HomeMy WebLinkAbout2015-025DFlorida,
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An independent licensee of the
Blue Cross and Blue Shield Association
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BLUEMEDICARE GROUP MASTER AGREEMENT
SECTION 1: INTRODUCTION
This BlueMedicare Group Master Agreement (this "Agreement") describes the rights and
obligations which you and Blue Cross and Blue Shield of Florida, Inc. ("Florida Blue") have
with respect to the group Medicare Advantage, Medicare Advantage Prescription Drug Plan,
and/or standalone Medicare Prescription Drug Plan (hereinafter, "Medicare Plan(s)") coverage to
be provided by us to your Covered Retirees and Covered Dependents.
References to "we", "us", "our," and Florida Blue throughout this Agreement refer to Blue Cross
and Blue Shield of Florida, Inc. In exchange for your payment of the Premium, we agree to
provide the coverage and/or benefits specified in the Evidence of Coverage for the Medicare
Plan(s) ("Evidence of Coverage"), a copy of which is attached to this Agreement. The coverage
to be provided by us under the Group Plan which you have established is described in the
Evidence of Coverage.
SECTION 2: DEFINITIONS
Certain terms defined in the Agreement are also used and defined (for the convenience of
Covered Persons) in the Evidence of Coverage. If a word or phrase starts with a capital letter, it
is either the first word in a sentence, a proper name, a title, or a defined term. The following
defined terms apply to this Agreement:
Anniversary Date means the date one year after the Effective Date of coverage and subsequent
annual anniversaries or such other date as mutually agreed to in writing by the parties.
Appeal means a request submitted by or on behalf of a Covered Person for a review of our
decision to deny a request for coverage of health care services or prescription drugs or payment
for services or drugs.
CMS means the Centers for Medicare and Medicaid Services.
CMS Requirements means the provisions of Parts C and D of Title XVIII of the Social Security
Act, CMS Medicare Part C and D regulations at 42 C.F.R. Parts 422 and 423, the CMS Managed
Care and Prescription Drug Benefit Manuals, other CMS instructions and guidance and the
provisions of Florida Blue's contracts with CMS to offer the Medicare Plans.
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Covered Dependent means an Eligible Dependent who continues to meet all applicable
eligibility requirements described in the Evidence of Coverage and who is enrolled, and actually
covered, under the Agreement other than as a Covered Retiree.
Covered Person means a Covered Retiree or a Covered Dependent.
Covered Retiree means an Eligible Retiree, who continues to meet all applicable eligibility
requirements described in the Evidence of Coverage and who is enrolled, and actually covered,
under the Agreement other than as a Covered Dependent.
Effective Date for the Group means 12:01 a.m. on the date specified on the last page of this
Agreement and for Covered Persons means 12:01 a.m. on the date coverage will begin as
specified in the Evidence of Coverage.
Eligible Dependent means an individual who meets and continues to meet all of the eligibility
requirements described in the Evidence of Coverage.
Eligible Retiree means an individual who meets and continues to meet all of the eligibility
requirements set forth in the Evidence of Coverage and is eligible to enroll as a Covered Retiree.
An Eligible Retiree is not a Covered Retiree until actually enrolled and accepted for coverage as
a Covered Retiree by us.
Enrollment Forms means those forms, electronic or paper, which are approved by us and used
to maintain accurate enrollment files under the Agreement.
Grace Period means the sixty (60) calendar day period beginning on the date the Premium is
due.
Grievance means a type of complaint submitted by a Covered Person (or other person eligible
under CMS Requirements to submit a Grievance) about us or one of our network providers or
pharmacies, including a complaint concerning the quality of care. This type of complaint does
not involve coverage or payment disputes.
Group means the employer, labor union, association, partnership, corporation, department, other
organization or entity through which coverage and benefits are issued by us.
Note: References to "you" or "your" throughout the first part of this Agreement also refer to the
Group. References to "you" or "your" in the Evidence of Coverage refer to Eligible Retirees,
Eligible Dependents, Covered Retirees and/or Covered Dependents depending on the context and
intent of the specific provision.
Group Master Agreement or Agreement means the written document which is evidence of the
entire agreement between the Group and Florida Blue whereby coverage and benefits are
provided to Covered Persons.
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Late Enrollment Penalty ("LEP") means an amount added to the Part D Premium of an
individual who did not have Part D coverage or other creditable prescription drug plan when the
individual first became eligible for Part D or who had a break in Part D or other creditable
prescription drug coverage for at least 63 days.
Low Income Subsidy ("LIS") means the premium subsidy amount paid to us by CMS for
qualifying Covered Persons with Medicare Part D coverage.
Medicare Plan means the group Medicare Advantage Plan, Medicare Advantage Prescription
Drug Plan, and/or standalone Medicare Prescription Drug Plan that you select.
Premium means the amount required to be paid by the Group to us for coverage under this
Agreement.
Service Area means a geographic area where a Medicare Plan accepts members.
