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Res No 171-10-13205RESOLUTION NO.: 171-10-13205 A Resolution of the Mayor and City Commission of the City of South Miami, Florida, authorizing the City Manager to renew the contract with AvMed to provide group health insurance for City of South Miami full time employees to be charged to the departmental account numbers respectively; providing and effective date. WHEREAS, the Agent of Record (Employee Benefits Consulting Group) secured 8 bids for the City's Group Health Insurance and recommended AvMed as the lowest responsive bidder; and WHEREAS, the City Commission compared the insurance rates, benefit plan designs, provider network as well as our previous claims experience /ratio; and WHEREAS, the Insurance Committee unanimously voted to renew with AvMed for another year; and WHEREAS, the City Commission wishes to renew Group Health Insurance with AvMed to all full -time employees; and WHEREAS, with the selection of Av Med, the designated Agent of Record is Employee Benefits Consulting Group until contract expiration or until otherwise determined by either party. NOW THEREFORE BE IT RESOLVED BY THE MAYOR AND CITY COMMISSION OF TIIE CITY OF SOUTH MIAMI, FLORIDA, THAT: Section 1. The contract with AvMed shall be effective October 1, 2010 and shall be renewable on an annual basis. Section 2. This engagement is at will and shall continue until either party terminates the engagement by giving written notice to the other party. The City shall not be charged for agent of record services; Employee Benefits Consulting Group shall be compensated by the insurer. Section 3. This resolution shall take effect immediately upon approval. PASSED AND ADOPTED this 17th day of Aug n s , 2010. ATTEST: 4kka_�� READ AND APPROVED AS TO FORM AND SUFFICIENCY: CITY ATTORNEY APPROVED: Commission Vote: Mayor Phillip Stoddard: Vice Mayor Valerie Newman: Commissioner Brian D. Beasley Commissioner Velma Palmer: Commissioner Walter Harris: 5 -0 Yea Yea Yea Yea Yea South Miami To: The Honorable Mayor & Members of the City Commission Via: Buford R. Witt, Acting City Manager From: Carmen V. Baker, Acting Human Resources Manager pj Date: August 17, 2010 Agenda Item No.: PM ®N Subject: Health Insurance Resolution Request: A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, AUTHORIZING THE CITY MANAGER TO RENEW THE CONTRACT WITH AVMED TO PROVIDE GROUP HEALTH INSURANCE FOR CITY OF SOUTH MIAMI FULL TIME EMPLOYEES TO BE CHARGED TO DEPARTMENTAL ACCOUNT NUMBERS RESPECTIVELY; PROVIDING FOR AN EFFECTIVE DATE. Reason /Need: We have received renewal rates from our current group health insurance carrier, AVMED. AVMED initially proposed 14.0 % increase; however we negotiated the rate increase to 13.5 %. The City had $662.439 in claims vs. $744.364 in premium. Although, renewal rates were received from AVMED, the Agent of Record recommended that we seek out bids from other carriers to ensure that we are being offered competitive rates. Our Agent of Record solicited bids from eight companies. Bids were received from the following companies: Aetna Declined to quote AVMED Submitted proposal Blue Cross & Blue Shield Declined to quote United Health Care Submitted proposal Cigna Submitted proposal NHP Submitted proposal Vista Submitted proposal Humana Submitted proposal The insurance Committee met to review and compare all the different alternatives. The Committee Members that participated were as follows: Maria L. Garcia City Manager's Office Maria Virguez Carol Bynum George Greene Lisa Morton James McCants Maria Stout -Tate Lorenzo Woodley Slaven Kobola Finance Code Enforcement Motor Pool (AFSCME) Police (PBA) South Miami Community Redevelopment Agency Parks & Recreation Parks & Recreation Public Works & Engineering The Insurance Committee made a recommendation to the City Commission to renew with AVMED for another year without any changes to the current benefit plan design. With the Triple Option, the City would cover the employee rate of $423.25 which is a (13.5 %). Based on current enrollment assumptions (127 FTE), the annual increase from this year to next year would be approximately $76,817.28. Current staffing levels are at 144 full time employees. During the Insurance Workshop with the City Commission, the City Commission concluded on AvMed as the proposed provider but requested to bring forth a third option which would be the 2nd Renewal Alternative. Below are the proposed options: Cost: Option I —.Renewal (AvMed) Employee Rate: $ 423.25 Total Cost per employee per month ( @127 (Full Time Employees)) = $53,752.75 Annual Premium $645,033.00 Option II — Renewal Alternative (AvMed) Employee Rate: $ 405.47 Total Cost per employee per month (@ 127 (Full Time Employees)) = $51,494.69 Annual Premium $617,936.28 Option III —,2 nd Renewal Alternative (AvMed) Employee Rate: $ 377.34 Total Cost per employee per month (@ 127 (Full Time Employees)) _ $ 47,922.18 Annual Premium $575,066.16 Backup Documentation: • Proposed Resolution • Proposals from Insurance Vendors LOW HMO HIGH HMO POS EE $423.25(city Portion) $490.92 $569.70 EC $749.16 $868.93 $1,008.37 ES $833.82 $967.11 $1,122.31 FAM $1,248.60 $1,448.21 $1,680.61 With the Triple Option, the City would cover the employee rate of $423.25 which is a (13.5 %). Based on current enrollment assumptions (127 FTE), the annual increase from this year to next year would be approximately $76,817.28. Current staffing levels are at 144 full time employees. During the Insurance Workshop