ARTICLE 4 ­ COORDINATION OF BENEFITS

For Members with health care insurance in addition to the Health Plan's benefits will be coordinated in accordance with the following rules.

A. Applicability.

(1) This COB provision applies when a Subscriber or the Subscriber's Family Dependent has coverage for health care services under more than one Plan.

(2) Coordination of benefits will not apply against an Indemnity­Type Policy, an excess insurance policy, a policy with coverage limited to specified illnesses or accidents, or a Medicare supplement policy.

(3) The Order of Benefit Determination rules in Article 4.1 .C will determine whether the benefits of the Health Plan are determined before or after those of another Plan. The benefits of the Health Plan:

(a) shall not be reduced when, under the Order of Benefit Determination rules, the Health Plan determines its benefits before another Plan; but

(b) may be reduced when, under the Order of Benefit Determination rules, another Plan determines its benefits first.

Definitions.

(1) A "Plan" for purposes of Article 4 is any of these which provides benefits or services for, or because of, medical treatment:

(a) Group health insurance or group­type coverage, whether insured or uninsured. This includes, but is not limited to, prepayment, group practice or individual practice coverage. It does not include school accident­type coverage.

(b) Coverage under a governmental plan or other coverage required or provided by law. This does not include a State plan under Medicaid or any Plan which is prohibited by law from coordinating benefits.

"Primary Plan"/"Secondary Plan" for purposes of Article 4:

(a) The Order of Benefit Determination rules state whether the Health Plan is a Primary Plan or Secondary Plan in relation to another Plan.

(b) When the Health Plan is a Primary Plan, its benefits are determined before those of another Plan and without considering the other Plan's benefits.

(c) When the Health Plan is a Secondary Plan, its benefits are determined after those of the other Plan and may be reduced because of the other Plan's benefits.

(d) When more than two other Plans cover the same Member, the Health Plan may be Primary Plan to one or more other Plans, and may be a Secondary Plan In a different Plan or Plans

(3) "Allowable Expense" for purposes of Article 4 means a Usual, Reasonable, and Customary item of expense for health care, when the item of expense is covered at least in part by one or more Plans covering the person for whom the claim is made.

(a) The difference between the cost of a private Hospital room and the cost of a semi­private Hospital room is not considered an Allowable Expense under the above definition unless the patient's stay in a private Hospital room is Medically Necessary either in terms of generally accepted medical practice, or as specifically defined in the Plan.

(b) When a Plan provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an Allowable Expense and a benefit paid.

(c) The Allowable Expense is the highest prevailing Usual, Customary and Reasonable allowance as determined by either group health insurance plans or the maximum amount contracted with Participating Physician and Participating Providers when Participating Physicians and Participating Providers are used.

(4) "Claim Determination Period" for purposes of Article 4 means a calendar year. However it does not include any part of a year during which a person has no coverage under the Health Plan, or any part of a year before the date this COB provision or a similar provision takes effect.

1. Order of Benefit Determination.

( 1 ) When there is a basis for benefits to be paid under the Health Plan and another Plan, the Health Plan is a Secondary Plan which has its benefits determined after those of the other Plan, unless:

(a) The other Plan has rules allowing it to coordinate its benefits with those of the Health Plan; and

(b) Both the other Plan's rules and the Health Plan's rules, in Article 4.1.C.2 require that the Health Plan's benefits be determined before those of the other Plan.

(2) The Health Plan determines its order of benefits using the first of the following rules which applies:

(a) The benefits of the Plan which covers the Member as a Subscriber (that is, other than as a Family Dependent) are determined before those of the Plan which covers the Member as a Family Dependent.

(b) Except as stated in paragraph 4.1.C.2.c, when the Health Plan and another Plan cover the same child as a Family Dependent of different persons, called "parents":

1. The benefits of the Plan of the parent whose birthday falls earlier in a year are determined before those of the Plan of the parent whose birthday falls later in the year; but

2. If both parents have the same birthday, the benefits of the Plan which covered a parent longer are determined before those of the Plan which covered the other parent for a shorter period of time.
However, if the Primary Plan does not have the rules described in paragraph 4.1.C.2.b.1, and if, as a result, the Plans do not agree on the order of benefits, the order of benefit determination in the Primary Plan will determine the order of benefits.

(c) If two or more Plans cover a Member as a dependent child of divorced or separated parents, benefits for the child are determined in this order:

1. First, the Plan of the parent with custody of the child, and

2. Then, the Plan of the spouse of the parent with custody of the child, and

3. Finally, the Plan of the parent not having custody of the child.

However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect to any Claim Determination Period or Plan year during which any benefits are actually paid or provided before the entity has that actual knowledge.

If the specific terms of the court decree state that the parents share joint custody, without stating that one of the parents is responsible for health care expenses of the child, the Plans covering the child shall follow the Order of Benefit Determination rules outlined in Article 4.1.C.2.b, dependent child/parents not separated or divorced.

Actively At Work/Non­Actively At Work Subscriber.

The benefits of a Plan which covers an Actively At Work Subscriber (or the Subscriber's Family Dependents) are determined before those of a Plan which covers a Non­Actively At Work Subscriber (or the Subscriber's Family Dependents). If the other Plan does not have this rule and if, as a result, the Plans do not agree on this order of benefits, this rule is ignored.

Longer/Shorter Length of Coverage.

If none of the above rules determine the order of benefits, the benefits of the Plan which covered a Member longer are determined before those of the Plan which covered that Member for a shorter term.

(1 ) To determine the length of time a Member has been covered under a Plan, two Plans shall be treated as one Plan, if the Member was eligible under the second Plan within twenty­four (24) hours after the first Plan ended.

