Res. No. 223-97-10193RESOLUTION NO.223-97-10193
A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH
MIAMI,FLORIDA,RELATING TO APPROVAL OF REQUEST FOR PROPOSALS FOR
GROUP LIFE,HEALTH AND DENTAL INSURANCE FOR THE CITY.
WHEREAS,the Mayor and Commission has authorized the City Manager to
request proposals for insurance forthe city;and
WHEREAS,a request for proposals document has been developed;and
WHEREAS,upon approval by the Mayor and Commission,the City Manager
will issue the request for proposals to receive bids for group life,health
and dental insurance for the city.
NOW THEREFORE BE IT RESOLVED BY THE MAYOR AND CITY COMMISSION OF THE
CITY OF SOUTH MIAMI,FLORIDA:
Section 1.That the City Manager is authorized to issue the attached
request for proposals document to solicit bids for group life,health and
dental insurance.
Section 4.This resolution shall take effect immediately upon approval.
PASSED AND ADOPTED this 21stday of
'(UutXC*2>^JOjjQen.
READ AND APPROVED AS TO FORM:
CITY ATTORNEY
COMMISSION VOTE:
Mayor Price:
Vice Mayor Robaina:
Commissioner Oliveros:
Commissioner Bethel:
Commissioner Young:
5-0
Yea
Yea
Yea
Yea
Yea
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CITY OF SOUTH MIAMI
INTER-OFFICE MEMORANDUM
To:Mayor and Commission Date:October 17,1997
^^^Agenda Item #g
From:L.Dennis Whitt oo^WV Subject:October 21,1997
CityManager CommissionMeeting
RFP for Insurance
TheattachedresolutionapprovesissuanceoftheattachedRequestforProposalforGrouplife,health
anddentalinsurancefortheCity of SouthMiami.
ThePrudentiallM?/
CITY OF SOUTH MIAMI
FREEDOM-OF-CHOICE
DMOe
BENEFIT SUMMARY
OfficeVisistCopaymem
PreventiveServicesDeductible
Annual Deductible (Bask and Major Services)
Annual Benefit Maximum
BENEFIT PERCENTAGES FOR COVERED DENTAL SERVICES
Visitfor Oral Examination
Complete X-ray Series
PeriapicalX-rays
Prophylaxis,including scaling andpolishing
Fluoride -Children underage18
OralHygieneInstruction
Sealants (permanent molars only)
SpaceMaintainers
Amalgam and Composite fillings
Inlays,Onlays andCrowns (other than stainless steel crowns)
Stainless Steel Crowns
PulpCapping
Pulpotomy
Root Canal Therapy (anterior and premolar tooth)
RootCanalTherapy(molartooth)
Apicoectomy
Gingival Currettage
Osseous Surgery,including flapentryandclosure
Scaling andRootPlaning
Full and Partial Dentures
FullandPartialDentureRepair
Tissue Conditioning forDentures
BridgePonticsandAbutments
Extractions (uncomplicated)
Surgical Removal ofEruptedTooth
Removal ofSoftTissueImpactedTooth
Removal ofFullorPartialBonyImpactedTooth
IncisionandDrainageofAbscess
Frenectomy
ExcisionofHyperplasticTissue
General Anesthesia
Orthodontic Appliances andTreatment
Deductible
Employee's responsibility (forthe DMOe,basedonDentist'susualandapprovedcharge).
TraditionalPlan Orthodontic Benefits are restricted toalifetimeoforthodontic maximum of $1,000
DMOe Orthodontic Benefits arerestrictedtoonefulltreatmentper lifetime perchild.Benefits forOrthodontictreatmentstartedbeforeyour effective dateunder
the DMOa arepayableatthesamelevelyourdependentchildisreceivingunderyour cumin dentalplan.
The DMOe benefits described above are available onlywhen services are rendered byyour DMOe Personal Dentist and/or pre-authorized by Prudential.Charges for
coveredservicesprovidedby non-participating dentistsareonlyeligibleforlimitedbenefitsaftersatisfactionofa$100annualdeductible.
Benefits are based onthe Usual and Prevailing Chargeforadentalserviceina geographic area.Frequencylimitsapplytocertainservices.
