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09-28-99MAYOR: VICE MAYOR: COMMISSIONER: COMMISSIONER: COMMISSIONER: ........................... Julio Rob aina Armando Oliveros, Jr. Horace G. Feliu David D. Bethel Mary Scott Russell CITY MANAGER: CITY ATTORNEY: CITY CLERK: Charles D. Scurr Earl G. Gallop Ronetta Taylor SPECIAL CITY COMMISSION AGENDA City Commission Meeting Meeting date: September 28, 1999 6130 Sunset Drive, South Miami, FL Next Regular Meeting date: October 5, 1999 Phone: (305) 663 -6340 Time: 6:30 PM PURSUANT TO FLA STATUTES 286.0105, "THE CITY HEREBY ADVISES THE PUBLIC THAT IF A PERSON DECIDES TO APPEAL ANY DECISION MADE BY THIS BOARD, AGENCY OR COMMISSION WITH RESPECT TO ANY MATTER CONSIDERED AT ITS MEETING OR HEARING, HE OR SHE WILL NEED A RECORD OF THE PROCEEDINGS, AND THAT FOR SUCH PURPOSE, AFFECTED PERSON MAY NEED TO ENSURE THAT A VERBATIM RECORD OF THE PROCEEDINGS IS MADE WHICH RECORD INCLUDES THE TESTIMONY AND EVIDENCE UPON WHICH THE APPEAL IS TO BE BASED. THIS NOTICE DOES NOT CONSTITUTES CONSENT BY THE CITY FOR THE INTRODUCTION OR ADMISSION OR OTHERWISE INADMISSIBLE OR IRREVELANT EVIDENCE, NOR DOES IT AUTHORIZE CHALLENGES OR APPEALS NOT OTHERWISE ALLOWED BY LAW. City of South Miami. Ordinance No. 6 -86 -1251 requires all persons appearing in a paid or remunerated representative capacity before the City Staff, Boards, Committees and the City Commission, to fill out the appropriate form and file it with the City Clerk prior to engaging in lobbying activities. CALL TO ORDER: ITEMS (S) FOR THE COMMISSION'S CONSIDERATION: 1. A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, AUTHORIZING THE CITY MANAGER TO ENTER INTO A CONTRACT WITH TO PROVIDE GROUP HEALTH INSURANCE FOR CITY OF SOUTH MIAMI FULL - TIME EMPLOYEES. 2. Adjournment SPECIAL CITY COMMISSION AGENDA - September 28, 1999 1 { Y- CITY OF SOUTH MIAMI INTER - OFFICE MEMORANDUM To: Mayor and City Commission Date: September 28, 1999 From: Charles D. Scurr Re: AGENDA ITEM # City Manager City Commission Meeting of Sept. 28, 1999 Health Insurance. REQUEST The attached resolution seeks the City Commission's authorization to award the contract for health insurance for the City of South Miami to Blue Cross Blue Shield of Florida. BACKGROUND Last year, the City approved a contract renewal with Prudential Health Systems for group health insurance coverage for its full time employees. The City recently received notice that the Baptist Health Systems network of hospitals would no longer be in the Prudential system effective September 30, 1999. Baptist Health Systems includes South Miami Hospital and Baptist Hospital. Access to the Baptist Health Systems network of hospitals is an essential component of any City health insurance plan. These hospitals are the principal facilities in the South -Dade area. They are the primary hospitals used by our employees and are the principal hospitals where doctors used by City employees admit patients. This situation has made it necessary for the City to rebid the health insurance contract. Our Agent of Record solicited bids from six different companies. Of these companies, the three companies listed below responded. Blue Cross Blue Shield of Florida Cigna Health Plan Neighborhood Health Plan A Committee was established to review the proposals. The Committee consisted of the Agent of Record, personnel manager, and employee representatives from the PBA, AFSCME, and general employees. C The Committee completed a review of the proposals prior to the September 21" Commission meeting. However, it was decided that a more thorough review of the proposals, including presentations by each of the companies, was required. The Committee has completed it's deliberations and has unanimously recommended the selection of Blue Cross Blue Shield of Florida. The Committee considered many factors including network of physicians, scope of coverage and cost. Blue Cross Blue Shield was felt to have the best overall qualifications and benefits. The City pays 100 % of the cost of individual coverage for the employee. The employee pays 100% of the additional cost of family coverage. Two options are offered, a Health Maintenance Organization (HMO) option and a Point of Service (POS) option. The cost to the City of the Blue Cross Blue Shield proposal is lower than the renewal rates quoted previously by Prudential and included in the FY 1999 -2000 budget. These rates include: Individual (Paid by City) Family (Paid by Employee) Pru - HMO Pru -POS $ 189 $ 248 $ 263 $ 346 BCBS -HMO BCBS -POS $ 189 $ 203 $ 265 $ 426 The lower BCBS rates will yield a projected savings to the City of $35,000 in the FY 1999 -2000 budget. This is $15,000 lower than the earlier projected savings of $50,000. The difference will be realized through additional cost savings or use of contingency funds. RECOMMENDATION Approval is recommended. L [ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 RESOLUTION NO. A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, AUTHORIZING THE CITY MANAGER TO ENTER INTO A CONTRACT WITH BLUE CROSS BLUE SHIELD TO PROVIDE GROUP HEALTH INSURANCE FOR CITY OF SOUTH MIAMI FULL -TIME EMPLOYEES. WHEREAS, in order to ensure adequate health insurance for City employees and their families, the City has found it necessary to seek an insurance