(2) The start of a new Plan does not include:

(a) A change in the amount or scope of a Plan's benefits;

(b) A change in the Plan which relates to the way the Plan pays, provides or administers the Plan's benefits; or

(c) A change from one type of Plan to another (such as, from a single­employer Plan to that of a multiple­employer Plan).

(3) The Member's length of time covered under a Plan is measured from the Member's first date of coverage under the Plan. If that date is not readily available, the date the Member first became a Member of the Plan shall be used as the date from which to determine the length of time the Member's coverage under the present Plan has been in force.

F. Effect on Health Plan Benefits.

(1) If the Health Plan is the Primary Plan in accordance with Article 4.1.C, the Health Plan will pay full benefits under this Member Services Contract.

(2) If the Health Plan is the Secondary Plan in accordance with Article 4.1.C, the benefits of the Health Plan will be limited to that portion of the Allowable Expense not paid by the Primary Plan incurred during the Claim Determination Period.

(3) The reasonable cash value of benefits in the form of services will be taken into

Right to Receive and Release Needed Information.

Each Subscriber is required to provide information on other Plans, in addition to the Health Plan, providing health care coverage to the Subscriber or Family Dependents. Members must also provide any factual and/or legal information needed by the Health Plan to make benefit determinations and coordinate benefits under Article 4. This factual information may be exchanged with other Plans as necessary to implement these COB provisions. Failure to provide the Health Plan with necessary information may result in delay of payment and/or benefits being withheld.

Facility of Payment

A payment under another Plan may include an amount which should have been paid by the Health Plan. The Health Plan may pay that amount to the organization which made that payment and that amount will be treated as though it were a benefit paid under the Health Plan. The Health Plan will not have to pay that amount again.

Right of Recovery.

If the amount of payment made by the Health Plan exceeds the amount of the Health Plan's obligation, the excess amount may be recovered from the person or organization receiving the over­payment.

Failure to Cooperate.

Any Member who fails to cooperate in the Health Plan's administration of Article 4 will be responsible for the eligible medical expense for services subject to Article 4, any legal expenses incurred by the Health Plan to enforce its rights under Article 4, and may be terminated in accordance with Article 4. Cooperation of Members means that:

(1 ) The Member must file the necessary papers that gives the Health Plan the right to collect payment from the Primary Plan for such services and supplies; and
Any benefits paid to the Member by the Primary Plan must be refunded to the health plan.

 

RIGHTS OF REIMBURSEMENT AND SUBROGATION

Upon the delivery of health care services or payment for such services pursuant to this Member Services Contract, the Health Plan shall be subrogated to any Member's rights against an Employer or other third party alleged to be legally responsible for bodily Injury or Illness to such Member, to the extent of the reasonable value on a fee­for­service basis of the health care services or payments provided and to the extent that compensation or damages are recovered. Any such right of subrogation provided to the Health Plan under this paragraph shall not apply or shall be limited to the extent Florida Statutes or the courts of Florida eliminate or restrict such a right.

The Health Plan may, at its option, take such action as may be necessary and appropriate to preserve its right to recover such compensation or damages, including the right to bring suit in the name of the Member. Such Member shall cooperate fully with the Health Plan in protecting its legal rights under this provision, including cooperating in obtaining information about the Injury or Illness and its cause.

To the extent not prohibited by Applicable State law, the Health Plan shall be entitled to be repaid first from, and have a lien against, the proceeds of any settlement or judgement which Member may recover against any employer or third party legally responsible for any bodily Injury or Illness for the reasonable value on a fee­for­service basis of health services provided by Plan. If paid directly to the Member, the Member shall hold such proceeds in trust for the benefit of the Health Plan and pay them over to the Health Plan upon demand.

The Member shall execute any documents and aid the Health Plan in any way required or requested by the Health Plan to secure a recovery.

MEDICARE ELIGIBLES

Medicare Part A means the Social Security program which provides hospital insurance benefits. Medicare Part B means the Social Security program which provides medical insurance benefits.

For the purposes of determining benefits payable for any Member who is eligible to enroll for Medicare Part B. but does not, the Health Plan will assume the amount payable under Medicare Part B to be the amount the Member would have received if he or she enrolled for it.

A Member is considered to be eligible for Medicare on the earliest date coverage under Medicare could become effective for him or her.

Integration With Medicare
Benefits under this Health Plan will be payable for a Member who is age 65 or older and eligible for Medicare as shown below.

A. If expenses are incurred for which benefits are payable by both this Health Plan and Medicare Part A, benefits are payable by this Health Plan only for those expenses which exceed the amount payable by Medicare Part A.

B. If expenses are incurred for which benefits are payable by both this Health Plan and Medicare Part B. the Health Plan will reduce the benefits payable by this Health Plan by the amount of benefits payable for those expenses by Medicare Part B.

C. The deductible of this Health Plan will apply only to covered benefits for prescription drugs and charges made by nurses.

For a Member who is under age 65 and eligible for Medicare, the benefits payable by this Health Plan will be reduced so that not more than 100% of the expenses incurred are paid jointly by this Health Plan and Medicare.

ARTICLE 5 ­ ELIGIBILITY

COMMENCEMENT OF COVERAGE

Coverage, unless otherwise provided in the Group Master Application, will commence as follows:

A. For a Subscriber eligible prior to and on the Effective Date of the Member Services Contract who elects coverage, coverage for the Subscriber and his/her Family Dependents will commence on the Effective Date of the Member Services Contract, provided prior written application (Group Enrollment Form) for enrollment is made.

