Res No 176-10-13210RESOLUTION NO.: 176-10-13210
A resolution of the Mayor and City Commission of the City of South Miami,
Florida, authorizing the City Manager to renew the contract with
Humana /CompBenefits to provide group dental and vision insurance for
City of South Miami full time employees to be charged to departmental
account numbers respectively; Providing an effective date.
WHEREAS, the Agent of Record (Employee Benefits Consulting Group) for the City's
Dental and Vision Insurance recommends Humana/CompBenefits as our carrier; 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
Humana/CompBenefits for another year; and
WHEREAS, the City Commission wishes to renew Group Dental and Vision Insurance
with Humana/CompBenefits to all full -time employees; and
WHEREAS; with the selection of Humana/CompBenefits, 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 THE CITY OF SOUTH MIAMI, FLORIDA, THAT;
Section 1. The contract with Humana/CompBenefits 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 19th day of AUgUSt 12010.
ATTEST:
APPROVED:
MAYOR
Page 1 of 2
Res. No. 176 -10 -13210
READ AND APPROVED AS TO FORM:
AND SUFFICIENCY:
M"',r zye-
CITY .
Commission Vote: 3 -0
Mayor Phillip Stoddard:
Yea
Vice Mayor Valerie Newman:
absent
Commissioner Brian D. Beasley:
Yea
Commissioner Velma Palmer:
absent
Commissioner Walter Harris:
Yea
W:\My Documents \resolutions\Resolution CompBenefits 2010 -201 Ldoc
Page 2 of 2
ROM IfflTATE
To: The Honorable Mayor & Members of the City Commission
Via: Buford R. Witt, Acting City Manager
From: Carmen V. Baker, Acting Human Resources Manager
Date: August 17, 2010 Agenda Item No.:_)Lt Ohl
Subject: Dental and Vision 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 COMPBENEFITS TO PROVIDE GROUP DENTAL AND VISION 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 dental and vision insurance
carrier, CompBenefits. CompBenefits proposed a 10.0 % increase for the Dental coverage
and 0.0% increase for the Vision coverage.
The insurance Committee met and reviewed the proposed rates. 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
CompBenefits for another year without any changes to the current benefit plan designs.
The City would cover the 50% of the employee rate for Dental of $24.70 which is $12.35.
Based on current enrollment assumptions (125 FTE), the annual increase from this year
to next year would be approximately $18,525.00. Current staffing levels are at 144 full
time employees.
Dental HMO
Dental PPO
Vision
EE
$24.70 (city Portion 50% of amount)
$38.44
$6.50 (City Portion 0 %)
EC
$49.64
$86.42
$12.36
ES
$50.24
$77.54
$13.00
FAM
$81.40
$138.50
$25.58
The City would cover the 50% of the employee rate for Dental of $24.70 which is $12.35.
Based on current enrollment assumptions (125 FTE), the annual increase from this year
to next year would be approximately $18,525.00. Current staffing levels are at 144 full
time employees.
Backup Documentation:
IL) Proposed Resolution
❑ Proposed Dental & Vision Rates
TABLE OF CONTENTS
I. Executive Summary
m
II. Proposed Rates
III. HMO Benefit Comparison
IV. POS Benefit Comparison
V. AvMed Renewal Alternative
Employee Benefits Consulting Group
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.
I Employee Benefits Consulting Group
Proposal Responses
Vendor Name
Aetna
AvMed
Blue Cross Blue Shield
CIGNA Healthcare
Humana
Neighborhood Health/United Healthcare
Vista
2
M
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
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A D Benefit Summary
y
H E A L T , H P L A N S
LARGE GROUP SCHEDULE OF BENEFITS COST TO MEMBER
$1 5/$250/$1,500/20%
CALENDAR YEAR INDIVIDUAL / FAMILY $250/$750 annually
nEDUCTIBLE 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-
inwerance 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
• SUDSe cent VISITS
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 day for the
• Room and board — unlimited days (semi - private)
first 5 days, per admission;
• Physicians', specialists' and surgeons' services
100% coverage 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 cathetenzations and
$250 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)
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
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 non - participating Urgent/Immediate Care $60 Co- payment
A V- LG- 15/250/1500/20%-06
MP- 3990(10/06)
Benefit `it Summary, continued
FAMILY PLANNING Voluntary family planning services J �$15 per visit
• 20. outpatient
$25 per
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, speech or occupational therapy for acute $15 per visit
OCCUPATIONAL THERAPIES conditions
Coverage is limited to 30 visits per calendar year for all services
combined
SKILLED NURSING
m 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
Benefits limited
• Wheelchairs
CARDIAC REHABILITATION
Cardiac rehabilitation is covered for the following conditions:
$15 per visit
Orthotic appliances are limited to:
• Acute myocardial infarction
• Leg, arm, back, and neck custom -made braces
• Percutaneous transluminal coronary angioplasty (PICA)
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 DARE Limited to 60 skilled visits per calendar year 20% of the contracted
DURABLE MEDICAL Equipment includes:
20% of the contracted
EQUIPMENT AND • Hospital beds
rate after Deductible
ORTHOTIC APPLIANCES • Walkers
° Crutches
Benefits limited
• Wheelchairs
to $2,000 per
Calendar Year
Orthotic appliances are limited to:
• Leg, arm, back, and neck custom -made braces
PROSTHETIC OEVIGES 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 HOSPITAL SERVICE CONTRACT.
