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Section III - Health Insurance - Humana Inc.
Broward County > Benefits > Section III - Health Insurance - Humana Inc.

Broward County offers three Consumer Driven Type Healthplans (CDH):

 • CDH Low Plan
 • CDH High Plan
 • CDH with Out-of-Network Plan

OPEN ACCESS

Although the County’s plans are Open Access, which means you do not need a referral to see a specialist, it is recommended that you have a Primary Care or Family Medicine Physician to coordinate and be the central repository where all your health records reside.

WHY IS IT IMPORTANT TO HAVE A PRIMARY/FAMILY CARE PHYSICIAN?

Often coordination of medical treatment and/or pharmacy prescribing is greatly hindered when important and essential medical records are not maintained in one centralized location. A good example of this would be during an emergency your Primary/Family Care provider and/or family members would not be able to give complete medical history information to the treating emergency room physician.

Another example would be if your specialist wanted to confer with your Primary/Family Care provider about prior medical treatments or history, your Primary/Family Care provider would be able to provide complete information. When self-referring to specialists, it is recommended that you request your medical reports be sent to your Primary/Family Care provider for the reasons described above.

Physicians/specialists join and leave health plans throughout the year based on their contract period and other factors; there is no guarantee that a physician, specialist, facility or hospital in the directory will continue in the plan through the end of the calendar year. It is recommended that you contact the physician or specialist prior to enrollment and at the time of making an appointment to verify that they are participating in the plan.

SERVICE AREA

Based on the employee’s address on file in the payroll system, the employee can enroll in the CDH as follows:

EMPLOYEE DOMICILED IN PLAN ALLOWED TO ENROLL IN NETWORK

Employee address on file with the County is in a Florida County covered by HUMANA’s Florida HMO Premier Network: Alachua, Baker, Bradford, Broward, Charlotte, Citrus, Clay, Collier, Columbia, Dixie, Duval, Flagler, Gilchrist, Hernando, Hillsborough, Indian River, Lake, Lee, Levy, Manatee, Marion, Martin, Miami-Dade, Nassau, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Putnam, Sarasota, Seminole, St. Johns, St. Lucie, Union andVolusia

CDH High Plan
CDH Low Plan 

HUMANA’s Florida HMO Premier Network 
with Open Access
No Out-of-Network coverage except for a true medical emergency

CDH with Out-of-Network 

HUMANA’s National POS-Open Access network
Services received in the network are covered at the In-network benefit level. Services received outside of the network are subject to Out of Network annual deductible and co-insurance.

STUDENTS GOING TO COLLEGE OUTSIDE OF THE NETWORK

  • Employee enrolled in CDH High or CDH Low Plans: Students going to college outside of Humana’s Florida HMO Premier Network can apply for the Student Passport Program which will allow the student to have access to Humana’s National Point of Service (POS)-Open Access Network.
  • Employee enrolled in CDH with Out-of-Network Plan: Students going to college outside of Humana’s National Point of Service (POS)-Open Access Network will be subject to the CDH with Out-of-Network Plan – Out of Network benefit level.

COMMON QUESTIONS ASKED ABOUT HEALTH INSURANCE

Is my medical card accepted at pharmacies?
   No, you must use your Catamaran pharmacy ID card. See the section on Pharmacy for details.

Am I covered in an emergency when away on vacation, or have children/dependents that live out of the area?
    Yes; however, follow-up or routine care is not covered unless you are on the CDH with Out-of-Network plan. 

  • CDH High and Low plans - Members will be covered on a participating level in an emergency. Routine and follow-up care from an emergency must be received by a participating provider within Humana’s Florida HMO Premier service area to be covered. Services received outside the service area, or from nonparticipating providers, with the exception of an emergency, ARE NOT COVERED by the insurance company. Any charges incurred, other than under the emergency provision, including follow-up emergency care, will be your responsibility to pay. Service areas are shown above.
  • CDH Out of Network plan – Members will be able to access Humana’s National POS - Open Access Network for in-network services. Services received outside of the network are subject to the annual deductible and co-insurance. Out-of-Network services (with the exception of wellness exams) are subject to a $2,100 annual deductible per person after which claims will be paid at 70 percent of the Usual and Customary rate.