B. For a Subscriber or a Family Dependent who submits a Group Enrollment Form more than thirty­one (31) days after the Effective Date, benefits shall become effective on the Eligible Date, which is the date the Group Enrollment Form is approved by the Health Plan, provided satisfactory Evidence of Insurability is furnished in writing by such Subscriber or Family Dependent for such Subscriber or Family Dependent, and payment of Premium is made for such benefits. If coverage of the Subscriber or Family Dependent is approved and payment of the additional Premium is received, coverage is effective on the Eligible Date. If coverage is denied, the Subscriber or Family Dependent must wait until the next Open Enrollment Period to enroll in the Health Plan.

C. An exception to Article 5.1 .B is for an after­acquired Family Dependent (e.g., newborn child, adopted child, or new Spouse). Benefits for the after­acquired Family Dependent shall become effective on the date such person becomes a Family Dependent provided the Group Enrollment Form is received by the Health Plan within thirty­one (31 ) days after the date such person became a Family Dependent, and payment of Premium is made for such family benefits. An additional premium charge will apply from the date of birth for newborns or the date of placement in the residence for an adopted child.

If the Group Enrollment Form is not submitted until after thirty­one (31 ) days from the date such person became a Family Dependent, Article 5.1.B is in effect.

For an Employee who is not Actively At Work on the Effective Date or thirty­one (31) days after the Effective Date, but then becomes Actively At Work and meets the definition of a Subscriber, such Employee and Family Dependents become effective on the Eligible Date, provided payment of Premium is made for such Family benefits.

 

EMPLOYMENT STATUS AND REQUIREMENTS

Any provisions related to eligibility that appear in the Group Master Application shall apply to this Member Services Contract, and to the extent they conflict, take precedence. The Group Master Application is specifically made a part of this Member Services Contract. Any Subscriber wishing to review the Group Master Application should contact his/her Employer.

FAMILY DEPENDENTS

Coverage for a Subscriber's Family Dependents begins on the Subscriber's Effective Date or Eligibility Date so long as the Subscriber has applied for Family Dependent coverage, the Premium is being paid, and the Health Plan has accepted the Family Dependents. Family Dependents may be enrolled in accordance with the following criteria or as specified in the

Group Master Application:

Spouse. If a Subscriber wishes to enroll a Spouse after the Effective Date, the Subscriber must provide a Group Enrollment Form to the Employer, appropriate legal papers and Evidence of Insurability, and pay any additional Premium. If coverage of the Spouse is approved and payment of additional Premium is received, coverage is effective on the Eligible Date. If coverage is denied, the Spouse must wait until the next Open Enrollment Period to enroll in the Health Plan.

An exception to the above criteria is if the Subscriber has just married the Spouse. In this case, the Spouse shall be eligible for benefits on the date of marriage, provided a Group Enrollment Form is submitted within thirty­one (31 ) days of the date of marriage. If a Group Enrollment Form is submitted within thirty­one (31) days of the date of marriage, benefits shall become effective on the Eligible Date, provided satisfactory Evidence of Insurability is furnished in writing by such Spouse for such Spouse, and payment of Premium is made. If coverage of the Spouse is approved and payment of additional Premium as received, coverage is effective on the Eligible Date. If coverage is denied, the Spouse must wait until the next Open Enrollment Period to enroll in the Health Plan.

Dependent Child.
For Dependent Children, the Subscriber must request enrollment, via the Group Enrollment Form, to his/her Employer within thirty­one (31) days of the child's birth, legal adoption, or assumption of legal guardianship to continue coverage. The Subscriber must also pay additional Premiums, if any, from the date of birth, legal adoption, or assumption of legal guardianship. If the Subscriber's Family Dependent is not enrolled within the thirty­one (31 ) days, Evidence of Insurability must be submitted. If coverage of the Dependent Child is approved and payment of additional Premium is received, coverage is effective on the Eligible Date. If coverage is denied, the Dependent must wait until the next Open Enrollment Period to enroll in the Health Plan. When a Dependent Child marries or reaches age nineteen (19) his/her membership will automatically end the last day of the month of his/her 19th birthday.

Newborn Child.
A newborn child of the Subscriber or Covered Family Member is covered at the moment of birth provided the newborn child is enrolled within thirty­one (31 ) days of the date of birth. If the newborn child is not enrolled within the first thirty­one (31) days of birth, Evidence of Insurability must be submitted. If coverage is denied, the Subscriber must wait until the next Open Enrollment Period to add the newborn child as a Dependent Child. Coverage for a newborn child of a Covered Dependent Child will terminate eighteen months after the birth of the newborn child.

Adopted Child.

An adopted child is covered from the moment of birth if a written agreement to adopt such child has been entered into by the Subscriber prior to the birth of the child, or an adopted child from the moment of placement in the residence of the Subscriber if enrolled within thirty­one (31) days of such placement. This Member Services Contract does not exclude coverage for any preexisting condition of an adopted child.

A child supported by the Subscriber pursuant to a valid court order, a stepchild, or a child for whom the Subscriber is the legal guardian are eligible for coverage, if enrolled within thirty­one (31 ) days of adoption or legal guardianship.

Disabled Dependent.
A Disabled Dependent is covered as a Dependent Child until the last day of the month of his/her 1 9th birthday. To be covered as a Disabled Dependent, the Subscriber must make a written request to the Health Plan for coverage of a Disabled Dependent thirty-one (31) days prior to the last day of the month of the Dependent Child's 19th birthday. The request must include written proof of disability and must be approved by the Health Plan, in writing. The Health Plan reserves the right to periodically review eligibility. The Disabled Dependent must be incapable of self­sustaining employment and is chiefly reliant on the Subscriber for support.

ENROLLMENT

To enroll as a Member of the Health Plan an Employee must complete a Group Enrollment Form provided by the Employer or the Health Plan. The Group Enrollment Form is the means by which the Employee identifies Family Dependents and selects a Primary Care Physician for each family Member. Once the Employee becomes a Subscriber the Group Enrollment Form is used to enroll newborns, Spouses and other Family Dependents eligible for membership after the initial enrollment by the Subscriber, and to convert from group to non­group coverage.