plan that will provide quality coverage including the use ; and WHEREAS, the City Agent of Record has solicited proposals from six (6) different companies on the group health insurance plan; and WHEREAS, three (3) companies submitted proposals; and WHEREAS, a review committee consisting of the Agent of Record, the Human Resources Director, representatives of the PBA, AFSCME and general employees carefully reviewed the proposals and unanimously recommended the selection of Blue Cross Blue Shield. NOW, THEREFORE, BE IT RESOLVED BY THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA: Section 1. The City Manager is hereby authorized to contract with Blue Cross Blue Shield of Florida for the city group health insurance; Section 2. The contract shall be effective October 15, 1999 and shall be renewable on an annual basis; Section 3. This resolution shall take effect immediately upon approval. S r 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 PASSED AND ADOPTED this day of 1999. ATTEST: CITY CLERK READ AND APPROVED AS TO FORM: CITY ATTORNEY APPROVED: MAYOR r r, RESOLUTION NO. A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, AUTHORIZING THE CITY MANAGER TO ENTER INTO A CONTRACT WITH BLUE CROSS BLUE SHIELD TO PROVIDE GROUP HEALTH INSURANCE FOR CITY OF SOUTH MIAMI FULL -TIME EMPLOYEES. WHEREAS, in order to ensure adequate health insurance for City employees and their families, the City has found it necessary to seek an insurance plan that will provide quality coverage including the use ; and WHEREAS, the City Agent of Record has solicited proposals from six (6) different companies on the group health insurance plan; and WHEREAS, three (3) companies submitted proposals; and WHEREAS, a review committee consisting of the Agent of Record, the Human Resources Director, representatives of the PBA, AFSCME and general employees carefully reviewed the proposals and unanimously recommended the selection of Blue Cross Blue Shield. NOW, THEREFORE, BE IT RESOLVED BY THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA: Section 1. The City Manager is hereby authorized to contract with Blue Cross Blue Shield of Florida for the city group health insurance; Section 2. The contract shall be effective October 15, 1999 and shall be renewable on an annual basis; Section 3. This resolution shall take effect immediately upon approval. PASSED AND ADOPTED this day of 1999. ATTEST: CITY CLERK READ AND APPROVED AS TO FORM: CITY ATTORNEY APPROVED: MAYOR SUMMARY OF BENEFITS BLUE CROSS AND BLUE SHIELD OF FLORIDA CARE MANAGER POINT -OF- SERVICE BENEFITS Lifetime Maximum Calendar Year Deductible Individual Aggregate Family BlueScript Prescription Drug Program (Including Oral Contraceptives) AUTHORIZED Services provided by or on referral of Insured's Care Manager No Maximum $0 $0 $7.00 Generic $20.00 Name Brand PLAN A 16 WITH BLUESCRIPT® NON - AUTHORIZED Services provided without authorization or referral from the Insured's Care Manager $1,000,000 $300 $900 $7.00 Generic $20.00 Name Brand The deductible does not apply to services with a copayment or where indicated. Coinsurance Requirement Limit Individual Aggregate Family Hospital Per Admission Deductible (PAD) Physician Office Services • Routine Services • Preventive Care • Well -Child Care • Allergy Injection (Without Office Visit) $0 $0 ER $5 Copay, 100% Allowed Amount $ 2,000 $6,000 $300 80% Allowed Amount $5 Copay, 100% Allowed Amount Not Covered $5 Copay, 100% Allowed Amount 80% Allowed Amount No Deductible $5 Copay, 100% Allowed Amount 80% Allowed Amount • Annual Gynecological Examination By An HOI OB /GYN Physician Up To $150 Per Calendar Year (Does Not Require Authorization By Care Manager) $5 Copay, 100% Allowed Amount Not Covered • Specialty Care $5 Copay, 100% Allowed Amount 80% Allowed Amount • Maternity Care First Office Visit $5 Copay, 100% Allowed Amount 80% Allowed Amount Total Maternity Care No Copay, 100% Allowed Amount 80% Allowed Amount A1600714 Rev. 3/99 BCBSF /CM (A1608) SUMMARY OF BENEFITS BLUE CROSS AND BLUE SHIELD OF FLORIDA PLAN Al 6 CARE MANAGER POINT -OF- SERVICE WITH BLUESCRIPTO BENEFITS AUTHORIZED NON - AUTHORIZED Hospital Services • Inpatient Care Manager No Copay, 100% Allowed Amount Not Applicable Facility PAD, then 100% Allowed. Amount PAD, Then 80% Allowed Amount All Other Providers No Copay, 100% Allowed Amount 80% Allowed Amount • Outpatient Hospital /Surgical Center Care Manager No Copay, 100% Allowed Amount Not Applicable Facility(Applies To Outpatient No Copay, 100% Allowed Amount 80% Allowed Amount Surgery Only) All Other Providers No Copay, 100% Allowed Amount 80% Allowed Amount • Non- Routine X -Rays (Inpatient Or Outpatient) No Copay, 100% Allowed Amount 80% Allowed Amount Other Health Care Services • Hospice Care Lifetime Maximum • Home Health Care Calendar Year Maximum • Skilled Nursing Facility 90 Day Calendar Year Maximum No Copay, 100% Allowed Amount No Limit No Copay, 100% Allowed Amount No Limit No Copay, 100% Allowed Amount 80% Allowed Amount $5,200 80% Allowed Amount $ 1,000 80% Allowed Amount • Outpatient Speech Therapy No Copay, 100% Allowed Amount Not Covered Calendar Year Maximum 20 Visits Not Covered • Outpatient Physical/ Occupational Therapy No Copay, 100% Allowed Amount 80% Allowed Amount 40 Visits Calendar Year Maximum • Outpatient