CONSUMER DRIVEN HEALTH PLANS

CDH Plan Definitions:

Copayment: A specific dollar amount, except as otherwise provided for by statute, that the member must pay upon receipt of Covered Services. Healthcare Professionals have the obligation to collect these copayments.

Co-insurance: The sharing of expenses for Covered Services between Insurance Plan and the Member. Coinsurance is expressed in a percentage rather than a dollar amount.

Deductible: The amount a member must pay before Insurance Plan will make any payment toward Covered Services subject to the annual deductible.

Health Reimbursement Account: A Health Reimbursement Account (HRA) is a County funded pool of money available at the beginning of the year, or prorated upon benefit eligibility, to pay eligible health care expenses for you and any enrolled dependent* which has not been previously reimbursed by your health plan, such as copayments, coinsurance and deductible.

*See Over Age Dependents age 26 to 30 and Domestic Partner exclusions on page 51.

Maximum Out of Pocket: A maximum out-of-pocket expense is the “maximum” amount of money you will be responsible to pay for services that are subject to a deductible and coinsurance before the plan pays 100 percent. (100 percent level based on contracted rate In-Network and usual and customary for Out-of-Network.)

HOW TO USE YOUR CDH PLAN

When Do I Pay A Copayment? Copays only apply to certain services and vary by plan design. Review the full Benefit Summary provided by Humana for a detailed list of services and cost.

When do I pay Coinsurance and/or a Deductible? You are subject to the annual deductible and coinsurance under the County’s CDH plans for all services not subject to a copay or covered under Preventative Services. As the plan designs vary, please review the Benefit Summary provided by Humana for a detailed list of services and costs.

How many family members must satisfy a deductible? The family deductible is equal to twice the individual deductible. Once any combination of family members has met the family deductible, all insured’s will be deemed to have met their deductible. No one individual can be charged more than his/her individual annual deductible.

How many family members must satisfy coinsurance? The family coinsurance maximum is equal to twice the individual coinsurance maximum. Once any combination of family members has met the family coinsurance maximum, all insured’s will be deemed to have met their coinsurance maximum. No one individual can be charged more than his/her individual coinsurance maximum.

HEALTH PLAN COMPARISON CHART

For your convenience we have taken the most commonly used plan benefits and prepared a comparison chart of the three CDH plans (CDH High, CDH Low, and CDH with Out-of-Network) offered. This information represents only some of the plans’ benefits.  You are encouraged to read the information provided by Humana as plan selection is irrevocable and cannot be changed after election is made unless due to a Change in Status/Qualifying Event under IRS Section 125 rules.  In the event of a discrepancy between the chart and the Certificate of Coverage, the Certificate of Coverage will govern.

Failure to read, understand and ask questions regarding this important informational document prior to enrollment deadlines will not constitute a valid reason for an exception.

THIS INFORMATION REPRESENTS ONLY HIGHLIGHTS OF SOME OF THE PLAN BENEFITS, SEE HUMANA’S BROCHURE FOR DETAILED INFORMATION.

We urge all individuals who have special health care needs to thoroughly research the health plan benefits, exclusions and limitations as well as discuss these concerns with the provider in order to make a choice by the enrollment deadline.  

CDH HIGH
Florida HMO Premier Network – Open Access

CDH LOW
Florida HMO Premier Network – Open Access

CDH OUT OF NETWORK
National POS Network-Open Access

BI-WEEKLY DEDUCTIONS

Employee Only

$10.00

$0.0

$16.55

Employee + Spouse/DP

$26.96

$3.24

$104.01

Employee + Child(ren)