SECTION 3: ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT
A. Eligibility Determination
Determination of whether an individual is an Eligible Retiree or Eligible Dependent will be a
two-step process:
1. You will determine whether the individual is eligible to participate in the retiree group
health benefit plan that you sponsor. For individuals meeting your eligibility criteria, you
will promptly forward completed applications to us. You are responsible for complying
with all applicable laws and regulations, including but not limited to the Employee
Retirement Income Security Act (ERISA) and the Internal Revenue Code, in making this
eligibility determination. You must also comply with all eligibility guidelines included
in the benefit administrative guide and Evidence of Coverage.
2. After receiving a complete application, we will process the application in accordance
with CMS Requirements. An application must be approved by us and accepted by CMS
for an individual to be enrolled in a Medicare Plan.
B. Distribution of. Enrollment Materials
You may only distribute materials describing the Medicare Plan that we have provided to you or
that we have approved in writing. You will distribute any pre -enrollment materials that we
provide to you to each potential enrollee before collecting enrollment applications. Nothing in
this Section will preclude you from making additional disclosures about your group health
benefit plan as applicable to comply with ERISA, such as a wrap-around summary plan
description or other plan document. If applicable, you are solely responsible for compliance with
ERISA disclosure requirements in connection with the Medicare Plan(s).
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C. Group Disenrollment
If you decide to disenroll all Covered Persons from a Medicare Plan, you must:
1. Notify all beneficiaries that you intend to disenroll them from the Medicare Plan. You
will provide this notice at least twenty one (21) calendar days before the disenrollment.
This notice will explain how to contact Medicare for information about other plan options
that may be available. You will include language provided by Florida Blue in this notice
to meet specific CMS Requirements for notice contents.
2. Provide us with all information necessary to submit a complete disenrollment request
transaction to CMS in accordance with CMS Requirements.
3. In the event of termination of this Agreement, provide advanced notice in accordance
with Section 4 of this Agreement.
D. Individual Covered Person Disenrollment
Covered Persons may be disenrolled from a Medicare Plan by Florida Blue if they become
ineligible for continued enrollment. Covered Persons may also be disenrolled if this Agreement
terminates or if you inform us that they are no longer eligible to participate in your retiree group
health plan. If Florida Blue determines that a Covered Person is ineligible for continued
enrollment or if you instruct us to disenroll an individual, you must:
1. Provide us with at least thirty (30) calendar days advanced notice of the ineligibility or
disenrollment election of an individual; and
2. Provide the Covered Person(s) who will be disenrolled with at least twenty one (21)
calendar days advanced notice of the termination and of other insurance options that are
available to them. You will include language provided by Florida Blue in this notice to
meet specific CMS Requirements for notice contents.
The Covered Person will have the opportunity to elect another plan offered by us or by you, join
Original Medicare, or join another carrier's Medicare Plan (by submitting an enrollment request
to that organization).
SECTION 4: TERM AND TERMINATION
A. Term of Agreement and Renewal Process
This Agreement shall become effective as of the Effective Date provided: (1) that we accept your
Group Application; and (2) that you pay the required initial Premium specified by us.
This Agreement shall continue in effect until the first Anniversary Date following the Effective
Date unless terminated earlier as permitted by its terms. After the initial term, this Agreement
shall automatically renew each succeeding year on the Anniversary Date for an additional one-
year period unless:
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1. At least sixty (60) calendar days prior to such Anniversary Date, you notify us that you
do not want the Agreement to automatically renew; or
2. It is -terminated as permitted by its terms.
At least ninety (90) calendar days before each Anniversary Date, we will provide you with notice
of changes in Premium and benefits under the Medicare Plan for the upcoming year (the
"Renewal Notice").
If this Agreement renews as specified above, all of its terms and provisions (including the
Premium due) shall be amended to include the terms of the Renewal Notice, and the amended
Agreement shall govern coverage as of the Anniversary Date. Payment of the new charges shall
constitute acceptance of the change in Premium rates. This Agreement is conditionally
renewable. This means that it automatically renews each year on your Anniversary Date unless
terminated earlier in accordance with its terms.
B. Termination by Group
The Group may cancel this Agreement on its Anniversary Date by giving written notice to us at
least sixty (60) calendar days in advance, unless we have initiated a termination for any of the
reasons stated below.
C. Termination by Florida Blue
We may terminate this Agreement or refuse to renew for the following reasons:
1. Failure to Pay Premiums. You do not pay Premiums in accordance with its terms or we
have not received timely Premium payments prior to the end of the Grace Period.
Termination of this Agreement for failure to pay premiums shall be effective as of the
end of the Grace Period. In the event of such termination, you are obligated to pay the
following:
a. Any portion of the Premium due for coverage provided by us prior to termination;
and
b. Any amounts otherwise due us.
2. Fraud or Intentional Misrepresentation of Material Fact. You perform an act, or
engage in any practice, that constitutes fraud or make an intentional misrepresentation of
material fact.