Cardiac /Pulmonary Rehabilitation No Copay, 100% Allowed Amount 80% Allowed Amount $1,200 Calendar Year Maximum • Ambulance, DME Suppliers, No Copay, 100% Allowed Amount 80 % Allowed Amount And Prosthetic /Orthotic Suppliers A1600714 Rev. 3/99 BCBSF /CM (A1608) SUMMARY OF BENEFITS BLUE CROSS AND BLUE SHIELD OF FLORIDA PLAN A 16 CARE MANAGER POINT -OF- SERVICE WITH BLUESCRIPTO Other Services That Do Not Require Authorization From The Insured's Care Manager • Emergency Care Services Hospital Emergency Room* (Copay Waived If Admitted) HOI Providers $25 Copay, 100% Allowed Amount Location other than Emergency Room: Primary Care Physician $5 Copay, 100% Allowed Amount All Other Providers $5 Copay, 100% Allowed Amount • Routine X -Rays/ Routine & Non - Routine Lab (Performed In Location Other Than Physician's Office) • Alcohol And Drug Dependency Lifetime Maximum Inpatient One Episode Of Detox Outpatient 20 Visits • Mental & Nervous Disorder Per Calendar Year Inpatient 31 Days Outpatient 20 Visits No Copay, 100% Allowed Amount PAD, Then 100% Allowed Amount $30 Copay Per Visit, 100% Allowed Amount PAD, Then 100% Allowed Amount $30 Copay Per Visit, 100% Allowed Amount • Spine And Back Disorder $5 Copay, 100% Allowed Amount Treatment 26 Visits Calendar Year Maximum • Podiatric Office Services $5 Copay, 100% Allowed Amount Non -HOI Providers $25 Copay, 100% Allowed Amount Not Applicable $5 Copay, 100% Allowed Amount 80% Allowed Amount PAD, Then 80% Allowed Amount 80% Allowed Amount PAD, Then 80% Allowed Amount 80% Allowed Amount 80% Allowed Amount 80% Allowed Amount • Dermatology Office Services Five Visits For Medically Necessary Minor Surgery, Tests And Office Visits Per Insured Per Calendar Year $5 Copay, 100% Allowed Amount 80% Allowed Amount Follow -up treatment must be provided or arranged by the Insured's Care Manager in order to receive the higher Authorized Services benefit level of coverage. A1600714 Rev. 3/99 BCBSF /CM (A1608) Li SUMMARY OF BENEFITS BLUE CROSS AND BLUE SHIELD OF FLORIDA PLAN A 1 G CARE MANAGER POINT -OF- SERVICE WITH BLUESCRIPTO EXCLUSIONS • Services and supplies which are, in our opinion, experimental, investigational, or not medically necessary; • Private duty nursing services; • Dental care except as covered under the Physician Care and the Accident Dental Care Sub - Sections; • Cosmetic surgery (surgery performed solely to improve appearance of an individual); • Eye refractions, eye glasses and hearing aids or examinations for their prescription or fitting, except as specified in the Preventive Health Services Sub - Section; • Routine health examinations, except as covered under the Well -Child Care Sub - Section and the Preventive Health Services Sub - Section; • Rehabilitative services except as provided in the Cardiac Rehabilitation and Pulmonary Rehabilitation Sub - Sections; • Care obtained without cost; • Services rendered by an individual who is related by blood or marriage; • Treatment in a VA hospital or government facility (due to service - related disability); • Treatment of any condition arising out of a felony, riot, rebellion, or war; • Treatment of any condition or an intentionally self - inflicted condition, suicide, or attempted suicide; • Speech therapy, except as provided under Home Health Care Services and Therapeutic Services Sub- Sections; • Diagnostic admissions; • Occupational therapy, except as provided under Home Health Care Services and Therapeutic Services Sub - Sections; • Services or supplies related to sexual reassignment; • Travel expenses, even if prescribed by a physician (this exclusion does not apply to medically necessary transportation of a newborn child); • Custodial care; • Exercise programs of any kind; • Non - prescription drugs, vitamins, mineral supplements, or fluoride drugs; • Contraceptive medication, devices, appliances or other supplies when used for contraception, except oral contraceptives provided under the BlueScript Pharmacy Endorsement; • Work - related injuries; • Services associated with autopsy or postmortem examination; and • Services and supplies not specifically covered under the BCBSF Care Manager Point Of Service Plan. This is not a contract. The above Summary of Benefits is only a partial description of the many benefits and service covered by Blue Cross and Blue Shield of Florida, Inc. These benefits apply only to groups of 51 or more employees. For a complete description of benefits and exclusions, please see Blue Cross and Blue Shield of Florida's Care Manager Point of Service Contract #15482- 1096SR, Schedule of Benefits #15499- 1096SR and Pharmacy Endorsement #11929- 994SR; its terms prevail. Blue Cross and Blue Shield of Florida, Inc. is an Independent Licensee of the Blue Cross and Blue Shield Association. A1600714 Rev. 3/99 BCBSF /CM (A1608) i i ♦ Indep Btde s BlueCare For Large Groups — Plan 4 BENEFIT HIGHLIGHTS Care must be received from or arranged by your HOI Primary Care Physician BENEFITS COPAYMENT Physician Office Services • Primary Care Physician Office Services • Participating Specialist Office Services • One Annual Self- Referral to Participating GYN for Well -Woman Exam These Office Services May Include: - Pediatric and Well -Baby Care - Periodic Health Evaluation & Immunizations - Other Diagnostic Services - Health