1062-Group Vision ContractGROUP VISION CONTRACT
CompBenefits Company
d/b /a
VisionCare Plan
(A licensed PLHSO under Chapter 636, F.S.)
and
City of Sanford
(Hereinafter Called Group)
In consideration of the Application made by the Group, a copy of which is attached hereto and made a part of this
Contract, and in consideration of payment by the Group of the appropriate premiums, VisionCare Plan (Hereinafter
called Plan) shall provide a provider network to perform services for eligible persons as defined by Group, subject to
the terms and conditions of this Contract.
Agreement
This Contract shall be effective October 1, 2005 (hereinafter called "Effective Date ") for an initial term of twenty -
four (24) months from the Effective Date and continuing thereafter for periods of twelve months each until
terminated by either party upon 60 days written notice prior to the anniversary date or as otherwise specified in the
Contract. Only authorized officers may make changes for Plan. Such changes must be in writing and attached to this
Contract. Plan reserves the right to amend the Contract from time to time. The Plan will provide, with respect to
each Member, the benefits provided in this Contract. Benefits are subject to the conditions, limitations and
exclusions of this Contract. This Contract is governed by the laws of the state of Florida.
Certificates
The Plan will furnish a Certificate for each Subscriber that will contain the benefits provided by this Contract.
Incorporation Provision
The provisions of the attached Certificate, Schedule of Benefits, and all rider(s) issued to amend this Policy on or
after the effective date are made a part of this Contract. This Contract was signed by the Group on the Group
Application form. We sign here on behalf of VisionCare Plan.
President & COO
CBC- Grp- Poticy.081
1 (Florida)
GROUPNUMBER. VS4753
DEFINITIONS
Copayment- the amount paid by Member for services rendered or materials purchased.
Contract- means the written agreement between CompBenefits Company and the Group.
Contribution- a periodic payment due to CompBenefits Company by or on behalf of Member to receive benefits as
provided by the Certificate.
Dependent— means any of the following persons: your spouse; your children; from birth to age 19 and dependent
upon you for support; or 19 years of age through the end of the calendar year in which the child reaches the age of
25, if the child meets all of the following: the child is dependent upon you for support; and the child is living in your
household, or the child is a full -time or part -time student. A child also includes adopted children, as well as
stepchildren or foster children living with the Subscriber in a parent -child relationship.
Group- means the aggregate of individuals eligible to be covered under the Plan as established by the terms of the
Contract.
Member- means the Subscriber and covered Dependents of a Subscriber.
Plan, We, Us or Our- means CompBenefits Company
Schedule of Benefits— means the listing of benefits showing what is paid.
Subscriber- an individual in good standing for whom the necessary contributions and Copayments have been made
and to whom a Certificate evidencing coverage has been issued.
VisionCare Plan Network Provider- a licensed optometrist or ophthalmologist under agreement with
CompBenefits Company to provide vision services to Plan Members.
LIMITATIONS
The Plan is designed to cover visual needs rather than cosmetic choices. Covered Materials that are lost or broken
will only be replaced at normal intervals as provided for in the Schedule of Benefits. The Member is responsible for
the following extra items selected, unless otherwise listed as a covered benefit in the Schedule of Benefits. These
items include but are not limited to:
• Coated or laminated lenses.
• Blended or progressive multifocal lenses.
* Tinted or photochromic lenses, sunglasses, prescription and plano.
* A frame that costs more than the Plan allowance.
* Groove, drill or notch, and roll and polish.
EXCLUSIONS
The Plan does not pay benefits for services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing;
• Subnormal vision aids, non - prescription or aniseikonic lenses;
• Contact lenses, except as covered in the Schedule of Benefits;
• Hi Index, aspheric and non - aspheric styles;
• Oversized 61 and above lens or lenses;
• Experimental or non - conventional treatment or device;
• Medical or surgical treatment of the eyes;
• Charges incurred after coverage ends;
• Cosmetic items, unless specifically covered in the Schedule of Benefits;
• Any injury or illness covered paid any Workers Compensation or similar law;
• Two pairs of glasses in lieu of bifocals, trifocals or progressives;
• Services or materials from a provider that is not a VisionCare Plan Network Provider; or
• Any services and/or materials required by an employer as a condition of employment.