DMO.F 8/95
DMOe TRADITIONS,
$5 N/A
NONE $0
NONE $100
NONE $1,000
100%
100%
100%
100%
80%
80%
80%
80%
100%
100%
100%
60%
80%
Not Covered
Not Covered
80%
80%
60%
80%
80%
50%
80%
80%
80%
80%
60%
80%
80%
80%
80%
80%
80%
60%
80%
80%
80%
80%
80%
60%
60%
80%
60%
50%
80%
50%
50%
80%
80%
80%
60%
80%
80%
80%
80%
80%
80%
80%
60%
80%
80%
80%
80%
None
50%
$100
50%
ThePrudential \Jmi
Covered Dental Services
Dental services covered and not covered are generally the same for both the DMOe and the Traditional Dental Plan.Services not covered under the
DMOe areshownbelow.Theservicesnotcoveredunderthe Traditional Dental Planareshowninyourcurrentbenefit plandescription.
DENTAL SERVICES NOT COVERED
1.Servicesnotreasonablynecessaryornot customarily performed.
2.Replacement ofa partial or full removable denture,a removable bridge or fixed bridgeworic,ora crown or gold restorarion within 5 years
after installation.
3.Initial placement of partial or full removable denture,removable bridge,or fixed bridgeworic ifit includes replacement of one or more natural
teeth missing before the person was covered under the Plan unless it also includes replacement ofa natural tooth that:
(a)isremovedwhilethepersoniscovered;and
(b)was not an abutment to a partial denture,removable bridge or fixed bridge installed during the prior 5 years.
4.An appliance,or modification of one,if an impression for it was made before the person was covered.
5.A crown,bridge,or gold restoration if the tooth was prepared before the person was covered.
6.Root Canal Therapy if the pulp chamber for it was opened before the person was covered.
7.Cosmetic Services unless needed asa result of accidental injuries sustained while covered.
8.Replacement of lostorstolen appliances.
9.Appliances,restorations or procedures needed to alter vertical dimensions or restore occlusion or for splinting or correcting attrition or
abrasion.
10.Services rendered in connection with work-related sickness or injury.
11 A charge for a service (a)furnished by or for the United States Government or any other government,unless payment for the services is
required by law;or (b)to the extent that the service or any benefit for the charge is provided by any law or governmental plan under which
thepersonisorcouldbecovered.
12.A charge for a service not included on the list of covered services,unless the unlisted service is a professionally acceptable alternative to a
covered service.The charge will be covered as if the covered service was rendered.
13.Acharge for aservice to the extent that it is more than the usual and prevailing charge made by the provider for the service in the area where
itisperformed.
14.Agold restoration orgoldcrownunless:
(a)it is treatment for decay or traumatic injury and tooth cannot be restored with a filling material or
(b)the tooth is an abutment toa covered partial denture or fixed bridge.
15 Services furnished aperson age 5or more if that person does not become covered (a)during the first 31 days the person is eligible,or (b)in
any period ofopen enrollment agreed to by the Employer and Prudential.This (b)applies only to the DMOe.
TTiis does not apply to services rendered (1)after the end of the 12 months period (24 months,for orthodontics)starting on the date die
person became covered;or (2)as a result of accidental injuries sustained while the person was covered;or (3)under the DMOe Plan,for
certain Basic Services in the list of covered services or under the Traditional Plan,for certain Preventive or Basic Services in the list of
covered services.
16 A charge in connection with treatment of jaw joint problems,by any method,including temporomandibular joint syndrome and
craniomandibular disorders or other conditions of the joint linking the jaw bone and skull,and the complex of muscles,nerves,and other
tissuesrelatedtothat joint.
Ed.b.9^
DMO.F 8/95
MMPO ALL
Montti/Yeer
May 1996
June 1998
July 1996
August 1996
September 1996
October 1996
November 1998
December 1996
January 1997
February 1997
March 1997
Apfl 1997
Totals lor MMPO:
ALL
°>
PREMUM AND CLAIM REPORT BY MMPO
Mey 1996 -April 1997
CITY OFSOUTHMIAMI
Case Control Number/Case Name:§9429
fkimiim
23.449
k\MAtClaims (]l«N«tClthra
1.372
Pharmacy N
4.936
ojflXQHC.Bl[QHC I
0
/^f^jma
14.699 3.487 24.397
24.001 6.416 1.248 3.307 3,660 0 14,633
23.197 14.039 2,460 3.276 3,624 0 23.399
23.030 4,198 761 3,103 3.762 0 11.813
22.904 12,586 1,609 2.946 3.423 0 20.S63
23.842 21.903 1,424 3,602 4,391 0 31.220
24,107 6.768 .277 2.870 4.269 0 16.194
24.107 46.326 736 3.179 4,762 0 24.994
24.107 24.642 85 3.231 4.702 0 32,661
23.799 13,313 673 1,092 4.424 0 19.S02
23.966 8,668 671 6.247 4.533 0 20.108
23.9B6 14,948 3,456 3.142 4.390 0 26.934
284.494 160.389 14.760 40.932 49.337 266,317
125 216 104%
128 222 61%
126 216 101%
123 214 51%
122 213 90%
120 216 131%
1?3 216 67%
123 216 104%
122 218 135%
123 216 82%
124 210 84%
124 216 108%
1,482 2.596 93%
CITY OF SOUTH MIAMI,FLORIDA
REQUEST FOR PROPOSALS
FOR
GROUP LIFE INSURANCE
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
HEALTH AND DENTAL BENEFITS
1.Sealed proposals will be received at the City Hall,6130 Sunset Drive,South Miami,Florida,
on or before the date and time specified in the Legal Notice,when they will be publicly
opened andread aloud.Proposals received afterthe deadline willbe returned tothe sender
unopened.