Education - Professional Counseling (Family Planning, Nutritional and Medical Social Services) - Vision and Hearing Screening - Family Planning Services - In -Office Surgery Additional Services (Office or Outpatient Facility) $10 Copay Per Visit $10 Copay Per Visit $10 Copay Per Visit • Allergy Testing No Copay • Allergy Injection, Including Serum $5 Copay • Outpatient Physical, Speech, Cardiac and Occupational Therapies $5 Copay Per Visit • Diagnostic lab and X -Ray No Copay Hospital Services (Inpatient Facility) • Room and Board These Inpatient Hospital Services May Include: - Anesthesia, Use of Operating and Recovery Rooms, Oxygen, Drugs and Medications - Intensive Care Unit and Other Special Units - Laboratory and X -Ray Services - Inpatient Physical, Speech, Cardiac and Occupational Therapies Hospital or Ambulatory Surgical Center (Outpatient Facility) • Outpatient Surgical Services May Include: Anesthesia, Use of Operating and Recovery Rooms, Oxygen, Drugs and Medication, Including: - Hospital or Surgical Center - Surgeon's Fees - Outpatient Laboratory, X -Ray and Other Tests No Copay No Copay ,r x BlueCros BlueSbield of Florida Health Uptionsi r Independent ueensees of the 3 r' BIUe.Cross and Blue Shield Ass -iatlon BlueCare For Large Groups — Plan 4 BENEFIT HIGHLIGHTS Emergency Services (Hospital) • Use of Emergency Rooms and Emergency Services $50 Copay Per Visit at Participating Hospitals • Use of Emergency Rooms and Emergency Services $50 Copay Per Visit Outside of Service Area Or At Non - Participating Hospitals BENEFITS COPAYMENT Maternity Services • Primary Care Physician Office Services $10 Copay • Participating Specialist Office Services - Initial OB Visit Only $10 Copay • Certified Nurse Midwife or Midwife No Copay • Inpatient Hospital Services No Copay • Birthing Center Services No Copay Behavioral Health Services Mental Health Care • Outpatient Visits - 20 Per Calendar Year $25 Copay Per Visit • Inpatient Facility - 30 Days Per Calendar Year No Copay • Partial Hospitalization (2 Partial Days for 1 Inpatient Day) No Copay Substance Dependency • Outpatient Visits - 20 Per Calendar Year $15 Copay Per Visit • Inpatient Hospitalization (Detoxification Only) No Copay Infertility Services • Primary Care Physician $10 Copay Per Visit • Participating Specialist $10 Copay Per Visit Special Services • Hospice Care No Copay • Skilled Nursing Facility - 90 Days Per Calendar Year No Copay • Home Health Care No Copay • Ambulance (Medically Necessary) No Copay • Durable Medical Equipment No Copay • Prosthetics and Orthotics No Copay BlueCare Rx: Pharmacy Program Retail Pharmacy • When Prescribed By A Participating Physician $7 Generic And Filled At A Participating Pharmacy $20 Brand (Includes Oral Contraceptives) Mail Order Pharmacy • For Your Convenience, A 90 -Day Supply of Maintenance $14 Generic Medication Is Available Through The Mail $40 Brand (Includes Oral Contraceptives) 2 � t n yw fflueCross B 6Sbhald of Florida i Health Options Independent Ucense65 of the Blue Cross and Blue Shield Asaogs6on r BlueCare For Large Groups — Plan 4 BENEFIT HIGHLIGHTS Maximum Out -of- Pocket Additional information related to access to Providers can be found in the Provider Directory. SELECT EXCLUSIONS AND LIMITATIONS $1,500 Per Member $3,000 Per Family The following is a partial listing of services that are excluded from coverage under this agreement, but only if, and to the extent that, such exclusion is permitted under law. For a complete listing please refer to the Master Policy • All services not specifically listed in the schedule of benefits or in any rider or endorsement, unless such services are specifically required by state or federal law • Elective cosmetic surgery • Hearing aids or eyeglasses, dental care, or oral appliances • Physical for insurance, licensing, school, or recreational purposes • Elective abortions • Workers compensation • Prescription drugs (unless included through BlueCare Rx) • Complementary and Alternative Healing Methods (CAM) The copayments are the responsibility of the Member and must be paid to the provider at the time service is rendered. Should it become necessary, a grievance procedure is available to all members, as detailed in the Master Policy. A pre - existing condition limitation applies for those who do not have previous creditable coverage at enrollment. Please refer to the Master Policy for details. All health care services must be provided or authorized by your Primary Care Physician. This Summary of Benefits is only a partial description of the many benefits and services covered by Health Options, the HMO subsidiary of Blue Cross and Blue Shield of Florida, Inc. These benefits apply only to groups of 51 or more employees. Health Options, Inc. and Blue Cross and Blue Shield of Florida, Inc. are Independent Licensees of the Blue Cross and Blue Shield Association. This does not constitute a contract. For a complete description of benefits and exclusions, please see Master Policy 86002 R0399 SR; its terms prevail. BlueCrom BlueSh eld' of Florida An Independent Licensee of the ' - Blue Cross and Blue Shield Assoc aeon CITY OF SOUTH MIAMI Rate Analysis DUAL OPTION SPLIT RATES: z, { HMO LG PLAN 4 RX $7/$20: Employee: $ 188.01 Employee & Family: $ 453.52 BCCM A16 RX $7/$20: Employee: $ 