list of QSC events, required documentation and important time frames is available on the myBenefits web site in the Forms and Resources section, QSC Matrix.

If you have a QSC event and want to change your health insurance election, you must:

• Make the change online in People First within 60 days of the event. If the specific QSC event is not listed, call the People First Service Center within 60 days of the event. You must make an allowable change within

60 days, unless otherwise noted, even if you do not yet have the supporting documentation.

• Provide the supporting documentation to People First (e.g., marriage license, birth certificate, divorce decree, etc.) before a change is processed.

Changes made during the year because of a QSC event are effective on the first day of the month after the month in which the state deducts (or People First receives) a full month’s premium. Coverage always begins on the first day of a month and continues for the rest of the calendar year, as long as you pay premiums on time and you and your dependents remain eligible.

Option 3 – Open Enrollment

Held in the fall, the annual Open Enrollment period gives you the opportunity to review available health insurance options to make any changes needed for the next Plan year, which starts January 1 and goes through

December 31. Any changes you make remain in effect for the entire calendar year, as long as you pay

21 State Employees' HMO Plan Group Health Insurance Plan Booklet and Benefits Document premiums on time and you and your eligible dependents remain eligible unless you experience a QSC event.

Option 4 – Spouse Program

If both you and your spouse are active state employees, you are eligible for health insurance coverage at a reduced monthly premium by enrolling in the Spouse Program during Open Enrollment or within 60 days of an appropriate QSC event. For example, if your spouse becomes employed full-time with the state or you marry another state employee, you are eligible to enroll. Both employed spouses must take the following steps to enroll in the Spouse Program:

• Complete and sign the Spouse Program Election Form located on the myBenefits web site in the Forms section and list all eligible dependents, and

• Attach a copy of your marriage license to the Spouse Program Election Form when you submit it to the

People First Service Center. Include both you and your spouse’s People First ID numbers on each page, and

• Enroll in the same health plan, and

• Agree to notify the People First Service Center within 60 days of becoming ineligible for the

Spouse Program. The employed spouse becomes ineligible for the Spouse Program if:

o One or both end employment with the state, including retirement, or o You divorce, or o Your spouse dies.

It is your responsibility to notify the People First Service Center if you become ineligible for the Spouse

Program. Failing to do so within 60 days of one of the listed events may make you liable for Claims or premiums back to the date you lost eligibility. In addition, you may have to pay for a higher level of coverage than you need; for example, you may be required to pay for family coverage instead of individual coverage.

Upon notification of ineligibility for the Spouse Program, the People First Service Center adds covered, eligible dependents to the primary spouse’s plan, unless otherwise requested.

Option 5 – Surviving Spouse

Surviving spouses are also eligible for coverage. The term “Surviving Spouse” means the widow or widower of:

• A deceased state officer, state employee or Retiree if the spouse was covered as a dependent at the time of the Enrollee’s death.

• An employee or Retiree who died before July 1, 1979.

• A Retiree who retired before January 1, 1976, under any state retirement system and who is not eligible for any Social Security benefits.

The Surviving Spouse and dependents, if any, must have been covered at the time of the Enrollee’s death. To enroll, the Surviving Spouse has 60 days to notify the People First Service Center of the death and 31 days to enroll after receipt of the enrollment package. Coverage is effective retroactively once the enrollment form

22 State Employees' HMO Plan Group Health Insurance Plan Booklet and Benefits Document and premiums have been received. Coverage begins the first of the month following the last month of coverage for the deceased; in other words, coverage must be continuous.

Coverage for Surviving Spouses and dependents ends on the first of the month following remarriage;

however, they are eligible to continue coverage under COBRA for a limited time, provided they provide a copy of the marriage certificate within 60 days of the marriage.

Coverage Continuation During Family and Medical Leave and Job-Protected Leave

This provision is administered by each employing agency just like any other leave whether paid or unpaid.

This section is provided for general information only. Each employing agency may administer family and medical leave differently. Contact your personnel office or People First for exact information concerning this provision.

As an employee, you may be entitled under the federal Family and Medical Leave Act (FMLA) for up to 12 work weeks of unpaid, job-protected leave in any 12-month period. You may be eligible if you have worked for the

State of Florida for at least one year and for 1,250 hours during the previous 12 months. Such leave may be available for the birth and care of a newborn child, the placement of a child for adoption or foster care, a serious health condition of a family member (child, spouse, or parent) or a personal, serious health condition.

In addition, the FMLA provides special unpaid, job-protected leave for up to 12 weeks if you have a family member called to active military duty and for up to 26 weeks when such family member is injured while on military duty.

As an Enrollee in the Plan, when you are on authorized FMLA leave, you have the option to continue your health benefits on the same terms and conditions as immediately prior to you taking such leave. The State of

Florida will continue to pay its share of the premium throughout your FMLA leave. You will still be responsible for your portion of the premium. Premium payments will be collected by People First. You and your eligible dependents shall remain covered under this Plan while you are on FMLA leave as if you were still at work as long as premiums are paid.

Furthermore, under the laws of the State of Florida, certain employees may be eligible to have their unpaid job- protected parental or family medical leave extended up to six months. Please call your personnel office if you need more details. If you are on authorized parental or family medical leave, your employing agency will continue to pay its share of the premium for up to six months of unpaid leave. Your coverage will be maintained until you return to work as long as premiums are paid.

If you cancel this Plan while on any of these leave types and subsequently return to work before or at the end of the leave, you and your eligible dependents may enroll under the Plan without regard to pre-existing conditions that arise while on job-protected leave, provided you cancelled your coverage within 60 days of going out on leave. If you do not cancel coverage within 60 days of going out on leave and your coverage is subsequently canceled for non-payment, you will only be able to enroll during the next Open Enrollment period.

Coverage Continuation When You Are Off Payroll

If you are an active employee and go off the payroll (e.g. military leave), you must pay your share of the health insurance premium by personal check, cashier’s check, or money order to continue coverage. You may be required to pay the full premium cost (your share plus the state’s share) depending on the reason you are not working. Call People

23 State Employees' HMO Plan Group Health Insurance Plan Booklet and Benefits Document

First for more information at (866) 663-4735.

If you do not want to continue insurance coverage while off the payroll, you must call People First to cancel within 60 days of your leave date. This notice ensures you can re-enroll in coverage upon returning to work.

If you do not cancel and are later cancelled because you did not pay the health insurance premium, you will only be allowed to enroll during the next Open Enrollment.

COBRA

Under the Consolidated Omnibus Budget Reconciliation Act (“COBRA”), you can continue healthcare coverage that would otherwise end because of dependent eligibility and because of voluntary or involuntary termination for reasons other than gross misconduct. You may also continue healthcare coverage that would otherwise end because you did not return to work after an unpaid leave under FMLA. You may keep this continuation coverage for up to 18 months, provided you pay the required cost of the continued coverage.