with the City Commission, the City Commission concluded on AvMed as the proposed provider but requested to bring forth a third option which would be the 2nd Renewal Alternative. Below are the proposed options: Cost: Option I —.Renewal (AvMed) Employee Rate: $ 423.25 Total Cost per employee per month ( @127 (Full Time Employees)) = $53,752.75 Annual Premium $645,033.00 Option II — Renewal Alternative (AvMed) Employee Rate: $ 405.47 Total Cost per employee per month (@ 127 (Full Time Employees)) = $51,494.69 Annual Premium $617,936.28 Option III —,2 nd Renewal Alternative (AvMed) Employee Rate: $ 377.34 Total Cost per employee per month (@ 127 (Full Time Employees)) _ $ 47,922.18 Annual Premium $575,066.16 Backup Documentation: • Proposed Resolution • Proposals from Insurance Vendors TABLE OF CONTENTS I. Executive Summary a II. Proposed Rates III. HMO Benefit Comparison IV. POS Benefit Comparison V. AvMed Renewal Alternative Employee Benefits Consulting Group C X Executive Summary Enclosed is our analysis of the group health insurance proposals that we received on behalf of the City of South Miami. We approached, the following vendors in regards to this project: Aetna Humana AvMed (incumbent) Neighborhood Health/United Healthcare Blue Cross Blue Shield Vista CIGNA The upcoming plan year represents the period of 10/1/2010- 9/30/2011. Here is a summary of our efforts: AvMed (Medical) AvMed has proposed a 13.5 %rate increase for the upcoming plan year. The paid loss ratio from 6/1/2009 - 5/31/2010 was 94% (i.e. for every $1 of premium AvMed paid $.94 in claims). We have also included several renewal alternatives for the upcoming plan year (AvMed Renewal Alternative tab). CompBenefits/Humana (Dental and Vision) CompBenefits has proposed a 10% rate increase for the upcoming plan year on the dental. The vision rates will remain unchanged. The paid loss ratio from 2/1/2009- 1/31/2010 was 88% for the dental plan (i.e. for every $1 of premium CompBenefits paid $.88 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. 1 Employee Benefits Consulting Group Proposal Responses Vendor Name Aetna AvMed Blue Cross Blue Shield CIGNA Healthcare Humana Neighborhood Health/United Healthcare Vista ZEe Response Declined to quote. Submitted a proposal. Declined to quote. Submitted a proposal. Submitted a proposal. Submitted a proposal. Submitted a proposal. Employee Benefits Consulting Group { j \ ) � \ ] E ) } \ u � \ � \ ® \\ }( \ \ ® \\ \ ) < E ) } \ u � \ � \ ® \\ \ \ ® \\ \ ) E ) } \ u � \ � \ ® \\ \ ) E ) } \ u � \ � \ to z d R. a F 1 1 1, Y 1 O N O C � m w v ao of N r m o rn m vhi m o m m tw.. 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U t Q 3 o N N O .- E } O m D d D U o E n C v a i Z u d t5 G ❑ 0 m m —d — p d m`m0) rL vN M d N CL 0 H q Y 0 q 0 U m Y W q Mo v D, W va For-M - D H E A L T H P L A N S Benefit Summary LARGE GROUP SCHEDULE OF BENEFITS COST TO MEMBER $151$250/$1,500 /20% CALENDAR YEAR INDIVIDUAL / FAMILY $2505750 annually DEDUCTIBLE The Deductible does not apply toward the Out -of- Pocket Maximum OUT -OF- POCKET MAXIMUM INDIVIDUAL / FAMILY $1,500/3,000 annually Per Calendar Year The Out -of- Pocket Maximum includes Co payments and Co- insurance amounts unless otherwise excluded AVMED PRIMARY CARE Services at Participating Physicians offices include, but are not $15 per visit PHYSICIAN limited to: • Routine office visits /annual gynecological examination when performed by Primary Care Physician • Pediatric care and well -child care • Periodic health evaluation and immunizations • Diagnostic imaging, laboratory or other diagnostic services • Minor surgical procedures • Vision and hearing examinations for children under 18 MATERNITY CARE Initial visit $15 Co- payment AVMED SPECIALISTS' • Office visits $25 per visit SERVICES • Annual gynecological examination when performed by a nsrtieinstinv Snecialty Health Care Phvsician Inpatient care at Participating Hospitals includes: • Room and board — unlimited days (semi - private) • Physicians', specialists' and surgeons' services • Anesthesia, use of operating and recovery rooms, oxygen, drugs and medication • Intensive care unit and other special units, general and special duty nursing • Laboratory and diagnostic imaging • Required special diets surgeries, including cardiac catheterizations and • Outpatient therapeutic services, including: • . Drug infusion therapy • Injectable Drugs (Co- payment for Injectable Drug $250 per day for the first 5 days, per admission; 100% coverage thereafter $100 Co- payment $75 Co- payment OUTPATIENT DIAGNOSTIC CAT Scan, PET Scan, MRI 20% of the contracted TESTS Other diagnostic imaging tests rate after Deductible EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition $100 Co- payment requiring immediate medical or surgical care. (Co- payment waived if admitted) • Emergency services at Participating Hospitals • Emergency services at non - participating Hospitals, facilities, and/or physicians AvMed must be notified within 24 hours of inpatient admission following emergency services or as soon as reasonably possible URGENTAMMED1ATE CARE • Medical Services at a participating Urgent/Immediate Care $40 Co- payment facility or services rendered after hours in your Primary Care Physician's office • Medical Services at a non - participating Urgent/Immediate Care $60 Co- payment AV- LG- 15125011 500/20 % -O6 MP- 3990(10/06) Benefit Summary, continued FAMILY PLANNING Voluntary family planning services $15 per visit TH - 20 outpatient visits $25 per