203.37 Employee & Family: $ 629.40 I s k ## #333333 F � C e This Proposal Expires: 11/30/99 — r See Accompanying Proposal Assumption Page All rates, benefits, and effective dates are subject to final rating of the actual _ enrollment, and subject to Home Office approval. A proposal for City of South Miami From: N eighborhoalHealth Partnership Agent Susan Redding PROPM DOC 0 1f d C9W (73 ..... .......:: .... : :.:.....: :: co. tam :..:.: CAP Health Care Services • Office visit - PCP $10 • Office visit - Specialist $10 • Routine pediatric exam $10 • Routine immunizations $10 • Gynecological exam (S examsperyear zithomt a rrferrao $10 • Maternity care $10 • Family Plug $10 • Infertility (i2,S001ifetime maximum) $10 • Sterilization (reversals not cornered) $0 • Allergy testing and treatment $10 • Chiropractic (12 vidapercalendaryear) $10 • Podiatry (no referral needed) $10 • Vision exam (to age 17 only)* $10 • 'Therapies 60 day limit - per calendar ear $0 Hospital Services • Inpatient per admission deductible $0 • Outpatient department $0 • Emergency Room co pay $50 Mental Heahb • Inpatient per admission (30 day limit -per cakndar year $0 • Outpatient 0 vidis per calendar year maximum $10 Substance Abuse • Inpatient per admission (Detax onfy) $0 • Outpatient 0 t&ts er calendar ear nr �mum $10 Supplemental Benefts • Skilled Nursing Facility (120 day limitper calendaryear) $0 • Home Health Care (60 day limitpercalendaryear) $0 • Hospice (180 day limit - lifetime) $0 • Prosthetic Devices $0 • Durable Medical Equipment and disposable medical supplies - (;2,500 $0 lifetime maedmum) • Miscellaneous services - X- ray /Lab, diagnostic, outpatient surgical, $0'c' ambulance Presce ption Drugs (indudes oral contracepaw) Generic On $10 * Neighborhood Health Partnership HMO is proud to offer its members the benefit of reduced prices on contact lenses, eyeglasses, eye exams and more at Visionworks ®. See the enclosed brochure for details. City of South Miami HMO Summary � t (73 e ff� e4, City of South Miami POS Summary Hospital Services • Inpatient per admission copay or deductible $0 $250 deductible per • Outpatient department $0 • Eme ncy Room co pay or deductible $50 calendar year individual, Health Care Services • Office visit - PCP $10 $500 family *, • Office visit - Specialist (referral required in- network) $10 • Routine immunizations $10 the plan pays • Maternity care $10 • Family planning $10 70% of Reasonable and • Infertility ( ;2,500 lifetime maximum) $10 Customary to a • Sterilization (hwnair not cot md) $0 $3,000 individual, • Allergy testing and treatment $10 $6,000 family • Chiropractic (12 vidaper calendaryear) $10 out of pocket maximum, • Podiatry $10 • The ies 60 day limit -per calendar ear $0 then the plan pays Supplemental benefits • Hospice (180 day limit - lifetime) $0 100% to a lifetime • Prosthetic devices, durable medical equipment $0 maximum of $1,000,000 (;2,S001ifed= maximum) per covered person • X-ray/Lab, di ostic, outpatient surgical, ambulance $0 Mental Health • Inpatient $0 per admission to a 30 day limit - per calendar year. In Network Only • Outpatient 20 visits per calendar ear maximum. Substance Abuse • Inpatient $0 per admission Detox only • Outpatient $10 to a $2,000 calendar In Network Only year maximum. Miscellaneous Services • Prescription DrtW (tndudes oral contraceput+er) $10 (generic only) • Gynecological exam (S examfier cahndaryear tv /out $10 rrfefr4 In Network Only • Vision exam (to age 17 onii ) $10 • Routine pediatric exam $10 • Home Health Care $0 co -pay 60 days per 60 Visits per calendar year calendar year maximum • Skilled Nursing Facility $0 co -pay 60 days per Subject to deductible and coinsurance — 20 days per calendar ear calendar ear maximum. * Deductible waived for child health su rvision services City of South Miami POS Summary _ .. ... .. j ;, ... ��y ♦ 0 'j@ �1 ...: . .. <.^^ .: is .. .::: %:::..: i.:::. f ♦M Sine $1: 59_!.;77 Faml mm� $423.38 ..................... . Sin a $194.92 Family $516.53 Final rates will be determined based on the actual census and the medical underwriting of the group, upon formal request for coverage. hmoppo.doc r.,._... , :._. �., .����. , . �� , -. Benefit Summaries CHMO Benefit Proposal for Page 16 CIGNA HealthCare Primary Care Physician Services ➢ Preventive Care $10 Copay ➢ Adult Medical Care $10 Copay ➢ Adult Physical Exams $10 Copay ➢ Well Child Care $10 Copay ➢ Routine Immunizations & Injections $10 Copay ➢ Vision & Hearing Screening (for members through age 17) $10 Copay ➢ Lab and X -rav No Charge Specialty Physician Services ➢ Office Visits $ 10 Copay ➢ Referral Physician Services $10 Copay ➢ Allergy Testing and Treatment $10 Copay ➢ Lab and X-ray No Charge Pre & Postnatal Exams No Charge Inpatient Hospital Services ➢ Semi - Private Room and Board No Charge ➢ Physician and Surgeon Charges ➢ Newborn Delivery Charges ➢ Diagnostic and Therapeutic Lab and X -ray Services ➢ Drugs and Medications ➢ Operating and Recovery Room ➢ Hemodialvsis Outpatient Hospital Services ➢ Operating and Recovery Room No Charge ➢ Physician Services ➢ Laboratory and X -ray ➢ Hemodialysis ➢ Radiation and Chemotheravv Emergency Care ➢ Participating or Non - Participating Physician's Office $10 Copay ➢ Hospital Emergency Room, Oupatient Facility or other Urgent Care $50 