CONTINUATION OF COVERAGE

A. Continuation of Group Benefits ­ Employer Subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA).

Subscribers whose coverage would otherwise terminate have the right to voluntarily continue Health Plan coverage at their own expense, subject to the following terms and conditions:

(1 ) A Subscriber whose Employer or other group affiliation is not eligible for coverage under COBRA is eligible for coverage in accordance with Applicable State law (Article 5.5.B) or for non­group conversion (Article 5.5.C).

(2) A Subscriber whose Employer or other group affiliation provides eligibility for coverage under COBRA may continue coverage as described below:

A Subscriber who ceases to be eligible due to termination of employment for reasons other then gross misconduct, or due to other circumstances specified in COBRA, may elect continuation of coverage as provided herein. An enrolled Family Dependent(s) whose coverage would terminate due to the death of the Subscriber, divorce or legal separation from the Subscriber, the Subscriber becoming eligible for Medicare, or cessation of Family Dependent coverage under the terms of this Member Services Contract, may elect continuation of coverage as provided herein.

The Subscriber's Employer shall send notice to eligible Subscribers or Family Dependents of their right to elect to continue coverage and the conditions of payment. Eligible Subscribers and Family Dependents shall have sixty (60) days from the date of eligibility for continuation of group benefits within which to elect such coverage.

Such a Subscriber may elect continuation of coverage for up to eighteen (18) months from the date Subscriber ceases to be eligible.

Subscriber's Family Dependent(s) may elect continuation of coverage for up to thirty­six (36) months from the date the Family Dependent ceases to be eligible for group coverage.

Continuation of coverage shall expire before the eighteenth (18th) or thirty-sixth (36th) month if:

This Member Services Contract is terminated;

(b) Premiums are not paid on or before the date it is due, or within the thirty­one (31) day grace period;

(c) The Family Dependent becomes eligible for coverage under another group health plan as a result of employment or remarriage; or

(d) The Subscriber or Family Dependent becomes entitled to Medicare benefits; or The Member moves out of the Service Area.

Upon expiration of the eighteen (18) or thirty­six (36) month period of continuation of coverage, application for non­group conversion coverage may be made to the Health Plan as provided under Article 5.5.C.

Continuation of Group Benefits ­ State Law Extensions.

In Applicable States with statutory requirements for the continuation of group benefits for groups not subject to COBRA, the Health Plan will provide continuation of benefits in accordance with the Applicable State law.

Non­Group Conversion.

If the Member becomes ineligible under continuation of group benefits based on the occurrence of qualifying events, the Member may convert to non­group coverage that is in effect and available at the time the Member applies for conversion. For all possible COBRA qualifying events, Members may refer to Federal law or see their Employer. Examples of circumstances leading to non­group conversion are as follows:

• A Subscriber retires or leaves his/her employment and is not eligible for continuation of group benefits under COBRA, or State law, or Medicare; or
  

• A Family Dependent reaches the age of nineteen (19) and is not a Full Time Student; or
  

• A Subscriber changes his/her marital status.

Conversion to non­group membership may not occur until the Member is ineligible for, or has exhausted, his/her group membership continuation privileges. The Member must apply for conversion within thirty­one (31 ) days of termination of group coverage. The Member's application for conversion coverage must include payment for three (3) months coverage at the non­group conversion Premium in effect at that time. Members will be billed quarterly after the initial payment. The application for non-group conversion is available from the Health Plan and is subject to periodic changes in benefits and rates as determined by the Health Plan. Members will receive thirty­one (31) days prior notification of changes in benefits or rates. The Member will not be allowed to convert to non­group coverage if any of the following has occurred:

Membership status ended because of nonpayment of Premiums or, Co-payments;
Membership was ended for cause under Article 7.2; or The Employer, Medicare or other group affiliation replaces the Health Plan with another means of group coverage; or

The Member moves out of the Service Area. If the Member plans to move out of the Service Area, the Member must contact the Health Plan for information regarding the Health Plan's arrangements for out­of­area conversion coverage.

ARTICLE 6 COMPLAINTS AND GRIEVANCES

DETERMINATION OF COVERAGE

Benefits are paid only if the services provided are Covered Services under this Member Services Contract and Medically Necessary. Decisions about medical need and appropriate treatment are made by the Health Plan's Medical Director or designee. Decisions about Covered Services are made by the Health Plan.

COMPLAINTS AND GRIEVANCE PROCEDURE

The Health Plan recognizes that from time to time Members may encounter situations where the performance of the Health Plan does not meet their expectations. When this occurs, the Member may call the matter to the attention of the Health Plan's management. It is the policy and practice of the Health Plan to promptly and fairly consider all complaints and grievances of its Members. Decisions about medical need and appropriate treatment are made by the Health Plan's Medical Director or designee. Decisions about Covered Services are made by the Health Plan.

Definitions of Terms Used.

For the purpose of Article 6, the following terms and definitions apply:

Complaint. (Informal)

A relatively minor verbal expression of concern about a condition in the Health Plan's operation which may be resolved on an informal basis by the Health Plan's Member Services Department.

Grievance. (Formal)

A more serious written expression of concern about the Health Plan 's operation or a Complaint which has not been resolved to the Member's satisfaction. Both types of Grievances require a written response by the Health Plan, after a thorough investigation.

Procedure for Filing a Complaint or Grievance.

A Complaint may be directed to the Health Plan by the Member by telephone, in person, or in writing, expressing the details of the Member's concern.