visit ALLERGY TREATMENTS Injections $15 per visit • Skin testing $50 per course of testing AMBULANCE Ambulance transport for emergency services $100 Co- payment • Non - emergent ambulance services are covered when the skill of medically trained personnel is required and the Member cannot PHYSICAL, SPEECH, AND • Short-term physical, OCCUPATIONAL THERAPIES conditions or occupational therapy for acute $15 per visit Coverage is limited to 30 visits per calendar year for all services combined SKILLED NURSING a Up to 20 days post - hospitalization care per Calendar Year when 20% of the contracted FACILITIES AND prescribed by physician and authorized by AvMed rate after Deductible REHABILITATION CENTERS CARDIAC REHABILITATION Cardiac rehabilitation is covered for the following conditions: $15 per visit • Acute myocardial infarction • Percutaneous transluminal coronary angioplasty (PTCA) Benefits limited ° Repair or replacement of heart valves to $1,500 per • Coronary artery bypass graft (CABG), or Calendar Year • Heart transplant Coverage is limited to 18 visits per Calendar Year HOME HEALTH CARE Limited to 60 skilled visits per calendar year 20% of the contracted rate after Deductible DURABLE MEDICAL Equipment includ EQUIPMENT AND • Hospital beds ORTHOTIC APPLIANCES • Walkers • Crutches • Wheelchairs Orthmic appliances are limited to: • Leg, arm, back, and neck custom -made braces 20% of the contracted rate after Deductible Benefits limited to $2,000 per Calendar Year PROSTHETIC DEVICES Prosthetic devices are limited to: 20% of the contracted • Artificial limbs rate after Deductible • Artificial joints FOR ADDITIONAL INFORMATION, PLEASE CALL: 1. 800 -88-AVMED (1 -800- 882.8633) THIS SCHEDULE OF BENEFITS IS NOT A CONTRACT. FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS, PLEASE CONSULT YOUR AVMED GROUP MEDICAL AND HOSPYiAL SERVICE CONTRACT. A V -LG- 15/250/ 1500/20 % -06 MP- 3990(10/06) MI, H E A L T n PLANS BASIC OPTION Benefit Summary r Calendar Year PRIMARY CARE Services at SCHEDULE OF BENEFITS offices include, but are not R i 11 A11 1 $1,500 INDIVIDUAL $3.000 FAMILY $15 per visit PHYSICIAN limited to: • Routine office visits / annual gynecological examination when performed by Primary Care Physician • Pediatric care and well -child care • Periodic health evaluation and immunizations • Diagnostic imaging, laboratory or other diagnostic services • Minor surgical procedures • Vision and hearing examinations for children under 18 MATERNITY CARE • Initial visit $15 Co- payment • Subsequent visits NO CHARGE AVMED SPECIALISTS' • Office visits $25 per visit SERVICES • Annual gynecological examination when performed by a participating Specialty Health Care Physician HOSPITAL Inpatient care at Participating Hospitals includes: $250 per admission; • Room and board - unlimited days (semi - private) 100% coverage • Physicians', specialists' and surgeons' services thereafter • Anesthesia, use of operating and recovery rooms, oxygen, drugs and medication • Intensive care unit and other special units, general and special duty nursing • Laboratory and diagnostic imaging • Required special diets • Radiation and inhalation therapies OUTPATIENT SERVICES • Outpatient surgeries, including cardiac catheterization $250 Co- payment and angioplasty • Outpatient therapeutic services, including: • Drug infusion therapy $100 Co- payment • Injectable Drugs (Co- payment for Injectable Drug waived if incidental to same -day drug $75 Co- payment infusion therapy) OUTPATIENT DIAGNOSTIC • CAT Scan, PET Scan, MRI $25 per test TESTS • Other diagnostic imaging tests $10 per test EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition requiring immediate medical or surgical care. (Co- payment waived if admitted) • Emergency services at Participating Hospitals $75 Co- payment • Emergency services at non - participating Hospitals, $100 Co- payment facilities, and/or physicians AvMed must be notified within 24 hours of inpatient admission following emergency services or as soon as reasonably possible URGENTAMMED1ATE CARE Medical Services at a participating Urgent/Immediate Care $40 Co- payment facility or services rendered after hours in your Primary Care Physician's office • Medical Services at a non - participating Urgent/Immediate $60 Co- payment Care facility AV- BASIC- 25OA -06 MP -3422 (10/06) Benefit Summary, continued MENTAL HEALTH • 20 outpatient visits $25 per visit FAMILY PLANNING Voluntary family planning services $15 per visit FACILITIES AND • Sterilization $250 Co- payment ALLERGY TREATMENTS - • Injections $10 per visit CARDIAC REHABILITATION • Skin testing $50 per course of testing AMBULANCE Ambulance transport for emergency services $100 Co- payment • Non - emergent ambulance services are covered when the Benefits limited skill of medically trained personnel is required and the to $1,500 per Member cannot be safely transported by other means Contract Year PHYSICAL, SPEECH, AND Short-term physical, speech or occupational therapy for $15 per visit OCCUPATIONAL THERAPIES acute conditions Coverage is limited to 30 visits per calendar year for all services combined SKILLED NURSING Up to 20 days post - hospitalization care per Contract Year $50 per day - FACILITIES AND when prescribed by physician and authorized by AvMed REHABILITATION CENTERS Benefits limited • Wheelchairs CARDIAC REHABILITATION Cardiac rehabilitation is covered for the following conditions: $20 per visit • Leg, arm, back, and neck custom -made braces • Acute myocardial infarction • Percutaneous transluminal coronary angioplasty (PTCA) Benefits limited • Repair or replacement of heart valves to $1,500 per • Coronary artery bypass graft (CABG), or Contract Year • Heart transplant Coverage is limited to 18 visits per Contract Year HOME HEALTH CARE Limited to 60 skilled visits per calendar year NO CHARGE DURABLE MEDICAL Equipment includes: $50 per episode of EQUIPMENT AND • Hospital beds illness ORTHOTIC APPLIANCES • Walkers • Crutches Benefits limited • Wheelchairs to $500 per Orthotic appliances are limited to: Contract Year • Leg, arm, back, and neck custom -made braces PROSTHETIC DEVICES Prosthetic devices are limited to: NO CHARGE • Artificial limbs • Artificial joints • Ocular prostheses FOR ADDITIONAL INFORMATION, PLEASE CALL: 1- 800 -88 -AVMED (1 -800- 882 -8633) THIS SCHEDULE OF BENEFITS IS NOT A CONTRACT. FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS, PLEASE SEE YOUR AVMED GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT. AV- BASIC- 250A -06 MP -3422 (10 /06) u LOW HMO RENEWAL Benefit Summary H 6 AL H PLANS LARGE GROUP SCHEDULE OF BENEFITS COST TO MEMBER $20/$500/$2,000 /20% • Physicians', specialists' and surgeons' services after Deductible CALENDAR YEAR INDIVIDUAL/ FAMILY $500 / $1,000 annually DEDUCTIBLE The Deductible does not apply toward the Out -of- Pocket Maximum $100 Co- payment OUT -OF- POCKET MAXIMUM INDIVIDUAL/ FAMILY per calendar year $2,000 / $4,000 annually The Out -of- Pocket Maximum includes Co payments and Co- • Radiation and inhalation therapies insurance amounts unless otherwise excluded OUTPATIENT SERVICES Outpatient surgeries, including cardiac catheterizations and AVMED PRIMARY CARE Services at Participating Physicians' offices include, but are not $20 per visit PHYSICIAN limited to: • Drug infusion therapy • Routine office visits /annual well -woman examination when performed by Primary Care Physician • Pediatric care and well -child care • Periodic health evaluation and immunizations • Diagnostic imaging, laboratory or other diagnostic services • Minor surgical procedures • Vision and hearing screenings for children under 18 MATERNITY CARE • Initial visit $20 Co- payment • Subsequent visits NO CHARGE AVMEO SPECIALITY HEALTH • Office visits $40 per visit CARE PHYSICIAN SERVICES • Annual well -woman examination when performed by a - participating Specialty Health Care Physician - - Additional charges will apply if Outpatient Diagnos(ic Tests are - HOSPITAL Inpatient care at Hospitals includes: 500gper admission; • Room and board — unlimited days (semi - private) 100% coverage thereafter • Physicians', specialists' and surgeons' services after Deductible • Anesthesia, use of operating and recovery rooms, oxygen, drugs and medication • Intensive care unit and other special units, general and special $100 Co- payment duty nursing • Laboratory and diagnostic imaging • Required special diets • Radiation and inhalation therapies OUTPATIENT SERVICES Outpatient surgeries, including cardiac catheterizations and $250 Co- payment angioplasty • Outpatient therapeutic services, including: $100 Co- payment • Drug infusion therapy • Injectable Drugs (Co- payment for Injectable Drug $75 Co- payment waived if incidental to same -day drug infusion therapy) • Preventive and diagnostic colonoscopies $250 Co- payment • One preventive colonoscopy per lifetime (Not subject to Calendar Year Deductible) NO CHARGE OUTPATIENT DIAGNOSTIC • CAT Scan, PET Scan, MRI 20% of the contracted rate, TESTS Other diagnostic imaging tests after Deductible Charges for office visits will also apply if services are performed in a Specialist's office EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition $100 Co- payment requiring immediate medical or surgical care. (Co- payment waived if admitted) • Emergency services at Participating Hospitals • Emergency services at non - participating Hospitals, facilities and /or physicians AvMed must be notified within 24 hours of inpatient admission following emergency services or as soon as reasonably possible. AV -LG- 20/500/200020 % -09 MP -5229 (10109) Benefit Summary, continuer. URGENT/IMMEDIATE CARE • Medical Services at a participating Urgent/Immediate Care $40 Co- payment facility or services rendered after hours in your Primary Care Physician's office • Medical Services at a participating retail clinic $20 per visit • Medical Services at a non - participating Urgent/Immediate Care $60 Co- payment facility or non - participating retail clinic FAMILY PLANNING Voluntary family planning services $25 per visit TREATMENTS • Injections %eo per AMBULANCE m Ambulance transport for emergency services $100 Co- payment • Non - emergent ambulance services are covered when the skill of medically trained personnel is required and the Member cannot be safelv transported by other means PHYSICAL, SPEECH AND Short-term physical, speech or occupational therapy for acute $25 per visit OCCUPATIONAL THERAPIES conditions Coverage is limited to 30 visits per calendar year for all services combined DIAGNOSIS AND TREATMENT Applied Behavior Analysis services $40 per visit OF AUTISM SPECTRUM Physical, speech or occupational therapy for the treatment of $25 per visit DISORDER Autism Spectrum Disorder FOR ADDITIONAL INFORMATION, PLEASE CALL:1. 