2.Proposals must be clearly identified as such on the outside of the envelope -"Proposal -
Employee Benefits".
3.Proposals mustbe submitted in duplicate.Failure todosomaybe grounds for
disqualification.
4.Specimenpoliciesare considered tobeanintegralpart of proposals andmustbeincluded.
However,printed brochures describing detail coverage,limitations and exclusions maybe
substituted if no material information is excluded.
5.Theproposalsmustincludethename of theinsurancecompanieswhichmusthaveaGeneral
Policyholder RatingofnolessthanA-anda Financial RatingofVIIor better,as published
by A.M.Best's Insurance Reports,latest edition.A copy ofthe report should be included
withthe proposal.
6.The insurance companies mustbe licensed todo business in Florida.
7.Any agent or agency submitting a proposal must be properly licensed.Ifa proposal from a
company is submitted on behalf of more than one agent or agency,designation of the agent
of record shall bethe responsibility of the insurance carrier.The City prefers notto have an
agent or agent of record.Bids which include a commission to an agent or broker shall fully
disclose theterms relating to payment of fees tosuchagentor broker.
8.The city expressly reserves the right to reject any or all proposals or to conduct negotiations
with any respondent in accordance with Chapter 112.08,F.S.
9.Before awarding any contracts,the City reserves the right to require the agent to submit
evidence of competency to serve the City's requirements,and the City may deem in its best
interest,withoutrecourseagainsttheCity.
10.Should the services of the designated agent become unsatisfactory during the term of the
insurance,the City may request the carrier to nominate a substitute agent without recourse
againsttheCity.
11.Proposals may include a full description of claims service and procedures.If an independent
firm will be engaged for claims service,the name and address of such firm must be indicated
together with its history and experience in rendering such services.
12.All rates must be firm.A proposal qualified by such terms,as "subject to Home Office
approval"or "subject to final enrollment"or similar qualifiers will not be considered.
13.Rates must be guaranteed fora minimum of twelvemonth.
14.Achangeinrates,notice of cancellation,intentionnottorenewor continue coverageon
anniversary,restrictionorelimination of coverageoranyothermaterialchangesinthe
insurance shallnotbe effective without a minimum of ninety days advance written notice.
15.Sworn statement on Public EntityCrimes pursuant to Chapter 287.133 F.S.must be
completed and enclosed with theproposal.
16.Theeffectivedateforallcoveragerequestedshallbethreemonthsafter acceptance of bid.
17.Itisnotthe City's intentiontosolicitproposalsonanannualbasis,buttoestablishalong-
termrelationshipprovidedrenewaltermsandservicesaremutuallyacceptable.Renewal
termsmustbe announced in writing nolessthanninetydays prior to October 1 of eachyear
the contract is in effect.
18.AllcorrespondenceandnoticesrelativetothisprogramwillbeaddressedtoHakeem
Oshikoya,FinanceDirector,CityHall,6130SunsetDrive,SouthMiami,Florida 33143.
19.Theinsurancecompaniesmustagreetofurnishastatement of premiumsandclaimsforeach
monthand cumulatively eachmonthfrominception.
20.SummaryPlanDescriptionbookletsand identification cardswillbefurnishedattheexpense
of the companies.
21.Theproposalsreceivedforthe coverage requested willbeviewedasseparateanddistinct
proposals.IFANY COVERAGE CANNOT BE OFFERED SEPARATELY FROMANY
OTHER COVERAGE,PLEASE SO INDICATE CLEARLY IN THE PROPOSAL.