Copay, Facility waived if admitted ➢ Ambulance No Charge Other Health Care Facilities (Skilled Nursing and Rehabilitation) ➢ Maximum of 60 days per contract year No Charge Home Health Care No Charge Outpatient Short Term Rehabilitation ➢ Maximum of 60 consecutive days per condition $10 Copay TS A(M.1MIUM W1171 CHMO Benefit Proposal for Page 17 Family Planning ➢ Tests, counseling $10 Copay ➢ Surgical sterilization procedures Inpatient Facility Charge No Charge Outpatient Facility Charge No Charge Surgery in Physician's Office No Charge Infertility ➢ Office visit $20 Copay Treatment/surgery Treatment/surgery 50% coins. Mental Health ➢ Inpatient Copay $50 /day ➢ Inpatient Days 30 MH &SA ➢ Outpatient Individual Copay $20 Copay ➢ Outpatient Group Copay $10 Copay ➢ Outpatient Individual Visits 30 Visits Substance Abuse ➢ Inpatient Copay $50 /day ➢ Inpatient Days 30 MH &SA ➢ Outpatient Individual Copay $20 Copay ➢ Outpatient Group Copay $10 Copay ➢ Outpatient Visits 30 Visits Out-of-Pocket Limits $1,500/$3,000 Deductible None Pre-Existing Condition Limitations None Li etime Maximum Unlimited 111CJC VC11C11.a 1CF1CJC111 "" J1411UG1U VC11C111J. 111C1C 1114 �' VC 111VU111C411V11J 1VL JV111C JIG ICJ UUC lV 111u11uulCu benefis that are not reflected in this benefit plan design. CHMO Benefit Proposal for Page 18 . _.. :,, ,, __ -�,: �,c.,. �h,:. � `... ... ' ^,:F t .., .. '"°re�,:v "';`;;WS'ti45•"�?�v`= f'aY,:, Primary Care Physician Services ➢ Preventive Care ➢ Adult Medical Care ➢ Adult Physical Exams ➢ Well Child Care ➢ Routine Immunizations & Injections ➢ Vision & Hearing Screening (for members through age 17) ➢ Lab and X -rav Specialty Physician Services ➢ Office Visits ➢ Referral Physician Services ➢ Allergy Testing and Treatment ➢ Lab and X -ray Pre &r Postnatal Exams Inpatient Hospital Services ➢ Semi - Private Room and Board ➢ Physician and Surgeon Charges ➢ Newborn Delivery Charges ➢ Diagnostic and Therapeutic Lab and X -ray Services ➢ Drugs and Medications ➢ Operating and Recovery Room ➢ Hemodialvcic Outpatient Hospital Services ➢ Operating and Recovery Room ➢ Physician Services ➢ Laboratory and X -ray ➢ Hemodialysis ➢ Radiation and Chemotherapv Emergency Care ➢ Participating or Non - Participating Physician's Office ➢ Hospital Emergency Room, Oupatient Facility or other Urgent Care Facility ➢ Ambulance Other Health Care Facilities (Skilled Nursing and Rehabilitation) ➢ Maximum of 60 days per contract year Home Health Care Outpatient Short Term Rehabilitation ➢ Maximum of 60 consecutive days per condition $10 Copay $10 Copay $10 Copay $10 Copay $10 Copay $10 Copay No Charge $10 Copay $10 Copay $10 Copay No Charge No Charge $250 Copay per admission' $ 75 Copay No Charge No Charge No Charge No Charge $10 Copay $50 Copay, waived if admitted No Charge $250 Copay per admission No Charge 10 CHMO Benefit Proposal for Page 19 Family Planning Tests, counseling $10 Copay ➢ Surgical sterilization procedures Inpatient Facility Charge $250 /admission Outpatient Facility Charge $75 Copay Surgery in Physician's Office No Charge Infertility ➢ Office visit $20 Copay ➢ Treatment/surgery Treatment/surgery 50% coins. Mental Health ➢ Inpatient Copay $50 /day ➢ Inpatient Days 30 MH &SA ➢ Outpatient Individual Copay $20 Copay ➢ Outpatient Group Copay $10 Copay ➢ Outpatient Individual Visits 30 Visits Substance Abuse ➢ Inpatient Copay $50 /day ➢ Inpatient Days 15 MH &SA ➢ Outpatient Individual Copay $20 Copay ➢ Outpatient Group Copay $10 Copay ➢ Outpatient Visits 30 Visits Out-of-Pocket Limits $2,000/$4,000 Deductible None Pre-Existing Condition Limitations None Li etime Maximum Unlimited 'Inpatient copay will be waived it a member is readmitted for the same condition within thirty (30) days of the initial confinement. This waiver applies to the admission to a Skilled Nursing Facility if it occurs within thirty (30) days of the hospital admission for the same condition. These benefits represent the "standard" benefits. There may be modifications for some states due to mandated benefis that are not reflected in this benefit plan design. CHMO Benefit Proposal for Page 20 -•— -.� _.' ..T . I �. - -._ .— .,_— ^� -,.uf ..�, .. ., -.:.,, ...._: ,,:. ���, - sue, �9��Jr .Y:�S.�'ia`��5. � ��mi'�ifF`�R, Ib CHMO Benef t Proposal for Page 21 r. .,r , r . --„ " __ ,. ,a . -....x 'W `1$9 . �—..�', GI NA Ma IIJ i Ben Cz a fSOUth ZLL%%t IGNA HeaXth Access PAS Plan fn Network t. Primary Care Physician Services: ➢ Adult & Child Medical Care /Allergy Treatment $10 Copay 70 %/30% Coinsurance ➢ Preventive Care ➢ Adult Physical Exams $10 Copay Not Covered ➢ Well Child Care $10 Copay $10 Copay Not Covered Not Covered ➢ Routine Immunizations & Injections $10 Copay Not Covered Vision & Hearing Screening (for $10 Copay Not Covered members age 17 and under) ➢ Lab and X-ray Specialty Physician Services: No Charge 70%/30% Coinsurance ➢ Office Visits ➢ Referral Physician Services $10 Copay $10 Copay 70 %/30% Coinsurance 70 %/30% ➢ Allergy Testing and Treatment $10 Copay Coinsurance 70%/30% Coinsurance ➢ Well Woman Visit (1 /year) ➢ $10 Copay Not Covered Lab and X-ray No Charge 70 %/30% Coinsurance Pre & Postnatal Exams No Charge 70 %/30 %Coinsurance Inpatient Hospital Services: ➢ Semi - Private Room and Board ➢ Physician and Surgeon Charges No Charge $250 Copay per ➢ Newborn