A Member Services Representative may be contacted by calling (904) 3900935 or (800) 358­6205, or writing to Principal Health Care of Florida, Inc., Attention: Member Services Coordinator, 1200 Gulf Life Drive, Suite 500, Jacksonville, Florida 32207.

or

A Member Services Representative may be contacted by calling: (904) 4844000 or (800) 426­8072, or writing to Principal Health Care of Florida, Inc., Pensacola Division, Attention: Member Services Coordinator, 7282 Plantation Road, Suite 300, Pensacola, Florida 32504.

Complaints will be handled by one of the Health Plan's Member Services Representatives who may involve other staff members of the Health Plan or Providers of health care before making a determination. The objective is to review all the facts and to handle the Complaint within thirty­one (31) days. If the solution is satisfactory the matter ends.

If the Member does not receive prompt resolution or wishes to express concern to a higher level of authority, the Member may file a written Grievance with the Health Plan. A Grievance is to be submitted to the Health Plan, at the address shown above, by completing a Grievance form available from the Health Plan. If the Grievance involves a payment issue, this form must be filed within one (1) year after a notice of denial has been sent to the Member. The Member must sign the form, acknowledging that all incidents are accurately described. Upon receipt of the Grievance form, the Health Plan's Member Services Manager will conduct a thorough review of the Grievance. Following discussion with the Health Plan staff, and the Medical Director when there is a medically related grievance, a response to the Member's Grievance will be prepared and the Member will be notified of the Health Plan's decision in writing within thirty­one (31 ) days of receipt of the Grievance. If the solution is satisfactory, the matter ends.

Appeal Process.

(1) If the solution is not satisfactory to the Member, the Member may, within thirty­one (31) days, submit a written request for review to the Health Plan's Executive Director. The request for review must state the Member's reason for review, including the reason for dissatisfaction with the Member Services Manager's response. The Member will be notified of the Executive Director's decision in writing within thirty­one (31 ) days of the receipt of the request for review. If the solution is satisfactory, the matter ends.

(2) If the solution is not satisfactory to the Member, the Member may, within thirty­one (31) days, submit a written request for review to the Health Plan's Grievance Committee. The request for review must state the Member's reason for review, including the reason for dissatisfaction with the Executive Director's response. If practicable the Committee will be convened within thirty­one (31 ) days after receipt of the request for review. The Member may request to appear before the Committee to explain his/her position on the issue. The Committee will meet at the Health Plan's administrative offices or at a location convenient to the Member. The Committee will review all previous findings of the Health Plan's staff. The Member will be notified of the Committee's decision within fifteen (15) days after the date the Committee convenes. The decision of the Health Plan's Grievance Committee is final.

(3) If the Member is not satisfied with the decision of the Health Plan's Grievance Committee, the Member may appeal to the Department of Insurance or the Department of Health and Rehabilitative Services. Such suit or proceeding must be commenced not later than three (3) years after the date of notice of final determination is transmitted to the Member.

ARTICLE 7 ­ TERMINATION

NOTIFICATION OF TERMINATION FOR REASONS OTHER THAN NON­PAYMENT OF PREMIUM

The Health Plan will give the Employer at least thirty (30) days notice in writing of the cancellation, termination or non-renewal of this Group Member Services Contract. Such notification shall state the reasons for such action. However, such notification is not required for the reason of non­payment of Premium by the Employer, because of the thirty­one (31 ) day Grace Period given to the Employer under 7.2.B of this Member Services Contract.

 

REASONS FOR TERMINATION

Voluntary Termination

The Subscriber shall have the right to terminate this Member Services Contract by written notice to the Health Plan or his/her Employer. Such termination shall be effective on the last day of the month in which such notice is received by the Health Plan, unless otherwise specified in the Group Master Application.

Failure to Make Payments.

The Member is expected to pay all Co-payments and Premium contributions. In the event that the Member fails to make these payments, the Health Plan will notify the Member in writing of the failure. If the Member then does not make payment within thirty­one (31) days, this Member Services Contract will be terminated effective the last day for which Premium was paid.

Grace Period: This Member Services Contract has a thirty­one (31 ) day grace period. This provision means that if any required Premium is not paid on or before the date it is due, it may be paid during the following grace period. During the grace period, the Member Services Contract will stay in force. However, if any required Premium is not paid by the end of the grace period, benefits will cease on the Premium due date.

Misrepresentation of Fact.
This Member Services Contract will automatically terminate retroactive to the date of enrollment if:

The Subscriber has provided false information on his/her Group Enrollment Form for membership; or The Subscriber otherwise misrepresents a material fact.

In either case, if that information is material to the Health Plan's acceptance of the Subscriber's membership, this Member Services Contract will retroactively terminate.

 

Misuse of Membership Card.
If a Member permits the use of his/her or any other Member's Health Plan identification card by any other person, or uses another person's card, the identification card may be retained by the Health Plan and coverage of the Member may be terminated with forty­five (45) days written notice. The Subscriber shall be liable to the Health Plan for all costs incurred as a result of the misuse of the identification card.

 

Failure to Cooperate in the Coordination of Benefits. If a Member fails to cooperate in the Health Plan's administration of the COB provisions set forth in Article 4 this Member Services Contract, coverage will terminate after forty­five (45) days written notice.

 

Failure to Cooperate in Receiving Services.

The Health Plan may disenroll a Member for cause if the Member's behavior is disruptive, unruly, abusive, unlawful, fraudulent, or uncooperative to the extent that his/her membership seriously impairs the Health Plan's ability to furnish services.

 

Lack of Satisfactory Physician/Patient Relationship.

If, after reasonable efforts, Participating Physicians are unable to establish or maintain a satisfactory Physician/patient relationship with a Member (i.e., Member exhibits abusive or disruptive behavior in a Physician's office, repeatedly refuses to accept procedures or treatment recommended by a Participating Physician, and/or attempts to secure services in a manner that impairs the ability of the Primary Care Physician to coordinate the Member's care, coverage will terminate after forty­five (45) days written notice.