22.Duecareand diligence hasbeen exercised inthe preparation ofthis information anditis
believedtobesubstantiallycorrect.However,theresponsibilityfordeterminingthefull
extentoftheexposuresisofthe proposer.TheCity,itselectedandappointed officials,
employees and representatives shall notbeheld responsible foranyerrorsor omissions in
these specifications norforthe failure onthepartofthe proposer to determine thefull extent
of the exposure.
GROUP LIFE INSURANCE
AND
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Prudential HealthCare-South Florida
GroupLifeInsurance-$10,000reduced25%atage65,furtherreducedatage70.
AD&D -Principal Sum $10,000 (Non-occupational)
Premium Rates
Member Life Insurance -$.37per$1,000permonth.
AD&D-$.05per$1,000permonth
NewEmployeesEligibility-All full-time employeesasofhiredate.
Elected Officials are included in the coverage
TotalpremiumpaidbytheCity.
Quotations for optional supplemental insurance tobe paid bythe employees willbe considered.
The reductions intheLifeandAD&D benefits indicated above are descriptive of the current
insurance and need notbe duplicated exactly.
Two deaths claim -1988 and 1996 -$20,000.
CURRENT HEALTH BENEFITS
Employeesmay choose toenrollinPrudential HealthCare HMOor Prudential HealthCare Point
of Service(POS).
Rates:HMO -$132.15 forsingle coverage and $316.02 forfamily coverage.
POS-$167.18 forsinglecoverageand $388.13 forfamilycoverage.
Asummary of benefits under bothplansisattached.
Note:Under either plan the employee paysfor dependent coverage only.TheCitypaysthe
premium forthe employee.
Thereareseven(7)COBRAparticipants.Itisnotacondition of thisRequestforProposalsthat
theadministration of COBRAwillbetheresponsibility of theCity.Administration byathird
partyisNOT acceptable.
Elected Officials are included in the coverage.
Proposed benefits must at minimum be equal to the existing benefits.
Plans with no provision for our-of-network "disincentives"must be reasonable.
SOUTH MIAMI HOSPITAL must be included in the network of participating hospitals.
CURRENT DENTAL BENEFITS
Employees may choose to enroll The Prudential Dental Maintenance Organization (DMO),or
Freedom-of-Choice Plan.
Rates:DMO/Freedom-of-Choice -$16.26 for single coverage,$32.83 for employee +1 and
$45.85 for family coverage.
A summary of benefits under both plans is attached
There areeight(8)COBRA participants.
Note:Under either plan the employee pays for dependent coverage.The City pays 66%of the
premium forthe employee.
Elected Officials are included inthe coverage
RATING HISTORY
HMO Single+Dependents=Family
1994-1995
1995-1996
1996-1997
POS
1994-1995
1995-1996
1996-1997
,DENTAL
1995-1996
1996-1997
173.53 +267.24 =440.77
125.86 +175.11 =300.97
132.15 +183.87 316.02
206.78 +312.64 519.42
167.18 +220.95 =388.13
167.18 +220.95 =388.13
Single +1+family =Rate
16.26 +16.57 =32.83
16.26 +29.59 =45.85
16.26 +16.57 =32.83
16.26 +29.59 =45.85
r
ThePrudentiai (SI
City of South Miami
Prudential HealthCare HMO
PROVIDER SERVICES
•Office visitstoyourPrimaryCarePhysician
(includingperiodic physical examinations.
pap smears,immunizations,injections,well baby care,
diagnosticX-rayandlab,and office surgery)
•Office visitstoa Specialist when referredby
PrimaryCarePhysician
•Maternity(including prenatal,delivery,andpostnatalcare)
•Hospital Visits (including well newborn care)
•Surgery (other thanduring Office Visit)
(including Surgeon.Asst Surgeon,and Anesthesiologist Services)
HOSPITAL SERVICES (INPATIENT)
•Room andboard (semi-private),intensive care,
pre-admissiontesting,other eligible hospital charges
•Newborn Care
HOSPITAL SERVICES (Outpatient)
•EmergencyRoom*
•Outpatient SurgicalFacilityCare
•Outpatient DiagnosticX-rayandLabFacility
•Outpatient Chemo/Radiation Treatment Facility
PRESCRIPTION DRUGS
(PrescriptiondrugsauthorizedorapprovedbyyourPrimaryCare
PhysicianoraSpecialistto whom youhavebeenreferred.)
