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HomeMy WebLinkAbout2016 Humana Insurance Vision PlanAdministrative Office: 1100 Employers Boulevard Green Bay, Wisconsin 54344 Group Vision Insurance Policy Humana Insurance Company Group Policy Number: 771470 Issued To: CITY OF SEBASTIAN Effective Date: 10/01/2016 Terns printed in italic type in this policy have the meaning as indicated in the "Definitions" section of the certificate. Defined terms are printed in italic type whenever found in this policy. This policy is delivered in and governed by the laws of: Florida. 0 0 Humana Insurance Company agrees, subject to all terms and provisions of this policy, to pay benefits as described in the Certificate of Insurance, incorporated by reference herein with respect to each covered person under this policy. Humana Insurance Company and the policyholder have agreed to all of the terms of this policy. This policy is issued in consideration of the policyholder's application, incorporated by reference herein, and such policyholder's payment of premiums as provided under this policy. This policy and the insurance it provides become effective at 12:01 A.M. (Standard Time) of the effective date stated above. This policy and the insurance it provides terminates at 12:00 A.M. (Standard Time) of the date of termination. The provisions stated above and on the following pages are part of this policy. IN WITNESS WHEREOF Humana Insurance Company has caused this policy to be issued at the address of the policyholder, as of the policy effective date. Bruce Broussard President This is not a policy of Workers' Compensation insurance. The employer does not become a subscriber to the Workers' Compensation system by purchasing this policy, and if the employer is a non -subscriber, the employer will not be provided those benefits which would otherwise accrue under the Workers' Compensation laws. The employer must comply with the Workers' Compensation law as it pertains to non -subscribers and the required notifications that must be Fled and posted. This is not a policy of Long Term Care insurance. FL -70148-01 LG 9/15 ] Subsidiaries or Affiliates Any employer which is a subsidiary or affiliate of the policyholder is eligible under the policyholder's group vision plan provided under the policy if the following conditions are met: • The subsidiary or affiliate is listed in the Employer Group Application of the policyholder, or in any amendment thereto. • The policyholder and the subsidiary or affiliate are members of the same controlled group of corporations or trades or business under common control, as described for employee benefits taxation purposes in the Internal Revenue Code; and • The subsidiary or affiliate has been approved for coverage under this policy, in writing or by electronic mail, by both the policyholder and us. For the purposes of this policy, an employee of such a subsidiary or affiliate of the policyholder shall be considered to be an employee of the policyholder. A subsidiary or affiliate of the policyholder shall cease to be eligible in the policyholder's group vision plan provided under this policy on the earliest of the following: • The date the policyholder and the subsidiary or affiliate are no longer members of the same controlled group of corporations or trades or business under common control, as described for employee benefits taxation purposes in the Internal Revenue Code; • The date the policyholder's written notice of its intent to terminate the participation of the subsidiary or affiliate is received by us, or on any later date as may be stated in such notice; or • The date the policy terminates. The insurance of any employee of a subsidiary or affiliate of the policyholder, and the insurance of such employee's covered dependents, shall immediately terminate on the date the subsidiary or affiliate ceases participation in the policyholder's group vision plan. FL -70148-01 LG 9/15 Requirements for Insurance Coverage Eligibility Apolicyholder must indicate on the Employer Group Application the eligible classes of employees under this policy, if applicable, as defined below: An eligible class includes regular full-time employees in active status, if paid a salary or wage by the employer that meets State or Federal minimum wage requirements. The eligible class may also include sole proprietors, partners, corporate officers if: • The employer is a sole proprietorship, partnership or corporation; and • The sole proprietor, partner or corporate officer is actively performing activities relating to the business, gains a livelihood from the sole proprietorship, partnership or corporation and meets the definition of employee as defined in the Certificate of Insurance. • The policyholder's group insurance plan may also provide coverage for retired employees and their dependents. The Retiree Class will be eligible only if the policyholder requests such coverage, and it is approved by us. No part-time or temporarily employed person may be included in an eligible class, unless the policyholder's Employer Group Application makes specific reference that part-time or temporarily employed persons are included and is approved by us. N 0 • Part-time employees and their dependents may be an eligible class only if the policyholder makes 0 specific reference that part-time employees be included, and it is approved by us. 0 • The spouse or child of an employee may be included in an eligible class as a dependent of the employee only if the employee is covered under this policy. Date eligible Each policyholder's group insurance plan may provide one of the following as the eligibility date for employees, or employees and dependents as provided by this policy. The eligibility date must be elected by the policyholder in the Employer's Group Application. Eligibility date options include immediate or first of the month as outlined below. Immediate eligibility Each employee included in an eligible class on, or after, the date the employer becomes a policyholder will be eligible under this policy on that date, provided the employee has completed the required waiting period, if any, indicated on the Employer Group Application. First of the month eligibility C Each employee included in an eligible class after the date the employer becomes a policyholder will be eligible under this policy on the first day of the next following calendar month, or the first day of the next following calendar month after the completion of the waiting period, if any, or as otherwise agreed to by the policyholder and us. Note: Any employee who voluntarily terminates his or her insurance must satisfy a new waiting period in order to become insured again under the policyholder's plan. However, if a person's insurance terminated because he or she was no longer considered to be in an eligible class, that person is not required to satisfy a new waiting period if he or she again becomes a member of an eligible class within one year from the date his or her insurance terminated. C FL -70148-01 LG 9115 3 Participation Requirements The policyholder is required to maintain our minimum underwriting, participation and contribution requirements, as specified on the Employer Group Application. We reserve the right to waive or modify the underwriting, participation and contribution requirements. Any such waiver shall not be construed as a waiver of any of the other requirements of this policy and shall not obligate us to provide any future waivers including any for underwriting, participation or contribution requirements. FL -70148-01 LG 9/15 Renewal and Termination Privilege Right to not renew or terminate this policy The policyholder may terminate this policy by giving written or electronic notice to its no later than 45 days prior to the desired termination date. The policyholder may terminate the insurance provided under any provision of this policy, with our consent, by giving written or electronic notice to us as of a date mutually agreeable to the policyholder and us. The policyholder may terminate an eligible class of covered persons, if applicable, from the policyholder's group insurance plan, with our consent, as of a date mutually agreeable to the policyholder and us. Termination will occur only with respect to covered persons included in the terminated class. We may terminate this policy, as allowed by applicable law, by giving written notice to the policyholder. Written notice will be mailed no later than 45 days prior to the termination date, except as otherwise outlined under this provision. We may refuse to renew or we may terminate the policy as follows o • The policyholder fails to remit premium when due, except that coverage continues during the grace period applicable to the due but unpaid premium. The policyholder is responsible for premium during the grace period. If payment is not remitted by the end of the grace period, the policy will terminate at 12:00 a.m. on the day the grace period ends. • The policyholder has failed to comply with our minimum underwriting, participation and/or contribution requirements, as specified on the Employer Group Application. • The policyholder has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact. We may terminate the policy immediately, by giving written or electronic notice to the policyholder for instances of fraud or intentional misrepresentation of a material fact. • If we decide to discontinue offering a particular group vision policy: • The policyholder and the employees will be notified of such discontinuation at least 90 days prior to the date of discontinuation of such coverage; and • The policyholder will be given the option to purchase any other group policy providing vision benefits that are being offered by us at such time. • We cease to do business in the group vision insurance market, as applicable and as allowed by the state requirements. If we cease doing business in the group vision market, the policyholder and the employees covered by such policies will be notified of such discontinuation at least 180 days prior to the date of discontinuation of such coverage. FL -70148-01 LG 9/15 Renewal and Termination Privilege Effect of termination of this agreement Upon termination of this policy, it is the policyholder's obligation to notify all employees insured under this policy of such termination, except for the specific situations outlined in the "Right to Not Renew or Terminate This Policy" provision. If the policyholder requires a contribution from the employees to offset a portion of the premiums, it is the responsibility of the policyholder to refund to those employees the portion of the contribution, if any, which the policyholder may have collected for any period of time following the termination of this policy. Our obligation to offer continuation coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) to covered persons ends on the date the policy terminates. Our obligation to offer continuation coverage to covered persons under any other applicable law ends on the date this policy terminates or on such date as may be required under the applicable continuation of coverage law. It shall be the responsibility of the policyholder to secure continuation of coverage for covered persons whose continuation rights run beyond the termination of this policy. Termination of insurance Unless otherwise agreed to by the policyholder and us, termination of insurance will occur following any of the events listed below: • The date this policy terminates in accordance with its terms and conditions; • The termination date according to the "Right to not renew or terminate this policy" provision; • The date the policyholder, acting with our knowledge and consent, deletes an optional benefit under this policy; termination under this paragraph will occur only with respect to such deleted optional benefit coverage; • The date the policyholder, acting with our knowledge and consent, deletes an eligible class of employees, if applicable, from the policyholder's group insurance plan; termination under this paragraph will occur only with respect to covered persons included in the terminated class; or • The date the policyholder, acting with our knowledge and written consent, terminates any provision of this policy; termination under this paragraph will occur on a date mutually agreeable to the policyholder and us. Retroactive terminations are not permitted under this policy. The policyholder will be required to pay premium through the actual date we are notified of the termination of a covered person or this policy. Reinstatement If the policy terminates, it may be reinstated at our option. Reinstatement requests must be submitted in writing or electronically by the policyholder, are subject to our approval and are not guaranteed. Any premium accepted in connection with a reinstatement will be applied to the period for which the premium was not previously paid. A policyholder that