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GROUP NUMBER: VS4753
USING YOUR PLAN
The Member may choose between either the Benefit Form Method or the Dash Method each time prior to
services being received.
Benefit Form Method: You may obtain a Benefit Form before scheduling an appointment. Benefit forms may be
requested by (i) calling the Plan's Member Services Department at I -800- 865 -3676; (ii) connecting to Our Web site
at w ww.visioncare.com ; (iii) faxing toll free at 1 -800- 421 -0100 or (iv) mailing Us at P.O. Box 30349, Tampa, FL
33630 -3349.
A Benefit Form, valid for sixty (60) days along with a list of VisionCare Plan Network Providers in your area, will
be sent to you. Members' use of benefits under another vision plan will affect determination of benefits under this
Plan. Members must choose a VisionCare Plan Network Provider from the list and schedule an appointment. Please
identify yourself as a VisionCare Plan Member and have your group name and policy number available.
Present the original Benefit Form to the VisionCare Plan Network Provider you selected at the time of your first
scheduled appointment. The VisionCare Plan Network Provider will provide the covered service and bill the Plan
directly. You will pay your Copayment and any extra costs for services and materials not covered by the Plan.
Dash Method: Before scheduling an appointment, the Member must choose a VisionCare Plan Network Provider
from the list of the network providers in the Member's area. The Member must call to schedule an appointment and
give the VisionCare Plan Network Provider his /her name, the patient's name, ID number, and the Group name and
number. After scheduling the appointment, the VisionCare Plan Network Provider's office verifies the Member's
eligibility and benefits before performing the exam. When the exam is completed, the VisionCare Plan Network
Provider has the Member sign a claim form. The VisionCare Plan Network Provider submits the form directly to
the Plan for payment. The Member is responsible for the Copayment and the costs of services and materials not
covered by the Plan.
PLEASE NOTE: If you visit a VisionCare Plan Network Provider and do not follow the proper procedures to
verily your eligibility and benefits in advance, you will be treated as a private patient. This means that the
VisionCare Plan Network Provider is not obligated to accept the Plan's fees and he can charge you his usual fees.
PROBLEM - SOLVING
Informal Grievances
Any Member who has a suggestion for improving services or wishes to register a complaint for any matter arising
out of the Certificate or for covered services rendered or materials received, may submit an informal oral grievance
to the Plan. Assistance with the Plan's grievance procedures, including informal oral grievances, may be obtained by
contacting the Member Services Department at the address and phone number shown below. Informal oral
grievances will be responded to as soon as possible. The Member has the right to file a formal written grievance
with the Plan and to grieve directly to the State of Florida Department of Insurance.
Submission of Formal Grievances
Any Member who has a suggestion for improving services or wishes to register a complaint for any matter arising
out of the Certificate, or for covered services or materials received, may submit a formal written grievance to the
Plan. The written grievance must be identified as such and submitted to the Plan's Grievance Coordinator within one
(1) year from the date of the occurrence of the events upon the grievance is based. The grievance must contain the
Member's name, address, phone number, ID number, signature, date, and the action requested. Assistance with the
Plan's grievance procedures may be obtained by contacting the Member Services Department at the address and
phone number shown below.
Response to Formal Grievances
The Grievance Coordinator will investigate the grievance, gather all of the relevant facts review the case with the
appropriate parties and respond in writing to the Member and the VisionCare Plan Network Provider, if appropriate,
CBC- Grp- Policy.001
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GROUPNUMBER: VS4753
within ten (10) days of completion of the review. If the grievance involves an eyecare related matter or claim, the
Plan's Medical Director shall be involved in the resolution. If it involves denial of benefits or services, the written
decision shall state the specific provisions of this Certificate upon which the denial is based. All grievances shall be
processed within sixty (60) days, however, if the grievance involves collection of information from outside the
Plan's service area, an additional thirty (30) days will be allowed for processing.