Deliver Charges g No Charge g No Charge admission 70 %/30% Coinsurance ➢ Diagnostic and Therapeutic Lab and X- No Charge Precertication applies ray Services ➢ Drugs and Medications No Charge ➢ Operating and Recovery Room No Charge ➢ Hemodial sis No Charge Outpatient Hospital Services: ➢ Operating and Recovery Room ➢ Physician Services No Charge 70%/30% Coinsurance Laboratory and X -ray No Charge No Charge Precertification applies ➢ Hemodialysis No Charge ➢ Radiation and Chemotherapy No Charge Emergency Care: ➢ Participating Physician's or Non- Participating Physician's Office $10 a Co Copay Emergency care meeting ➢ Hospital Emergency Room, Outpatient Facility, or other Urgent Care Facility $50 Copay, waived if emergency definition s de n tionsis ➢ Ambulance admitted paid at in- network levels No Charge regardless of the rovider Ib CHMO Benef t Proposal for Page 21 r. .,r , r . --„ " __ ,. ,a . -....x 'W `1$9 . �—..�', CrGN A HeWthCare Bet'Ce ummacr}� E� 3 Ci o f ,youth �Vliam� CINAtHeaith AcGessPOS flan h; Gene is ' In Network . Ozct :Q ; . Network . Other Health Care Facilities (Skilled Nursing and Rehabilitation): $250 Copay per ➢ Maximum of 60 days per contract year No Charge admission 70 %/30% Coinsurance ** Precertification applies 70 %/30% Coinsurance Home Health Care No Charge limited to 40 visits per contract. ear ** $10 Copay 70 %/30% Coinsurance Outpatient Short Term — Maximum of 60 — Maximum of 60 Rehabilitation consecutive days per consecutive days per condition contract ear ** Family Planning: ➢ Tests, counseling $10 Copay $250 Copay per ➢ Surgical sterilization procedures admission (vasectomy, tubal ligation): 70 %/30% Coinsurance • Inpatient Facility Charge No Charge Precertification applies • Outpatient Facility Charge No Charge • Surgery in Physician's Office No Charge Infertility. ➢ Office visit $20 Copay Covered in- network ➢ Treatment /surgery 50 %/50% Coinsurance only ➢ Exclusions (where allowed by state): • Invitro fertilization • Infertility drugs (oral, injectable, suppository) • Costs connected with collection, preparation, storage of sperm, for artificial insemination, including donor fees DME Outpatient No Charge g 70 %/30% Coinsurance $ 700 per contract ear ** External Prosthetics $200 Deductible 70 %/30% Coinsurance $1,000 per contract $1,000 Maximum ear ** ro CHMO Benefit Proposal for Page 22 I 4C ] NOTE: All out -of- network services are subject to the contract year deductible and reasonable and customary charge limitations. The out -of- network inpatient per admission deductible (if any) does not apply to the out - of- network deductible or OOP. All out -of- network hospital admissions, outpatient surgeries and Mills must be precertified. Hospital admissions are subject to Continued Stay Review (CSR). Penalty for non - compliance with precertification or CSR is 50 %. Non - certified admissions /days result in the denial of benefits. The 50% penalty or cost of denied benefits does not apply to deductible or OOP. The following services are covered in- network only: Organ Transplant, TMJ, Injectable Drugs, Chiropractic Services. These benefits represent the "standard" benefits. There may be modifications for some states due to mandated benefits that are not reflected in this benefit plan design. CHMO Bene f t Proposal for Page 23 CIGNA Healthcare: Bp in Summary 3 C pry osouthi arnz 'CIGNA- Heafith'Access =Pf)S Play Bene is In Nerivork - taut Q ;Network, Mental Health: ➢ Inpatient Copay MH /SA Rider A $250 Copay per admission ➢ Inpatient Days 70 %/30% Coinsurance 30 combined with SA ** ➢ Outpatient Individual Copay Precertification applies ➢ Outpatient Group Copay 50 % /50% Coinsurance ➢ Outpatient Individual Visits 50 1/6/50% Coinsurance 20 Visits combined Substance Abuse: w /SA ** ➢ Inpatient Copay MH /SA Rider A $250 Copay per admission ➢ Inpatient Days 70%/30% Coinsurance 30 combined with MH ** ➢ Outpatient Individual Copay Precertification applies ➢ Outpatient Group Copay 50 0/o/50% Coinsurance ➢ Outpatient Individual Visits 50%/50% Coinsurance 20 Visits combined Prescription Drugs Selected Drug Rider w /MH ** 70 %/30% Out-Of-Pocket Limits $1,500/$3,000 Coinsurance * ** Deductible $3,000/$6,000 N/A Li etime Maximum $300/$600 ** Unlimited In- network visits /days reduce this $1,000,000 maximum. * *' Must be prescribed by a physician for illness or injury. NOTE: All out -of- network services are subject to the contract year deductible and reasonable and customary charge limitations. The out -of- network inpatient per admission deductible (if any) does not apply to the out - of- network deductible or OOP. All out -of- network hospital admissions, outpatient surgeries and Mills must be precertified. Hospital admissions are subject to Continued Stay Review (CSR). Penalty for non - compliance with precertification or CSR is 50 %. Non - certified admissions /days result in the denial of benefits. The 50% penalty or cost of denied benefits does not apply to deductible or OOP. The following services are covered in- network only: Organ Transplant, TMJ, Injectable Drugs, Chiropractic Services. These benefits represent the "standard" benefits. There may be modifications for some states due to mandated benefits that are not reflected in this benefit plan design. CHMO Bene f t Proposal for Page 23 Iq CHMO