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Res No 143-11-13457RESOLUTION NO.: 143 -11 -13457 A Resolution approving the selection of Neighborhood Health Partnership to provide group health insurance for the City of South Miami full time employees to be charged to departmental account numbers respectively. WHEREAS, the Agent of Record (Employee Benefits Consulting Group) secured 3 bids for the City's Group Health Insurance and recommended Neighborhood Health Partnership as the lowest responsive bidder; and WHEREAS, the City Commission compared the insurance rates, benefit plan design, provider network as well as our previous claims experience /ratio; and WHEREAS, the City Commission wishes to approve of the selection of Neighborhood Health Partnership as the provider of Group Health Insurance Benefits for all full time employees and participating retirees. NOW THEREFORE, BE IT RESOLVED BY THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, THAT: Section 1: The City Commission hereby approves and selects Neighborhood Health Partnership to provide group health insurance for the City of South Miami full time employees for the 2011 -2012 fiscal year. Section 2: This resolution shall take effect immediately upon adoption PASSED AND ADOPTED this 6th day of September, 2011. EST: CLERK READ AND APP ED AS TO FORM UAGE LANG, CUTION 4-NO -"-1 Approved: MAY Commission Vote: 5 -0 Mayor Stoddard: Yea Vice Mayor Newman: Yea Commissioner Palmer: Yea Commissioner Beasley: Yea Commissioner Harris: Yea South Miami bAd H 3 ACdnlelicaCltY CITY OF SOUTH MIAMI , 1 OFFICE OF THE CITY MANAGER xoor INTER- OFFICE MEMORANDUM To: The Honorable Mayor & Members of the City Commission Via: Hector Mirabile, Ph.D., City Manager % From: LaTasha Nickle, Human Resources Director Date: September 6, 2011 Agenda Item No.: Subject: Health Insurance Resolution Request: A Resolution of the Mayor and City Commission of the City of South Miami, Florida, approving the selection of Neighborhood Health Partnership to provide group health insurance for the City of South Miami full time employees to be charged to departmental account numbers respectively; providing for an effective date. Reason/Need: The City's Agent on Record, Employee Benefits Consulting Group solicited bids from seven companies. Bids were received from the following companies: Aetna AvMed Blue Cross Blue Shield Cigna Healthcare Humana Neighborhood Health Partnership Vista Declined to quote Submitted proposal Declined to quote Declined to quote Submitted proposal Submitted proposal Proposal not submitted The City recommendation to the City Commission to select Neighborhood Health Partnership as health insurance provider for the 2011 -2012 benefit plan year. Neighborhood Health Partnership has proposed a 1.7% rate decrease for the upcoming plan year with comparable benefits to the current plan with AvMed. Backup Documentation: Q Proposed resolution. U Employee Benefits Consulting Group Summary Report LOW HMO HIGH HMO POS EE $416.26 $482.80 $560.28 BE + CH $736.63 $854.37 $991.49 EE +SP $819.86 $950.92 $1,103.52 EE +FM $1,227.69 $1,423.96 $1,652.46 Backup Documentation: Q Proposed resolution. U Employee Benefits Consulting Group Summary Report Benefit Summary Report By: Employee Benefits Consulting Group TABLE OF CONTENTS I. Executive Summary II. Proposed Rates III. HMO Benefit Comparison IV. POS Benefit Comparison V. Appendix Employee Benefits Consulting Group Executive Summary Enclosed is our analysis of the group behalf of the City of South Miami, We this project: Aetna AvMed (incumbent) Blue Cross Blue Shield CIGNA health insurance proposals that we received on approached the following vendors in regards to Humana Neighborhood Health/United Healthcare Vista The upcoming plan year represents the period of 10/1/2011- 9/30/2012. Here is a summary of our efforts: AvMed (Medical) AvMed has proposed a 15.1% rate increase for the upcoming plan year. The paid loss ratio from 5/1/2010 - 4/30/2011 was 109% (i.e. for every $1 of premium AvMed paid $1.09 in claims). Neighborhood Health/United Healthcare . submitted a proposal that warrants further consideration. Here are the highlights from the Neighborhood Health/United Healthcare proposal: Neighborhood Health/United Healthcare has proposed a 1.7% rate decrease for the upcoming plan year. ■ Neighborhood Health/United Healthcare's proposed benefits are comparable to the current plan with AvMed. Neighborhood Health/United Healthcare has a comprehensive network of providers and hospitals in South Florida. Humana (Dental and Vision) Humana has proposed a 10% rate decrease for the upcoming plan year on the dental and vision. The paid loss ratio from 3/1/2010- 2/28/2010 was 68% for the dental plan (i.e. for every $1 of premium Humana paid $.68 in claims). We appreciate the opportunity the City of South Miami has given us in regards to this project. Employee Benefits Consulting Group is prepared to assist the City of South Miami in managing healthcare costs while still maintaining the integrity of the benefits package. Employee Benefits Consulting Group Proposal Responses Vendor Name Aetna AvMed Blue Cross Blue Shield CIGNA Healthcare Humana Neighborhood Health/United Healthcare Vista Response Declined to quote. Submitted a proposal. Declined to quote. Declined to quote. Submitted a proposal. Submitted a proposal. As of 6/27/2011 has not submitted a proposal. Employee Benefits Consulting Group N U G N Q. Rlf U -a m N O M V d r N 'o O om. d N E U O � � C (q o f o 0 0 I a sr CO .-h ^ e� of � i � I,. �tMO V'c -1CJ ti00 O J R r w CO �:, I� 1� OO o N t0 t, E U~J_MM��� W W �C�OM� Em • d 7E a . am vtO -a uhNr Cm V r rNN m » CcFSO O o , m eMOn t C0C<eO a O t 0 MceNta > o rNOCfl O Co er w aV M (31 01 N r 0 CO3 <M 1m N� a - cj, � t��'" " • � U S'i. M � aM- .M- rraN -r cf.N -NCO U �00000000�r�c Al a 7 O w C7 p 2 d U u L q O W A O W tO o m. n M' m "m � [O M.. j oi. L 1 [O NN M N M O N» i0 m (OO O ••"� GC IV C! m O w W Vh! 