800- 88 -AVMED (1.800- 882.8633) This Schedule of Benefits is not a contract. For specific information on Benefits, Exclusions and Limitations, please consult your AvMed Group Medical and Hospital Service Contract. AV- LG- 20/500/2000/20 % -09 MP- 5229 (10/09) Coverage for all services related to Autism Spectrum Disorder is HOME HEALTH CARE limited to $36,000 annually and may not exceed $200,000 in total 20% of the contracted rate, benefits. after Deductible SKILLED NURSING FACILITIES Up to 20 days post - hospitalization care per calendar year when 20% of the contracted rate, AND REHABILITATION prescribed by physician and authorized by AvMed after Deductible CENTERS . Walkers CARDIAC REHABILITATION Cardiac rehabilitation is covered for the following conditions: $25 per visit Acute myocardial infarction Benefits limited to $2,000 • Peremaneous transluminal coronary angioplasty (PTCA) per calendar year • Repair or replacement of heart valves Benefits limited to $1,500 PROSTHETIC DEVICES • Coronary artery bypass graft (CABG), or per calendar year • Heart transplant after Deductible FOR ADDITIONAL INFORMATION, PLEASE CALL:1. 800- 88 -AVMED (1.800- 882.8633) This Schedule of Benefits is not a contract. For specific information on Benefits, Exclusions and Limitations, please consult your AvMed Group Medical and Hospital Service Contract. AV- LG- 20/500/2000/20 % -09 MP- 5229 (10/09) Coverage is limited to 1S visits per calendar year HOME HEALTH CARE • Limited to 60 skilled visits per calendar year 20% of the contracted rate, after Deductible DURABLE MEDICAL Equipment includes: 20% of the contracted rate, EQUIPMENT AND • Hospital beds after Deductible ORTHOTIC APPLIANCES . Walkers • Crutches • Wheelchairs Benefits limited to $2,000 Orthotic appliances are limited to: per calendar year • Leg, arm, back and neck custom -made braces PROSTHETIC DEVICES Prosthetic devices are limited to: 20% of the contracted rate, • Artificial limbs after Deductible • Artificial joints • Ocular prostheses FOR ADDITIONAL INFORMATION, PLEASE CALL:1. 800- 88 -AVMED (1.800- 882.8633) This Schedule of Benefits is not a contract. For specific information on Benefits, Exclusions and Limitations, please consult your AvMed Group Medical and Hospital Service Contract. AV- LG- 20/500/2000/20 % -09 MP- 5229 (10/09) I Benefit Summary H E r AvMED H PLANS LARGE GROUP SCHEDULE OF BENEFITS COST TO MEMBER $10/$250/$750/10% • Subsequent visits NO CHARGE CALENDAR YEAR INDIVIDUAL/ FAMILY $250 / $750 annually DEDUCTIBLE The Deductible does not apply toward the Out -of- Pocket Maximum OUT -OF- POCKET MAXIMUM INDIVIDUAL/ FAMILY per calendar year $750 / $1,500 annually The Out -of- Pocket Maximum includes Co payments and Co- insurance amounts unless otherwise excluded AVMED PRIMARY CARE Services at Participating Physicians' offices include, but are not $ 10 per visit PHYSICIAN limited to: coverage thereafter • Routine office visits /annual well -woman examination when performed by Primary Care Physician • Pediatric care and well -child care • Periodic health evaluation and immunizations • Diagnostic imaging, laboratory or other diagnostic services • Minor surgical procedures • Vision and hearing screenings for children under 18 MATERNITY CARE • Initial visit $10 Co- payment • Subsequent visits NO CHARGE AVMED SPECIALITY HEALTH • Office visits $20 per visit CARE PHYSICIAN SERVICES • Annual well -woman examination when performed by a participating Specialty Health Care Physician Additional charges will apply if Outpatient Diagnostic Tests are performed in the Specialist's Office. HOSPITAL Inpatient care at Hospitals includes: $150 per admission; 100% • Room and board — unlimited days (semi - private) coverage thereafter • Physicians', specialists' and surgeons' services • Anesthesia; use of operating and recovery rooms, oxygen, drugs and medication • Intensive care unit and other special units, general and special duty nursing • Laboratory and diagnostic imaging • Required special diets • Radiation and inhalation therapies _ OUTPATIENT SERVICES Outpatient surgeries, including cardiac catheterization and $150 Co- payment angioplasty • Outpatient therapeutic services, including: • Drug infusion therapy $100 Co- payment • Injectable Drugs (Co- payment for Injectable Drug $75 Co- payment waived if incidental to same -day drug infusion therapy) • Preventive and diagnostic colonoscopies $150 Co- payment • One preventive colonoscopy per lifetime (Not subject to NO CHARGE Calendar Year Deductible) OUTPATIENT DIAGNOSTIC • CAT Scan, PET Scan, MRI 10% of the contracted rate, TESTS Other diagnostic imaging tests after Deductible Charges for office visits will also apply if services are performed in a Specialist's office EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition $75 Co- payment requiring immediate medical or surgical care. (Co- payment waived if admitted) • Emergency services at Participating Hospitals • Emergency services at non - participating Hospitals, facilities and/or physicians AvMed must be notified within 24 hours of inpatient admission following emergency services or as soon as reasonably possible. A V d.G- 10/250n50/ 10 % -09 MP -5228 (10 /09) Benefit Summary, continued URGENT/IMMEDIATE CARE • Medical Services at a participating Urgent Immediate Care $40 Co- payment DIAGNOSIS AND TREATMENT facility or services rendered after hours in your Primary Care $20 per visit OF AUTISM SPECTRUM Physician's office $10 per visit DISORDER • Medical Services at aparticipating retail clinic $10 per visit • Medical Services at a non - participating Urgent/Immediate Care $60 Co- payment facility or non - participating retail clinic FAMILY PLANNING • Voluntary family planning services $10 per visit SKILLED NURSING FACILITIES • Sterilization (In addition to any Outpatient Facility charge) $250 Co- payment ALLERGY TREATMENTS • Injections $10 per visit CENTERS • Skin testing $50 per course of testing AMBULANCE Ambulance transport for emergency services $100 Co- payment • Non- emergent ambulance services are covered when the skill of medically trained personnel is required and the Member cannot be safely transported by other means Benefits limited PHYSICAL, SPEECH AND Short-term physical, speech or occupational therapy for acute $10 per visit OCCUPATIONAL THERAPIES conditions Coverage is limited to 30 visits per calendar year for all services FOR ADDITIONAL INFORMATION, PLEASE CALL: 1. 