Appeal of Decision
If the Member is not satisfied with the formal grievance decision, the Member may request reconsideration by the
Grievance Committee and may also request a personal appearance before the Committee. A request for
reconsideration must be made within sixty (60) days after receipt of the written decision. In addition, at any time a
Member always has the right to grieve directly to the State of Florida Department of Insurance.
Contact Information
CompBenefits Company Florida Department of Insurance
P.O. Box 30349 Consumer Assistance
Tampa, FL 33630 -3349 200 East Gaines Street
Att: Member Services Department Tallahassee, FL 32399 -032
or call, toll free at (800) 865 -3676 or call toll free Consumer Hotline at (800) 342 -2762
A Member whose coverage was terminated may receive a converted contract if he was continuously covered under
the Plan for at least three (3) consecutive months immediately prior to termination. The converted contract will
provide coverage and benefits similar to the Contract previously in effect. A Member is not entitled to a converted
contract if termination occurred for any of the following reasons:
• Failure to pay contributions.
• Replacement by similar coverage within thirty -one (3 1) days.
• Material misrepresentation or fraud in applying for any benefit under the Contract.
• Disemollment for cause.
Willful and knowing misuse of the Plan I.D. card or Certificate.
Willful and knowing furnishing to the Plan incorrect information for the purpose of fraudulently obtaining
coverage or benefits.
The Subscriber has left the Plan's geographic area with the intent to relocate or establish a new residence outside
the Plan's geographic area.
Subject to the conditions set forth above, the conversion privilege shall also be available to:
* The surviving spouse and/or children, if any, at the death of the Subscriber, with respect to the spouse and such
children whose coverages under Plan contract terminate by reason of such death.
* To the former spouse whose coverage would otherwise terminate because of annulment or dissolution of
marriage, if the former spouse is dependent for financial support.
* To the spouse of the Subscriber upon termination of coverage of the spouse, while the Subscriber remains covered
under a group contract, by reason of ceasing to be a qualified family member under the group contract.
* To a child solely with respect to himself or herself, upon termination of coverage by reason of ceasing to be a
qualified family member under a group contract.
DURATION OF AGREEMENT
Except under the following conditions, this Certificate shall remain in force for a period of not less than twelve (12)
months. Except for nonpayment of Contributions or termination of eligibility, the Plan may cancel this Certificate
with forty -five (45) days written notice for the following reasons:
- When a Member commits any action of fraud or material misrepresentation in applying for or presenting any claim
for benefits involving the Plan.
CBC- Grp- Pulicy_001
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GROUP NUMBER VS4753
- When a Member's behavior is disruptive, unruly, abusive, unlawful, fraudulent, or uncooperative to the extent that
the Member's continuing participation seriously impairs the ability of a VisionCare Plan Network Provider, to
provide services to the Member and/or to other Members.
- When a Member misuses the documents provided as evidence of benefits available pursuant to the Contract or this
Certificate.
- When a Member fumishes to the Plan incorrect or incomplete information for the purposes of fraudulently
obtaining services.
- When a VisionCare Plan Network Provider is not available within the immediate geographical area of the
Subscriber.
- When reasonable efforts by the Plan to establish and maintain a satisfactory patient relationship are unsuccessful or
when the Member has indicated unreasonable refusal to accept necessary treatment. When a Member refuses to
accept treatment from two (2) VisionCare Plan Network Providers, proof of unreasonable refusal shall be presumed
conclusively.
- Prior to cancellation, the Plan shall make every effort to resolve the problem through its grievance procedure and
to determine that the Member's behavior is not due to use of the vision care services provided or mental illness.
Coverage for a Member will end on the earlier of:
• On the date the Group tells Us that the Member ceases to be eligible for coverage.
