State Employees’ HMO Plan - Florida

State Employees' HMO Plan

Group Health Insurance Plan Booklet and Benefits Document

Effective January 1, 2019

My Health

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 ........................................................................................................................................................... 7 III. ELIGIBILITY, ENROLLMENT AND EFFECTIVE DATE............................................................................... 14 IV. SCHEDULE OF BENEFITS................................................................................................................................... 27 V. MEDICAL BENEFITS............................................................................................................................................ 37 VI. LIMITATIONS AND EXCLUSIONS .................................................................................................................... 57 VII. SPECIAL HMO PLAN FEATURES .................................................................................................................. 62 VIII. PRESCRIPTION DRUG PROGRAM ............................................................................................................... 68 IX. HOW TO FILE A CLAIM ...................................................................................................................................... 77 X. COORDINATION OF BENEFITS ........................................................................................................................ 79 XI. SUBROGATION AND RIGHT OF RECOVERY, RECOUP, AND SUE FOR LOSSES.................................. 87 XII. DISCLAIMER OF LIABILITY.......................................................................................................................... 89 XIII. APPEALS AND GRIEVANCE PROCEDURE ................................................................................................. 90 XIV. BUNDLED SERVICES AND PRICING TRANSPARENCY PROGRAMS .................................................. 96 XV. MISCELLANEOUS............................................................................................................................................... 102 SUMMARY PLAN DESCRIPTION INFORMATION..................................................................................................111

CONTACT INFO and SERVICE AREA

Claims Administration: AvMed

9400 S. Dadeland Blvd. Miami, FL 33156-9004

Member Engagement ? All Areas

(888) 762-8633

Service Area

Broward

Hillsborough

Putnam

Dixie

Miami-Dade

St. Lucie

Gilchrist

Pinellas

Suwannee

Hamilton

Polk

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

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(Summary Plan Description or "SPD")

If you need information about... Medical benefits or Claims administered by AvMed, or finding a medical Network Provider participating with AvMed within the State of Florida Prescription drug program information

Contact... MEMBER ENGAGEMENT (888) 762-8633

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

Enrollment, eligibility, or changing coverage

Level I Appeals: CVS Caremark Attention: Appeals Department MC 109 P.O. Box 52071 Phoenix, AZ 85072-2071 Fax: (866) 443-1172

People First Service Center P.O. Box 6830 Tallahassee, FL 32314

(866) 663-4735 peoplefirst.

Medicare eligibility and enrollment

Fax: (800) 422-3128 (Include your People First ID number on the top right of each page) The Social Security Administration office in your area

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

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(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), AvMed, 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 AvMed 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 AvMed 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. AvMed, 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;

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

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(Summary Plan Description or "SPD")

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