800- 88-AVMED (1- 800 -882 -8633) This Schedule of Benefits is not a contract. For specific information on Benefits, Exclusions and Limitations, please consult your AvMed Group Medical and Hospital Service Contract. AV -LG- 10/250/750/10% -09 MP -5228 (10/09) combined DIAGNOSIS AND TREATMENT • Applied Behavior Analysis services $20 per visit OF AUTISM SPECTRUM Physical, speech or occupational therapy for the treatment of $10 per visit DISORDER Autism Spectrum Disorder Coverage for all services related to Autism Spectrum Disorder is limited to $36,000 annually and may not exceed $200,000 in total benefits. SKILLED NURSING FACILITIES Up to 20 days post - hospitalization care per calendar year when 10% of the contracted rate, AND REHABILITATION prescribed by physician and authorized by AvMed after Deductible CENTERS CARDIAC REHABILITATION Cardiac rehabilitation is covered for the following conditions: $10 per visit • Acute myocardial infarction • Percutaneous transluminal coronary angioplasty (PTCA) • Repair or replacement of heart valves Benefits limited • Coronary artery bypass graft (CABG), or to $1,500 per • Heart transplant calendar year Coverage is limited to 18 visits per calendar year HOME HEALTH CARE • Limited to 60 skilled visits per calendar year 10% of the contracted rate, after Deductible DURABLE MEDICAL Equipment includes: 10% of the contracted rate, EQUIPMENT AND • Hospital beds after Deductible ORTHOTIC APPLIANCES • Walkers • Crutches • Wheelchairs Benefits limited Orthotic appliances are limited to: to $2,000 per • Leg, arm, back and neck custom -made braces calendar year PROSTHETIC DEVICES Prosthetic devices are limited to: 10% of the contracted rate, • Artificial limbs after Deductible • Artificial joints • Ocular prostheses FOR ADDITIONAL INFORMATION, PLEASE CALL: 1. 800- 88-AVMED (1- 800 -882 -8633) This Schedule of Benefits is not a contract. For specific information on Benefits, Exclusions and Limitations, please consult your AvMed Group Medical and Hospital Service Contract. AV -LG- 10/250/750/10% -09 MP -5228 (10/09) q x 4 Employee Benefits Consulting Group August 10, 2010 Ms. Carmen Baker Human Resource Manager City of South Miami 6130 Sunset Drive South Miami, Florida 33143 Re: Group Health Insurance Dear Carmen: RECEIVED AUG 1 o 2010 HUMA.J•! RESOURCES As a follow -up to the Insurance Workshop we have designed a plan that will keep the City's annual contributions flat for the upcoming fiscal year. As you will note, there are 3 renewal options: ■ Option #1— No change in benefits (Low HMO rates increased by 13.5 %). Option 92 — Change in benefits (Low HMO rates increased by 8.8 %) ■ Option #3 — Change in benefits and keep the City's annual contribution flat for the upcoming fiscal year. Carmen, please call me if you have any questions or concerns after reviewing this information. I look forward to discussing this in further detail. Regards, Gene Baynon Principal GB /jc 12525 Orange Drive, Suite 703 • Davie, Florida 33330 Phone: (954) 473 -1034 • Fax: (954) 473 -0146 m Web: http: / /www.ebcg.net k k # 0 \ \ / \ / ( \ / \£ 7a §} ( 0� §} 7a ! ( zi \ \ / 0� 7a ! J { Ak ) \k !I2 3 - , ) M,G - / k j /jj \ } \ ( 000 zi \ \ / / 3 \ f \ \ § \ { LU ) IL m -,m=© a k \CA \ # /k7q$« ±kEG »» % < _ V4 ƒ] . m -,m=© a k \CA \ # MMMA » _k�} ƒ] . m -,m=© a a \ uQ \ / \ \ / o((/( ¥asp- �E Q E Q /333\ ±u \ uQ \ q M a q U u q d m � kl C R O 'o O Q. < \ d O O O O Q a-O p 0 mO� O O O U V U U Z ooh oo q O(U N O Q M N Cl) C O y`+ d O C � N o Q m a mho m m a.aaa. ar m n. T N jZ � r NN N O C11 0 M C r V ar in � vr o yr i» c� d o 07 � O Y 3 0 T T •N � rn o ro '° E v a O N V N ,,,, c O N Z Li N m IL S@ c d m rn o 4 3 .O 0 nE•aar R m O O. 00-U) O w Chmm`m O c f \ k # ) ) k ¥ \ �� r. \ E E ) $ o §{ . ■)#\ #« \ \ \\ _ \) }� \\ �� � \ \ �\ _\ �} \\ \ ) a B& 2 2 ) 2 E as ƒ \\ ~ \ \ \\ §} 8 \ \ \{ e _ { ` \ e w) k § \7 E ) Ufz _ « CL ( ! ) ([ % \ k \)5 k \ (» � / w k \\ ./ 1a \ �� r. \ E Benefit Summary ary H a AL tt P ED LARGE GROUP SCHEDULE OF BENEFITS COST TO MEMBER $251$5 00/20% • Subsequent visits NO CHARGE CALENDAR YEAR INDIVIDUAL/ FAMILY $500 / $1,500 annually DEDUCTIBLE The Deductible does not apply toward the Out -of- Packet Maximum $75 Co- payment CO- INSURANCE OUT-Of- INDIVIDUAL/ FAMILY per calendar year $3,000 / $6,000 annually POCKET MAXIMUM Additional charges will apply if Outpatient Diagnostic Tests are rate, after Deductible AVMED PRIMARY CARE Services at Participating Physicians' offices include, but are not $25 per visit PHYSICIAN limited to: 20% of the contracted + Routine office visits /annual well -woman examination when rate, after Deductible performed by Primary Care Physician + Pediatric care and well -child care • Periodic health evaluation and immunizations • Diagnostic imaging, laboratory or other diagnostic services • Minor surgical procedures