• The last day of the month in which a Dependent of Subscriber is no longer a Dependent as defined.
• Subject to the grace period provision, the last day of the month for which a premium has been paid.
• The date coverage ends for any class or group to which Subscriber belongs.
• The date the Contract ends.
EXTENSION OF BENEFITS
Cancellation of this Certificate by the Plan is without prejudice to any continuous loss which commenced while
this Certificate was in force. VisionCare Plan Network Providers shall complete all procedures undertaken upon the
Member, until the specific treatment or procedure is completed or for ninety (90) days, whichever occurs first.
CONTINUATION OF COVERAGE
Unless cancellation of this Certificate is made for reasons specified in the Section entitled "Duration of Agreement ",
Members for whom appropriate Contributions and Copayments are paid will have their Certificates automatically
renewed at the expiration of the first twelve (12) months. The following conditions also will apply:
At the attainment of the applicable age, coverage as a Dependent shall be extended if the individual is and continues
to be both (1) incapable of self - sustaining employment by reason of mental retardation or physical handicap; and (2)
dependent upon the Subscriber for support and maintenance, provided proof of such incapacity and dependency is
furnished to the Plan within thirty -one (31) days of the Dependent's attainment of the limiting age and subsequently
as may be required by the Plan but not more frequently than once every two years.
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) for employers size 20+ requires that
certain employers maintaining group medical plans offer employees and their Dependents the opportunity to
continue their coverage when such coverage ends under certain conditions. More information about COBRA
continuation can be obtained from your employer.
CBC- Grp- Policy _001
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GROUP NUMBER: VS4753
EFFECTIVE DATE OF COVERAGE
If you qualify under the rules of your group medical insurance and have selected to receive vision care benefits
under this Plan, you will be covered on the later of:
• The first of the month following the date first eligible for coverage.
• The date CompBenefits Company accepts your enrollment if you are not enrolled within 30 days of becoming
eligible.
Dependents will be covered on the later of:
• The date you first acquire a new Dependent.
• The date the Plan accepts a new Dependent's enrollment if the Dependent is not enrolled within 30 days of
becoming eligible.
Newborn Child- A child born to you or your Dependent spouse is covered from the moment of birth for 30 days. If
you elect to cover your newborn under this Plan, you must enroll the child within 60 days from the date of birth and
pay the additional premium, if any, or coverage for that child will terminate at the end of the 30 day period.
Adopted Child- A child placed with you for adoption will be covered from the earlier of: 1) the date of birth if a
petition for adoption is filed within 30 days of the birth of such child; 2) the date you gain custody of the child under
a temporary court order that grants you conservatorship of the child; or 3) the date the child is placed with you for
adoption; and additional premium, if any, is paid.
COORDINATION WITH OTHER BENEFITS
APPLICABILITY
This Coordination With Other Benefits provision applies to This Plan when you or your covered Dependents have
vision care coverage under more than one Plan. For the purposes of this section only, 'Plan" and "This Plan" are
defined below. If this provision applies, the Order of Benefit Determination Rules should be looked at first. Those
rules determine whether the benefits of This Plan are determined before or after those of another Plan. The benefits
of This Plan: (a) will not be reduced when, under the Order of Benefit Determination Rules, This Plan determines its
benefits before another Plan; but (b) may be reduced when, under the Order of Benefit Determination Rules, another
Plan determines its benefits first. The above reduction is described in the Section entitled Effect on the Benefits of
this Plan.
DEFINITIONS
A "Plan" is any group insurance or group type insurance, whether insured or uninsured, which provides benefits for,
or because of, visual care specifically related to a vision exam, lenses and frames. This also includes 1) group or
group -type coverage through HMOs and other prepayment, group practice and individual practice plans; and 2)
group coverage under labor - management trusteed plans, union welfare plans, employer organization plans,
employee benefit organization plans or self insured employee benefit plans. It does not include school accident
type coverages, coverage under any governmental plan required or provided by law, or any state plan under
Medicaid. Each contract or other arrangement for coverage is a separate Plan. Also, if an arrangement has two parts
and coordination applies only to one of the two, each of the parts is a separate Plan.