3. Group Contribution and Participation and CMS Rules. You do not comply with: (1)
a material provision which relates to rules for Group contributions or Covered Person
participation; or (2) any provision in this Agreement which relates to LIS or other CMS
Requirements.
4. Service Area. There is no longer any Covered Person who lives, resides, or works in the
Service Area.
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5. Termination or Non -renewal of the CMS Contract. We will provide you with at least
ninety (90) calendar days' notice upon termination or non -renewal of our contract with
CMS.
Except as specifically provided in this Subsection 4.C, if we decide to terminate or not renew the
Agreement based on one or more of the circumstances mentioned above, we will give you at
least forty-five (45) calendar days advance written notice.
D. Notification of Termination to Covered Retirees
It is your obligation to immediately notify each Covered Person of any such termination of this
Agreement for any reason, consistent with the requirements of Section 3 of this Agreement.
E. Representations Made By, and Obligations of, the Group
In agreeing to provide coverage in accordance with the terms of this Agreement, we rely on the
representations you made when you applied for coverage with us and your representation that
you have authority to act on behalf of all Covered Persons with respect to this Agreement.
Consequently, every act by, agreement with, or notice given to, you will be binding on all
Covered Persons. You agree that you shall offer to all Eligible Retirees the opportunity to
become a Covered Person under this Agreement. You agree that, if requested by us, you will
distribute the Evidence of Coverage and other coverage materials to Covered Persons.
SECTION 5: PAYMENT PROVISIONS
A. Monthly Invoice
We will prepare a monthly invoice of the Premium due on or before the due date. This monthly
invoice will also reflect any prorated charges and credits resulting from changes in the number of
Covered Persons and changes in the types of coverage that took place in the previous or current
month.
If you become aware that a Covered Person will become ineligible, you must provide us with
written notice of such ineligibility as described in Section 3 of this Agreement. You shall be
liable to us for the Premium due for each individual enrolled in a Medicare Plan under this
Agreement until the effective date of disenrollment, which is set by CMS Requirements.
You must pay the total amount of the invoice. Do not add names to an invoice, change coverage
or pay for a retiree or dependent whose name does not appear on the invoice. No changes can be
made to a Group invoice unless a signed application form is on file and submitted to Florida
Blue. Payment shall be for the total amount of the Group invoice.
B. Payment Due Date
The first Premium payment is due before the Effective Date of the Agreement. Each following
payment is due monthly unless you agree with us in writing on some other method and/or
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frequency of payment. The Premium is due and payable on or before the first day of each
succeeding calendar month to which such payments apply.
C. Grace Period
This Agreement has a thirty (30) calendar day Premium payment Grace Period, which begins on
the date the Premium payment is due. If we do not receive the required Premium payment on or
before the date it is due, it may be paid during this Grace Period. Coverage will stay in force
during the Grace Period. If Premium payments are not received by the end of the Grace Period,
we will terminate this Agreement and proceed with the disenrollment of Covered Persons as
described in Section 3 of this Agreement.
D. Changes in Premium
Premium rates may be changed on your Anniversary Date as described in Section 4.A above
regarding renewal.
E. Other Rules Regarding the Payment of Premiums
1. CMS rules govern the effective date of any disenrollment of a Covered Person under this
Agreement, and we are not required to retroactively terminate this Agreement or
coverage for any Covered Person.
2. If full payment of the Premium is not paid when due, this Agreement may be terminated
as described in Section 4 of this Agreement.
F. Premium Subsidization
You may subsidize Premium amounts charged to Eligible Retirees. You are responsible for
compliance with all applicable laws and regulations relating to your subsidy of Premiums,
including ERISA and CMS Requirements, as applicable. You acknowledge and agree that
Premium subsidization may vary for different classes of Eligible Retirees only if such classes are
reasonable and based on objective business criteria. You represent and warrant that you will not
vary Premium subsidization based on any Covered Person's eligibility for LIS. Further, you will
not vary Premium subsidization for individuals within a given class of Eligible Retirees. In no
case will you charge an Eligible Retiree more than the sum of the monthly Premium that we
charge you for the Medicare Plan benefits.
G. Low Income Subsidy
You will comply with the following requirements in connection with LIS:
1. You are required to pass through any LIS payments received from CMS to reduce the
Premium amount that the Covered Retiree pays. You will first apply any LIS amounts to
a Covered Person's share of Premium. You may not benefit from any LIS amount until
the Premium for a Covered Person (including amounts for the non -drug benefits in a
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combined Medicare Advantage Prescription Drug Plan) paid by a Covered Retiree is
reduced to zero ($0.00).
2. You are responsible for reducing up -front Premium contributions that you collect from
Covered Retirees for any Covered Persons eligible for LIS. In limited situations where
you are unable to reduce the up -front Premium contribution (e.g. if LIS is awarded
retroactively), you will directly refund the LIS amount to the Eligible Retiree within
fifteen (15) calendar days of the date you receive the LIS amount from Florida Blue.