AV- LG- 15/250/ 1500/20 % -06
MP- 3990(10/06)
LA Benefit Summary
HE A L S H PLAN S
BASIC OPTION SCHEDULE OF BENEFITS COST TO MEMBER
250-ADMIT
OUT -OF- POCKET MAXIMUM $1,500 INDIVIDUAL
Per Calendar Year $3,000 FAMILY
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 IS
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 catheterizations
$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, MR! $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
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 non - participating Urgent/Immediate $60 Co- payment
Care facility
AV- BASIC- 25OA -06
MP-3422 (10/06)
Benefit Summary, continued
• 20 outpatient visits $25 per visit
FAMILY PLANNING Voluntary family planning services
$15 per visit
° Sterilization
$250 Co- payment
ALLERGY TREATMENTS = Injections
$10 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
$20 per visit
skill of medically trained personnel is required and the
• Acute myocardial infarction
Member cannot be safely transported by other means
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 IS 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- 25OA -06
MP-3422 (10/06)
e e/ GL Summary H G H P�
.9_./ N S
LARGE GROUP SCHEDULE OF BENEFITS COST TO MEMBER
$20/$500/$2,000 /20% —
CALENDAR YEAR INDIVIDUAL/ FAMILY $500 / $1,000 annually
DEDUCTIBLE The Deductible does not apply toward the Out -of- pocket Maximum
INDIVIDUAL/ FAMILY per calendar year $2,000 / $4,000 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 $20 per visit
PHYSICIAN
limited to:
Calendar Year Deductible)
• Routine office visits /annual well -woman examination when
20% of the contracted rate,
TESTS • Other diagnostic imaging tests
performed by Primary Care Physician
Charges for office visits will also apply if services are performed in a
• Pediatric care and well -child care
EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition
• Periodic health evaluation and immunizations
requiring immediate medical or surgical care. (Co- payment waived
• Diagnostic imaging, laboratory or other diagnostic services
• Emergency services at Participating Hospitals
• Minor surgical procedures
• Emergency services at non - participating Hospitals, facilities
• Vision and hearing_ screenings for children under 18
MATERNITY CARE
• Initial visit
$20 Co- payment
• Subsequent visits
NO CHARGE
AVMED 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 -
performed in the Specialist's Office.
HOSPITAL
Inpatient care at Hospitals includes:
$500�per admission;
• Room and board — unlimited days (semi - private)
100% 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
$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
NO CHARGE
Calendar Year Deductible)
OUTPATIENT DIAGNOSTIC • CAT Scan, PET Scan, NM
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.
A V -LG- 20/500/2000/20 % -09
MP -5229 (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
OF AUTISM SPECTRUM
Physician's office
$25 per visit
• 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
20% of the contracted rate,
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 testine
$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
$40 per visit
OF AUTISM SPECTRUM
• Physical, speech or occupational therapy for the treatment of
$25 per visit
DISORDER
Autism Spectrum Disorder
after Deductible
DURABLE MEDICAL
Coverage for all services related to Autism Spectrum Disorder is
20% of the contracted rate,
EQUIPMENT AND
limited to $36,000 annually and may not exceed $200,000 in total
after Deductible
ORTHOTIC APPLIANCES
benefits.
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
Orthotic appliances are limited to:
per calendar year
CARDIAC REHABILITATION
Cardiac rehabilitation is covered for the following conditions:
$25 per visit
PROSTHETIC DEVICES
• Acute myocardial infarction
20% of the contracted rate,
• Percutaneous transluminal coronary angioplasty (PTCA)
after Deductible
• Repair or replacement of heart valves
Benefits limited to $1,500
• Coronary artery bypass graft (CABG), or
per calendar year
• Heart transplant
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-LO-20/500/2000120%-09
MP- 5229(10/09)
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 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-LO-20/500/2000120%-09
MP- 5229(10/09)
r
.- �
Benefit Summary HE H PEII�
LARGE GROUP
SCHEDULE OF BENEFITS
COST TO MEMBER
$70/$2501$750/10%
• Room and board — unlimited days (semi - private)
coverage thereafter
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:
• Routine office visits /annual well -woman examination when
OUTPATIENT SERVICES
performed by Primary Care Physician
$150 Co- payment
• Pediatric care and well -child care
• Periodic health evaluation and immunizations
• Diagnostic imaging, laboratory or other diagnostic services
-
Minor surgical procedures
$75 Co- payment
• Vision and hearing screenings for children under 18
MATERNITY CARE • Initial visit 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
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 catlneterizations 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.