•At participatingEckerd &Walgreens pharmaciesinDade,Broward
andPalmBeach counties.Copayment isforuptoa 30-day supply
of eachprescriptionorrefill.
•PrescriptionsbyMail-Copayment isuptoa90-day supply of each
prescription or refill.
Bl EFIT SUMMARY
Prudential HealthCare HMO Benefits
All services and supplies mustbe
provided or authorized bya
Network PrimaryCarePhysician
100%after$10 copayment pervisit
100%after$10 copayment pervisit
100%after$10copayforfirstvisit
100%
100%
100%
100%
100%after$50 copayment pervisit
100%
100%
100%
100%after$5copaymentfor generic/
$10 brand name
100%after$5copaymentfor generic/
$10 brand name
♦NOTE CONCERNING EMERGENCY ROOM:Asa Prudential HealthCare HMOmember,youarecoveredformedical
emergencies that occur when you are inoroutof your service area (Service Area:Dade,Broward and Palm Beach counties).
In a medical emergency,please call your Primary Care Physician as soon as possible (within 48 hours if reasonably possible)so
that your medical care can be coordinated.A medical emergency is generally defined asa sickness or injury of such a nature
that failure to get immediate medical care could put a person's life in danger or cause serious harm to bodily functions.Some
examples of medical emergencies are:apparent heart attack,severe bleeding,sudden loss of consciousness,severe or multiple
injuries,convulsions,apparent poisoning.
Ed.1/1/95
Plan 4;Local
FL ME 0200
GI-602 Ed.5/94
ThePrurientiai Ufife
Prudential HealthCare HMO
MENTAL HEALTH CARE
•Outpatient Care:Benefits are limited toa maximum of20 visits
per calendar year orSI,000 maximum,whichever is greater
•Hospital Inpatient Care:Annual Benefits will not be more than
the equivalent ofthe full amount ofeligible charges for 30 days in the
hospital in which the person is confined.**
•Partial Hospitalization:Annual benefits wiil not be more than the
equivalent charge for 30 days of Hospital Inpatient Stay**
*'(Combined annual benefits for Inpatient and Partial Hospitalization
will not be more than the equivalent charge for 30 days of Inpatient
Hospital Slav)
CHEMICAL DEPENDENCY
•Inpatient and/or Outpatient carefor medical condition for detoxification,
sickness that isa direct result of alcoholism or drug abuse,and adverse
reaction to alcohol and chemical substances
•Rehabilitation (inpatient and/or outpatient)
Limited to a maximum of 30 visits/days per calendar year
VISION CARE
•At participating in-networkoptometrists
(see Provider Directory)
OTHER SERVICES
•SkilledNursingFacility
(upto 100 dayspercalendaryear)
•Home Health Care
•Hospice Care ($7,400 per period of care)
•Outpatient Private Duty Nursing
•Short-term Outpatient Speech.Physical &Occupational Therapy
(60 consecutive calendardaysfromfirsttreatment
foranyoneSicknessorinjury)
•DurableMedical Equipment
(S100.000 lifetime maximum)
Ed.1/1/95
Plan 4;Local
FL ME 0200
BL.iEFIT SUMMARY
Prudential HealthCare HMO Benefits
Allservicesandsuppliesmustbe
providedorauthorizedbya
NetworkPrimaryCare Physician
100%afterS20copaymentpervisit
100%
100%
100%after S10 copayment
per Outpatient visit
100%after S10 copayment
per Outpatient visit
S10 pereye exam
(limited to1 exam per calendar year)
100%
100%
100%
100%
100%after S10 copayment
per visit
100%
GI-602 Ed.5/94
ThePrudentiai (fib Prudential HealthCare HMO
EXCLUSIONS
The following are excluded from coverage-
Services not provided or approved by your Primary Care Physician or Specialist
Services not medically necessary.
Services tumished in connection with military service connected disabilities.
Services,including surgery,to improve appearance (cosmetic surgery;.
Dental services and X-ray exams involving one or more teeth,the tissue or structure around them,the alveolar
process or the gums.This applies even ifa condition requiring any of these services involves a part of the
body other than the mouth such as Temporamandibular Joint Disorders (TMJD)or malocclusion involving
jointsor muscles by methods including,butnotlimitedto,crowning,wiring,or reposition teeth.Thisalso
excludes any services and supplies furnished in connection with an excluded dental service.
Services in connection with long-term physical medicine and rehabilitative services.(Including long-term
physical therapy andcognitive rehabilitation).
Custodial or domiciliary care.