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J §f \ ) e & CL \ / \ \0 0 /� \( \\ \ \ \\ \ \ \ \ z §{ a k§{ z � � \ A e {)§ \ ) — . J ( b e & CL \ / \ \0 0 ! �t \af 0.3 \ \\ \ \ \ \ k §{ a k§{ /\ � � \ A § {)§ 4322 zzzz z } \ \ - $ � ) k \ /\ \\ \ .,/ — . J ( b e & 2=aq \ / \ \0 {\ �t \af 2 \ \\ \ \ \ \ k 0 z / /\ � � \ rA ~ 4322 zzzz z } \ \ ) .,/ — . J ( b e & 2=aq \ / .,/ E — . J ( b e � E/ _ / \ \0 {\ �t \af 2 \ \\ \ \ \ \ k 0 z / /\ � � \ ~ 4322 zzzz z } \ \ ) E — . J ( b e � E/ _ / \ \0 �t \af 2 \ \\ \ \ \ k 0 z / /\ � � 4322 22 } \ \ ) E — . J ( b e � E/ _ / \ \0 �t \af 2 \ / \ \ \ k 0 z / — - ( � E/ k \ \0 �t \af 2 \ \3 /} \ � k NEIGHBORHOOD HEALTH/UNITED HEALTHCARE LOW HMO FV-C $15425425041,500 R 'III SUMMARY OF C A quick glance at this Summary of Benefits will introduce you to the important advantages of the Neighborhood Health Partnership (NHP), a Florida HMO, The Summary of Benefits, although a helpful tool, is only a summary. Always refer to your Handbook for a fuller explanation of your coverage or call Customer Services at the phone numbers on your NHP ID Card when you have a question about your plan. in the event of a conflict between this Summary of Benefits and the Handbook, the Handbook will control Services must be provided by health care providers which have contracts with NHP, referred to as "Plan Providers," "Plan Physicians" or "Plan Hospitals," unless in an Emergency or with prior authorization by NHP. Features Your Responsibility for Coverage When Care Is Managed By Your PCP. Please note: if your Plan has a deductible, the deductible must be satisfied unless otherwise noted below. You are also responsible for any copayments and/or coinsurance listed below. Primary Care Physician (PCP) $15 copayment per visit Copayments per visit (Office Visit) Specialist (Office Visit) $25 copayment per visit Urgent Care Center $50 copayment per visit Emergency Room $100 copayment per visit Outpatient Therapy $20 copayment per visit Inpatient Hospital $250 copayment per day up to a maximum of 5 days per admission Radiology No copayment for minor diagnostics; $50 copayment for major diagnostics including CT, MRI, MRA, PET scans and nuclear imaging Allergy Testing $25 copayment per visit UnitedHealtheare® NHP HMO HSA 9(10 Rev1 -1- FVC 15125!25011500 R Features Your Responsibility for Coverage When Care Is Managed By Your PCP. Please note: if your Plan has a deductible, the deductible must be satisfied unless otherwise noted below. You are also responsible for any copayments and /or coinsurance listed below. Out of Pocket The limit which you and your eligible family members must pay in Maximum copayments and coinsurance per calendar year is $1,500 per member, and $3,000 per family. All individual Out of Pocket Maximum amounts will count toward the family Out of Pocket Maximum. However, an individual will not have to pay more than the individual Out of Pocket Maximum amount. Maximum Benefit No Maximum Benefit Primary Care Your PCP is responsible for coordinating all your health care services, including referrals to Specialists. Your PCP or Physician Specialist must obtain Pre Authorization for designated services including, but not limited to, all inpatient care, outpatient surgical procedures, durable medical equipment (DME), home health services, home infusion, hospice care, rehabilitation, skilled nursing facility, and transplant services. Referrals Your PCP is responsible for coordinating all referrals to specialists, except for the following specialties which you may access directly: Podiatry. Chiropractic. Coverage is limited to 12 visits per year. Dermatology (5 visits per calendar year). Additional visits require referrals, Gynecology Substance Use Disorders. Services must be provided by NHP's behavioral health network. Mental Health Services must be provided by NHP's behavioral health network. Neurobiological Disorder Services — Autism Spectrum Disorder. Services must be provided by NHP's behavioral health network. Note: if your Employer purchased a Direct Access Rider, you may see a Specialist without a referral from your PCP. Please refer to your NHP ID Card or call Customer Services to verify the need to obtain a referral to a Specialist. Even when the Plan includes a Direct Access Rider, you must select a PCP or NHP will assign one to you. If you need assistance, call Customer Services. Prescription Drugs If your Employer has elected to provide coverage for prescription drugs, you will receive a copy of a Prescription Drug Rider which explains your prescription drug coverage. NHP HMO HSA 9110 keel -2- FVC 15125125019500 R YOUR NHP PLAN COVERAGE IMPORTANT Unless otherwise stated, care, services or treatment not managed by your Primary NOTICE: Care Physician, not Medically Necessary, or not pre - certified by NHP are not Covered Services. Services must be provided by Plan Providers, except when prior authorized or in the case of an Emergency Medical Condition. You must check your Handbook for further details relating to your coverage. NHP HMO HSA 9110 Revi -3- FVC 151251250N599 R i x Ambulance $50 copayment in emergency situations or when authorized by NHP to transfer you to a NHP facility. Autism Spectrum Disorder Covered as any other eligible service, based on place of service. (Applies only to Large Employer Limited to $36,000 per calendar year and $200,000 during the entire groups) time covered by NHP. Chiropractic services $25 copayment per visit Limited to 12 treatments per calendar year; PCP referral not required. Dermatology $25 copayment per visit PCP referral not required for 5 visits per calendar year; further visits require PCP referral. Diabetes $25 copayment per visit Services include outpatient self management training and educational services. Durable Medical Equipment No copayment (DME) and disposable medical Limited to $2,500 per calendar year. supplies Emergency room services $100 copayment per visit Any deductible and /or copayment for the emergency room is waived if the patient is admitted to the hospital, Enteral Formula No copayment Limited to $2,500 per calendar year. Family Planning Covered as any other eligible service, based on place of service. Limited to surgical sterilization, implantable contraceptives and intrauterine birth control devices, Gynecology $25 copayment per visit POP referral not required. Hearing Aids No copayment Limited to $2,500 per year and to a single purchase (including repair /replacement) every three years. Hearing Exams No copayment when performed by PCP to determine need for hearing (children through age 21) correction. Limited to one exam per calendar year. NHP HMO HSA 9110 Revi -3- FVC 151251250N599 R Home health services No copayment Limited to 60 visits per calendar year. Custodial care is not covered. Home infusion services No copayment Limited to 60 visits per calendar year. Hospice care No copayment Limited to a Maximum Benefit of 180 days of inpatient and/or outpatient care for a terminally ill member when requested by a Plan Hospital facility care Inpatient. $250 copayment per admission and 0% after deductible Outpatient: Minor Diagnostic /X -Ray No copayment Major Diagnostic Services, $50 copayment per service including CT, MR1, MRA, PET