$27.12

$6.84

$93.00

Employee + Family

$126.13

$91.46

$238.77

Over Age Dependent (age 26-30) additional $20 bi-weekly

DEDUCTIBLE/CO-INSURANCE/COPAY MAXIMUMS

IN-NETWORK

IN-NETWORK

IN-NETWORK

OUT OF NETWORK

Annual Deductible

Individual $1,300
Family $2,600

Individual $2,100
Family $4,200

Individual $1,300
Family $2,600

Individual $2,100
Family $4,200

Co-insurance/Co-pay Maximum

Individual $1,500
Family $3,000

Individual $1,500
Family $3,000

Individual $1,500
Family $3,000

Individual $1,500
Family $3,000

Maximum Out of Pocket Limit
(Deductible/Co-insurance/Copays)

Individual $2,800
Family $5,600

Individual $3,600
Family $7,200

Individual $2,800
Family $5,600

Individual $3,600
Family $7,200

PREVENTIVE CARE

Preventive office visits (up to age 18)

Preventive office visits and tests are covered at 100 percent.
Visit/tests/services must be billed by the physician as a "preventive visit."

30%, no deductible

Preventive immunization (up to age 18)

30%, no deductible

Preventive office visit (over age 18)

30%, no deductible

Preventive mammography

30%, no deductible

Preventive pap smears

30%, no deductible

Preventive outpatient lab tests

30%, no deductible

Preventive endoscopy

30%, no deductible

Preventive prostrate screenings

30%, no deductible

Preventive flu/ pneumonia immunization

30%, no deductible

PHYSICIAN SERVICES

Office visit – primary care physician

$25 copay

$30 copay

$25 copay

30% after annual deductible

Office visit – specialist

$50 copay

30% after annual deductible

$50 copay

30% after annual deductible

Diagnostic tests, lab and x-rays in physician’s office

Included in applicable office visit copay

30% after annual deductible

Included in applicable office visit copay

30% after annual deductible

Chiropractor – Exam only

$50 copay

30% after annual deductible

$50 copay

30% after annual deductible

Chiropractor – Treatment/Manipulation

20% after annual deductible

30% after annual deductible

20% after annual deductible

30% after annual deductible

Allergy Injections (when no other health service is received)

$25 copay

30% after annual deductible

$25 copay

30% after annual deductible

Infertility Services

Not Covered

Not Covered

Not Covered

Not Covered

FACILITY SERVICES

Retail Clinics (located inside stores or pharmacies)

$25 copay

$30 copay

$25 copay

30% after annual deductible

Concentra Urgent Care Facility
(owned by Humana)

$30 copay

$30 copay

$30 copay

30% after annual deductible

Urgent Care Facility $50 copay $50 copay $50 copay 30% after annual deductible

Emergency Room

$250 copay (waived if admitted)

30% after annual deductible

$250 copay (waived if admitted)

$250 copay (waived if admitted)

Inpatient Care

20% after annual deductible

30% after annual deductible

20% after annual deductible

$500 copay per admission, plus 30% after annual deductible

Outpatient Surgery at Freestanding Facility

Outpatient Surgey at Hospital

20% after annual deductible

30% after annual deductible

20% after annual deductible

30% after annual deductible

40% after annual deductible

Outpatient nonsurgical care

20% after annual deductible

30% after annual deductible

20% after annual deductible

40% after annual deductible

Organ Transplants

20% after annual deductible

30% after annual deductible

20% after annual deductible

50% after annual deductible

Skilled Nursing Facility (up to 60 days per calendar year)

20% after annual deductible

30% after annual deductible

20% after annual deductible

30% after annual deductible

Ambulance

20% after annual deductible

30% after annual deductible

20% after annual deductible

30% after annual deductible

Diagnostic Tests at a Freestanding Facility (including Advanced Imaging-MRI, CRA, CAT, PET scans, etc.)

20% up to a maximum of $100

30% up to a maximum of $100

20% up to a maximum of $100

30% after annual deductible

Diagnostic Tests at an outpatient Hospital-based Facility (including Advanced Imaging-MRI, CRA, CAT, PET scans, etc.)