H. Late Enrollment Penalty ("LEP")
The Premium for an individual Covered Person may be higher if the Covered Person is assessed
an LEP for not enrolling in Part B in a timely manner. This higher Premium will be reflected on
the bill you receive from us.
I. Premium Billing
You will be responsible for the payment of the "Total Monthly Premium per Covered Retiree" of
all Group members. The Total Monthly Premium may be less for Covered Persons who qualify
for LIS as defined by CMS. You will also be responsible for any LEP charges that Group
members have been assessed by CMS. The first Premium charge is payable before the Effective
Date of this Agreement. Monthly charges are payable on the first day of each following month
during the time this Agreement is in effect.
J. Retroactive Premium Adjustment
The monthly charge will be determined from our records by the number of Covered Retirees
who have been confirmed through the CMS enrollment transaction process. Retroactive
adjustments will be made for additions and terminations of Covered Retirees and for Covered
Retirees who have been confirmed through the CMS enrollment transaction process after the
initial billing statement. Any refund that is owed to a Covered Retiree must come from the
Group, unless the Covered Retiree is billed directly by us. Florida Blue will only adjust the
amount due of a Group and will not refund Premium(s) paid to a Covered Retiree, unless we
mutually agree that a Covered Retiree is to be directly billed by Florida Blue. You must refund
to Covered Retirees any amounts received from us that are due to Covered Retirees in a timely
manner.
SECTION 6: HOST BLUE PLANS
A. Out of Area Services
We have relationships with other Blue Cross and/or Blue Shield Licensees ("Host Blues")
referred to generally as the "Medicare Advantage Program." When Covered Persons access
healthcare services outside of Florida, the claim for those services will be processed through the
Medicare Advantage Program and presented to us for payment in accordance with the rules of
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the Medicare Advantage Program policies then in effect. The Medicare Advantage Program
available to Covered Persons under this Agreement is described generally below.
B. Covered Persons Liability Calculation
The cost of the service on which the Covered Person's liability is based, will be either:
1. The Medicare allowable amount for covered services; or
2. The amount we negotiate with the provider of the Host Blue negotiates with its provider
on behalf of our Covered Persons, if applicable. The amount negotiated may be either
higher than, lower than, or equal to the Medicare allowable amount..
SECTION 7: GENERAL PROVISIONS
A. Administration and Record Retention
You must provide us with any information we need to administer the coverage and/or benefits to
be provided or needed to compute the Premium due. While this coverage is in force, we have the
right, at any reasonable time, to examine your records on any issues necessary to verify
information provided by you. You must retain all records relating to this Agreement, including
but not limited to those relating to LIS administration, for the current calendar year plus an
additional ten (10) years.
B. Assignment and Delegation
You may not assign, delegate or otherwise transfer this Agreement and the obligations hereunder
without our written consent. Any assignment, delegation, or transfer made in violation of this
provision shall be void. We may assign, delegate, or otherwise transfer this Agreement to our
successor in interest or an affiliated entity without your consent at any time.
C. Authorization
Where this Agreement requires that an act involving the administration of coverage and/or
benefits be authorized or approved by us, such authorization or approval shall be considered
given when provided in writing by a duly authorized officer of Florida Blue or his or her
designee.
D. Evidence of Coverage
We will provide an Evidence of Coverage and ID Card for each Covered Retiree. The Evidence
of Coverage will describe the coverage and benefits to be provided to Covered Persons by us.
You agree that, if requested by us, you will distribute the Evidence of Coverage (and any
Endorsements to it) and other coverage materials to Covered Persons.
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E. Grievance and Appeals Process
We have established and will maintain a process for hearing and resolving Grievances and
Appeals raised by Covered Persons in accordance with CMS requirements. Details regarding this
process are provided in the Evidence of Coverage.
F. Changes to the Agreement
Florida Blue may make any changes to this Agreement that are necessary to meet CMS
Requirements ("CMS Mandated Amendments") with sixty (60) calendar days advanced written
notice to you. Such changes shall become effective as amendments to this Agreement upon
expiration of this sixty (60) calendar day notice period.
Except in the case of (a) CMS Mandated Amendments or (b) Renewal Notices as described in
Section 4.A., no person may change, modify, or revise the written terms or provisions of this
Agreement unless such change is made by a written amendment signed by one of our duly
authorized officers. For example, no Eligible Retiree or agent of Florida Blue or the Group can
change or waive the written terms or provisions of this Agreement except as stated in the first
sentence of this paragraph.
G. Furnishing and Maintaining Enrollment Records
You must provide any information required by us for the purpose of creating and maintaining
enrollment records, processing terminations, and recording changes in family status. In addition,
you and each Eligible Retiree must submit accurate and complete Enrollment Forms on a timely
basis. You are responsible for collecting the Enrollment Forms, reviewing them for accuracy and
completeness, and forwarding them to us, along with the applicable Premium payment. All
enrollment record information which is relevant to the eligibility or coverage status of any
individual must be made available to us for inspection and copying upon request.