Mammograms No copayment for one baseline for women age 35 through 39, one every year for women age 40 and over, or more frequently based on physician's recommendation. Mastectomy Covered as any other eligible service, based on place of service. Maternity care, including pre- Covered as any other eligible service, based on place of service. and post -natal care and Note: any office visit copayment applies only to the initial visit. delivery* Physician office services include one OB ultrasound between weeks 13 and 24 of pregnancy. Mental Health (Services must be I Outpatient: $25 copayment provided by NHP's behavioral Limited to a maximum of 20 visits per calendar year. PCP referral Not health network) required. Inpatient: $250 copayment per admission and 0% after deductible of 30 days per calendar NHP HMO HSA 9110 Ravi -4- FVC 15125125011500 R NHP HMO HSA 9110 Rev1 -5- FVC 1512512501150D R a¢ Neurobiaiogical Disorder Outpatient: $25 copayment Services — Autism Spectrum Limited to a maximum of 20 visits per calendar year. PCP referral Not Disorder required. inpatient: $250 copayment per admission and 0% after deductible Limited to a maximum of 30 days per calendar year. Newborn Children* No copayment per visit for well baby care and treatment of Illness or (birth — 30 days) Injury. Organ Transplant Inpatient Covered as any other eligible service, based on place of service. Must Services be prior authorized by NHP Medical Director. Osteoporosis Covered as any other eligible service, based on place of service. Limited to diagnosis and treatment of high-risk individuals. Outpatient therapies $20 copayment per visit Limited to 60 visits per calendar year for all physical, respiratory, speech, cardiac and occupational therapy combined. These limits do not apply to Autism Spectrum Disorder for Large Employer Groups, Physical Rehabilitation — No copayment Inpatient Care Limited to 60 days per calendar year for restorative physical therapy. Physician Services No copayment for inpatient care or outpatient surgical services when performed in an inpatient setting or an outpatient facility. Podiatry $25 copayment per visit PCP referral not required. Preventive health services No copayment Primary Care Physician (PCP) $15 copayment per visit Only applies to your designated PCP. Prosthetic Devices No copayment Limited to one prosthetic per loss of limb or eye during the entire period of time you are covered. Skilled nursing facility No copayment Limited to120 days per calendar ear; custodial care is not covered. Specialist office visits $25 copayment per visit PCP referral required excepj as noted above. Sterilization Covered as any other eligible service, based on place of service. Reversals are not covered. NHP HMO HSA 9110 Rev1 -5- FVC 1512512501150D R Substance Use Disorders Outpatient. $25 copayment per visit (Services must be provided by Limited to 44 visits per calendar year. PCP referral not required. NHP's behavioral health network) Inpatient. $250 copayment per admission and 0% after deductible Limited to a maximum of 30 days per calendar year. Limited to crisis intervention and detoxification only. Urgent Care Center $50 copayment per visit Vision screening No copayment when performed by PCP. (children through age 21) Limited to services necessary to determine need for vision correction and to one exam per calendar year. For coverage to begin at the date of birth for newborn children, a completed and signed enrollment form must be received by NHP. When received within 30 days of birth; no additional premium will be charged for this 30 day period. When notice is received within 60 days from the date of birth, premium will be charged from the date of birth. if the enrollment form is not received within 60 days of birth, the newborn child will be considered a Late Enrollee by NHP. You must enroll your newborn within these time periods regardless of whether your coverage is family coverage. A full list and description of benefits, including any limitations and exclusions, are in your Handbook. 7600 Corporate Center Drive, Miami, FL 331261 PO Box 025680, Miami, FL 33102 -5680 www.myNHP.com -or call Customer Services at the phone number on your NHP ID Card. NHP HMO NSA 9110 ReA •6- FVC 15125!25011500 R 1 Ev -A $151$15/$01$500 R NEIGHBORHOOD HEALTH PARTNERSHIP HMO SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to the important advantages of the Neighborhood Health Partnership (NHP), a Florida HMO. The Summary of Benefits, although a helpful tool, is only a summary. Always refer to your Handbook for a fuller explanation of your coverage or call Customer Services at the phone number on your NHP I D Card when you have a question about your plan. in the event of a conflict between this Summary of Benefits and the Handbook, the Handbook will control. Services must be provided by health care providers which have contracts with NHP, referred to as "Plan Providers," "Plan Physicians" or "Plan Hospitals," unless in an Emergency or with prior authorization by NHP. Features Your Responsibility for Coverage When Care Is Managed By Your PCP. Please note., if your Plan has a deductible, the deductible must be satisfied unless otherwise noted below. You are also responsible for any copayments and /or coinsurance listed below. Copayments per visit Out of Pocket Maximum Maximum Benefit Primary Care Physician (PCP) (Office Visit) Specialist (Office Visit) Urgent Care Center Emergency Room Outpatient Therapy Inpatient Hospital Radiology Allergy Testing $15 copayment $15 copayment $25 copayment per visit $50 copayment per visit $0 copayment per visit $500 copayment per admission No copayment for minor diagnostics; $0 copayment for major diagnostics including CT, MRI, MRA, PET scans and nuclear imaging $15 copayment The limit which you and your eligible family members must pay in copayments and coinsurance per calendar year is $1,500 per member, or $3,000 per family, whichever comes first. No Maximum Benefit NHP HMO HSA 9119 Rev1 -1- EVA 15115/01600 R Features Your Responsibility for Coverage When Care Is Managed By Your PCP. Please note: if your Plan has a deductible, the deductible must be satisfied unless otherwise noted below. You are also responsible for any copayments and/or coinsurance listed below. Primary Care Your PCP is responsible for coordinating all your health care services, including referrals to Specialists. Your PCP or Physician Specialist must obtain Pre - Authorization for designated services including, but not limited to, all inpatient care, outpatient surgical procedures, durable medical equipment (DME), home