20% after annual deductible

30% after annual deductible

20% after annual deductible

40% after annual deductible

Physical, occupational, cognitive, and speech therapy (limited to 60 visits per year)

20% after annual deductible

30% after annual deductible

20% after annual deductible

30% after annual deductible

Durable Medical Equipment

20% after annual deductible

30% after annual deductible

20% after annual deductible

50% after annual deductible

BEHAVIORAL HEALTH

Mental Health – Outpatient Services

$0 copay for first 20 visits; $25 copay per visit thereafter

30% after annual deductible

$0 copay for first 20 visits; $25 copay per visit thereafter

30% after annual deductible

Mental Health – Inpatient Services

20% after annual deductible

30% after annual deductible

20% after annual deductible

$500 copay, then 30% after annual deductible

Alcohol and Chemical Dependency – Outpatient Services

$0 copay for first 20 visits; $25 copay per visit thereafter

30% after annual deductible

$0 copay for first 20 visits; $25 copay per visit thereafter

30% after annual deductible

Alcohol and Chemical Dependency – Inpatient Services

20% after annual deductible

30% after annual deductible

20% after annual deductible

$500 copay, then 30% after annual deductible

ADDITIONAL SERVICES

Vision Care – basic eye exam at a participating optometrist

No copay

No copay

No copay

Not Covered

Dental Discount Plan

Refer to Dental Schedule of Benefits

Refer to Dental Schedule of Benefits

Refer to Dental Schedule of Benefits

Not Covered

Open Access: Member does not need a referral to see a specialist. Physicians not listed under the Primary Care and Family Medicine category are considered specialists.  Prior Authorization: Some services/tests require Prior Authorization by the carrier.  Your physician is responsible for submitting the Prior Authorization request along with the documentation of medical necessity.  Exclusions and Limitations: All plans have exclusions and limitations. Please review your Certificate of Coverage for details.  This summary is provided for information only; it does not contain complete details of the Plan which are available in the Certificate of Coverage, and it does not constitute an agreement.  In the event of a discrepancy, the Certificate of Coverage will govern.

HEALTH REIMBURSEMENT ACCOUNT (HRA)

As a component of the health plan, the County funds a Health Reimbursement Account (HRA) based on tier of coverage. This account may be used to reimburse eligible health care expenses for you and any enrolled, eligible dependent(s)* which have not been reimbursed by your health plan such as copayments, coinsurance and deductible. These expenses can be reimbursed up to the HRA account balance. Vision and dental expenses are not reimbursable under the HRA. *See Over Age Dependents age 26-30 and Domestic Partner exclusions on page 51.  You may also choose to “bank” your HRA funds for rollover accrual.  The accrual maximum is $20,000. See Health Reimbursement Account & Flexible Spending Account booklet for detailed plan rules on usage, documentation and payback rules.

--- VISION AND DENTAL EXPENSES ARE NOT REIMBURSABLE UNDER THE HRA ---

OTHER HRA HIGHLIGHTS:

Unused balances rollover into the next plan year when continuously enrolled in a County CDH plan.

Health copays, coinsurance and deductible can be paid at time of service/sale by using your myFBMC Visa payment card up to the available balance. Pharmacy* copays are included, but must be coordinated if also enrolled in an FSA Medical Expense Account. Some expenses will require supporting documentation.

Unused balances are eligible for vesting; upon separation of employment vested monies are placed in a tax advantaged account with ICMA and can be drawn upon tax-free beginning at age 55.  See vesting schedule on page 26.

COUNTY FUNDED 2013 CALENDAR YEAR HRA

COUNTY FUNDED 2012 CALENDAR YEAR HRA

 Employee Only  $  600 
 Employee + Child(ren)  $1,350
 Employee + Spouse   $1,350
 Employee + Family $1,600  $1,600

How can I use my HRA account to pay for eligible services?

There are two ways to access your HRA funds:

  • By using your myFBMC Visa payment card at the time of service/sale for immediate payment to the provider. (Note: expenses other than set copays will require further documentation, see your HRA & FSA booklet); or
  • By mailing or faxing a manual reimbursement request using an HRA/FSA claim form and attaching a copy of your Explanation of Benefits (EOB) from the health insurance provider or an itemized bill/receipt showing date of service, type of service, name of patient, name of provider, cost of service. Under IRS rules, a credit card or “paid” receipt is not detailed enough to substantiate an expense. 