requests reinstatement will be assessed a Reinstatement Fee. FL -70148-01 LG 9/15 E Premiums Payment of premiums Unless otherwise agreed to by us, the fust premium is due on the policyholder's effective date under this policy and subsequent premiums are due the first of each calendar month thereafter. The required premium due on each premium due date is the sum of the premium for all employees in the policyholder's group health plan. The premiums due will be determined by applying the premium rates then in effect for each type of insurance provided by this policy to the amount of insurance in force. Premium rate change Premium rates for this policy will be calculated as specified in the "Payment of Premiums" provision. We reserve the right to change any premium rate, including on retrospective basis when: • Terms of the policy are changed; or • Our liability has been altered, in our opinion, because of: • A change in state of federal law; or • A substantive change in the composition of the group; or • Fraud or misrepresentation of a material fact by the policyholder, employee or an employees N o dependent; or 0 g The policyholder changes the terms of this policy with our written or electronically transmitted consent; or N • We provide 45 days written or electronic notice to the policyholder that rates will change, as permitted by applicable law. Such notice shall include the effective date of the change in premium rates. We reserve the right to rescind this policy or reduce insurance coverage or increase past premium, unless prohibited by applicable law. This action may be applied to one or all covered persons when we have been provided incomplete or inaccurate or untimely information on any enrollment form, Employer Group Application or any other eligibility form, if such intentional misrepresentation materially affected the acceptance of the group, the individual, or the risk. If on the date coverage is rescinded or reduced, no claims have been paid under this policy, we will return to the policyholder all premiums paid for such coverage. If on the date coverage is rescinded or reduced, claims have been paid under this policy, we reserve the right to deduct an amount equal to the amount of such claims paid from the premiums to be returned to the policyholder. The policyholder is responsible for any amount of claims in excess of premium. Premium charges for benefit changes or a modification of an individual's coverage If the group vision plan benefits or an individual's insurance coverage are modified other than on a C premium due date, any applicable change in premium resulting from the modification will become effective as follows: FL -70148-01 LG 9/15 Premiums For groups with 51 or more employees the change in premium will be effective on the date the change in coverage becomes effective. If the change is effective on or before the 15`h of the month, the change in premium will be effective on the first of the month during which the change in coverage is effective; If the change is effective after the 15s' of the month, the change in premium will be effective on the first of the month following the effective date of change in coverage. The effective date of a change in premium will only vary from the above upon mutual written agreement between the policyholder and us. Grace period While this policy continues in force, a grace period of 31 days will be allowed to the policyholder following the premium due date, for the payment of each required premium due. This policy will remain in force during the grace period. If the required premium is not paid by the end of the 31 day period, this policy will terminate. Unpaid premium If the required premium is not paid by the end of the 31 day grace period, we reserve the right to collect the premium for the grace period. FL -70148-01 LG 9/15 Benefits Enclosed GN -61201 -HH Administrative Office: 1100 Employers Boulevard Green Ba% Wisconsin 54344 Group Vision Certificate of Insurance Humana Insurance Company Policyholder: Policy Number: Effective Date: Product Name: CITY OF SEBASTIAN 771470 10/01/2016 FL HUMANA VISION 130 In accordance with the terms of the policv issued to the policyholder, Humana Insurance Company certifies that a covered person is insured for the benefits described in this cerli. icale. This certi/icale becomes the Certificate of Insurance and replaces any and all certificates and certificate riders previously issued. Bruce Broussard President The insurance policy under which this certificate is issued is not a policy of Workers' Compensation insurance. You should consult your employer to determine whether your enrplo�yer is a subscriber to the Workers' Compensation system. This is not a policy of Long Term Care insurance. >> This Benefit Plan Document is a summary of your Humana coverage FL -70147-01 CERT LG 1 FL -70147-01 CERT LG Table of contents Claims.................................................................................................................................................... 3 Howyour plan works............................................................................................................................ 3 Howwe pay claims................................................................................................................................ 5 Recoveryrights..................................................................................................................................... 7 Eligibility..............................................................................................................................................10 When you are eligible for coverage.....................................................................................................10 Terminatingcoverage..........................................................................................................................13 Replacementprovisions.......................................................................................................................14 Definitions............................................................................................................................................16 Benefits.................................................................................................................................................21 Scheduleof benefits.......................................................................................................................21 Limitations & exclusions (all services).........................................................................................23 DiabeticEyeCare Benefit.....................................................................................................................25 OpenEnrollment..................................................................................................................................27 FL -70147-01 CERT LG Claims How your plan works As you read through this certificate, you will notice that certain words and phrases are printed in italics. An italicized word may have a different meaning in the context of this certificate than it does in general usage. Please check the "Definitions" section for the definitions of italicized words, so you can understand their meaning as it relates to your insurance coverage. How to use this certificate This certificate provides you with detailed information regarding your coverage. It explains what is covered and what is not covered. It also identifies your duties and how much you must pay when obtaining services. Although your coverage is broad in scope, it is important to remember that your coverage has limitations. Be sure to read your certificate carefully before using your benefits. Please note the provisions and conditions of this certificate apply to you and to each of your covered dependents. Entire contract The entire contract is made up of the policy, the application of the policyholder, incorporated by reference herein, and the application of the employees, if any. Absent of fraud, all statements made by the Policyholder or by any Member will be deemed representations and not warranties. No statement made by the Policyholder or by any Member can be contested unless it is in written form and signed by the Policyholder or Member. A copy of the form must then be given to the Policyholder or Member or their beneficiary. General benefit payments We pay benefits for covered expenses, as stated in the Schedule of Benefits and your "Vision Benefits" sections, and according to any riders that are part of your policy Paid benefits are subject to the conditions, limitations and exclusions of this policy. After you receive a service, we will determine if it qualifies as a covered service. If we determine it is a covered service, we will pay benefits as follows: 1. We will determine the total covered expense. 2. We will review the covered expense against any reimbursement limit that may apply. Benefit maximums The amount we pay for services are limited to a reimbursement limit. We will not make benefit payments that are more than the reimbursement limit for the covered services shown in the Schedule of Benefits. How to find a preferred provider An online directory of network providers will be made available to you and accessible via the internet on our website at Humana.com at the time of your enrollment. This directory is subject to change. Due to the possibility of preferred providers changing status, please check the online directory of preferred providers prior to obtaining services. Ifyou do not have access to the online directory, you may telephone our customer service center prior to service being rendered or to request a directory. Our relationship with providers Preferred providers and non preferred providers are not our agents, employees or partners. Preferred providers are independent contractors. We do not endorse or control the clinical judgment or treatment recommendation made by preferred providers or non preferred providers. FL -70147-01 CERT LG 3 Claims Nothing contained in the policy or any agreement or reimbursement document shall, nor is it intended to, interfere with communication between you and vision providers regarding your condition or treatment options. When ordering services, vision providers and other providers are acting on your behalf All decisions related to patient care are the responsibility of the patient and the treating vision provider, regardless of any coverage determination(s) we have made or will make. We are not responsible for any misstatements made by any provider with regard to the scope of covered expenses and/or non -covered expenses under your certificate. Ifyou have any questions concerning your coverage, please call the customer service number on the back of your identification card. Privacy and confidentiality statement We understand the importance of keeping your personal and health information (PHI) private. PHI includes both medical information and individually identifiable information, such as your name, address, telephone number or Social Security number. We are required by applicable federal and state law to maintain the privacy of your PHI. Under both law and our policies, we have a responsibility to protect the privacy of your PHI. We: I. Protect your privacy by limiting who may see your PHI; 2. Limit hox\ we may use or disclose your PHI; 3. Inform you of your legal duties with respect to your PHI; 4. Explain our privacy policies; and 5. Strictly adhere to the policies currently in effect. We reserve the right to change our privacy practices at any time, as allowed by applicable law, rules and regulations. We reserve the right to make changes in our privacy practices for all PHI that we maintain, including information we created or received before we made the changes. When we make a significant change in our privacy practices, we will send notice to our plan subscribers. For more information about our privacy practices, please contact us. As a covered person, we may use and disclose your PHI, without your consent/authorization in the following ways: 1. Treatment —we may disclose your PHI to a healthcare practitioner, a hospital or other entity which asks for it in order for you to receive medical treatment; and 2. Payment —we may use and disclose your PHI to pay claims for covered expenses provided to you by health care practitioners, hospitals or other entities. We may also use and disclose your PHI to conduct other health care operations activities. It has always been our goal to ensure the protection and integrity of your PHI. Therefore, we will notify you of any potential situations where your identification would be used for reasons other than treatment, payment and health plan operations. Additional policyholder responsibilities In addition to responsibilities outlined in the policy, the policyholder is responsible for: — Collection of premium; and — Providing access to: — Benefit plan documents; — Renewal notices and policy modification information; — Product discontinuance notices; and — Information regarding continuation rights. FL -70147-01 CERT LG Claims No policyholder has the power to change or waive any provision of the policy. Certificate of insurance A certificate setting forth a statement of insurance protection to which the employee and the employee's covered dependents are entitled will be available via internet access or in writing when requested. The policyholder is responsible for providing employees access to the certificate. Assignment The policy and its benefits may not be assigned by the policyholder. Conformity with statutes Any provision of the policy which is not in conformity with applicable state law(s) or other applicable law(s) shall not be rendered invalid, but shall be construed and applied as if it were in full compliance with the applicable state law(s) and other applicable law(s). Modification of policy This plan may be modified at any time by agreement between us and the policyholder without the consent m of any covered person. Modifications will not be valid unless approved by our president, vice president, secretary or other authorized officer. The approval must be endorsed on, or attached to, the policy. No agent has the authority to modify the policy, waive any of the policy provisions, extend the time for S premium payment, make or alter any contract, or waive any of the Company's other rights or 0 responsibilities. A note about this certificate — "benefit plan document" This certificate is part of the insurance policy and describes the benefits, provisions and limitations of the policy. Nothing in this certificate waives or alters any of the terms or conditions of the policy. The final interpretation of any specific provision in this certificate is governed by the terms of the policy. In the event of conflict between the policy and this certificate, the provisions of the policy will prevail. The benefits outlined in this certificate are effective only if you are eligible for insurance, become insured and remain insured in accordance with the terms of the policy. How we pay claims Identification numbers You will receive an electronic identification (ID) card showing your name, identification number and group number. Show this ID card to your vision provider when you receive services. Submitting claim information and proof of loss When services are rendered by a preferred provider, that provider will submit claim information. When services are rendered by a non preferred provider, you must submit the claim form directly to us. That claim form may be found on our website, Humana.com. Please contact the customer service number on your identification card if you have any questions regarding this process, or to request a paper COPY. We would like to receive this information within 90 days after the expense incurred date; however, the -C claim will not be reduced or denied if it was not reasonably possible to meet the 90 -day guideline. In any event, we will need written proof of loss notice within one year after the date proof of loss is requested, except ifyou were legally incapacitated. FL -70147-01 CERT LG Claims Ifyou do not provide us with the necessary information, we will deny any related claims until you provide it to us. Paying claims Once we receive all the necessary information, we will determine if benefits are available, and if they are, we will pay any amount due under this policy within 45 days of receipt of the claim. If we cannot process your claim due to lack of information, we will notify vou, or whoever is claiming payment under the policy if it is not you, of the information needed within 45 days of receipt of claim. Once we have received the necessary information, we will process your claim within 60 days of receipt of information. We may pay all or a portion of any benefit provided for covered expenses to the provider unless you or the covered person has notified us in writing by the time the claim form is submitted. Reasons for denying a claim Below is a list of the most common reasons we cannot pay a claim. Claim payments may be limited or denied in accordance with any of the provisions contained in this certificate. 1. Not a covered benefit: The service is not a covered service under the certificate. 2. Eligibility: You no longer are eligible under the "Terminating Coverage" section of this certificate, or the expense incurred date was prior to your effective date. 3. Fraud: You make an intentional misrepresentation by not telling us the facts or withhold information necessary for us to administer this certificate. Insurance fraud is a crime. Anyone who willingly and knowingly engages in an activity intended to defraud us by filing a claim or form that contains false or deceptive information may be guilty of insurance fraud. If a covered person commits fraud against us, as determined by us, coverage ends automatically, without notice, on the date the fraud is committed. This termination may be retroactive. We also will provide information to the proper authorities and support any criminal charges that may be brought. Further, we reserve the right to seek civil remedies available to us. We will not end coverage if, after investigating the matter, we determine that the member provided information in error. We will adjust premium or claim payment based on this new information. If you provided correct information and we made a processing error, you will be eligible for coverage and claims payment for covered expenses. We will adjust your premium or claim payment based on the correct information. Duplicating provisions: If any charge is described as covered under two or more benefit provisions, we will pay only under the provision allowing the greater benefit. This may require us to make a recalculation based on both the amounts already paid and the amounts due to be paid. We have no obligation to pay for benefits other than those this certificate provides. How to Challenge Our Claim Decision (Appeal Rights) If a covered person disagrees with our decision on payment of a particular claim, the covered person can request a second review of the claim, also known as an appeal. To request this review, you must send us a letter requesting a second claim review within 60 days from the time you received notice of our claim FL -70147-01 CERT LG Claims payment decision. The covered person may also send any documents or information that are relevant to our decision of how to pay the claim. Once we receive the request, we will make a second review of the claim and provide notice of our decision within 15 business days. Legal actions You cannot bring a legal action to recover a claim until 60 days after the date written proof of loss is made. No action may be brought after the expiration of the applicable statute of limitations after such proof of loss is required to be given. Clerical error, misstatement of age or gender If it is determined that information about the age or gender of you or your dependents was omitted or misstated in error, the amount of insurance for which you are properly eligible will be in effect. An equitable premium adjustment will be made. This provision applies equally to you and to us. Right to collect needed information m You must cooperate with us and when asked, assist us by providing information we request to administer the policy. 0 m 0 g If you fail to cooperate or provide the necessary information, we may recover payments made by us and deny any pending or subsequent claims for which the information is requested. k Claims paid incorrectly If a claim was paid in error, we have the right to recover our payments. We may correct this error by an adjustment to any amount applied to the reimbursement limits. Errors may include such actions as: 1. Claims paid for services that are not actually covered under the policy. 2. Claims payment that is more than the amount allowed under the policy. 3. Claims paid based on fraud or an intentional misrepresentation. We may seek recovery of our payments made in error from anyone to, for or with respect to whom such payments were made; or any insurance companies or organizations that provide other coverage for the covered expenses. We will determine from whom we shall seek recovery. For information on our process, see the Recovery rights provision. Recovery rights Your obligation in the recovery process We have the right to collect our payments made in error. You are obligated to cooperate and assist us and our agents to protect our recovery rights by: 1. Obtaining our consent before releasing any party from liability for payment of vision expenses. 2. Providing us with a copy of any legal notices arising from your injury and its treatment. 3. Assisting our enforcement of recovery rights and doing nothing to prejudice our recovery rights FL -70147-01 CERT LG Claims 4. Refraining from designating all (or any disproportionate part) of any recovery as exclusively for "pain and suffering." If you fail to cooperate, we will collect from you any payments we made. Right of subrogation You agree to transfer any rights to us that you have to recover any expenses paid under this policy. We will be subrogated to these recovery rights from any funds paid or payable. We may enforce our subrogation rights by asserting a claim to any coverage to which you may be entitled. If we are precluded from exercising our subrogation rights, we may exercise our right of reimbursement. Right of reimbursement If we pay benefits and you later recover payment from the liable party, we have the right to recover from you the amount we paid. You must notif\ its in writing within 31 days of any settlement, compromise or judgment. If you waive or impair our right to reimbursement, we will suspend payment of past or future services until all outstanding lien(s) are resolved. Ifyou recover payments from and release any legally responsible party from future expenses relating to a sickness or bodily injury, we have a continuing right to seek reimbursement from you. This right, however, will apply only to the extent allowed by law. This reimbursement obligation exists regardless of whether a settlement, compromise or judgment designates that recovery includes or excludes vision expenses. Limitations to recovery rights Any such Right of Subrogation or Reimbursement provided to us under this policy shall not apply or shall be limited to the extent that the Florida Statutes or the Courts of Florida eliminate or restrict such rights. Cost of legal representation The costs of our legal representation in matters related to our recovery rights shall be borne solely by us. The costs of legal representation incurred by you shall be home solely by you, unless we were given timely notice of the claim and an opportunity to protect our own interests and we failed or declined to do SO. Workers' compensation If we pay benefits but determine that the benefits were for the treatment of bodily injury or sickness that arose from or was sustained in the course of any occupation or employment for compensation, profit or gain, we have the right to recover that payment. We will exercise our right to recover against you. The recovery rights will be applied even though: 1. The Workers' Compensation benefits are in dispute or are made by means of settlement or compromise; 2. No final determination is made that bodily injury or sickness was sustained in the course of, or resulted from, your employment; 3. The amount of Workers' Compensation due to medical or health care is not agreed upon or defined by yogi or the Workers' Compensation carrier; or FL -70147-01 CERT LG Claims 4. Medical or healthcare benefits are specifically excluded from the Workers' Compensation settlement or compromise. You agree that, in consideration for the coverage provided by the policy, we will be notified of any Workers' Compensation claim that you make, and you agree to reimburse us as described above. FL -70147-01 CERT LG VI Eligibility When you are eligible for coverage Employee coverage Eligibility date: The employee is eligible for coverage when: 1. Eligibility requirements listed in the Employer Group Application (see your employer for details) are satisfied; and 2. Employee is in active status. Effective date: The employee's effective date will be calculated after we receive the completed enrollment forms we furnish. The employee's Effective Date provision is outlined in the Employer Group Application (see your employer for details). Your effective date may be: 1. Immediately after the waiting period; 2. The first of the month after the waiting period; or 3. The date approved by us. Employee delayed effective date: If the employee is not in active status on the effective date, coverage is effective on the day after the employee returns to active status. The employer must notify us in writing when an