H. Errors or Delays
Clerical errors or delays by us in maintaining enrollment records regarding Covered Persons will
not invalidate coverage which would otherwise be validly in force or continue coverage which
would otherwise be validly terminated, provided you have furnished us with timely and accurate
enrollment information. Errors or delays by you in furnishing accurate enrollment information to
us will not affect our right to strictly enforce any and all eligibility requirements.
I. Entire Agreement
This Agreement sets forth the exclusive and entire understanding and agreement between the
parties and shall be binding upon the Covered Persons, the parties, and any of their subsidiaries,
affiliates, successors, heirs, and permitted assigns. All prior negotiations, agreements, and
understandings are superseded hereby. No oral statements, representations, or understanding by
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any person can change, alter, delete, add or otherwise modify the express written terms of this
Agreement, which includes the terms of coverage and/or benefits set forth in the Evidence of
Coverage, the Schedule of Benefits, and any other attachments, amendments or riders.
J. Financial Responsibilities of the Group
We reserve the right to recover any benefit payments made to or on behalf of any individual
whose coverage has been terminated. Our recovery efforts may relate to benefit payments made
for health care services rendered subsequent to the Covered Person's termination date and prior
to the date notice of coverage termination is required to be made by you. Your cooperation with
and support such recovery efforts is required.
In the event that you do not comply with the notice requirements set forth in Subsection 5.A
(Monthly Invoice), you shall be solely liable to us for Premium due until the effective date
established by CMS for a Covered Person's disenrollment.
'K. Indemnification
You shall hold harmless and indemnify Florida Blue, against all claims, demands, liabilities, or
expenses (including reasonable attorney fees and court costs), which are related to, arise out of,
or are in connection with any of your acts or omissions, or acts or omissions of any of your
employees, retirees or agents, in the performance of your obligations under this Agreement. We
are not your agent, nor are you our agent, for any purpose. This paragraph shall only apply to the
extent allowed under Florida Statutes § 768.28.
L. Representations on the Group Application and the Enrollment Forms
We rely on the information you and your Eligible Retirees provide to determine whether to issue
coverage; the appropriate Premium and financing method; and eligibility for coverage. All such
information must be accurate, truthful, and complete. Statements made on the Enrollment Forms
are representations and not warranties.
We may cancel, terminate, or void this Agreement if the information which you provide is
fraudulent, or if you make an intentional misrepresentation.
M. Reservation of Right to Contract
We reserve the right to contract with any individuals, corporations, associations, partnerships, or
other entities for assistance with the servicing of coverage and benefits to be provided by us or
obligations due, under this Agreement.
N. Service Mark
You, on behalf of the Group and its Covered Retirees, hereby expressly acknowledge your
understanding that this Agreement constitutes a contract solely between you and Florida Blue.
We are an independent corporation operating under a license with the Blue Cross and Blue
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Shield Association, an association of independent Blue Cross and Blue Shield Plans, (the
"Association") permitting us to use the Blue Cross and Blue Shield Service Mark in the state of
Florida and that we are not contracting as the agent of the Association. You further acknowledge
and agree that you have not entered into this contract based upon representations by any person
other than us and that no person, entity, or organization other than us shall be held accountable or
liable to you for any of our obligations created under this Agreement. This paragraph shall not
create any additional obligations whatsoever on our part other than those obligations created
under other provisions of this Agreement.
O. Third Party Beneficiary
This Agreement was entered into solely and specifically for the benefit of Florida Blue and the
Group. The terms and provisions of the Agreement shall be binding solely upon, and inure solely
to the benefit of, Florida Blue and the Group, and no other person shall have any rights, interest
or claims under this Agreement, including the Evidence of Coverage, or be entitled to sue for a
breach thereof as a third -party beneficiary or otherwise. Florida Blue and the Group hereby
specifically express their intent that health care providers that have not entered into contracts
with Florida Blue to participate in Florida Blue's provider networks shall not be third -party
beneficiaries under this Agreement, including the Evidence of Coverage.
P. Inspection and Audit
You shall permit CMS, The U.S. Department of Health and Human Services, the Comptroller
General, or their designees, to inspect, evaluate, and audit any of your books, contracts, medical
records, patient care documentation, documents, papers, and other records pertaining to coverage
by providing records to Florida Blue, which will submit the records to CMS. This right to
inspect, evaluate, and audit shall extend ten (10) years from the expiration or termination of the
Agreement or completion of final audit, whichever is later, unless otherwise required by
applicable law.
Q. Benefit Administrator Guide
We will provide you with a Benefit Administrator Guide, which provides details related to how
your plan is administered and your responsibilities as a benefit administrator.
R. Member Communications and Campaigns
We may send CMS required or Florida Blue member communications without your consent.
Samples of all required materials are available upon request for informational purposes.