Eye surgery such asradial keratotomy,when theprimary purpose istocorrect myopia (nearsightedness),
hyperopia (farsightedness)orastigmatism(blurring;.
Eyeglasses orlensesofany type.
Routine foot careservices including,butnot limited to.foot pain causedby corns,calluses,or toenails.
Hearing aids,exams to determine the need for hearing aids,or the need to adjust them (except for screening of
members underage 18 todeterminetheneedforhearingcorrection).
Emergency service charges that are in excess of the usual and prevailing charges as determined by Prudential
HealthCare.
Charges charged in connection with,but not limited to,in vitro fertilization,embryo transfer or freezing,
Gamete Intra-fallopian Transfer (GIPT)and Zygote Intra-fallopian Transfer (ZIFT).
Personal comfort and convenience items and services.
Any procedure or treatment which is determined by Prudential HealthCare to be:
a)experimental,investigational,or educational innature:or
b)not medically necessary unless approved by Prudential HealthCare's Medical Director.
Sexchangeoperationsandreversalsforvoluntary sterilization.
Any non-prescription drugs.
Prescription drugs not obtained from a Prudential HealthCare participating pharmacy or Prescription by Mail
Program except prescriptions tilled outside the Service Area in connection with a medical emergency.
Prescription drugs whose quantities are in excess of:(a)A 30-day supply or (b)A 90-day supply ofa
maintenance drug or oral contraceptive for participating pharmacies in the Service Area or in excess of 90 day
supply through the Prescription by Mail Program.
Prescription refills dispensed more than 12 months after the date of the doctor's original order.
Conditions thatstateorlocallawrequiresbetreatedinapublicfacility.
Services and supplies that are experimental or investigational as determined by Prudential HealthCare.
Services and supplies thatare educational as determined by Prudential HealthCare.
Services and supplies solely required in connection with insurance,licensure,school or employment,or for
travel outside the United States.
Blood &blood plasma which is replaced byorforthepatient.
Services and supplies furnished by (a)the Employer;or (b)you,your spouse,ora close relative of you or your
spouse.
Ed.1/1/95
Plan 4:Local
FL ME 0200 r
GI-602 Ed.S9J
ThePrudentiaffe p™dential HealthCare HMO
EXCLUSIONS (continued)
Services and supplies in connection with termination ofa pregnancy outside of the Service Area,except in
connectionwitha medical emergency.
Services and supplies furnished in connection with any weight loss program,unless the person is morbidly
obeseorobesityhasbeenclinically demonstrated tohaveanadverse effect onaconcurrentsickness.
Services and supplies required solely because a service or supply that isnotcovered is provided.
Services and supplies required pursuant toa court decree regarding a divorce action,a motor vehicle violation,
or other judgment not directly related tothis coverage,if theywouldnotbe covered inthe absence of such a
decree.
Exercise equipment including,but not limited to,exercycies,treadmills,stepping machines,rowing
machines,weights,spasandpools.
This summary isnota contract but a general description ofthe basic benefits,exclusions and other provisions of
the plan.Services and other benefits for a each member are those contained inthe Group Health Care Contract
86100 cov 4023 issued to your employer.After you enroll in Prudential HealthCare HMO,you will receive a
certificate which describes the lull details of the Contract.
GENERAL INFORMATION ABOUT PRUDENTIAL HEALTHCARE HMO
If you haveany questions or concerns about Prudential HealthCare HMO benefits or policies while you area
member,we encourage youtocontactyour local Member Services Department at 1-800-457-3885.
Prudential HealthCare HMOisofferedby Prudential Health Care Plan,Inc.
Ed.1/1/95
Plan 4;Local
FL ME 0200
GI-602 Ed.5/94
ThePrudeniiai(Mj
City of South Miami
Prudential HealthCare POS
Benefit Summary
IN-NETWORK BENEFITS:
All servicesandsuppliesmust
be provided or authorized byyour
network Primary Care Physician.
OUT-OF-NETWORK BENEFITS:
Alleligible charges aresubject
toanannualdeductibleexcept
where noted otherwise.
Maximum eligiblechargesare
limitedto Usual &Prevailing
charges within thearea services
are rendered.