employee returns to active status. Benefit changes: Benefit changes will become effective on the date specified by its. Late applicant: If you enroll or are enrolled more than 31 days after your eligibility date, you will be considered a late applicant. Incontestability: After two years from the effective date of the policy, no misstatement made by the policyholder, except a fraudulent misstatement made in the application may be used to void the policy. After you are insured without interruption for two years, we cannot contest the validity of your coverage except for: • Nonpayment of premium; or • Any fraudulent misrepresentation made by you. At anytime, we may assert defenses based upon provisions in the policy which relate to your eligibility for coverage under the policy. Absent of fraud, all statements made by you will be deemed representations and not warranties. No statement made by you can be contested unless it is in a written or electronic form signed by you. A copy of the form must be given to you or your beneficiary. An independent incontestability period begins for each type of change in coverage or when a new employee enrollment form is completed. Dependent coverage Eligibility date: If an employee is covered, the employee's dependent is eligible for coverage: 1. On the date the employee is eligible for coverage: 2. On the date of the emplo vee's marriage (spouse and/or stepchildren); 3. On the date of birth of the employee's natural-born child; 4. On the date of placement of a child for the purpose of adoption by the employee; however, in the case of a newborn child, coverage begins at the moment of birth if a written agreement to adopt such child has been entered into by the employee prior to the birth of the child, whether or not the agreement is enforceable: FL -70147-01 CERT LG 10 Eligibility 5. The date a foster child is placed in the employee's home; or 6. The date any child for whom the employee is the legal guardian, who is dependent on the employee for health care coverage pursuant to a valid court order, or who lives with the employee in a normal parent-child relationship and qualifies for the dependent exemption as defined in the Internal Revenue Code and Federal Tax Regulations. We have the right to request proof of the child's dependency status at any time. Dependents who become employed by the employer participating in this policy must apply for coverage as an eligible employee. Enrollment: Check with the employer on how to enroll for dependent coverage. Late enrollment may reduce benefits. The employee must enroll for dependent coverage and enroll additional dependents on enrollment forms we furnish. Effective date: Each dependent's effective date of coverage is determined as follows, subject to the Dependent Delayed Effective Date provision: 1. If we receive the enrollment form before the dependent's eligibility date, the dependent is covered on the date he or she is eligible. 2. If we receive the enrollment form within 31 days after the dependent's eligibility date: • The dependent is covered on the date we receive the completed enrollment form; or • The dependent is covered on the date he or she is eligible if the employee already had dependent coverage in force. 3. If we receive the completed enrollment forms more than 31 days after the dependent's eligibility date the dependent will be considered a late applicant. A dependent's effective date cannot occur before the employee's effective date of coverage. Dependent delayed effective date: A dependent's effective date of coverage will be delayed if the dependent is homebound due to bodily injury or sickness, or is confined to a hospital or mental health center. The dependent's coverage will be effective one day after discharge from confinement. A physician must certify the discharge. Foster Child effective date Coverage for a foster child or a child otherwise placed in the employee or covered spouse's custody by a court order, prior to the child's eighteenth birthday, will be provided from the date of placement if, on the date of placement, the employee had dependent coverage. No coverage will be provided under this provision for the child who is not ultimately placed in the employee's home. For a child in the employee's custody, coverage will terminate the date the employee no longer has legal custody. Late applicant: Ifyou enroll or are enrolled more than 31 days after your eligibility date, you will be considered a late applicant. Retired employee coverage Eligibility date: Retired employees are considered an eligible class if requested in the Employer Group Application and approved by us. Retired employees are eligible for coverage when the eligibility requirements in the Employer Group Application are satisfied. FL -70147-01 CERT LG 11 Eligibility Effective date: Retired employees must enroll for coverage on forms we furnish. The effective date of coverage for an eligible retired employee is the latter of: 1. The date retired employees are eligible for coverage under this policy; 2. The actual retirement date for employees who retire after that date; or 3. The date we specify if we receive the enrollment forms more than 31 days after the retired employee's eligibility date. Retired employee delayed effective date: A retired employee's effective date of coverage will be delayed if the person is homebound due to bodily injury or sickness; or is confined to a hospital or mental health center. Coverage will be effective one day after discharge from confinement. A physician must certify the discharge. A decrease in insurance will be effective on the approved date of change. Late applicant: If you enroll or are enrolled more than 31 days after your eligibility date, you are considered a late applicant. FL -70147-01 CERT LG 12 Eligibility Terminating coverage Your insurance coverage may end at any time, as stated below and in the "Employer Group Application. Coverage terminates on the earliest of the following events: 1. Termination date listed in the policy; 2. The date premiums are not paid by the required due date; 3. The date the employer stops participating in the policy; 4. The date you enter the military fulltime; 5. When you no longer are eligible for coverage as outlined in the "Employer Group Application;" 6. The date you terminate employment with the employer; 7. For a dependent, the date the employee's insurance terminates; 8. For a dependent, the end of the month he/she no longer meets the definition of a dependent; 9. The date an employee requests that insurance be terminated for the employee and/or dependents; 10. An employee's retirement date unless the "Employer Group Application" provides coverage for retirees; or 11. For any benefit that may be deleted from the policy, the date it is deleted. You and the employer are responsible to notify us of any change in eligibility, including the lack of eligibility, of any covered person. Termination for cause We will terminate your coverage for cause under the following circumstances: 1. If you allow an unauthorized person to use your identification card or ifyou use the identification card of another covered person. Under these circumstances, the person who receives the services provided by use of the identification card will be responsible for paying us for those services. 2. Ifyou or the policyholder perpetrate fraud and/or intentional misrepresentation on claims, identification cards or other identification in order to obtain services or a higher level of benefits. This includes the fabrication and/or alteration of a claim, identification card or other identification. Special provisions for active status If the employer continues coverage under this policy, your coverage remains in force for no longer than three consecutive months if the employee is: 1. Temporarily laid off; 2. Temporarily in part-time status; or 3. On an employer -approved leave of absence. All premiums must be submitted to us through the employer. FL -70147-01 CERT LG 13 Eligibility Continuation of coverage during military leave An employee called to active duty or state active duty is eligible for continuation if they are: 1. A member of the Florida National Guard; or 2. A Florida resident and a member of any branch of the United States military reserves. Any employee's dependents who have coverage under this plan immediately prior to the date of the employee's covered absence are also eligible to elect continuation. You or an appropriate military authority, must notify your employer of your intent to continue coverage under this section. Notification must occur prior to reporting to active duty or state active duty, unless such notice is precluded by military necessity or if such notice is impossible or unreasonable. Coverage available under any insurance sponsored by the Department of Defense will be coordinated with benefits available under this plan, as allowed by the Department of Defense. Premium payment If continuation coverage is elected under this section, coverage will have the same premium in effect as for other members under this same plan, unless the employee requests coverage changes that might alter the premium in effect prior to such activation. Reinstatement We will reinstate coverage for the members who elected not to continue coverage under this plan while on active duty or state active duty: 1. After receipt of that person's request for reinstatement upon return from active duty or state active duty; and 2. If reinstatement is requested within 30 days after returning to work with the same employer. Upon reinstatement of coverage, no additional waiting period will be applied for any condition that existed at the time the member was called to active duty or state active duty. Other information The employee should contact the employer with any questions regarding coverage normally available during a military leave of absence or continuation coverage and notify the employer of any changes in marital status, or a change of address. Replacement provisions Applicability: This provision applies only if. 1. You are eligible for vision coverage on your employer's effective date under this policy; and 2. You were covered on the final day of coverage on your employer's previous group vision plan (Prior Plan). Delayed effective date: We will waive the "Delayed Effective Date" provision if it applies to you when you would otherwise be eligible for vision coverage on your employers effective date under this police. Vision coverage is provided to you until the earlier of the following dates: 1. 90 days after your employer's effective date under this plan. 2. The date your vision coverage would otherwise terminate according to the "Terminating coverage" section in the certificate. FL -70147-01 CERT LG 14 Eligibility Ifyou satisfy the "Delayed Effective Date" provision before either of these dates, your vision coverage will continue uninterrupted. FL -70147-01 CERT LG 15 Definitions Alloivance: The maximum amount we will pay for a covered service as shown in the "Schedule". Active status: The employee performs all of his or her duties on a regular full-time basis for the required number of hours per week shown on the Employer's Group Application, for 48 weeks per year. Active status applies to employees whether they perform their duties at the employer's business establishment or at another location when required to travel for job purposes; on each regular paid vacation day; and any regular non -working holiday if the employee is not totally disabled on his or her effective date of coverage. An employee is considered in active status if he or she was in active status on his or her last regular working day. Benefit: The amount payable in accordance with the provisions of this plan. Certificate: This benefit plan document, which outlines the benefits, provisions and limitations of the policy. Comprehensive eye exam: An exam of the complete visual system which includes: case history; monocular and binocular visual acuity, with or without present corrective lenses; neurological integrity (pupil response); biomicroscopy (external exam); visual field testing (confrontation); ophthalmoscopy (internal exam); tonometry (intraocular pressure); refraction (with recorded visual acuity); extraocular muscle balance assessment; dilation as required; present prescription analysis: specific recommendation; assessment plan; and provider signature. Contact lens fitting and follow-up: A diagnostic evaluation and fitting include contact lens compatibility tests, diagnostic evaluations and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Procedures for the diagnostic evaluation may include: 1. Contact lens related history 2. Keratometry and/or corneal topography 3. Anterior segment analysis with dyes 4. Biomicroscopy of eye and adnexia 5. Biomicroscopy with diagnostic lenses 6. Over -refraction 7. Visual acuity with diagnostic lenses 8. Determination of contact lens specifications 9. Patient