We may also contact Covered Persons by telephone regarding any Florida Blue campaign and
any campaign approved by the Florida Office of Insurance Regulation and/or CMS, as
applicable. We will notify you of the campaign prior to making contact with members.
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S. COBRA
You are solely responsible for determining when individuals are eligible for coverage under a
Medicare Plan pursuant to the Consolidated Omnibus Budget Reconciliation Act ("COBRA").
You will notify us promptly of any COBRA elections. For more information on your COBRA
responsibilities refer to the Benefit Administrator Guide.
In consideration of the payment of Premiums when due and subject to all of the terms of this
Agreement, Blue Cross Blue Shield of Florida, Inc. hereby agrees to provide each enrollee of
Indian River County BOCC the benefits of this Agreement as set forth in the attached
Evidence of Coverage beginning on each enrollee's effective date.
The Group has selected the following plan and premium:
BlueMedicare Group
PPO*Plan 1 ---$379.99
The Group's Agreement is effective as of October 1, 2014.
IN WITNESS WHEREOF, the parties have executed this Agreement as of
Blue Cross Blue Shield of Florida, Inc.
Indian River County BOCC
By: By:
(Signature) (Signature)
Name: Lynn Esposito Name:
(Please Print or Type)
Title: Vice President, Sales Operations Title:
13
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urn kidlni n redo('
APPROVED AS TO FORM
AND LEGAL SUFFICIENCY
BY
DYLAN REINGOLD
COUNTY ATTORNEY
In the pursuit of health'
Indian River County Board of County Commissioners
2014 BlueMedicare Group PPO* Health Benefits
Benefits � � R y `
BlueMedicare Group P0 P
Premium (per member, per month)
$379.99
Deductible
$0 In -Network / $1,000 Out -of -Network
Out -of Pocket Max
$1,000 In -Network / $3,000 Out -of -Network.
In -Network out-of-pocket max accumulates
toward Out -of -Network out-of-pocket max.
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Primary Care (per visit)
In -Network $10 copay
Out -of -Network CYD & 20%
Specialist Care (per visit)
In -Network $30 copay
Out -of -Network CYD & 20%
e -visit
In -Network $5 copay
Out -of -Network CYD & 20%
Convenient Care Center
In -Network $30 copay
Out -of -Network CYD & 20%
Podiatry Services (per visit)
(Routine foot care up to 6 visits per year)
In -Network $30 copay
Out -of -Network CYD & 20%
Chiropractic Services (per visit)
For each Medicare covered visit (manual
manipulation of the spine to correct
subluxation)
In -Network $20 copay
Out -of -Network CYD & 20%
Outpatient Mental Health Care (per visit)
For individual or group therapy
In -Network $35 copay
Out -of -Network CYD & 20%
Outpatient Substance Abuse Care (per visit)
In -Network $35 copay
Out -of -Network CYD & 20%
Part B drugs (including Chemotherapy)
In -Network 20% coinsurance
Office visit or facility copay may apply
Out -of -Network CYD & 20% coinsurance
Office visit or facility charges may apply
Allergy Injections
In -Network $5 copay
Out -of -Network CYD & 20%
Other Services ' S t `
Outpatient Surgery
In -Network
• $150 copay for each outpatient
hospital facility visit
• $100 copay for each visit to an
ambulatory surgical center
Out -of -Network CYD & 20%
Y0011_31917 0913R2 EGWP C: 09/2013
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In the pursuit of health'
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Benef!ts � � � $� �
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Aare 'Orel roup PO P9 t 1
In -Network / Out -of -Network
• $0 copay for Physician Services
Diagnostic Tests, X -Rays
Office
IDTF
Lab Services
Independent Clinical Lab
Outpatient Hospital
Advanced Imaging (MRI, MRA, Cat Scan, Pet
Scan & Nuclear Med):
Office
IDTF
Outpatient Hospital
In -Network
• PCP $10 copay
• Specialist $30 copay
Office visit copay may apply
Out -of -Network CYD & 20%
In -Network $50 copay
Out -of -Network CYD & 20%
In -Network $0 copay
In -Network $15 copay
Office visit or facility copay may apply
Out -of -Network CYD & 20%
In -Network $125 copay
Out -of -Network CYD & 20%
In -Network $125 copay
Out -of -Network CYD & 20%
In -Network $150 copay
Out -of -Network CYD & 20%
Outpatient Hospital Services (per visit):
• Occupational Therapy, Physical
Therapy, Speech & Language Therapy,
Cardiac and Pulmonary Rehab
• Radiation
• Dialysis
• Lab only
• All other Diagnostic Tests, X -Rays
Advanced Imaging, etc.
In -Network Out -of -Network
$30 CYD & 20%
$50 CYD & 20%
20% 20%
$15 CYD & 20%
$150 CYD & 20%
Urgently Needed Care
(This is not emergency care, and in most cases
is out of the service area.)