 

Loss of Eligibility.

Subject to the continuation and conversion privileges of this Member Services Contract, the coverage of any Member who ceases to be eligible shall terminate on the last day of the calendar month in which eligibility ceased, unless otherwise specified in the Group Master Application. This paragraph also applies to a Family Dependent of a Subscriber who becomes ineligible as a Member for whatever reason, including the death of the Subscriber.

Termination of Member Services Contract.

The Health Plan reserves the right to terminate the Member Service Contract if there is a change in the Effective Date, the benefits, or the Employee information used to determine rates; if the Employer fails to meet minimum enrollment requirements; or if the Health Plan amends the Member Services Contract and the Employer does not accept the amendment.

The Member Services Contract has a thirty­one (31) day grace period. This provision means that if any required Premium is not paid on or before the date it is due, it may be paid during the following grace period. During the grace period, the Member Services Contract will stay in force. However, claims incurred during the grace period will be suspended until Premium is received. If any required Premium is not paid by the end of the grace period, benefits will cease on the Premium due date. The termination of benefits shall not prejudice any claim incurred prior to the date of such termination.

 

Extension of Benefits.

If a Member is receiving Medically Necessary care on the date this Health Plan is terminated, benefits are provided only for those Covered Services incurred for the same Illness or Injury which caused the Member to be Totally Disabled until the earliest of the following:

• When the Member is no longer Totally Disabled;

• Twelve (12) months after the date the coverage would have otherwise ended;

• When the Member's maximum lifetime benefit has been reached; or

• When the Member becomes covered by a succeeding group health plan that does not limit benefits incurred as a result of the Member's totally disabling Illness or Injury.
  

In the case of extending benefits for a Member who is pregnant at the time the Group Master Application terminates, we will continue to provide benefits for maternity care. This extension of benefits will automatically terminate on the date of the birth of the newborn child and shall not be based on the Member being Totally Disabled.

ARTICLE 8 ­ ADMINISTRATION

IDENTIFICATION CARD

The Member will be asked to present his/her identification card, or otherwise show that he/she is a Member, whenever a Member receives services. The Member may not permit anyone else to use his/her identification card to obtain care. If the Member permits someone else to use his/her identification card, or the Member misuses it, this Member Services Contract will be terminated in accordance with Article 7.2.C. The Health Plan will notify the Member in the event such termination is necessary.

 

HOURS OF SERVICE

The Member should consult his/her Primary Care Physician concerning the Primary Care Physician's office hours and Medical Emergency arrangements.

EVENTS BEYOND CONTROL

The Health Plan is not liable for any delay or failure to provide services, or for any consequence thereof, due to events beyond its control. The Health Plan agrees to make all reasonable efforts to provide services through a contingency plan should such an event occur. Such events may include, but are not limited to: (1 ) non­Health Plan labor disputes; (2) an epidemic; (3) a public emergency; (4) a natural disaster; (5) the partial or total destruction of a Participating Provider facility; or (6) the disability of a Participating Provider, should a Member request care specifically from that Participating Provider.

 

SUBMISSION OF BILLS AND CLAIMS

Itemized statements of medical service provided must be furnished to the Health Plan within ninety (90) days after the date of such service. Failure to furnish such statements within ninety (90) days shall not invalidate or reduce any claim if it was not reasonably possible to provide the statements within ninety (90) days. Except in the absence of legal capacity, bills will not be accepted later than one (1) year after the date of service.

ARTICLE 9 ­ ACCESS TO RECORDS AND CONFIDENTIALITY

As part of this Member Services Contract, the Member authorizes the Health Plan to have access to any health records and medical information held by any health care Provider who delivers health services to the Member under this Member Services Contract. The Member also authorizes the Health Plan, or its representatives to use his/her general medical record, when necessary, for: claims processing, including claims the Health Plan makes on the Member's behalf for reimbursement; quality assessment; underwriting (for the purpose of reinstatement or adding a Family Dependent); and evaluation of potential or actual claims against the Health Plan.

 

ARTICLE 10 ­ CONFLICTS WITH EXISTING LAWS

In the event any term or condition of this Member Services Contract is found to be in irreconcilable conflict with Applicable State or Federal law, that law shall pre­empt only that provision of this Member Services Contract which is in conflict.

 

ARTICLE 11 -AMENDMENTS TO THIS MEMBER SERVICES CONTRACT

Amendments which the Health Plan makes part of this Member Services Contract, or sends to the Member at a later time, are incorporated and are fully a part of this Member Services Contract.

 

APPENDIX A ­ DEFINITIONS OF TERMS USED

(Alphabetical)

Actively at Work: An Employee who is regularly scheduled to work those hours per week and months per year as defined in the Group Master Application, thereby making that Employee eligible for Covered Services under the terms of this Member Services Contract. An employee is considered Actively at Work on the following days, if he or she was actually at work on the immediately preceding work day, and is not totally disabled by reason of injury or sickness on such day:

(1) a full normal work day of his or her regular duties;

(2) a weekend, except for one or both of these days if they are scheduled days of work;

(3) holidays, except when such holiday is a scheduled work day;

(4) paid vacations;

(5) any regularly scheduled non­working day;

(6) any non­scheduled non­working day;

(7) excused leave of absence, except medical leave; and emergency leave of absence except emergency medical leave.

Applicable State: The State(s) in which the Health Plan is duly licensed.

Business Days: A day of the week other than Saturday, Sunday or legal holiday.

Case Management: A systematic process performed by the Health Plan to:

(1) identify high cost cases;

(2) assess potential opportunities to coordinate care;

(3) develop treatment plans that improve quality and control costs; and

(4) menace total health care to ensure optimum outcome.