instructions and consultations 10. Proper documentation with assessment and plan. Appropriate follow-up evaluations may include the following procedures: 1. contact lens history including a review of care and hygiene regimen 2. visual acuities 3. Over -refraction, as indicated 4. Keratometry and/or corneal topography as indicated 5. Evaluation of prescription contact lenses with appropriate instruments 6. Biomicroscopy of eyes and adnexia (with fluorescein or other dyes as indicated) 7. Consultation and proper documentation with assessment and plan. Copayment: The charge, in addition to premiums, which members are required to pay for certain covered services provided under the policy. A copayment is either expressed as a flat dollar amount, or a percentage of the reimbursement limit. The member must make copayments at the time of service directly to the provider. Cosmetic service: Services provided primarily for the purpose of improving appearance. FL -70147-01 CERT LG 16 Definitions Covered expense: The reimbursement limit for a covered service. Covered person: An employee and/or the employee's dependents who are enrolled for benefits provided under the policy. Covered service: A service considered visually necessary or appropriate, or routine, that is: 1. Ordered by a vision provider; 2. For the benefits described, subject to any reimbursement limit, as well as all other terms, provisions, limitations and exclusions of the policy; and 3. Incurred when a member is insured for that benefit under the policy on the date the expense incurred date. Dependent: A covered employee's: 1. Lawful spouse; and 2. Natural born child, step -child, foster child, legally adopted child, or child placed for adoption, whose age is less than the limiting age; 3. Child whose age is less than the limiting age and for whom the employee has received a Qualified Medical Child Support Order (QMCSO) or National Medical Support Notice (NMSN) to provide coverage, if the employee is eligible for family coverage until: o Such QMCSO orNMSN is no longer in effect; or o The child is enrolled for comparable health coverage, which is effective no later than the termination of the child's coverage under the policy. The limiting age for each dependent child is the end of the calendar year in which the child reaches the age of 30; or The end of the calendar year a dependent reaches 30 years if such child is dependent upon the employee for support and is: • unmarried and does not have a dependent of his or her own • is a resident of this state or a fall -time or part-time student A covered dependent child who becomes an employee eligible for other group coverage no longer is eligible for coverage under this policy. A covered dependent child who reaches the limiting age while insured under this policy remains eligible for vision care service benefits if. 1. Mentally or physically disabled; and 2. Dependent on the covered employee for support and maintenance. You need to provide us with satisfactory proof that the above conditions continually exist after the dependent reaches the limiting age. We may not request proof more often than annually after two years from the date the first proof was furnished. If we do not receive satisfactory proof, the child's coverage ends on the date proof is due. Electronic or electronically: Relating to technology having electrical, digital, magnetic, wireless, optical, electromagnetic, or similar capabilities. Electronic mail: A computerized system that allows a user of a network computer system and/or computer system to send and receive messages and documents among other users on the network and/or with a computer system. Eligibility date: The date the employee or dependent is eligible to participate in the plan. FL -70147-01 CERT LG 17 Definitions Employee: The person who is regularly employed and paid a salary or earnings and is in active status at the employer's place of business. If the employer is a union, the employee must be in good standing and eligible for insurance according to the union's rules of eligibility. Emplgver: The policyholder of the group insurance plan, or any subsidiary described in the Employer Group Application. Expense incurred. The amount you are charged for a service. Family member: Anyone related to you by blood, marriage or adoption. Group: The persons for whom this insurance coverage has been arranged to be provided. Health care practitioner: A practitioner professionally licensed by the appropriate state agency to diagnose or treat sickness or bodily injury and who provides services within the scope of that license. Materials: Lenses, frame, and contact lenses covered under this policy. Member: The person covered under the policy. Employees and/or their covered dependents. Member Cost in Network: The amount of the member's responsibility for services provided by a preferred provider. Non preferred provider: A vision provider who has not entered into a service agreement with us nor has been designated by its to provide vision care services to covered persons. Out of Network Allowance: The benefit available to a member for services provided by a non preferred provider. Policy: The document describing the benefits we provide as agreed to by us and the policyholder. Policyholder: The legal entity named on the face page of the policy. Preferred provider: A vision provider who has entered into a service agreement with us to provide vision care services to covered persons. Reimbursement limit is the maximum allowable fee for a covered service. It is the lesser of the charged amount, or: 1. In the case of services rendered by providers with whom we have agreements, the fee that we have negotiated with that preferred provider; 2. In the case of services rendered by providers with whom we do not have agreements, the amount shown in the Plan's Non -Preferred Provider Benefit on the schedule. Services: Procedures, surgeries, exams, consultations, advice, diagnosis, referrals, treatment, tests, supplies, drugs, devices or technologies. Total disability/totally disabled: An employee or employed covered spouse who, during the first 12 months of a disability, is prevented by bodily injury or sickness from performing all aspects of his or her respective job or occupation. After 12 months, total disabilityltotally disabled means the person is prevented by bodily iniury or sickness from engaging in any paid job or occupation that he/she is reasonably qualified for by education, training or experience. FL -70147-01 CERT LG 18 Definitions For any member who is not employed, total disability means a disability preventing him/her from performing the usual and customary activities of someone in good health of the same age and gender A totally disabled individual may not engage in any paid job or occupation. Visually necessary or appropriate. Services and materials medically or visually necessary to restore or maintain a patient's visual acuity and health and for which there is no less expensive professionally acceptable alternative, as determined by us. Vision provider: An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision care materials. Waiting period: The period of time, elected by the policyholder, which must pass before an employee is eligible for coverage under the policy. We, us and our: The insurance company as shown on the cover page of this certificate mYou and your: Any covered employee and/or dependent(s). h O m O O O O P b k FL -70147-01 CERT LG 19 Humana Toll Free: 877-398-2980 1100 Employers Blvd. Green Bay, WI 54344 Humana.com INSURED BY HUMANA INSURANCE COMPANY FL -70147-01 CERT LG 20 Benefits Policyholder: CITY OF SEBASTIAN Group Number: 771470 Type of coverage: FL HUMANA VISION 130 Effective Date: 10/01/2016 Schedule of benefits This summary provides an overview of plan benefits. Refer to your "Vision Benefits" provision {s) for detailed descriptions, including additional limitations or exclusions. When services or materials are provided by preferred providers, your cost will be the cost shown in the Preferred Provider Benefit column shown in the Vision Benefits provision below. When services or materials are provided by non preferred providers, we will pay the lesser of the actual expense incurred or the reimbursement limit for each covered benefit. If a benefit is subject to a frequency limitation, that limitation is calculated based on the length of time m between dates of service. m r 0 Vision benefits Service/Material Frequency Preferred Provider Non -Preferred Benefit Provider Benefit Routine Vision 1 per 12 months $10 Copayment $30 Allowance Examination w/dilation as necessary Frames 1 per 24 months $130 Allowance $65 Allowance Standard Plastic Lenses I per 12 months Single Vision/Materials $15 Copayment $25 Allowance Bifocal $15 Copayment $40 Allowance Trifocal $15 Copayment $60 Allowance Lenticular $15 Copayment $100 Allowance Contact Lenses(in lieu of 1 per 12 months frames and lenses) _ Conventional $130 Allowance $104 Allowance Disposable $130 Allowance $104 Allowance Medically Necessary Paid in Full $200 Allowance Lens Options includes Lens Copay FL -70147-01 EM HV LG 21 HV Plan 100-200 Standard Progressive (add on to Bifocal) Benefits $15 Copayment $40 Allowance Frames - The preferred provider will show the covered person the frames that this policy covers in full. If a covered person selects a frame that costs more than the amount covered under this policy, the covered person is responsible for the difference in cost. Where the vision exam shows new lenses or frames or both are a visual necessity. benefits for lenses and frames include (1) prescribing and ordering proper lenses; (2) assisting with selection of frames; (3) verifying accuracy of finished lenses; and (4) proper fitting and adjustments. Lenses — Whcre the vision exam shows new lenses or frames or both are a visual necessity, benefits for lenses and frames include (1) prescribing and ordering proper lenses; (2) assisting with selection of frames, (3) verifying accuracy of finished lenses; and (4) proper fitting and adjustments. Contact Lenses Contact lenses are provided in lieu of all other lens and frame benefits available herein. This means that utilization of contact lens benefits exhausts all of the covered person's lens and frame benefits for the current benefit period and future eligibility for lenses and frames will be determined as if spectacle lenses and frames were obtained in the current benefit period. Contact lens materials when medically necessary — We will pay a benefit for one pair of contact lenses under the following circumstances and only if prior authorization from us is obtained: 1) following cataract surgery without intraocular lens; 2) correction of extreme visual acuity problems not correctable with glasses; 3) high ametropia of either +1 OD or -IOD in any meridian; 4) Anisometropia greater than 5.00 diopters and aesthenopia or diplopia, with spectacles; 5) Diagnosis of Keratoconus supported by medical record documentation consistent with a two line improvement of visual acuity with contact lenses as the treatment of choice; or 6) monocular aphakia and/or binocular aphakia where the provider certifies contact lenses are medically necessary for safety and rehabilitation to a productive life. FL -70147-01 EM HV LG 22 HV Plan 100-200 Benefits Limitations & exclusions (all services) In addition to the limitations and exclusions listed in your "Vision Benefits" section, this policy does not provide benefits for the following: 1. Any expenses incurred while you qualify for any worker's compensation or occupational disease act or law. 2. Services: • That are free or that you would not be required to pay for if you did not have this insurance, unless charges are received from and reimbursable to the U.S. government or any of its agencies as required by law; • Furnished by, or payable under, any plan or law through any government or any political subdivision (this does not include Medicare or Medicaid); or • Furnished by any U.S. government-owned or operated hospital/institutionlagency for any service connected with sickness or bodily injury. 3. Any loss caused or contributed by: • War or any act of war, whether declared or not; • Any act of international armed conflict; or • Any conflict involving armed forces of any international authority. 4. Any expense arising from the completion of forms. 5. Your failure to keep an appointment. 6. Any hospital, surgical or treatment facility, or for .services of an anesthesiologist or anesthetist. 7. Prescription drugs or pre -medications, whether dispensed or prescribed. 8. Any service not specifically listed in the Schedule of Benefits. 9. Any service that we determine: • Is not a visual necessity; • Does not offer a favorable prognosis; • Does not have uniform professional endorsement; or • Is deemed to be experimental or investigational in nature. 