Benefit Proposal for Page 24 CINAealth+arE Bcr�te fi�t_Summaly o �rout� Miami . d d k Heath Access POS PYan >�ion HPrimary Bene fs " In Network :Qua oNetwar�C Care Physician Services: ➢ Adult & Child Medical Care /Allergy $10 Copay 70 %/30% Coinsurance Treatment ➢ Preventive Care $10 Copay Not Covered ➢ Adult Physical Exams $10 Copay Not Covered ➢ Well Child Care $10 Copay Not Covered ➢ Routine Immunizations & Injections $10 Copay Not Covered ➢ Vision & Hearing Screening (for $10 Copay Not Covered members age 17 and under) ➢ Lab and X-ray No Charge 70%/30% Coinsurance Specialty Physician Services: ➢ Office Visits $10 Copay 70%/30% Coinsurance ➢ Referral Physician Services $10 Copay 70%/30% Coinsurance ➢ Allergy Testing and Treatment $10 Copay 70%/30% Coinsurance ➢ Well Woman Visit (1 /year) $10 Copay Not Covered ➢ Lab and X-ray No Charge 70 %/30% Coinsurance Pre &r Postnatal Exams No Charge 70%/30% Coinsurance Inpatient Hospital Services: ➢ Semi - Private Room and Board $250 Copay per 70%/30% Coinsurance ➢ Physician and Surgeon Charges admission $250 Copay per ➢ Newborn Deliver Charges admission ➢ Diagnostic and Therapeutic Lab and X- Precertication applies ray Services ➢ Drugs and Medications ➢ Operating and Recovery Room ➢ Hemodial sis Outpatient Hospital Services: ➢ Operating and Recovery Room $75 Copay 70 %/30% Coinsurance ➢ Physician Services No Charge Precertification applies ➢ Laboratory and X -ray No Charge ➢ Hemodialysis No Charge ➢ Radiation and Chemotherapy No Charge Emergency Care: ➢ Participating Physician's or Non- $10 Copay Emergency care meeting Participating Physician's Office CIGNA HealthCare's ➢ Hospital Emergency Room, Outpatient $50 Copay, waived if emergency definition is Facility, or other Urgent Care Facility admitted paid at in- network levels ➢ Ambulance No Charge regardless of the provider CHMO Benefit Proposal for Page 24 "t ', a $ w CINA SedIthGare Bene 'Summary ..... . Cif o South Mxdm �r ; u, LISA Healt'A ess �'()S I'layt (; tiOt #2.: r Benej�its - lac Network d but o f network; Other Health Care Facilities (Skilled Nursing and Rehabilitation): 70 %/30% Coinsurance ** ➢ Maximum of 60 days per contract year $250 Copay per $250 Copay per admission admission Precertification applies 70%/30% Coinsurance Home Health Care No Charge limited to 40 visits per contract ear ** $10 Copay 70%/30% Coinsurance Outpatient Short Term — Maximum of 60 — Maximum of 60 Rehabilitation consecutive days per consecutive days per condition contract ear ** Family Planning: ➢ Tests, counseling $10 Copay 70 %/30% Coinsurance ➢ Surgical sterilization procedures $250 Copay per (vasectomy, tubal ligation): admission • Inpatient Facility Charge $250 Copay per Precertification applies admission • Outpatient Facility Charge $ 75 Copay • Surgery in Physician's Office No Charge Infertility. ➢ Office visit $20 Copay Covered in- network ➢ Treatment /surgery 50 %/50% Coinsurance only ➢ Exclusions (where allowed by state): • Invitro fertilization • Infertility drugs (oral, injectable, suppository) • Costs connected with collection, preparation, storage of sperm, for artificial insemination, including donor fees DME Outpatient No Charge g 70 %/30% Coinsurance $ 700 per contract ear ** External Prosthetics $200 Deductible 70 %/30% Coinsurance $1,000 per contract $1,000 Maximum ear ** " �� k1l: M. MM CHMO Benefit Proposal for Page 25 r .— . a. 1 a Mental Health: ➢ Inpatient Copay ➢ Inpatient Days ➢ Outpatient Individual Copay ➢ Outpatient Group Copay ➢ Outpatient Individual Visits MH /SA Rider A $250 Copay per admission 70 %/30% Coinsurance 30 combined with SA ** Precertification applies 50 %/50% Coinsurance 50 %/50% Coinsurance 20 Visits combined —is A ** Substance Abuse: ➢ Inpatient Copay MH /SA Rider A $250 Copay per admission 70 %/30% Coinsurance ➢ ' Inpatient Days 30 combined with MH ** Precertification applies ➢ Outpatient Individual Copay 50 %/50% Coinsurance ➢ Outpatient Group Copay 50 %/50% Coinsurance ➢ Outpatient Individual Visits 20 Visits combined w /MH ** Prescription Drugs Selected Drug Rider 70 %/30% Coinsurance * ** Out-of-Po ket Limits $1,500/$3,000 $1,500/$3,000 Deductible N/A $300/$600 Lifetime Maximum Unlimited $1,000,000 ** In- network visits /days reduce this maximum. * ** Must be prescribed by a physician for illness or injury NOTE: All out -of- network services are subject to the contract year deductible and reasonable and customary charge limitations. The out -of- network inpatient per admission deductible (if any) does not apply to the out - of- network deductible or OOP. All out -of- network hospital admissions, outpatient surgeries and MRIs must be precertified. Hospital admissions are subject to Continued Stay Review (CSR). Penalty for non - compliance with precertification or CSR is 50 %. Non - certified admissions /days result in the denial of benefits. The 50% penalty or cost of denied benefits does not apply to deductible or OOP. The following services are covered in- network only: Organ Transplant, TMJ, Injectable Drugs, Chiropractic Services. These benefits represent the "standard" benefits. There may be modifications for some states due to mandated benefits that are not reflected in this benefit plan design. CHMO Benefit Proposal for Page 26 ! 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