Coinsurance: The Member's responsibility to pay a share of the amount approved for payment by the Health Plan based on charges submitted by the Participating Physician and Participating Provider. The Member pays the Coinsurance amount directly to the Participating Physician and Participating Provider.

Co-payment: The Member's responsibility to pay a dollar amount per service, as specified in the Schedule of Benefits. A Co-payment is paid to the Participating Physician or Participating Provider by the Member when a health service is rendered.

Covered Family Member: A member of the Subscriber's family who is receiving Covered Services under this Member Services Contract.

Covered Services: Except as expressly limited or excluded by this Member Services Contract, those Medically Necessary services as indicated in Article 2 of this Member Services Contract, the Schedule of Benefits and the applicable Supplemental Benefit Explanations.

Crisis Intervention: A timely, rapid assessment and treatment to stabilize a patient's emotional and psychological condition in order to return the patient to an improved level of functioning. This can also mean an acute exacerbation in a Chronic Mental Health Condition.

Chronic Mental Health Condition: A psychiatric condition that has a recurrent, episodic course regardless of treatment. Chronic psychiatric conditions may have intermittent periods of quiescence. Periodic flare­ups of systems can be decreased with treatment. "Chronic" refers to a condition, not a type of treatment.

Durable Medical Equipment Reference List: A list by category or item of equipment covered which is designed for repeated use serves primarily a medical purpose, and is appropriate for use in a Member's home.

Effective Date: The date, as specified in the Group Master Application, that coverage begins for services under the terms of this Member Services Contract for those Subscribers and their Family Dependents who enrolled for Health Plan coverage during the Open Enrollment Period and are accepted by the Health Plan for coverage.

Eligible Date: The date a Group Enrollment Form is approved by the Health Plan and coverage begins for services under the terms of this Member Services Contract for those Subscribers and their Family Dependents who enrolled for Health Plan coverage at least thirty­one (31) days after the Effective Date.

Employee: One who works for an Employer and receives wages or a salary.

Employer: A company with whom the Health Plan has a signed Group Master Application to provide Subscribers and their Family Dependents the benefits and services under the terms of this Member Services Contract.

Evidence of Insurability: A signed statement from a Member verifying health status and Pre­Existing Conditions used by the Health Plan to determine eligibility for membership.

Family Dependents: Family Dependents under family coverage are limited to the following:

A. Spouse.
A Subscriber's Spouse or eligible former Spouse as defined by Applicable State law or Court Decree.

B. Dependent Child: Dependent Child means:

(1) the Subscriber's unmarried natural child residing within the Service Area;

(2) the Subscriber's newborn child residing within the Service Area;

(3) the Covered Family Member's newborn child residing in the Service Area;

(4) the Subscriber's adopted child from the moment of placement in the residence

of the Subscriber;

(5) the Subscriber's adopted newborn from the moment of birth if a written agreement to adopt such child has been entered into by the Subscriber prior to the birth of the child, whether or not such agreement is enforceable; however, coverage for such child shall not be required in the event the child is not ultimately placed in the Subscriber's residence; or

(6) an unmarried child not legally related to the Subscriber but residing in the Subscriber's home in an ongoing parent/child relationship which is intended to continue to adulthood and whereby the Subscriber is the renal guardian.

In each case the child must be dependent on the Subscriber for a majority of his or her financial support and must be either under nineteen (19) years of age, a full-time Student, or a Disabled Dependent. An unmarried child who is a Full­Time Student under twenty­four (24) years of age is a Family Dependent. Coverage is through the last day of the month in which he/she turns 19 or 24 for student status. or as specified in the Group Master Application.

C. Full­Time Student. A Full­Time Student is a Dependent Child:

1. under twenty­four (24) years of age;

(2) enrolled in and attending full­time (twelve (12) credit hours per semester) a recognized course of study or training in a public or private secondary school, college, university, or licensed trade school, and provide a Registrar's letter of student status confirmation as evidence thereof, upon the Health Plan's request.

Full­Time Student status continues during:

(1) regularly scheduled school vacation periods;

(2) absence from classes, in which enrolled, for up to four months due to physical or mental disability (Note: this does NOT include absence from classes for personal reasons); or

(3) temporary residence outside the Service Area for the purpose of attending school.

Disabled Dependent.

An unmarried child who would otherwise be ineligible for coverage and, who while continuously covered as a dependent under a Group Master Application and Member Services Contract issued by the Health Plan, is and continues to be:

(1) Incapable of self­sustaining employment by reason of mental retardation or physical handicap, and

(2) Dependent upon the Subscriber, who has fulfilled the Health Plan's eligibility requirements, for at least fifty­one percent (51 %) of support and maintenance.

Group Master Application: A contract, signed by the Health Plan and the Employer and filed with the Employer, that sets out additional terms of coverage for Subscribers and their Family Dependent who receive Health Plan coverage through their Employer.

Health Plan: Principal Health Care of Florida, Inc.

Hospital: An institution which maintains affiliation or contractual agreement with the Health Plan for Hospital services or which is otherwise specified by the Health Plan and which is either:

A. An institution which is primarily engaged in providing, on an inpatient basis, medical care and treatment for sick and injured persons through medical, diagnostic and major surgical facilities, under the supervision of a staff of Physicians, and with twenty­four­hour­a­day (24) service;

or

B. An institution not meeting all the requirements of (A) above, but which is accredited as an allopathic Hospital by the Joint Commission on Accreditation of Health Care Organizations or Title XVIII of the Social Security Act of 1965 as amended; or is accredited as an osteopathic Hospital by the American Osteopathic Association. In no event shall the term "Hospital" include a convalescent nursing home or any institution, or part thereof, which is used principally as $. convalescent facility rest facility or nursing facility for the aged.