10. Orthoptic or vision training. FL -70147-01 EM HV LG 23 HV Plan 100-200 Benefits 11. Subnormal vision aids and associated testing. 12. Aniseikonic lenses. 13. Any service we consider cosmetic. 14. Any expense incurred before your effective date or after the date your coverage under this policy terminates. 15. Services provided by someone who ordinarily lives in your home or who is a family member. 16. Charges exceeding the reimbursement limit for the service. 17. Treatment resulting from any intentionally self-inflicted injury or bodily illness. 18. Plano lenses. 19. Medical or surgical treatment of eye, eyes, or supporting structures. 20. Replacement of lenses or frames furnished under this plan which are lost or broken, unless otherwise available under the plan. 21. Any examination or material required by an Employer as a condition of employment. 22. Non-prescription sunglasses. 23. Two pair of glasses in lieu of bifocals. 24. Services or materials provided by any other group benefit plans providing vision care. 25. Certain name brands when manufacturer imposes no discount. 26. Corrective vision treatment of an experimental nature. 27. Solutions and/or cleaning products for glasses or contact lenses. 28. Pathological treatment. 29. Non-prescription items. 30. Costs associated with securing materials. 31. Pre- and Post-operative services. 32. Orthokeratology. 33. Routine maintenance of materials. 34. Refitting or change in lens design after initial fitting, unless specifically allowed elsewhere in the certificate. 35. Artistically painted lenses. FL -70147-01 EM HV LG 24 HV Plan 100-200 Supplemental Vision Expense Benefit Diabetic EyeCare Benefit Your certificate is amended to include this supplemental plan benefit. The effective date of the benefit is the latter of the effective date of your certificate or the date this benefit is added to your certficate. Benef is are subject to visual necessity and all policy terms, conditions and limitations. The following benefit is added to your certificate as follows: We will pay listed benefits for covered expenses received from a preferred provider for eye care related to diabetes as follows: Service/Material Frequency Preferred Provider Non -Preferred Provider Benefit Benefit Medical Office Visit 2 per year Paid in Full $77 Allowance Retinal Imaging 2 per year Paid in Full $50 Allowance m (not covered if extended 0 ophthalmoscopy has been o done in the last 6 months) 0 0 0 Extended 2 per year Paid in Full $15 Allowance k Ophthalmoscopy (not covered if retinal imaging has been done in the last 6 months) Gonioscopy 2 per year Paid in Full $15 Allowance Scanning Laser 2 per year Paid in Full $33 Allowance The following definitions are added to your certificate: Office Service Visit (Medical Follow-up Exam) - means an office visit for the evaluation and management of an established patient. The office visit includes patient history, follow-up examination services as deemed appropriate by the provider, and medical decision making. Extended Ophthalmoscopy means an examination of the interior of the eye, focusing on the posterior segment of the eye, including the lens, retina, and optic nerve, by direct or indirect ophthalmoscopy, and includes a retinal drawing with interpretation and report. Gonioscopy means a procedure to look at the front part of the eye (anterior chamber) to check the angle where the iris meets the cornea with a gonioscope or with a contact prism lens. Retinal Imaging Examination means the recording of a portion(s) or complete retina surface and structures. Scanning Laser means a computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral. FL -VIS DIB MED LG 25 Supplemental Vision Expense Benefit EXCLUSIONS In addition to the Exclusions in the certificate, no benefits will be paid for services connected with of charges arising from: I. any vision materials; 2. orthoptic or vision training, subnormal vision aids and any associated supplemental testing; 3. medical, pathological and/or surgical treatment of the eye, eyes or supporting structures: or 4. any vision examination by a policyholder as a condition of employment. Humana / ' - A r�4,.e Bruce Broussard President FL -VIS DIB MED LG 26 Change in Plan Rider: Open Enrollment Your certificate is amended to include this plan rider. The effective date of the rider is the latter of the effective date of your certificate or the date this rider is added to your certificate. Benefits are subject to all policy terms, conditions and limitations, including waiting periods, if any. Open enrollment period The open enrollment period is the annual period during which eligible employees may apply for coverage for themselves and their eligible dependents as outlined in the Employer Group Application (see your employer for details). To enroll for coverage The employee must complete the enrollment/change form provided by us, carefully listing each person to be covered. Enrollment during the open enrollment period will be allowed if we receive the completed forms within the open enrollment period. Any reference to late applicants within the Eligibility section of your certificate and/or policy is removed. Late applicants are not eligible for coverage, and must wait until the following open enrollment period to apply. The When you are eligible for coverage section in your certificate is amended as follows: The eligibility date of coverage is amended to read: Employee Coverage: Eligibility date: The employee is eligible for coverage: 1. When eligibility requirements listed in the Employer Group Application (see your employer for details) are satisfied; and 2. When he or she is in active status, or; 3. On the employer's annual anniversary date. Dependent coverage Eligibility date: If an employee is covered, the employee's dependent is eligible for coverage on: 1. The date the employee is eligible for coverage; 2. The date of the employee's marriage (spouse and/or stepchildren); 3. The date of birth of the employee's natural-born child; 4. The date a child is placed in the employee's home for adoption by the employee, or; 5. The employer's annual anniversary date. Please check the Schedule of benefits section of this certificate for any waiting periods that may apply to you. Humana FL -70147-01 OE 9/15 LG Arz--�'- '�e Bruce Broussard President 27 Notice of Non -Insured Benefits Discount/access disclosure From time to time, we may offer or provide you with additional goods and/or services that are not related to the benefits provided under the Policy. In addition, we may arrange for third -party service providers to provide you with discounts on goods and services. Some of these third party service providers may make payments to us when these discount programs are used. These payments offset the cost to us of making these programs available and may help reduce the costs of your plan administration. Who has responsibility for these discounts? Although we have arranged for third parties to offer discounts on these goods and services, these discount programs are not insured benefits under the Policy. The third -party providers are solely responsible for providing the goods and/ or services. We are not responsible for any goods and/ or services nor are we liable if vendors refuse to honor such discounts. Further, we are not liable for the negligent provision of such goods and/ or services by third -party service providers. Discount programs may not be available to people who "opt out" of marketing communications, or where otherwise restricted by law. DISC NOT 9/12 28 Notices The following pages contain important information about certain federal laws. There may be differences between the Certificate of Insurance and this Notice packet. There may also be differences between this notice packet and state law. You are eligible for the rights more beneficial to you, unless preempted by state or federal law. a This section includes notices about: P F m Claim procedures 0 0 0 0 P e Federal legislation Medical child support orders Continuation of coverage for full-time students during medical leave of absence General notice of COBRA continuation of coverage rights Family and Medical Leave Act (FMLA) Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) Your Rights under ERISA Claim procedures The Employee Retirement Income Security Act of 1974 (ERISA) established minimum requirements for claims procedures. Humana complies with these standards. Covered persons in insured plans subject to ERISA should also consult their insurance benefit plan documents (e.g., the Certificate of Insurance or Evidence of Coverage). Humana complies with the requirements set forth in any such benefit plan document issued by it with respect to the plan unless doing so would prevent compliance with the requirements of the federal ERISA statute and the regulations issued thereunder. The following claims procedures are intended to comply with the ERISA claims regulation, and should be interpreted consistent with the minimum requirements of that regulation. Covered persons in plans not subject to ERISA should consult their benefit plan documents for the applicable claims and appeals procedures. Discretionary authority With respect to paying claims for benefits or determining eligibility for coverage under a policy issued by Humana, Humana as administrator for claims determinations and as ERISA claims review fiduciary, shall have full and exclusive discretionary authority to: 1. Interpret plan provisions; 2. Make decisions regarding eligibility for coverage and benefits; and 3. Resolve factual questions relating to coverage and benefits. Claim procedures Definitions Adverse determination: means a decision to deny benefits for a pre -service claim or a post -service claim under a group health and/or dental plan. Claimant: A covered person (or authorized representative) who files a claim. Concurrent -care Decision: A decision by the plan to reduce or terminate benefits otherwise payable for a course of treatment that has been approved by the plan (other than by plan amendment or termination) or a decision with respect to a request by a Claimant to extend a course of treatment beyond the period of time or number of treatments that has been approved by the plan. Group health plan: an employee welfare benefit plan to the extent the plan provides dental care to employees or their dependents directly (self insured) or through insurance (including HMO plans), reimbursement or otherwise. Health insurance issuer: the offering company listed on the face page of your Certificate of Insurance or Certificate of Coverage and referred to in this document as "Humana." Post -service Claim: Any claim for a benefit under a group health plan that is not a Pre -service Claim. Pre -service Claim: A request for authorization of a benefit for which the plan conditions receipt of the benefit, in whole or in part, on advance approval. Urgent -care Claim (expedited review): A claim for covered services to which the application of the time periods for making non -urgent care determinations: could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or in the opinion of a physician with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the service that is the subject of the claim. Humana will make a determination of whether a claim is an Urgent -care Claim. However, any claim a physician, with knowledge of a covered person's medical condition, determines is a " Urgent -care Claim" will be treated as a "claim involving urgent care." Submitting a claim This section describes how a Claimant files a claim for plan benefits m A claim must be filed in writing and delivered by mail, postage prepaid, by FAX or e-mail. A request for pre -authorization may be filed by telephone. The claim or request for pre -authorization must be submitted to Humana or to Human's designee at the address indicated in the covered person's benefit plan document or identification card. Claims will be not be deemed submitted for purposes of these * procedures unless and until received at the correct address Claims submissions must be in a format acceptable to Human and compliant with any legal requirements. Claims not submitted in accordance with the requirements of applicable federal law respecting privacy of protected health information and/or electronic claims standards will not be accepted by Humana. Claims submissions must be timely. Claims must be filed as soon as reasonably possible after they are incurred, and in no event later than the period of time described in the benefit plan document. Claims submissions must be complete and delivered to the designated address. At a minimum they must include: • Name of the covered person who incurred the covered expense. C • Name and address of the provider • Diagnosis • Procedure or nature of the treatment • Place of service • Date of service • Billed amount A general request for an interpretation of plan provisions will not be considered a claim. Requests of this type, such as a request for an interpretation