90/70 W/Rx Rider
SOUTH FLORIDA
5/96
Gi-602 Ed.5.94
r
ThePrudentiai \m»
PROVIDER SERVICES
Provider Office Visits
Physical.Speech,andOccupational Therapy1
Child Health Supervision Services (periodic check-up visits
at specified intervals frombirthtoage16)
Hospital Visits(including surgical procedures,assistant
surgeon,and anesthesia)
Maternity (including pre-natal,delivery,and post-natal care)
OutpatientPsychiatricCare
$2,500 maximum annual benefit
Outpatient Alcoholand Drug Dependency Care*
44 visit lifetime maximum
535 pervisit maximum benefit
HOSPITAL SERVICES (Inpatient)
Roomandboard(semi-private room),intensivecare,
pre-admission testing,allotherhospitalcharges
Newborn care
Institutes ofQuality
Psychiatric Care2,3
Alcohol and Drug Dependency Care4
HOSPITAL SERVICES (Outpatient)
Surgery (servicesandsupplies)
EmergencyRoom(see NOTE below)
IN-NETWORK'
BENEFITS
100%after S15 copayment per visit
(periodic physical examinations,pap
smears,immunizations,injections
diagnostic x-ray andlabcovered)
100%after 515 copayment per visit
100%after 515 copayment per visit
90%
90%after 515 copayment
for the first visit
100%first3 visits per calendar year
70%each visit thereafter
100%first3 visits per calendar year
90%each visit thereafter
90%
90%
100%
90%
90%
90%
100%after 550 copayment per visit
OUT-OF-NETWORK
BENEFITS
70%
(periodic physical exams,immunizations.
pap smears not covered)
70%
70%(no deductible)
70%
70%
50%
($80pervisit eligible chargelimit)
70%
SUBJECT TO PRUPASS
70%
70%(upto7daysforwellbabycare)
NotApplicable
70%
70%
70%(subjectto PruPASS)
70%
NOTECONCERNING EMERGENCY ROOM:In-network benefits are available forEmergencyRoom charges onlyfor medical emergencies;ifthe Emergency
Room is used for a condition thatisnota medical emergency,out-of-network benefits apply.A medical emergency is generally defined asa sickness or injury of such a
nature that failure togetimmediatemedicalcarecouldputa person's life in danger orcauseseriousharmtobodily functions.Some examples ofamedicalemergencyare:
apparent heart attack,severebleeding,suddenlossof consciousness,severeormultipleinjuries,convulsions,apparent poisoning.Some examples of conditions thatare not
considered medical emergencies are:colds,influenza,ordinary sprains,earinfections,nausea,headaches.
INFORMATION CONCERNING PRUPASS:The out-of-network benefitsincludePruPASS.Prudential's Patient AdvisorySupportService program.Wheneveryou
oroneof your dependents faces confinement ina hospital or needs non-emergency surgery,call PruPASS fora pre-admission andconcurrent hospitalization reviewora
second surgical opinion.Ifyoudonotuse PruPASS,eligible charges for hospitalization maybe reduced for days not pre-certified.and eligible charges for elective surgery
mayalsobe reduced.Seeyour Booklet/Certificate fordetails.
All benefits are subject to Coordination of Benefits.
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OTHER SERVICES
ConvalescentNursingHomeCare
Psychiatric Care Partial Hospitalization3'6
Alcohol and drug related care in an Intermediate Care FacilityA
Home Health Care
Durable Medical Equipment
HospiceCare
57,400 maximum benefitperperiod ofcare
Outpatient Private Duty Nursing
Ambulance
Chcmo/RadiationTherapy
DiagnosticX-rayandLab(otherthan office visit)
Annualdeductible per calendaryear
Stop Loss (100%Benefit Feature)
Individual Lifetime Maximum
PrescriptionDrug Benefit
Prescriptions by Mail -Copayment isuptoa 90-day supplyof
each prescription orrefill
IN»NETWOfrK
BENEFITS
OUT-OF-NETWORK
BENEFITS
90%upto 100 days per period of care 5 70%upto60 days per period of care5
90%70%
90%70%
90%70%upto60 visits per calendar year5
(550pervisiteligiblechargelimit)
90%70%
90%70%
90%
90%
70%
(510,000 annual eligible charge limit5)
70%
90%
90%
70%
70%
None 5300 per individual
5750perfamily
After anindividualhasincurred 510.000 of eligible chargesinacalendaryear(not including
payments,deductibles,andanychargesalready payable at 100%)theplanpays 100%of
remaining eligible charges in that year7
Unlimited
Planpays 100%aftercopaymentof
55forgenericor 510 non-generic.
Prescriptions mustbefilledat participating
Eckerdor Walgreens pharmacies in
Broward.Dade,or Palm Beach counties.