In -Network / Out -of -Network $30 copay
Emergency Services
In -Network / Out -of -Network $50 copay
Worldwide coverage
Dental - Medicare approved (No Preventive)
In -Network $30 copay
Out -of -Network CYD & 20%
Y0011_31917 0913R2 EGWP C: 09/2013
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Home Health
In -Network / Out -of -Network $0 copay
Ambulance
In -Network / Out -of -Network $150 copay for
Medicare -covered ambulance services
Qutpatient lledIcaervices `arwdl SuppUea
Durable Medical Equipment/Diabetic Supplies
• Diabetic Supplies (glucose meters, test
strips and Lancets) — needles, syringes
and insulin for self -injection is covered
under your Part D benefit
• Equipment: Electric customized
wheelchairs, electric scooters
• All other Medicare -covered durable
medical equipment
In -Network $0 copay
Out -of -Network CYD & 20%
In -Network 20% coinsurance
Out -of -Network CYD & 20%
In -Network $0 copay
Out -of -Network CYD & 20%
Prosthetic Devices
In -Network $0 copay for Medicare -covered
items
Out -of -Network CYD & 20%
Outpatient Rehabilitation - Office or Free
Standing Facility Services:
• Occupational Therapy
• Physical Therapy
• Speech and Language Therapy
• Cardiac and Pulmonary Rehab
• Dialysis
In -Network $30 copay for each visit
Out -of -Network CYD & 20%
In-Network/Out-of-Network 20% coinsurance
Outpatient Rehabilitation — Outpatient Hospital
Services:
• Occupational Therapy
• Physical Therapy
• Speech and Language Therapy
• Cardiac and Pulmonary Rehab
In -Network $30 copay for each visit
Out -of -Network CYD & 20%
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Inpatient Hospital Care
(includes Substance Abuse)
In -Network
• $150 copay each day for day(s) 1-7
for a Medicare -covered stay in a
network hospital
• After the 7th day, the plan pays 100%
of covered expenses per stay.
Out -of -Network CYD & 20%
Inpatient Mental Health Care
(may also include Substance Abuse)
In -Network
• $200 copay each day for day(s) 1-7
for a Medicare -covered stay in a
network psychiatric hospital
• For day(s) 8-90, $0 copay for
Y0011_31917 0913R2 EGWP C: 09/2013
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Medicare -covered stay in a network
psychiatric hospital
190 -day lifetime limit in a psychiatric hospital
Out -of -Network CYD & 20%
Skilled Nursing Facility
(in a Medicare -certified skilled nursing facility)
In -Network
• $0 copay each day for days 1-20 per
benefit period
• $75 copay each day for days 21-100
per benefit period
There is a limit of 100 days for each benefit
period
3 -day prior hospital stay is not required
Out -of -Network CYD & 20%
Hospice
Member must receive care from a Medicare -
certified hospice
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Annual Screening Mammograms
(for women with Medicare age 40 and older)
In -Network:
• $0 copay for Medicare -covered
Screening Mammogram
Out -of -Network CYD & 20%
Pap Smears and Pelvic Exams
(for women with Medicare)
In -Network:
• $0 copay per Pap smear
• $0 copay per pelvic exam
Out -of -Network CYD & 20%
Bone Mass Measurement
(for people with Medicare who are at risk)
In -Network:
• $0 copay for each Medicare -covered
Bone Mass Measurement
Out -of -Network CYD & 20%
Colorectal Screening Exams
(for people with Medicare age 50 and older)
In -Network:
• $0 copay for Medicare -covered
Colorectal screening exam
Out -of -Network CYD & 20%
Prostate Cancer Screening Exams
(for men with Medicare age 50 and older)
In -Network:
• $0 copay for Medicare -covered
Prostate Cancer Screening exam
Out -of -Network CYD & 20%
Vaccines — Medicare covered
In -Network / Out -of -Network
• $0 copay for Influenza vaccine
• $0 copay for Pneumococcal vaccine
• $0 copay for Hepatitis B vaccine
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Health & Wellness Benefit
Fitness
Free membership through SilverSneakers
Y0011_31917 0913R2 EGWP C: 09/2013
4
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In the pursuit of health*
* BlueMedicare Group PPO out-of-pocket maximum includes all covered health services member
cost share rendered in/out of network on a calendar year basis. Supplemental services and Part
D costs are not applied to out-of-pocket maximum.
Medicare Part B - the premium provided under this plan excludes the Medicare Part B premium
payments. (Members must continue to pay the Medicare Part B premium unless paid by
Medicaid or another third party.)
Florida Blue is a PPO Plan with a Medicare contract. .