health services, home infusion, hospice care, rehabilitation, skilled nursing facility, and transplant services. Referrals Your PCP is responsible for coordinating all referrals to specialists, except for the following specialties which you.may access directly: Podiatry. Chiropractic. Coverage is limited to 12 visits per year. Dermatology (5 visits per calendar year). Additional visits require referrals. Gynecology Substance Use Disorders. Services must be provided by NHP's behavioral health network. Mental Health Services must be provided by NHP's behavioral health network. Neurobiological Disorder Services — Autism Spectrum Disorder. Services must be provided by NHP's behavioral health network. Note: If your Employer purchased a Direct Access Rider, you may see a Specialist without a referral from your PC.P. Please refer to your NHP ID Card or call Customer Services to verify the need to obtain a referral to a Specialist. Even when the Plan includes a Direct Access Rider, you must select a PCP or NHP will assign one to you. If you need assistance, call Customer Services. Prescription Drugs If your Employer has elected to provide coverage for prescription drugs, you will receive a copy of a Prescription Drug Rider which explains your prescription drug coverage. NHP HMO HSA 9110 Rev1 -2- EVA 15/15/01500 R YOUR NHP PLAN COVERAGE IMPORTANT Unless otherwise stated, care, services or treatment not managed by your Primary NOTICE: Care Physician, not Medically Necessary, or not pre - certified by NHP are not Covered Services. Services must be provided by Plan Providers, except when prior authorized or in the case of an Emergency Medical Condition. You must check your Handbook for further details relating to your coverage. NHP HMO HSA 9110 Rev1 -3- EVA 15/15/0/500 R r Ambulance $0 copayment after deductible in emergency situations or when authorized by NHP to transfer you to a NHP facility. Autism Spectrum Disorder Covered as any other eligible service, based on place of service. (App lies only to Large Employer Limited to $36,000 per calendar year and $200,000 during the entire groups.) time covered by NHP. Chiropractic services $15 copayment per visit Limited to 12 treatments per calendar year; PCP referral not required. Dermatology $15 copayment per visit PCP referral not required for 5 visits per calendar year; further visits require PCP referral. Diabetes $15 copayment per visit Services include outpatient self management training and educational services. Durable Medical Equipment No copayment (DME) and disposable medical Limited to $2,500 per calendar year supplies Emergency room services $50 copayment per visit Any deductible and /or copayment for the emergency room is waived if the patient is admitted to the hospital. Enteral Formula No copayment Limited to $2,500 per calendar year. Family Planning Covered as any other eligible service, based on place of service. Limited to surgical sterilization, implantable contraceptives and intrauterine birth control devices. Gynecology $15 copayment per visit PCP referral not required. Hearing Aids No copayment Limited to $2,500 per year and to a single purchase (including repair /replacement) every three years. Hearing Exams No copayment when performed by PCP to determine need for hearing (children through age 2 f) correction. Limited to one exam per calendar year. NHP HMO HSA 9110 Rev1 -3- EVA 15/15/0/500 R NHP HMO HSA 9110 Rev1 -4- EVA 1571510/500 R q f a Home health services No copayment Limited to 60 visits per calendar year. Custodial care is not covered. Home infusion services No copayment Limited to 60 visits per calendar year. Hospice care No copayment Limited to a Maximum Benefit of 180 days of inpatient and /or outpatient care for a terminally ill member when requested by a Plan Physician. Hospital facility care Inpatient: $500 copayment per admission Outpatient: $0 copayment Minor Diagnostic/X -Ray No copayment Major Diagnostic Services, No copayment including CT, MRI, MRA, PET scans and nuclear imaging Mammograms No copayment for one baseline for women age 35 through 39, one every year for women age 40 and over, or more frequently based on physician's recommendation. Mastectomy Covered as any other eligible service, based on place of service. Maternity care, including pre- Covered as any other eligible service, based on place of service. and post -natal care and delivery" Note: any office visit copayment applies only to the initial visit. Physician office services include one OB ultrasound between weeks 13 and 24 of pregnancy. Mental Health (Services must be Outpatient: $15 copayment provided by NHP's behavioral Limited to a maximum of 20 visits per calendar year. PCP referral not health network) required. Inpatient: $500 copayment per admission Limited to a maximum of 30 days per calendar year. Neurobiological.Disorder Outpatient: $15 copayment Services —Autism Spectrum Limited to a maximum of 20 visits per calendar year. PCP referral not Disorder required. Inpatient: $500 copayment per admission Limited to a maximum of 30 days per calendar year. Newborn Children* No copayment per visit for well baby care and treatment of illness or birth — 30 days) NHP HMO HSA 9110 Rev1 -4- EVA 1571510/500 R * For coverage to begin at the date of birth for newborn children, a completed and signed enrollment form must be received by NHP. When received within 30 days of birth; no additional premium will be charged for this 30 day period. When notice is received within 60 days from the date of birth, premium will be charged from the date of birth. If the enrollment form is not NHP HMO HSA 8110 Rev1 -5- EVA 15115!01500 R a. f Organ Transplant Inpatient Covered as any other eligible service, based on place of service. Must Services be prior authorized by NHP Medical Director. Osteoporosis Covered as any other eligible service, based on place of service. Limited to diagnosis and treatment of high-risk individuals. Outpatient therapies $0 copayment Limited to 60 visits per calendar year for all physical, respiratory, speech, cardiac and occupational therapy combined. These limits do not apply to Autism Spectrum Disorder for Large Employer Groups. Physical Rehabilitation — No copayment Inpatient Care Limited to 60 days per calendar year for restorative physical therapy. Physician Services No copayment for Physician Services for inpatient care or outpatient surgical services. Podiatry $15 copayment per visit PCP referral not required. Preventive health services No copayment Primary Care Physician (PCP) $15 copayment per visit Only applies to your designated PCP. Prosthetic