of the eligibility provisions of the plan, should be directed to the plan administrator. Procedural defects If a Pre -service Claim submission is not made in accordance with the plans requirements, Humana will notify the Claimant of the problem and how it may be remedied within five (5) days (or within 24 hours, in the case of an Urgent -care Claim). If a Post -service Claim is not made in accordance with the plan's requirement, it will be returned to the submitter. Authorized representatives A covered person may designate an authorized representative to act on his or her behalf in pursuing a benefit claim or appeal. The authorization must be in writing and authorize disclosure of health information. If a document is not sufficient to constitute designation of an authorized representative, as determined by Humana, the plan will not consider a designation to have been made. An assignment of benefits does not constitute designation of an authorized representative. • Any document designating an authorized representative must be submitted to Humana in advance or at the time an authorized representative commences a course of action on behalf of the covered person. Humana may verify the designation with the covered person prior to recognizing authorized representative status. • In any event, a health care provider with knowledge of a covered person's medical condition acting in connection with an Urgent -care Claim will be recognized by the plan as the covered person's authorized representative. Covered persons should carefully consider whether to designate an authorized representative. Circumstances may arise under which an authorized representative may make decisions independent of the covered person, such as whether and how to appeal a claim denial. Claims decisions After a determination on a claim is made, Humana will notify the Claimant within a reasonable time, as follows: Pre -service claims Humana will provide notice of a favorable or adverse determination within a reasonable time appropriate to the medical circumstances but no later than 15 days after the plan receives the claim. This period may be extended by an additional 15 days, if Humana determines the extension is necessary due to matters beyond the control of the plan. Before the end of the initial 15 -day period, Humana will notify the Claimant of the circumstances requiring the extension and the date by which Humana expects to make a decision. If the reason for the extension is because Humana does not have enough information to decide the claim, the notice of extension will describe the required information, and the Claimant will have at least 45 days from the date the notice is received to provide the necessary information. Urgent -care claims (expedited review) Humana will determine whether a particular claim is an Urgent -care Claim. This determination will be based on information furnished by or on behalf of a covered person. Humana will exercise its judgment when making the determination with deference to the judgment of a physician with knowledge of the covered person's condition. Humana may require a Claimant to clarify the medical urgency and circumstances supporting the Urgent -care Claim for expedited decision-making. Notice of a favorable or adverse determination will be made by Humana as soon as possible, taking into account the medical urgency particular to the covered person's situation, but not later than 72 hours after receiving the Urgent -care Claim. If a claim does not provide sufficient information to determine whether, or to what extent, services are covered under the plan, Humana will notify the Claimant as soon as possible, but not more than 24 hours after receiving the Urgent -care Claim. The notice will describe the specific information necessary to complete the claim. The Claimant will have a reasonable amount of time, taking into account the covered person's circumstances, to provide the necessary information - but not less than 48 hours. Humana will provide notice of the plan's Urgent -care Claim determination as soon as possible but no more than 48 hours after the earlier of: • The plan receives the specified information; or M T r • The end of the period afforded the Claimant to provide the specified additional information. 0 m 0 g Concurrent -care decisions 0 Humana will notify a Claimant of a Concurrent -care Decision involving a reduction or termination of pre - authorized benefits sufficiently in advance of the reduction or termination to allow the Claimant to appeal and obtain a determination. Humana will decide Urgent -care Claims involving an extension of a course of treatment as soon as possible taking into account medical circumstances. Humana will notify a Claimant of the benefit determination, whether adverse or not, within 24 hours after the plan receives the claim, provided the claim is submitted to the plan 24 hours prior to the expiration of the prescribed period of time or number of treatments. Post -service claims Humana will provide notice of a favorable or adverse determination within a reasonable time appropriate to the medical circumstances but no later than 30 days after the plan receives the claim. This period may be extended an additional 15 days, if Humana determines the extension is necessary due to matters beyond the plan's control. Before the end of the initial 30 -day period, Humana will notify the affected Claimant of the extension, the circumstances requiring the extension and the date by which the plan expects to make a decision. If the reason for the extension is because Humana does not have enough information to decide the claim, the notice of extension will describe the required information, and the Claimant will have at least 45 days from the date the notice is received to provide the specified information. Humana will make a decision on the earlier of the date on which the Claimant responds or the expiration of the time allowed for submission of the requested information. Initial denial notices Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e-mail, as appropriate, within the time frames noted above. With respect to adverse decisions involving Urgent -care Claims, notice may be provided to Claimants orally within the time frames noted above. If oral notice is given, written notification must be provided no later than 3 days after oral notification. A claims denial notice will convey the specific reason for the adverse determination and the specific plan provisions upon which the determination is based. The notice will also include a description of any additional information necessary to perfect the claim and an explanation of why such information is necessary. The notice will disclose if any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of the rule, protocol or similar criterion will be provided to Claimants, free of charge, upon request. The notice will describe the plan's review procedures and the time limits applicable to such procedures, including a statement of the Claimant's right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination on review. If an adverse determination is based on medical necessity, experimental treatment or similar exclusion or limitation, the notice will state that an explanation of the scientific or clinical basis for the determination will be provided, free of charge, upon request. The explanation will apply the terms of the plan to the covered person's medical circumstances. In the case of an adverse decision of an Urgent -care Claim, the notice will provide a description of the plan's expedited review procedures Appeals of Adverse determinations A Claimant must appeal an adverse determination within 180 days after receiving written notice of the denial (or partial denial). An appeal may be made by a Claimant by means of written application to Humana, in person, or by mail, postage prepaid. A Claimant, on appeal, may request an expedited appeal of an adverse Urgent -care Claim decision orally or in writing. In such case, all necessary information, including the plan's benefit determination on review, will be transmitted between the plan and the Claimant by telephone, facsimile, or other available similarly expeditious method, to the extent permitted by applicable law Determination of appeals of denied claims wi II be conducted promptly, will not defer to the initial determination and will not be made by the person who made the initial adverse claim determination or a subordinate of that person. The determination w ill take into account all comments, documents, records, and other information submitted by the Claimant relating to the claim. On appeal, a Claimant may review relevant documents and may submit issues and comments in writing. A Claimant on appeal may, upon request, discover the identity of medical or vocational experts whose advice was obtained on behalf of the plan in connection with the adverse determination being appealed, as permitted under applicable law. If the claims denial is based in whole, or in part, upon a medical judgment, including determinations as to whether a particular treatment, or other service is experimental, investigational, or not medically necessary or appropriate, the person deciding the appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The consulting health care professional will not be the same person who decided the initial appeal or a subordinate of that person. Time periods for decisions on appeal Appeals of claims denials will be decided and notice of the decision provided as follows: Urgent -care Claims As soon as possible but no later than 72 hours after Humana receives the appeal request. Pre -service Claims Within a reasonable period but no later than 30 days after Humana receives the appeal request. Post -service Claims Within a reasonable period but no later than 60 days after Humana receives the appeal request. Concurrent -care Within the time periods specified above depending on the type of Decisions claim involved. Appeals denial notices Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e-mail, as appropriate, within the time periods noted above. A notice that a claim appeal has been denied will include: • The specific reason or reasons for the adverse determination; • Reference to the specific plan provision upon which the determination is based; • If any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of the rule, protocol or similar criterion will be provided to the Claimant, free of charge, upon request; • A statement describing any voluntary appeal procedures offered by the plan and the claimant's right to obtain the information about such procedures, and a statement about the Claimant's right to bring an action under section 502(a) of ERISA; • If an adverse determination is based on medical necessity, experimental treatment or similar exclusion or limitation, the notice will state that an explanation of the scientific or clinical basis for the determination will be provided, free of charge, upon request. The explanation will apply the terms of the plan to the covered person's medical circumstances. In the event an appealed claim is denied, the Claimant will be entitled to receive without charge reasonable access to, and copies of any documents, records or other information that: • Was relied upon in making the determination; • Was submitted, considered or generated in the course of making the benefit determination, without regard to whether such document, record or other information was relied upon in making the benefit determination; • Demonstrates compliance with the administrative processes and safeguards required in making the determination; • Constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether the statement was relied on in making the benefit determination. Exhaustion of remedies Upon completion of the appeals process under this section, a Claimant will have exhausted his or her administrative remedies under the plan. If Humana fails to complete a claim determination or appeal within the time limits set forth above, the claim shall be deemed to have been denied and the Claimant may proceed to the next level in the review process. After exhaustion of remedies, a Claimant may pursue any other legal remedies available, which may include bringing civil action under ERISA section 502(a) for judicial review of the plan's determination. Additional information may be available from the local U.S. Department of Labor Office. Legal actions and limitations No lawsuit may be brought with respect to plan benefits until all remedies under the plan have been exhausted. No lawsuit with respect to plan benefits may be brought after the expiration of the applicable limitations period stated in the benefit plan document. If no limitation is stated in the benefit plan document, then no such suit may be brought after the expiration of the applicable limitations under applicable law. Medical child support orders An individual who is a child