Y0011_31917 0913R2 EGWP C: 09/2013 5
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In the pursuit of health'
Indian River County Board of County Commissioners
2014 BlueMedicare Group Rx*
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Premium
Included in PPO1 Plan Offer
Deductible
$0
Retail
31 -day Supply
$10
Tier 1 - Preferred Generics
Tier 2 - Non -Preferred Generics
$10
Tier 3 - Preferred Brand
$40
Tier 4 - Non -Preferred Brand
$70
Tier 5 - Specialty Drugs
25%
Mail Order
90 -day Supply with PRIME Mail Order
Tier 1 - Preferred Generics
$0
Tier 2 - Non -Preferred Generics
$0
Tier 3 - Preferred Brand
$80
Tier 4 - Non -Preferred Brand
$140
Tier 5 - Specialty Drugs
25%
Formulary Type
Added coverage for selected CMS excluded drugs. Generic
& multi -source brand prescription drugs will be covered for
the following categories:
• Cough
• Cold
Gap
31 -day Supply
Tier 1 - Preferred Generics
$10
Tier 2 - Non -Preferred Generics
$10
Tier 3 - Preferred Brand
$40
Tier 4 - Non -Preferred Brand
$70
Tier 5 - Specialty Drugs
25%
Catastrophic
Greater of $2.55 or 5% / Greater of $6.35 or 5%
• Florida Blue is an Rx (PDP) Plan with a Medicare contract.
• Prescription drug copays do not accumulate towards the health plan calendar year out-of-pocket
maximum.
• Part D Creditable Coverage — The enrolling member may incur late enrollment penalties as defined and
set by CMS in accordance with Part D guidelines if prior creditable coverage cannot be proven.
Y0011_31964 0612 EGWP C: 06/2013
EXHIBIT "B"
to the
ADMINISTRATIVE SERVICES AGREEMENT
between
BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. DIBIA FLORIDA BLUE
and
INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS
FINANCIAL ARRANGEMENTS
Banking Arrangement
I. Effective Date.
The effective date of this Exhibit is October 1, 2015.
II. Bank Account.
The Employer agrees to establish a bank account prior to the effective date
of this Agreement, in its own name, at the bank designated by Florida Blue.
The Employer authorizes Florida Blue to write checks on the bank account
in order to pay claims pursuant to this Agreement. The Employer agrees to
maintain the bank account and the reserve amount as set forth below. The
Employer shall be responsible for the reconciliation of its bank account,
based on information and reports provided by Florida Blue and the bank.
III. Special Banking Information.
A. Name of Employer (as it is to appear on the checks) - no more than
25 characters:
R.
INDIAN RIVER COUNTY
Employer Bank Account Reference Number - 5 characters:
10047
C. Reserve Requirement: $108,000
D. Funding Frequency: Daily
E. Method of Funding: ACH
-1-
IV. Administrative Fees:
A. Administrative fees during the term of the Agreement:
$49.95 per enrolled employee per month from October 1, 2015
through September 30, 2017.
$51.50 per enrolled employee per month from October 1, 2017
through September 30, 2018.
B. Administrative fees after the termination of the Agreement: 15% of
claims paid.
C. Florida Blue will pay Employer a $50,000 wellness contribution upon
the Board's approval of renewing this Agreement, for any wellness
related initiatives or activities; Florida Blue will pay an additional
$50,000 wellness contribution on October 1, 2015, for a total of
$100,000.
V. Late Payment Penalty
A. A daily charge of .00038 times the amount of overdue administrative
fees.
VI. Expected Enrollment
A. The administrative fees and reserve requirement referenced above
are based on an expected enrollment of: 1,500.
B. If the actual enrollment is materially different from this expected
enrollment, Florida Blue reserves the right to adjust the
administrative fees and the reserve requirement as set forth in the
Agreement.
-2-
AMENDMENT TO ADMINISTRATIVE SERVICES AGREEMENT
THIS AMENDMENT, entered into on February 17, 2015 is by and between Blue
Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue (hereinafter called "Florida Blue")
and Indian River County Board of County Commissioners (hereinafter called the
"Employer"). In consideration of the mutual and reciprocal promises herein contained, the
Administrative Services Agreement between Florida Blue and the Employer (hereinafter
"Agreement") effective October 1, 1996 is amended as follows:
1. Section I, subsection 1.1, is hereby amended to extend the term of the Agreement
until September 30, 2018 unless the Agreement is terminated earlier in accordance
with the terms of the Agreement.
2. Exhibit B to the Agreement is hereby amended, effective October 1, 2015. The
revised Exhibit B is attached to this Amendment and replaces the Exhibit B
previously attached to the Agreement.
3. Except as otherwise specifically noted in this Amendment, all other terms and
conditions of the Agreement shall remain unchanged and in full force and effect.
IN WITNESS WHEREOF, this Amendment has been executed by the duly
authorized representatives of the parties.
BLUE CROSS AND BLUE SHIELD
OF FLORIDA, INC. D/B/A FLORIDA
BLUE
By:
Title: VE) 30. \vs Cies2-5—
;2/ 7f 5
Date:
INDIAN RIVER COUNTY BOARD OF
COUNTY COMMISSIONERS
By:
f IL
Title:/County7 Administrator
Date:
..9111/)s -
APPROVED
AND EGAUFFICIFORM
ENC
SUFFICIENCY
AY
DYLAN REINGOLD
COUNTY ATTORNEY