Indemnity­Type Policy: An accident or health insurance policy that pays a set dollar amount for daily benefits for hospital confinements in an amount not less than ten dollars ($10) per day.

Illness: A sickness or disease including all related conditions and recurrences. Illness also includes pregnancy and all related conditions, and chemical detoxification.

Injury: An accident to the body requiring medical or oral surgery treatment.

Inpatient Hospital Stay: A Hospital stay for which a room and board charge is made by the Hospital.

Medical Director: The Physician so specified by the Health Plan as the Medical Director.

Medical Emergency: The sudden and acute onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably result in:

• Permanently placing the Member's health in jeopardy.

• Serious impairment to bodily function.

• Serious and permanent dysfunction to any bodily organ or part.

• Other serious medical consequences.

Medically Necessary: Any service or supply for the prevention, diagnosis or treatment which is:

(1) consistent with Illness, Injury or condition of the Member;

1. in accordance with the approved and generally accepted medical or surgical practice prevailing in the geographical locality where, and at the time when, the service or supply is ordered. Determination of "generally accepted practice" is the discretion of the Medical Director or designee.

In the event of a disagreement between a Member and a Participating Physician as to the Medical Necessity of a particular service, the Medical Director or designee shall make the final determination of Medical Necessity.

Medicaid: Title XIX of the Social Security Act and all amendments thereto.

Medicare: Title XVIII of the Social Security Act and all amendments thereto

Member: Any Subscriber or Family Dependent duly enrolled in the Health Plan.

Member Services Department: The department of the Health Plan that provides information, resolves complaints and maintains effective communication with Members.

Open Enrollment Period: A thirty (30) day time period established by an Employer at least every eighteen (18) months when eligible Employees are offered the option to choose, change or reallocate benefits.

Out­of­Pocket Maximum: The limit of a Member's payments to the Health Plan, as specified in the Schedule of Benefits. Only Coinsurance applies to a members Out-of-Pocket Maximum.

Partial Hospitalization: These are services offered by a program accredited by the Joint Commission on Accreditation of Hospitals (JCAH) or in Compliance with equivalent standards. Partial hospitalization benefits shall be provided under the direction of a licensed Physician who is associated with or under contract by the Health Plan. Alcohol and Drug Abuse benefits (Substance Abuse) shall also qualify under this definition.

Participating Physician: Any doctor of medicine or osteopathy who is licensed to practice medicine and has a contractual arrangement with the Health Plan for the provision of Covered Services to the Health Plan's Members

Participating Provider: Any Hospital, Skilled Nursing Facility, individual, organization or agency:

( 1 ) licensed to provide professional services within the scope of that license or certification; and

(2) has a contractual arrangement with the Health Plan for the provision of Covered Services to the Health Plan's Members.

Physician: An individual who is licensed to practice medicine under the laws of the State of Florida or a partnership or professional association of such persons and is licensed as a Doctor of Medicine or Doctor of Ophthalmology, Optometry, Osteopathy, Podiatry or Chiropractic Medicine.

Pre­Existing Condition: An Illness or Injury for which a Member is confined or received treatment or service in the ninety (90) day period before the Member became covered under this Member Services Contract.

Premiums: A payment for a contract of Principal Health Care of Florida, Inc. health maintenance organization health insurance made by Members, or through the Subscriber's Employer to the Health Plan.

Primary Care Physician: An individual who is licensed to practice medicine under the laws of the State of Florida or a partnership or professional association of such persons and is licensed as a Doctor of Medicine or Doctor of Osteopathy, Podiatry or Chiropractic Medicine; and is associated with or engaged (or under contract) by the Health Plan, in the specific medical fields of Internal Medicine, Family Practice, or Pediatrics, or who is specified as a Primary Care Physician by the Health Plan for the purpose of this Member Services Contract.

Principal Health Care of Florida, Inc.: A licensed health maintenance organization in the State of Florida.

Provider: Any Hospital, Skilled Nursing Facility, individual, organization or agency licensed to provide professional services within the Scone of that license or certification.

Skilled Nursing Facility: An institution which is:

accredited as a Skilled Nursing Facility by the Joint Commission on Accreditation of Health Care Organizations; recognized and eligible for payment under Medicare as a Skilled Nursing Facility; and recognized by the Health Plan

Subscriber: An Employee who is Actively At Work:

(1) works or resides in the Service Area;

(2) signs the Group Enrollment Form;

(3) meets all applicable eligibility requirements in this Member Services Contract:

(4) is duly enrolled on the Effective Date or Eligible Date; and

(5) for whom prepayment has been accepted by the Health Plan.

Supplemental Benefit Explanation: A description of coverage for services and benefits offered in addition to the coverage set forth in the Member Services Contract.

Usual, Customary and Reasonable Fee: A fee which is consistent with the fee of other Providers for a given service or item in the same community and is reasonable for that service as determined by the Health Plan. Specifically:

A. A fee is "Usual" if it is the fee generally charged by an individual Physician to private patients for a particular service.

B. A fee is "Customary" if it is within the normal range of usual fees charged by most Physicians of similar training and experience for the same service within the service area.

A fee is "Reasonable" which meets the above two criteria, or, in the opinion of the Medical Director and the Health Plan, is justifiable in the special circumstances of the particular case in question.

 

APPENDIX B ­ DEFINED SERVICE AREAS

The following geographic areas within the State of Florida and any expansion thereto as approved by the Florida Department of Insurance:

North Florida: The counties of Alachua, Baker, Clay, Columbia, Duval, Nassau and St.Johns.

Panhandle: The counties of Escambia, Santa Rosa, Okaloosa and Walton.

South Florida: The counties of Dade, Broward and Palm Beach.

Central Florida: The counties of Hillsborough, Lake, Orange, Osceola, Pasco, Pinellas