of a covered employee shall be enrolled for coverage under the group health plan in accordance with the direction of a Qualified Medical Child Support Order (QMCSO) or a National Medical Support Notice (HMSO). A QMCSO is a state -court order or judgment, including approval of a settlement agreement that: • provides for support of a covered employee's child; • provides for health care coverage for that child: • is made under state domestic relations law (including a community property law); • relates to benefits under the group health plan; and • is "qualified," i.e., it meets the technical requirements of ERISA or applicable state law. QMCSO also means a state court order or judgment enforcing state Medicaid law regarding medical child support required by the Social Security Act § 1908 (as added by Omnibus Budget Reconciliation Act of 1993). An NMSO is a notice issued by an appropriate agency of a state or local government that is similar to a QMCSO requiring coverage under the group health plan for a dependent child of a non-custodial parent who is (or will become) a covered person by a domestic relations order providing for health care coverage. Procedures for determining the qualified status of medical child support orders are available at no cost upon request from the plan administrator. Continuation of coverage for full-time students during medical leave of absence A dependent child who is in regular fidl-time attendance at an accredited secondary school, college or university, or licensed technical school continues to be eligible for coverage for until the earlier of the following if the dependent child takes a medically necessary leave of absence: - Up to one year after the first day of the medically necessary leave of absence; or - The date coverage would otherwise terminate under the plan. We may require written certification from the dependent child's health care practitioner that the dependent child has a serious bodily injury or sickness requiring a medically necessary leave of absence. General notice of COBRA continuation coverage rights Introduction You are getting this notice because you recently gained coverage under a group health and/or dental plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health and/or dental coverage. It can also become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan's Summary Plan Description or contact the Plan Administrator. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a "qualifying event." Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you too lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced; or 0 Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will become a qualified beneficiary if you too lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse's hours of employment are reduced; • Your spouse's employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following events: • The parent -employee dies; • The parent -employee's hours of employment are reduced; • The parent -employee's employment ends for any reason other than his or her gross misconduct; • The parent -employee becomes entitled to Medicare benefits (Part A, Part B or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the plan as a "dependent child." Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to the employer, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee's spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA coverage available? The plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • the end of employment or reduction of hours of employment; • death of the employee; • commencement of a proceeding in bankruptcy with respect to the employer; or • the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both). For allother qualifying events (divorce or legal separation of the employee and spouse or a dependent child's losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. How is COBRA Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events or a second qualifying event during the initial period of coverage may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18 -month period of COBRA continuation coverage can be extended: Disability extension of 18 -month period of continuation coverage - If you or anyone in your famil} covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional I I months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60'h day of COBRA continuation coverage and must last at least until the end of the 18 -month period of COBRA continuation coverage Second qualifying event extension of 18 -month period of continuation coverage - If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, or other laws affecting your group heath and/or dental plans, contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit at www.dol.gov/ebsa. (address and phone numbers of Regional and District EBSA Office are available through EBSA's website.) Keep your plan informed of address changes To protect your family's rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan contact information: Humana Billing/Enrollment Department 101 E Main Street Louisville, KY 40201 1-800-872-7207 Family and Medical Leave Act (FMLA) If an employee is granted a leave of absence (Leave) by the employer as required by the Federal Family and Medical Leave Act, s/he may continue to be covered under the plan for the duration of the Leave under the same conditions as other employees who are currently employed and covered by the plan. If the employee chooses to terminate coverage during the Leave, or if coverage terminates as a result of nonpayment of any required contribution, coverage may be reinstated on the date the employee returns to work immediately following the end of the Leave. Charges incurred after the date of reinstatement will be paid as if the employee had been continuously covered. Uniformed Services Employment and Reemployment Rights Act of 1994 Continuation of benefits Effective October 13, 1994, federal law requires health plans offer to continue coverage for employees that are absent due to service in the uniformed services and/or dependents. Eligibility An employee is eligible for continuation under USERRA if he or she is absent from employment because of voluntary or involuntary performance of duty in the Armed Forces, Army National Guard, Air National Guard, or commissioned corps of the Public Health Service. Duty includes absence for active duty, active duty for training, initial active duty for training, inactive duty training and for the purpose of an examination to determine fitness for duty. An employee's dependents that have coverage under the plan immediately prior to the date of the employee's covered absence are eligible to elect continuation under USERRA. If continuation of Plan coverage is elected under USERRA, the employee or dependent is responsible for payment of the applicable cost of coverage. If the employee is absent for not longer than 31 days, the cost will be the amount the employee would otherwise pay for coverage. For absences exceeding 30 days, the cost may be up to 102% of the cost of coverage under the plan. This includes the employee's share and any portion previously paid by the employer. Duration of coverage If elected, continuation coverage under USERRA will continue until the earlier of. • 24 months beginning the first day of absence from employment due to service in the uniformed services; or • The day after the employee fails to apply for a return to employment as required by USERRA, after the completion of a period of service. Under federal law, the period coverage available under USERRA shall run concurrently with the COBRA period available to an employee and/or eligible dependent. Other information Employees should contact their employer with any questions regarding coverage normally available during a military leave of absence or continuation coverage and notify the employer of any changes in marital status, or change of address. Your Rights Under the Employment Rights Income Security Act of 1974 (ERISA) Under ERISA, all plan participants covered by ERISA are entitled to certain rights and protections, as described below. Nom ithstanding anything in the group health plan or group insurance policy, following are a covered person's minimum rights under ERISA. ERISA requirements do not apply to plans maintained by governmental agencies or churches. Information about the plan and benefits Plan participants may: Examine, free of charge, all documents governing the plan. These documents are available in the plan administrator's office. Obtain, at a reasonable charge, copies of documents governing the plan, including a copy of any updated summary plan description and a copy of the latest annual report for the plan (Form 5500), if any, by writing to the plan administrator. Obtain, at a reasonable charge, a copy of the latest annual report (Form 5500) for the plan, if any, by writing to the plan administrator. As a plan participant, you will receive a summary of any material changes made in the plan within 210 days after the end of the plan year in which the changes are made unless the change is a material reduction in covered services or benefits, in which case you will receive a summary of the material reduction within 60 days after the date of its adoption. If the plan is required to file a summary annual financial report you will receive a copy from the plan administrator. Responsibilities of plan fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the plan. These people, called 'fiduciaries" of the plan, have a duty to act prudently and in the interest of plan participants and beneficiaries. No one, including an employer, may discharge or otherwise discriminate against a plan participant in any way to prevent the participant from obtaining a benefit to which the participant is otherwise entitled under the plan or from exercising ERISA rights. Continue group health plan coverage Participants may be eligible to continue health care coverage for themselves, their spouse or dependents if there is a loss of coverage under the group health plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review the COBRA notice in this document regarding the rules governing COBRA continuation coverage rights. Claims determinations If a claim for a plan benefit is denied or disregarded, in whole or in part, participants have the right to know why this was done, to obtain copies of documents relating to the decision without charge and to appeal any denial within certain time schedules. Enforce your rights Under ERISA, there are steps participants may take to enforce the above rights. For instance: • if a participant requests a copy of plan documents and does not receive them within 30 days, the participant may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $ 110 a day until the participant receives the materials, unless the materials were not sent because of reasons beyond the control of the plan administrator, • if a claim for benefits is denied or disregarded, in whole or in part, the participant may file suit in a state or Federal court: • if the participant disagrees with the plan's decision, or lack thereof, concerning the qualified status of a domestic relations order or a medical child support order, the participant may file suit in Federal court: • if plan fiduciaries misuse the plan's money, or if participants are discriminated against for asserting their rights, they may seek assistance from the U.S. Department of Labor, or may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If the participant is successful, the court may order the person sued to pay costs and fees. If the participant loses, the court may order the participant to pay the costs and fees. Assistance with questions • Contact the group health plan human resources department or the plan administrator with questions about the plan, • For questions about ERISA rights, contact the nearest area office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or: The Division of Technical Assistance and Inquiries Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue N.W. Washington, D.C. 20210; • Call the publications hotline of the Employee Benefits Security Administration to obtain publications about ERISA rights. Florida Notice: Effective July 1, 1994, certain victims of violent crime do not have to meet the deductible or copayment provision of any insurance policy for the treatment of their crime -related injuries pursuant to the Florida Crimes Compensation Act, excluding 960.28. Eligibility under the Florida Crimes Compensation Act is determined when victims of violent crime apply for services with the Office of the Attorney General, Division of Victim Services. When victims arc determined eligible, they are given written notification which references their insurance exemption. If you are eligible under the Florida Crimes Compensation Act, please forward a copy of such written notification to us to report your status.