Devices No copayment Limited to one prosthetic per loss of limb or eye during the entire period of time you are covered. Skilled nursing facility No copayment Limited to120 days per calendar ear; custodial care is not covered. Specialist office visits $15 copayment per visit PCP referral required except as noted above. Sterilization Covered as any other eligible service, based on place of service. Reversals are not covered. Substance Use Disorders Outpatient: $15 copayment per visit (Services must be provided by Limited to 44 visits per calendar year. PCP referral not required. NHP's behavioral health network) Inpatient. $500 copayment per admission Limited to crisis intervention and detoxification only. Urgent Care Center $25 copayment per visit Vision screening No copayment when performed by PCP. (children through age 21) Limited to services necessary to determine need for vision correction and to one exam per calendar year. * For coverage to begin at the date of birth for newborn children, a completed and signed enrollment form must be received by NHP. When received within 30 days of birth; no additional premium will be charged for this 30 day period. When notice is received within 60 days from the date of birth, premium will be charged from the date of birth. If the enrollment form is not NHP HMO HSA 8110 Rev1 -5- EVA 15115!01500 R received within 60 days of birth, the newborn child will be considered a Late Enrollee by NHP. You must enroll your newborn within these time periods regardless of whether your coverage is family coverage. A full list and description of benefits, including any limitations and exclusions, are in your Handbook. 7600 Corporate Center Drive, Miami, FL 331261 PO Box 025680, Miami, FL 33102 -5680 www.myNHP.com -or call Customer Services at the phone number on your NHP ID Card.] NHP HMO HSA 9119 Rev1 -5- EVA 15/15/0/500 R 3 -TIER Prescription Drug Benefit with Birth Control SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to your prescription drug benefits at Neighborhood health Partnership (NHP) HMO. You only have prescription drug benefits if your group elected to purchase this coverage. The Summary of Benefits, although a helpful tool, is only a summary. If you have specific questions about pharmacy management procedures or whether a specific drug is covered, please call our Customer Service Department at 305.715 -2500, 1- 800 -354 -0222 (outside Miami -Dade) or 305 - 715.2322 for the hearing impaired. Always refer to your Prescription Drug Rider for a more - detailed explanation of your drug coverage. The Neighborhood Health Partnership (NHP) group plans include a prescription drug benefit that featreres a 3- der structum. This offers you more f%xibility when making decisions about your prescription drug purchases. Copayment per Prescription Order or Refill. Your Copayment is determined by the tier to which the NHP has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. Please access www.mynhp.com through the Internet, or call the Customer Service number on your ID card to determine tier status. For a single Copayment, you may receive a Prescription Drug Product up to the stated supply limit. Some products are.subject to additional supply limits, All prescription drugs must be obtained from a Plan Retail Network Phamracy or Plan Home Delivery Network Pharmacy and must be medically necessary for the cue and treatment of an illness or injury. RETAIL NETWORK PHARMACY Prescription drugs may be dispensed up to a 30 -day supply by a retail Plan pharmacy. Oral contraceptives may be dispensed for up to three cycles (upon payment of three co- payments). HOME DELIVERY NETWORK PHARMACY Prescription drugs may be dispensed up to a 90 -day supply by maiLorder pharmacy. * Any amount you pay under the m4risurance provision for designated self - injectable drugs will not be included in calculating any out-of-pocket maximum. *Any amountyou pay for growth hormone therapy raider the co- insurance provision orany amount in excess of the annual thnit will not be included in calculating any out -of- pocket maximum HM- 3$66 -0F vos Neighborhood Health Paris>ership AUnited Healthe mCompany 3 -TIER Prescription Drug Benefit with Birth Control SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to your prescription drug benefits at Neighborhood Health Partnership (NHP) HMO. You only have prescription drug benefits if your group elected to purchase this coverage. The Summary of Benefits, although a helpful tool, is only a summary. If you have specific questions about pharmacy management procedures or whether a specific drug is covered, please call our Customer Service Department at 305 -715. 2500,1- 800 - 354 -0222 (outside Miami -Dade) or 305.715 -2322 for the hearing impaired. Always refer to your Prescription Drug Rider for a more - detailed explanation of your drag coverage. The Neighborhood Health Partnership (NHP) group plans include a prescription drug benefit that features a 3- rierstructure, This offers you more jlexibithy when making decisions about your prescription drug purchases. Copayment per Prescription Order or Refill. Your Copaymcnt is determined by the Her to which the NHP has assigned the Prescription Drug Product, All Prescription Drug Products on the Prescription Drag List are assigned to Tier 1, Tier 2 or Tier 3. Please access www.mynhp.com through the Internet, or call the Customer Service number on your ID card to determine tier status. Por a single Copaymem, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subject to additional supply limits. All prescription drugs must be obtained from a Plan Retail Network Pharmacy or Plan Home Delivery Network Pharmacy and must be medically necessary for the care and treatment of an illness or injury. RETAIL NETWORK PHARMACY Prescription drugs may be dispensed up to a 30-day supply by a retail Plan pharmacy. Oral contraceptives may be dispensed for up to three cycles (upon payment of three co- payments). HOME DELIVERY NETWORK PHARMACY Proscription drugs may be dispensed up to a 9Uay supply by mail -order pharmacy. Any amount you pay under the co-insurance provision for designated self injectable drugs will not be included in calculating any out -of- pocket rnaxintum. * *Any amount you pay for gmowth honnone therapy under the co- insurance provision or any amotmt in excess of the annual limit will not be included in calculating any out -of- pocket maximum. HW3366 -op 1/06 Nee borhood Health ership A Unitedtlealtheam Company NEIGHBORHOOD IIEALTHIUNITED HEALTHCARE POINT- O&SER'VICE DV -13 $151$151$0/$500 R NEIGHBORHOOD HEALTH