State Employees’ HMO Plan - Florida

State Employees¡¯

HMO Plan

Group Health Insurance Plan Booklet

and Benefits Document

Effective January 1, 2018

My Health

My Benefits

My Decisions

MyBenefits

State of Florida

Department of Management Services

Division of State Group Insurance

P.O. Box 5450

Tallahassee, FL 32314-5450

Table of Contents

I.

INTRODUCTION............................................................................................................................................................. 3

II.

DEFINITIONS ................................................................................................................................................................. 6

III.

ELIGIBILITY, ENROLLMENT AND EFFECTIVE DATE....................................................................................................................... 13

IV.

SCHEDULE OF BENEFITS .............................................................................................................................................. 26

V.

MEDICAL BENEFITS ..................................................................................................................................................... 37

VI.

LIMITATIONS AND EXCLUSIONS.................................................................................................................................. 57

VII.

SPECIAL HMO PLAN FEATURES ................................................................................................................................................63

VIII. PRESCRIPTION DRUG PROGRAM ............................................................................................................................... 71

IX.

HOW TO FILE A CLAIM ................................................................................................................................................ 80

X.

COORDINATION OF BENEFITS ..................................................................................................................................... 82

XI.

SUBROGATION AND RIGHT OF RECOVERY ...................................................................................................................... 90

XII.

DISCLAIMER OF LIABILITY ........................................................................................................................................... 92

XIII. GRIEVANCE PROCEDURE ............................................................................................................................................ 95

XIV. MISCELLANEOUS......................................................................................................................................................... 98

CONTACT INFO and SERVICE AREA

Claims Administrator: United Healthcare

Services, Inc. (United Healthcare)

Member Services ¨C All Areas

Citrus

Clay

De Soto

Hendry

Hernando

Lake

Martin

Monroe

Service Area

P.O. Box 740835

Atlanta, GA 30374

(877) 614-0581

Okeechobee

Osceola

Palm Beach

Pasco

Santa Rosa

Sumter

Taylor

Union

1

If you need information about¡­

Medical benefits or Claims administered by

United Healthcare, or finding a medical Network

Provider participating with United Healthcare

within the State of Florida

Prescription drug program information

Contact¡­

MEMBER SERVICES

(877) 614-0581

CVS/caremark

Customer Care Team

(888) 766-5490

sofrxplan (plan information)

(user account information)

For paper Claims only:

CVS/caremark

P.O. Box 52010 MC 003

Phoenix, AZ 85072-2010

General and Customer Care Correspondence:

P.O. Box 7074

Lees¡¯ Summit, MO 64064-7074

Level I Appeals:

CVS/caremark

Attention: Appeals Dept.

MC 109

P.O. Box 52071 Phoenix, AZ

85072-2071

Fax: (866) 443-1172

Enrollment, eligibility, or changing coverage

People First Service Center

P.O. Box 6830 Tallahassee,

FL 32314

(866) 663-4735

peoplefirst.

Fax: (800) 422-3128 (Include your People First ID

number on the top right of each page)

Medicare eligibility and enrollment

The Social Security Administration office in your area

2

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), United Healthcare, 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 (Plan), for Health Plan Members, as defined herein, who have selected United

Healthcare 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 expressly stated in their contract.

United Healthcare, in arranging for the delivery of Medical Services or benefits, does not directly provide

these Medical Services or administer the Plan. United Healthcare arranges for the provision of Medical

Services and administers Claims in connection therewith in accordance with the covenants and conditions

contained in this SPD and medical guidelines.

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.

2.

3.

4.

5.

Deductibles (HIHP Option only);

Coinsurance (HIHP Option only);

Copayments;

Hospital admission fees;

Non-covered services;

3

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