For pharmacy copay reimbursements, attach a copy of your itemized pharmacy receipt showing your name, date, and prescription information and mail or fax it to FBMC. Reimbursements are made on a daily cycle.  You may also elect direct deposit so that you can receive your reimbursement more quickly than by mail.

Payment order, if enrolled in the FSA Medical Expense Account:

 First: Prescription drug copays must be reimbursed from your FSA.
 Second: After the FSA is exhausted pharmacy copays may be submitted to your HRA for reimbursement.

If enrolled only in the HRA:

Prescription drug copays will automatically be deducted from your HRA.

ACCOUNT

Primary account for claim payment if enrolled in an HRA and FSA

Claim Type

HRA

FSA

Health Claims: Copays, Coinsurance & Deductible

First

Second if HRA is exhausted

Pharmacy Claims: Copays

Second if FSA is exhausted

First

Dental Expenses

Not eligible

First

Vision Expenses

Not eligible

First

Can I receive reimbursement from both my HRA account and FSA Medical Expense Account for the same expense?
No, the IRS does not allow duplicate reimbursement.

What if I don’t use all my HRA money before the end of the year?
HRA accounts will automatically rollover in early January and be added to your 2013 allotment. You may use the account balance to pay for 2012 or 2013 claims. Upon separation all vested (see vesting schedule) monies are invested in a Retirement Health Savings Account in your name per plan guidelines.

What if I use all my HRA money before the end of the year?
Being able to use your HRA monies to offset out of pocket expense is a great plan benefit to you. However, once your monies are exhausted you would then have the same responsibility to pay any health plan expenses for the remainder of the year. Medical claims submitted via myFBMC card or paper submission will automatically adjudicate from the HRA plan first.

               Reminder: The HRA will not reimburse dental or vision claims.

HEALTH REIMBURSEMENT ACCOUNT (HRA) GUIDELINES

HEALTH REIMBURSEMENT ACCOUNT (HRA) ROLLOVER

Accumulate/rollover cap of $20,000 for all employees regardless of tier of coverage.

VESTING SCHEDULE

Upon Retirement
Vesting Schedule
Less than 1 calendar year = 0%
1 full calendar year = 20%
2 full calendar years = 40%
3 full calendar years = 60%
4 full calendar years = 80%
5 full calendar years = 100%
20% - for every consecutive year of HRA enrollment beginning with the second plan year.
100% - Upon completion of six (6) consecutive years of participation in the HRA

Upon Termination
Less than 6 consecutive years of calendar years = 0%
6 full calendars years = 100%

 

TERMINATION OR NON RE-ENROLLMENT OF COVERAGE PRIOR TO VESTING

Termination of employment or non re-enrollment in a CDH plan prior to vesting will cause any unused HRA funds to forfeit and reverts back to the County. Upon subsequent re-enrollment in any given year, HRA allowance begins at entry level amount.

TERMINATION OF PROGRAM BY COUNTY

All unused HRA funds will automatically vest and roll into a Retirement Health Savings Account through ICMA.

ROLLOVER OF HRA MONIES UPON RETIREMENT FROM COUNTY

HRA monies rollover after the group account has been reconciled at the end of the plan year. The account remains open under the group plan for 90 days after the end of the calendar year in order to allow for run out of claims from the prior year. Once the account has been reconciled, the money will be transferred to a Retirement Health Savings Account through ICMA.

ADDING NEW DEPENDENTS

HRA is prorated for the remainder of the year – Employees enrolled in the HRA plan who add a new dependent midyear will receive an increase, if the tier of coverage increases, to their HRA amount equivalent to one-twelfth of the annual HRA allocation, for each full month remaining in the plan year after effective date of change. Accumulated HRA balances from prior years would not be affected.

DROPPING DEPENDENTS

The HRA account of an employee enrolled in the HRA plan, who drops a dependent mid-year, thus changing their tier of coverage, would not be affected.