PARTNERSHIP POS SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to the Point of Service (POS) Plan you have with Neighborhood Health Partnership (NHP). The Summary of Benefits, although a helpful tool, is only a summary. Always refer to your Handbook for a fuller explanation of your coverage or call Customer Services at the phone number on your NHP ID Card when you have a question about your plan. In the event of a conflict between this Summary of Benefits and the Handbook, the Handbook will control. As a Member of the POS Plan, you are eligible to receive the HMO Benefit Level by accessing all of your care through your Primary Care Physician (PCP). In other words, if the health care services you receive are provided or arranged upon referral of your PCP, you are accessing your health care through your HMO Benefit Level. When obtaining Covered Services under your HMO Benefit Level, you will only be responsible for paying copayments for designated Covered Services. Important aspects of your POS Plan: In addition to direct access to certain Plan Providers under your HMO Benefit Level, you may access other health care providers without a referral from your PCP. You may access Plan Providers or Non -Plan Providers. Your Benefit Level, Deductibles, Coinsurance and Out of Pocket Maximum are affected by whether you access a Plan Provider or a Non -Plan Provider under your POS Plan. For example: If your Physician is a Non -Plan Provider, all related Covered Services will be paid at the POS Benefit Level, regardless of the status of other providers and facilities. Except for designated direct access services, when you access providers without a referral from your PCP, you are obtaining your healthcare services through the POS Benefit Level. Even when your Plan includes a POS Rider, you must select a PCP or NHP will assign one to you. If you need assistance, call Customer Services. NHP POS HSA91iD Revt •1- OV8 1 511 510/50 0 R Features Your Responsibility for Coverage When Care Is Managed By Your PCP Please note: if your Plan has a deductible, the deductible must be satisfied first unless otherwise noted below. You are also responsible for any copayments andfor coinsurance listed below. Copayments Primary Care Physician (PCP) $15 copayment per visit (Office Visit) Primary Care Specialist (Office Visit) $15 copayment per visit Urgent Care Center $25 copayment per visit Outpatient Therapy No copayment Inpatient Hospital $500 copayment per admission Radiology No copayment Emergency Room $50 copayment per visit Allergy Testing $15 copayment per visit Out of Pocket The limit which you and your eligible family members must pay in Maximum copayments and coinsurance per calendar year is $1,500 per member and $3,000 per family. Maximum Benefit No Maximum Benefit. Primary Care Your PCP is responsible for coordinating all your health care services, including referrals to Specialists. Your PCP or Physician Specialist must obtain Pre- Authorization for designated services including, but not limited to all inpatient care, outpatient surgical procedures, durable medical equipment (DME), home health services, home infusion, hospice care, rehabilitation, skilled nursing facility and transplant services. Referrals Your PCP is responsible for coordinating all referrals to specialists, except for the following specialties which you may access directly: Podiatry. Chiropractic. Coverage is limited to 12 visits per year. Dermatology (5 visits per calendar year). Additional visits require referrals. Gynecology Substance Use Disorders. Services must be provided by NHP's behavioral health network. Mental Health. Services must be provided by NHP's behavioral health network. Neurobiological Disorder Services — Autism Spectrum Disorder. Services must be provided by NHP's behavioral health network. Prescription If your Employer has elected to provide coverage for prescription drugs, you will Drugs receive a copy of a Prescription Drug Rider which explains your prescription drug coverage. NHP POS NSA 9110 Rev1 -2- DVB 15115101500 R NHP POS HSA 9110 Rev1 •3- DVB 1 5/1 510150 0 R YOUR NHP PLAN COVERAGE IMPORTANT Unless otherwise stated, care, services or treatment not managed by your Primary Care NOTICE; Physician, not Medically Necessary, or not pre - certified by NHP are not considered HMO Covered Services. HMO Services must be provided by Plan Providers, except when pre - certified or in the case of an Emergency Medical Condition. You must check your Handbook for further details relating to your coverage. NHP POS HSA 9110 Rev! -4- DVB 15115/000 R P i Please note: if your Plan has a deductible, the The deductible must deductible must be satisfied first unless be satisfied. You are otherwise noted below. You are also responsible also responsible for for any copayments and/or coinsurance listed any coinsurance below. listed below. Ambulance $0 copayment in emergency situations or when 30% after deductible authorized by NHP to transfer you to a NHP facility. Autism Spectrum Covered as any other eligible service, based on place 30% after deductible Disorder of service. Combined HMO and POS coverage is limited to $36, 000 per calendar year and $200, 000 during the entire time covered by NHP. This benefit only applies to Large Employergroups. Chiropractic Services $15 copayment per visit 30% after deductible Combined HMO and POS coverage is limited to 12 treatments per calendar year. PCP referral is not required. Dermatology $15 copayment per visit 30% after deductible PCP referral not required for 5 visits per calendar year; further visits require PCP referral. Diabetes $15 copayment per visit 30% after deductible Services include outpatient self management training and educational services. NHP POS HSA 9110 Rev! -4- DVB 15115/000 R NHP POS HSA 91`10 Rev? -5- DVB 15/15/01500 R ryA oa, 3 4 ft pp Durable Medical No copayment 30% after deductible Equipment (DME) and disposable medical supplies. Combined HMO and POS coverage is limited to $2,500 per calendar ear. Emergency Room $50 copayment per visit Benefits paid at the Services Any deductible and /or copayment for the emergency HMO Benefit Level. room is waived if the patient is admitted to the hospital, Enteral Formula No copayment Benefits accessed only Limited to $2,500 per calendar year through HMO Benefit Level, Family Planning Covered as any other eligible service, based on place 30% after deductible of service, Limited to surgical sterilization, implantable contraceptives and intrauterine birth control devices. Gynecology $15 copayment per visit 30% after deductible PCP referral not