AV -LG- 10/250/7501 10 % -09
MP -5228 (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 $10 per visit
• Medical Services at a non - participating Urgent/Immediate Care $60 Co- payment
Y PLANNING • Voluntary family planning services $10 per visit
ALLERGY TREATMENTS • Injections $10 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 transnorted by other means
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
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 -1 0/250/750/10 % -09
MP -5228 (10/09)
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 9 o 2010
HUMAN 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 93 — 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 • Web: http: / /www.ebcg.net
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LOW HMO RENEWAL
ALTERNATIVE (OPTION #3)
Benefit Su r a y � HEALTH P lED
LARGE GROUP SCHEDULE OF BENEFITS COST TO MEMBER
'251$500/20%
CALENDAR YEAR
INDIVIDUAL/ FAMILY $500 / $1,500 annually
DEDUCTIBLE
The Deductible does not apply toward the Out -of- Pocket Maximum
CO- INSURANCE OUT -OF-
INDIVIDUAL/ FAMILY per calendar year $3,0001 $6,000 annually
POCKET MAXIMUM
AVMEO PRIMARY CARE
Services at Participating Physicians' offices include, but are not $25 per visit
PHYSICIAN
limited to:
and medication
• Routine office visits /annual well -woman examination when
•
performed by Primary Care Physician
• Pediatric care and well -child care
duty nursing
• Periodic health evaluation and immunizations
•
• Diagnostic imaging, laboratory or other diagnostic services
• Minor surgical procedures
Required special diets
• Vision and hearing screening_s_for children under 18
MATERNITY CARE • Initial visit $25 Co- payment
• Subsequent visits NO CHARGE
AVMED SPECIALITY HEALTH • office visits $50 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
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
•
Radiation and inhalation therapies
OUTPATIENT SERVICES •
Outpatient surgeries, including cardiac catheterization 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.
Calendar Year Deductible)
OUTPATIENT DIAGNOSTIC • CAT Scan, PET Scan, MRI Lu io or 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 (10/09)
Benefit Summary, continued
URGENTIIMMEDIATE 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 Urgentltmmediate Care $60 Co- payment
rAMILY rLANNINty • voluntary ramny planning services $25 per visit
• Sterilization (In addition to any Outpatient Facility charge) $250 Co- payment
ALLERGY TREATMENTS • Injections $25 per visit
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 (CABO), or
to $1,500 per
• Heart transplant
calendar year
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
EQUIPMENT AND
• Hospital beds
rate, 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:
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 -8033)
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- 1,0- 25/500120% -09
MM402 (10109)
Mom
Benefit Summ ry L n PEA
LARGE GROUP
SCHEDULE OF BENEFITS
COST TO MEMBER
$15/$2501$1,500 /10%
CALENDAR YEAR
INDIVIDUAL/ FAMILY
$250 / $750 annually
DEDUCTIBLE
The Deductible does not apply toward the Out -of- Pocket Maximum
OUT -OP- POCKET MAXIMUM
INDIVIDUAL/ FAMILY per calendar year
$1,500 / $3,000 annually
The Out -of- Pocket Maximum includes Ca 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 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
$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
participating Specialty Health Care Physician
Additional charges will apply if Outpatient Diagnostic Tests are
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
• Radiation and inhalation therapies
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 $250 Co- payment
• One preventive colonoscopy per lifetime (Not subject to NO CHARGE
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 $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-1,0- 1512501150011 N.-09
MP.-M7 (10/09)
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 $15 per visit
• Medical Services at a non - participating Urgent/Immediate Care $60 Co- payment
FAMILY PLANNING • Voluntary family planning services $15 per visit
• Sterilization (In addition to any Outpatient Facility charge) $250 Co- payment
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
be safelv transnorted by other means
PHYSICAL, SPEECH AND Short-term physical, speech or occupational therapy for acute $I5 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
$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 (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
0 Wheelchairs
Benefits limited
Ortbotic 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
• Artificialjoints
• 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- 15125011500110 %09
MP -5227 (10109)