MATERNITY CARE • Initial visit u� uo- payment rate, after Deductible • Subsequent visits NO CHARGE AVMED SPECIALITY HEALTH • Office visits $50 per visit CARE PHYSICIAN SERVICES • Annual well -woman examination when performed by a $75 Co- payment waived if incidental to same -day drug infusion therapy) participating Specialty Health Care Physician • Preventive and diagnostic colonoscopies 20% of the contracted Additional charges will apply if Outpatient Diagnostic Tests are rate, after Deductible • One preventive colonoscopy per lifetime (Not subject to performed in the Specialist's Office HOSPITAL Inpatient care at Hospitals includes: 20% of the contracted • Room and board — unlimited days (semi - private) rate, after Deductible • Physicians', specialists' and surgeons' services • Anesthesia, use of operating and recovery rooms, oxygen, drugs and medication • Intensive care unit and other special units, general and special duty nursing • Laboratory and diagnostic imaging • Required special diets • Outpatient surgeries, including cardiac catheterizations and 20% of the contracted angioplasty rate, after Deductible • Outpatient therapeutic services, including: • Drug infusion therapy 20% of the contracted rate, after Deductible • Injectable Drugs (Co- payment for Injectable Drug $75 Co- payment waived if incidental to same -day drug infusion therapy) • Preventive and diagnostic colonoscopies 20% of the contracted rate, after Deductible • One preventive colonoscopy per lifetime (Not subject to NO CHARGE. OUTPATIENT DIAGNOSTIC • CAT Scan, PET Scan, MRI 20% of the contracted TESTS • Other diagnostic imaging tests rate, after Deductible Charges for office visits will also apply if services are performed in a Specialist's office EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition $100 Co- payment requiring immediate medical or surgical care. (Co- payment waived if admitted) • Emergency services at Participating Hospitals • Emergency services at non - participating Hospitals, facilities and /or physicians AvMed must be notified within 24 hours of inpatient admission following emergency services or as soon as reasonably possible. Av -LG- 25/500/20 % -09 MP -3402 (10109) Benefit Summary, continued URGENTAMMEDIATE CARE • Medical Services at a participating Urgent/Immediate Care $40 Co- payment facility or services rendered after hours in your Primary Care Physician's office • Medical Services at a participating retail clinic $25 per visit • - Medical Services at a non - participating Urgentimmediate Care $60 Co- payment facility or non- Dartieinatine retail clinic FAMILY PLANNING • Voluntary family planning services $25 per visit • Sterilization (In addition to any Outpatient Facility charge) $250 Co- payment ALLERGY TREATMENTS • Injections $25 per visit • Skin testing $50 per course of testing AMBULANCE • Ambulance transport for emergency services $100 Co- payment • Non - emergent ambulance services are covered when the skill of medically trained personnel is required and the Member cannot be safely transported by other means PHYSICAL, SPEECH AND • Short-term physical, speech or occupational therapy for acute $25 per visit OCCUPATIONAL THERAPIES conditions Coverage is limited to 30 visits per calendar year for all services combined DIAGNOSIS AND TREATMENT • Applied Behavior Analysis services $50 per visit OF AUTISM SPECTRUM • Physical, speech or occupational therapy for the treatment of $25 per visit DISORDER Autism Spectrum Disorder Coverage for all services related to Autism Spectrum Disorder is limited to $36,000 annually and may not exceed $200,000 in total benefits. SKILLED NURSING FACILITIES • Up to 20 days post - hospitalization care per calendar year when 20% of the contracted AND REHABILITATION prescribed by physician and authorized by AvMed rate, after Deductible CENTERS CARDIAC REHABILITATION Cardiac rehabilitation is covered for the following conditions: $25 per visit • Acute myocardial infarction • Percutaneous transluminal coronary angioplasty (PTCA) • Repair or replacement of heart valves Benefits limited • Coronary artery bypass graft (CABG), or to $1,500 per • Heart transplant calendaryear Coverage is limited to IS visits per calendar year HOME HEALTH CARE • Limited to 60 skilled visits per calendar year 20% of the contracted rate, after Deductible DURABLE MEDICAL Equipment includes: 20% of the contracted EQUIPMENT AND • Hospital beds rate, after Deductible ORTHOTIC APPLIANCES • Walkers • Crutches • Wheelchairs Benefits limited Orthotie appliances are limited to: to $2,000 per • Leg, arm, back and neck custom -made braces calendar year PROSTHETIC DEVICES Prosthetic devices are limited to: 20% of the contracted • Artificial limbs rate, after Deductible • Artificial joints • Ocular prostheses FOR ADDITIONAL INFORMATION, PLEASE CALL; 1. 