required. Hearing Aids No copayment 30% after deductible Combined HMO and POS coverage is limited to $2,500 per year and to a single purchase (including repair /replacement) every three years. Hearing Exams No copayment when performed by PCP to determine Benefits accessed only (children through age need for hearing. correction. Limited to one exam per through HMO Benefit 21) calendar year. Level. Home Health No copayment 30% after deductible Services Combined HMO and POS coverage is limited to 60 visits per calendar year. Custodial care is not covered. NHP POS HSA 91`10 Rev? -5- DVB 15/15/01500 R NHP POS NSA 9110 ReA -6- OVS 15/15101500 R MU. Home Infusion No copaymentu 30% after deductible Services Combined HMO and POS coverage is limited to 60 visits ercalendar year. Hospice Care No copayment 30% after deductible Combined HMO and POS coverage is limited to a Maximum Benefit of 180 days of inpatient and /or outpatient care for a terminally ill member. Hospital Facility Care Inpatient: $500 copayment per admission 30% after deductible Outpatient: No copayment Minor DiagnasticlX- No copayment 30% after deductible Ray Major Diagnostic No copayment 30% after deductible Services, including CT, MRI, MRA, PET scans and nuclear imaging Mammogram No copayment for one baseline for women age 35 30% after deductible through 39, one every year for women age 40 and over or more frequently based on physician's recommendation. Mastectomy Covered as any other eligible service, based on place 30% after deductible of service. Maternity care, Covered as any other eligible service, based on place 30% after deductible including pre- and of service. post -natal care and Note: any office visit copayment applies only to the delivery* initial visit. Physician office services include one OB ultrasound between weeks 13 and 24 of pregnancy. NHP POS NSA 9110 ReA -6- OVS 15/15101500 R NHP POS HSA W10 RVI -7- Dvs 1511510(500 R Mental Health Outpatient: $15 copayment Benefits accessed only (Services must be Limited to a maximum of 20 visits per calendar year. through HMO Benefit provided by NHP's PCP referral not required. Level. behavioral health network) Inpatient: $500 copayment per admission Maximum benefit period of 30 days per calendar year. Neurobiological Outpatient: $15 copayment Benefits accessed only Disorder Services — Limited to a maximum of 20 visits per calendar year. through HMO Benefit Autism Spectrum PCP referral not required. Level. Disorder Inpatient: $500 copayment per admission Maximum benefit period of 30 da s per calendar year. Newborn Children' . No copayment per visit for well baby care and 30% after deductible birth — 30 days) treatment of Illness or Injury. Organ Transplant Covered as any other eligible service, based on place 30% after deductible Inpatient Services of service. Must be pre - certified by NHP Medical Director. Osteoporosis Covered as any other eligible service, based on place 30% after deductible of service. Limited to diagnosis and treatment of high - risk individuals. Outpatient Therapies No copayment 30% after deductible Limited to 60 visits per calendar year for all physical, respiratory, speech, cardiac and occupational therapy combined. These combined limits do not apply to Autism Spectrum Disorder for Large Employer Groups. Physical No copayment 30% after deductible Rehabilitation — Inpatient Care Combined HMO and POS coverage is limited to 60 days per calendar year for. restorative physical thera . NHP POS HSA W10 RVI -7- Dvs 1511510(500 R * For coverage to begin at the date of birth for newborn children, a completed and signed enrollment form must be received by NHP. When received within 30 days of birth, no additional premium will be charged for this 30 day period. When notice is received within 60 days from the date of birth, premium will be charged from the date of birth. If the enrollment form is not received within 60 days WHIP POS HSA9110 Revi ^8- DV815115/0i500 R Physician Services No copayment for inpatient care or outpatient 30% after deductible surgical services when performed in an inpatient setting or an outpatient facility. Podiatry $15 copayment per visit 30% after deductible PCP referral not required. Preventive Health 100% coverage 30% after deductible Services Prosthetic Devices No copayment 30% after deductible Combined HMO and POS coverage is limited to one prosthetic per loss of limb or eye during the entire period of time you are covered. Skilled Nursing No copayment 30% after deductible Facility Custodial care is not covered. Combined HMO and POS coverage is limited to 120 days per calendar year. Specialist Office $15 copayment per visit Visits PCP referral required unless direct access is allowed, 30% after deductible as indicated. Sterilization Covered as any other eligible service, based on place 30% after deductible of service. Reversals are not covered. Substance Use Outpatient: $15 copayment per visit Benefits accessed only Disorders Limited to a maximum of 44 visits per calendar year. through HMO Benefit (Services must be PCP referral not required. Level• provided by NHP's behavioral health network) Inpatient: $500 copayment per admission Limited to crisis intervention and detoxification only. Urgent Care Center $25 copayment per visit 30% after deductible Vision Screening No copayment when performed by PCP. Benefits accessed only (children through age Limited to services necessary to determine need for through HMO Benefit 21) vision correction and to one exam per calendar year. Level. * For coverage to begin at the date of birth for newborn children, a completed and signed enrollment form must be received by NHP. When received within 30 days of birth, no additional premium will be charged for this 30 day period. When notice is received within 60 days from the date of birth, premium will be charged from the date of birth. If the enrollment form is not received within 60 days WHIP POS HSA9110 Revi ^8- DV815115/0i500 R of birth, the newborn child will be considered a Late Enrollee by NHP. You must enroll your newborn within these time periods regardless of whether your coverage is family coverage. A full list and description of benefits are in your Handbook and POS Rider. Your Handbook and POS Rider also list the Exclusions, Limitations and Restrictions which apply. You have coverage for Prescription Drugs only if your Group has elected to obtain a Prescription Drug Rider. Benefit levels when accessing services through your POS plan. Plan payment when accessing services without PCP referral is as follows: When accessing a Plan Provider, plan will pay based