Plan pays100%after55 copayment for
Generic/510 brand name
51,000.000
Planpays70%afteraseparate550
annual deductible
Physical,speech,and occupational therapy has a 90-day maximum per condition per calendar year.
Annual benefits will not bemore than the equivalent ofthe full amount of the eligible charges for 35days inthehospital(s)in which the person is confined.
The combined annual benefits for Inpatient Hospital and Partial Hospitalization will not be more than the prevailing charge for 30 days of Inpatient Hospital
Stay.
4A1I Alcohol and Drug Dependency Care related charges,excluding charges for detoxification,are subject toacombined 52,000 lifetime benefit maximum.
This limit applies to all days orvisits used or charges incurred,whether benefits for those days or visits are provided in-network orout-of-network.
'Annual benefits will not be more than the prevailing charge for 30 days ofHospital Inpatient Slay.
Benefits for eligible charges for outpatient psychiatric care willnotincrease to 100%,butwill continue tobe paid atthe percentages shown in this Benefit
Summary.However,the eligible outpatient charges (in excess of the deductible)for which benefits are paid at 50%and 70%will count toward the Stop Loss.
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DEFINITIONS
COORDINATION OF BENEFITS
The total benefits payable under this plan for a covered person when combined with other group health insurance planbenefitswillnotexceed 100%of allowable expenses.
COPAYMENT
The amount which a patient is required topaytoa network provider at die timeof service.
DEDUCTIBLE
The amount ofthe covered charges whichyou and/or youreligible dependent(s)mustpaybeforebenefitsare paidbytheplan.
INTERMEDIATE CARE FACILITY (ICF)SERVICES
Thismeansonly continuous treatment atanICFofnotlessthanthreehoursandnotmorethantwelvehoursina 24-hour period.Itdoesnotincludea hospital inpatient
stay.
STOP LOSS (100%BENEFIT FEATURE)
A feature underwhichthe plan pays 100%of remaining eligible charges in a calendar yearafteran individual hasincurredaspecifiedamountof eligible charges (not
including copayments.deductibles,andany charges already payable at 100%).
NOTE:Eligible charges for outpatient psychiatric care will notbe paid at 100%but will continue tobe paid atthe percentage shown in the Benefit Summary.However,
these charges (in-networkand out-ot-network)will counttowardthespecifiedamountofeligiblecharges.
SERVICES NOT COVERED
The services andsupplies briefly described below are notcovered under the plan.Theseservices and supplies are:
•For any work-connected injury orforany sickness coveredby •Forcosmeticsurgery,exceptforcertainaccidental injuries.
Workers'Compensation orsimilarlaw;bothabnormalitiesor defects,orreconstructivesurgery;
•Furnished by governmental plans;•For impregnation andfertilization procedures,and surgery for sex
changesortoreverseaprevious surgery forvoluntarysterilization:
•Notmedicallynecessary or experimental or educational in nature;
•Abovethe provider's usual charge;•Forsicknessorinjuryresulting fromwaroranyactof war;
•Abovetheprevailingchargefortheserviceinthearea;Forcustodialcare;
•Furnished byacloserelative;•For any sickness orinjuryforwhich charges wereincurred,or services
receivedortreatmentgiven,formedicalcarewithin90daysofthe
•For blood that hasbeenreplaced;the date you become covered,ifyourplanhasa pre-existing condition
provision.However,this provision willnotapplytothe first 51,000
•For dental services,including those for Temporomandibular of benefits payable.Whenyouenroll,youwillbe informed whether
Joint Disorders (TMJD)or malocclusion.This does not apply this provision applies to your employer's plan.Innoevent will
to treatment of malignancies or accident-related injuries;this provision applyfor more than 12 months from the date you
become covered.
•For treatment of foot conditions except metabolic or peripheral
vascular diseaseoropencuttingoperations;
•For eyeor hearing examinations,the routine purchase
ofeyeglasses,orfor radial keratotomy;
This Benefit Summary provides abriefoutline ofthe services covered by Prudential HealthCare POS.RefertoyourPrudential HealthCare POS Handbook for
information regarding the administration ofthe plan.Whenyour coverage becomes effective,youwill receive a Group Insurance Booklet/Certificate describing your
coverage in greater detail.The complete termsofthe coverage will be governed bya group insurance contract form83500COV 1004 issued byThe Prudential Insurance
Company of America.
Prudential HealthCare POS isa service markofThe Prudential Insurance Company of America,registered inthe V.S.Patent and Trademark Office.
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