800.88 -AVMED (1- 800.882 -8633) This Schedule of Benefits is not a contract. For specific information on Benefits, Exclusions and Limitations, please consult your AvMed Group Medical and Hospital Service Contract. AV -LG- 25/500/20 % -09 MP -3402 (10109) WHOM IMA UNHIM Benefit Summarily li 8 AL lr P EL� LARGE GROUP SCHEDULE OF BENEFITS COST TO MEMBER 0/$11500110% UALMMAK ThAR 1NWVWUAL /MMILY $250 /$750, annually DEDUCTIBLE The Deductible does not apply toward the Out -of- Pocket Maximum NO CHARGE OUT -OP- POCKET MAXIMUM INDIVIDUAL/ FAMILY per calendar year $1,500 / $3,000 annually CARE PHYSICIAN SERVICES The Out- of- Pockel Maximum includes Copaymenis and Co- • Preventive and diagnostic colonoscopies insurance amounts unless otherwise excluded • One preventive colonoscopy per lifetime (Not subject to AVMED PRIMARY CARE Services at Participating Physicians' offices include, but are not $15 per visit PHYSICIAN limited to: HOSPITAL • Routine office visits /annual well -woman examination when $250 per admission; 100% performed by Primary Care Physician coverage thereafter • Pediatric care and well -child care • Periodic health evaluation and immunizations • Diagnostic imaging, laboratory or other diagnostic services • Minor surgical Droeedures is MATERNITY CARE • Initial visit $15 Co- payment • Subsequent visits NO CHARGE AVMED SPECIALITY HEALTH • Office visits $25 per visit CARE PHYSICIAN SERVICES • Annual well -woman examination when performed by a • Preventive and diagnostic colonoscopies participating Specialty Health Care Physician • One preventive colonoscopy per lifetime (Not subject to NO CHARGE Additional charges will apply if Outpatient Diagnostic Tests are performed in the Specialist's Office. HOSPITAL Inpatient care at Hospitals includes: $250 per admission; 100% • Room and board — unlimited days (semi - private) coverage thereafter • Physicians', specialists' and surgeons' services • Anesthesia, use of operating and recovery rooms, oxygen, drugs and medication • Intensive care unit and other special units, general and special duty nursing Laboratory and diagnostic imaging • Required special diets • Outpatient surgeries, including cardiac catheterization and - $250 Co- payment angioplasty • Outpatient therapeutic services, including: • Druginfusiontherapy $ 100 Co-payment • injectable Drugs (Co- payment for Injectable Drug $75 Co- payment waived if incidental to same -day drug infusion therapy) • Preventive and diagnostic colonoscopies $250 Co- payment • One preventive colonoscopy per lifetime (Not subject to NO CHARGE OUTPATIENT UTAONUSTIC • CAT Scan, PET Scan, MRl 10% of the contracted rate, TESTS • Other diagnostic imaging tests after Deductible Charges for office visits will also apply if services are performed in a Specialist's office. EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition $100 Co- payment requiring immediate medical or surgical care. (Co- payment waived if admitted) • Emergency services at Participating Hospitals • Emergency services at non- participating Hospitals, facilities and /or physicians AvMed must be notified within 24 hours of inpatient admission following emergency services or as soon as reasonably possible. AV -LG45 /250/1 500/10°/ -09 MP-5227 (10/09) Benefit Summary, continued URGENT/IMMEDIATE CARE • Medical Services at a participating Urgent/Immediate Care $40 Co- payment facility or services rendered after hours in your Primary Care Physician's office • Medical Services at a participating retail clinic $15 per visit • Medical Services at a non - participating Urgent/Immediate Care $60 Co- payment • Skin testing $50 per course of testing AMBULANCE • Ambulance transport for emergency services $100 Co- payment • Non - emergent ambulance services are covered when the skill of medically trained personnel is required and the Member cannot be safely transported by other means PHYSICAL, SPEECH AND Short-term physical, speech or occupational therapy for acute $15 per visit OCCUPATIONAL THERAPIES conditions Coverage is limited to 30 visits per calendar year for all services FOR ADDITIONAL INFORMATION, PLEASE CALL :1 - 800- 88 -AVMED (1. 800.882.8633) This Schedule of Benefits is not a contract. For specific information on Benefits, Exclusions and Limitations, please consult your AvMed Group Medical and Hospital Service Contract. A V -LG- 15/250/ 1 500/ 10%09 MP -5227 (10109) combined DIAGNOSIS AND TREATMENT • Applied Behavior Analysis services $25 per visit OF AUTISM SPECTRUM Physical, speech or occupational therapy for the treatment of $15 per visit DISORDER Autism Spectrum Disorder Coverage for all services related to Autism Spectrum Disorder is limited to $36,000 annually and may not exceed $200,000 in total benefits, SKILLED NURSING FACILITIES • Up to 20 days post - hospitalization care per calendar year when 10% of the contracted rate, AND REHABILITATION prescribed by physician and authorized by AvMed after Deductible CENTERS CARDIAC REHABILITATION Cardiac rehabilitation is covered for the following conditions: $15 per visit • Acute myocardial infarction • Percutaneous transluminal coronary angioplasty (PICA) • Repair or replacement of heart valves Benefits limited • Coronary artery bypass graft (CABG), or to $1,500 per • Heart transplant calendar year Coverage is limited to 18 visits per calendar year HOME HEALTH CARE • Limited to 60 skilled visits per calendar year 10% of the contracted rate, after Deductible DURABLE MEDICAL Equipment includes: 10% of the contracted rate, EQUIPMENT AND • Hospital beds after Deductible ORTHOTIC APPLIANCES • Walkers • Crutches - • Wheelchairs i Benefits limited Orthotic appliances are limited to: to $2,000 per • Leg, arm, back and neck custom -made braces calendar year PROSTHETIC DEVICES Prosthetic devices are limited to: 10% of the contracted rate, • Artificial limbs after Deductible • Artificial joints • Ocular prostheses FOR ADDITIONAL INFORMATION, PLEASE CALL :1 - 800- 88 -AVMED (1. 800.882.8633) This Schedule of Benefits is not a contract. For specific information on Benefits, Exclusions and Limitations, please consult your AvMed Group Medical and Hospital Service Contract. A V -LG- 15/250/ 1 500/ 10%09 MP -5227 (10109)