on plan's contracted rate; when accessing a Non -Plan Provider, plan will pay based on plan's usual, customary and reasonable rate. Please note that if you access a Non -Plan Provider under your POS plan, the difference between the plan's payment of the usual, reasonable, and customary charge and the Non -Plan Provider's charge will be your responsibility. PRE - CERTIFICATION REQUIREMENTS Certain services require pre - certification by NHP. You are responsible for assuring that your treating physicians (Plan Providers and Non -Plan Providers) obtain the necessary pre - certifications for services and that they otherwise comply with applicable UR requirements. FAILURE TO OBTAIN PRE - CERTIFICATIONS WILL RESULT IN A 20% DECREASE IN YOUR POS BENEFIT LEVEL Pre - certification is required for any of the following services: 1. Inpatient: hospital (including observation), psychiatric, rehabilitation facility and skilled nursing facility 2. Surgery and invasive procedures: performed in an outpatient hospital or ambulatory facility (with the exception of Colonoscopies for customers 50 years of age and older and Sigmoidoscopies). 3. Implantable cardiac defibrillators, ventricular assist devices, and lung volume reduction surgery procedures, even if the inpatient admission has been authorized 4. All out of network and out of area services, except for emergencies. 5. MRI, MRA, CT Scans, PET scans 6. Sleep studies 7. Nuclear stress tests, including without limitation thallium, technetium, Cardiolite, Myoview, sestamibi; and myocardial perfusion and ejection fraction, and wall motion studies. Nuclear stress tests encompass nonpharmacological (exercise) and NHP POS HSA 9110 Revi -9- DV9 75175/01500 R pharmacological stress tests, including without limitation, adenosine, persantine and dobutamine. 8. Invasive vascular studies and procedures /EP studies 9. Durable medical equipment, including insulin pumps and supplies 10. Prosthetic and orthotic devices 11. Home health care 12. Outpatient therapy: physical, occupational, speech, cardiac, and respiratory 13. Hyperbaric oxygen treatment 14. Wound care 15. Mental Health, Substance Use Disorders and Neurobiological Disorders - Autism Spectrum Disorder Services 16. Dialysis 17. Chemotherapy (chemotherapeutic agents regardless of indication), radiation therapy, transfusions, infusions 18. Chronic specialist care 19. Pain management 20. Hospice 21. Biophysical profiles and amniocentesis 22. Laboratory services 23.Ambulance service, other than emergencies 24. Genetic Testing 25. Drugs: Botox, Epogen, Procrit, Lupron 11.25 mg, Prolastin, Remicaid, Synvisc /Hyalgan, Growth Hormone, Alferon, and Mifeprex 7600 Corporate Center Drive, Miami, FL 33126 / PO Box 025680, Miami, FL 33102 -5680 www.myNHP.com or call Customer Services at the phone number on your NHP ID Card HHP POS HSA 9110 R"I -10- DV815115/0(500 R UnitedHealthcarer AUm[edHeaNhGrouP Comparry DIRELY' ACCESS RIDER As of the Effective Date, and notwithstanding anything in the Group Service Agreement ( "Agreement ") to the contrary, the following Direct Access hider is hereby made a part of the Agreement if elected by the Group and such election is evidenced in the Group's Application for Group Service Agreement. The terms used in this Rider shall have the same meaning ascribed thereto or used in the Agreement, unless otherwise stated herein. DIRECT ACCESS PROGRAM A Member with a Direct Access Rider has the right to elect to visit an NHP Specialist without a referral from the Primary Care Physician or Plan ("Direct Access Visit(s) "). Direct Access Visits are subject to the terms and conditions of the Agreement and this Direct Access Rider. All services and treatment rendered to the Member by a NHP Specialist during or in connection with a Direct Access Visit are subject to NHP's Utilization Review (UR) requirements and the Agreement, except as may be stated otherwise in this Rider. A Direct Access Visit includes services and treatment received from an NHP Specialist, so long as such services do not require pre - certification from NI-1P. Those services which require pre -cei tificatiion under the Plan's UR requirements require pre - certification on a Direct Access Visit. HEALTH PARTNERSHIP, INC. Daniel 1. Rosenthal CEO for South Florida Region 3 -TIER Prescription Drug Benefit with Birth Control SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to your prescription drug benefits at Neighborhood Health Partnership (NW) HMO. You only have prescription drug benefits if your group elected to purchase this coverage. The Summary of Benefits, although a belpful tool, is only a summary. If you have specific questions about pharmacy management procedures or whether a specific drug is covered, please call our Customer Service Department at 305.715- 2500,1.800. 3540222 (outside Miami -Dade) or 305.715 -2322 for the hearing impaired. Always refer to your Prescription Drug Rider for a more - detailed explanation of your drug coverage. The Neighborhood Health Partnership (NHP) group plans include a prescription drug benefit that features a 3 -tier structure. This offers you more flexibility when making decisions about your prescription drug purchases. Copayment per Prescription Order or Rerilt. Your Copayment is determined by the tier to which the NHP has assigned the Prescription Drug Product. All Prescription Dmg Products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. Please access www.mynhp.com through the Internet, or call the Customer Service number on your ID card to determine tier status. For a single Copaymem, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subject to additional supply limits. All Prescription drugs must be obtained from a Plan Retail Network Pharmacy or Plan Home Delivery Network Pharmacy and must be medically necessary for the care and treatment of an illness or injury. RETAH. NETWORK PHARMACY Prescription drugs may be dispensed up to a 30 -day supply by a retail Plan pharmacy. Oral contraceptives may be dispensed for up to three cycles (upon payment of three co- payments). HOME DELIVERY NETWORK PHARMACY Prescription drugs may be dispensed up to a 90 -day supply by mail -order pharmacy. Any amount you pay under the co- insurance provision for designated self- injectable drugs will not be included in calculating airy out -of- pocket mash um. "Any amount you pay forgmwth hormone therapy tinder the co- insurance provision or any amount in excess of the annual limit will not be included in calculating any our -of- packet maximum. HM- 3366 -0F 1106 N Mrhood Health ership A UnitedHealthrare Company