"This Plan" means this Certificate.
CBC-Grp- Policy.001
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GROUP NUMBER: VS4753
"Primary Plan "/"Secondary Plan ". The Order of Benefit Determination Rules state whether This Plan is a Primary
Plan or Secondary Plan as to another Plan covering the person. When This Plan is a Primary Plan, its benefits are
determined before those of the other Plan and without considering the other Plan's benefits. When This Plan is a
Secondary Plan, its benefits are determined after those of the other Plan and may be reduced because of the other
Plan's benefits. When there are more than two Plans covering the person, This Plan may be a Primary Plan as to one
or more other Plans, and may be a Secondary Plan as to a different Plan or Plans.
"Allowable Expenses" means the allowed amount as shown in the Schedule of Benefits or the amount
CompBenefits Company is obligated to pay the Vision Care Plan Network Provider for the service or material
pursuant to the terms of the parties written agreement.
"Claim Determination Period" means a benefit year. However it does not include any part of a year during which a
person has no coverage under This Plan, or any part of a year before the date this provision or a similar provision
takes effect.
ORDER OF BENEFIT DETERMINATION RULES
This Plan determines its order of benefits using the first of the following rules which applies
(a) The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a
dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person
is also a Medicare beneficiary, Medicare is secondary to the Plan covering the person as a dependent and primary to
the Plan covering the person as other than a dependent, then the benefits of the Plan covering the person as a
dependent are determined before those of the Plan covering that person as other than a dependent. Except in the
case of legal separation or divorce (further described below), when This Plan and another Plan cover the same child
as a dependent of different persons, called "parents ": (1) the benefits of the Plan of the parent whose birthday falls
earlier in a year are determined before those of the Plan of the parent whose birthday falls later in that year; but (2) if
both parents have the same birthday, the benefits of the Plan which covered the parent longer are determined before
those of the Plan which covered the other parent for a shorter period of time. However, if the other Plan does not
have the rule described immediately above, and if, as a result, the Plans do not agree on the Order of Benefits, the
rule in the other Plan will determine the order of benefits.
(b) If two or more Plans cover a person as a dependent child of divorced or separated parents, benefits for the child
are determined in this order: (1) first, the Plan of the parent with custody of the child; (2) then, the Plan of the spouse
of the parent with custody of the child; and (3) finally, the Plan of the parent not having custody of the child.
However, if the specific terms of a court decree state that one of the parents is responsible for the health care
expenses of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual
knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect
to any Claim Determination Period or Plan Year during which any benefits are actually paid or provided before the
entity has that actual knowledge.
(c) The benefits of a Plan which covers a person as an employee who is neither laid off, retired or continuing
coverage under a right of continuation (or as a dependent of the person) are determined before those of a Plan which
covers that person as a laid off, retired or continuing coverage (or as a dependent of that person). If the other Plan
does not have this rule, and if, as a result, the Plans do not agree on the Order of Benefits, this rule is ignored.
(d) If none of the above rules determines the Order of Benefits, the benefits of the Plan which covered an
employee, member, or subscriber longer are determined before those of the Plan which covered that person for the
shorter time.
EFFECT ON THE BENEFITS OF THIS PLAN
This section applies when this Plan is a Secondary Plan to one or more other Plans. In the event the benefits of This
Plan may be reduced under this section. Such other Plan or Plans are referred to as 'the Other Plans ".
CBC- Grp- Policy.001
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GROUP NUMBER: VS4753
The benefits of This Plan will be reduced when the sum of: (a) the benefits that would be payable for the Allowable
Expenses under This Plan in the absence of this provision; and (b) the benefits that would be payable for the
Allowable Expenses under the other plans, in the absence of provisions with a purpose like that of this provision,
whether or not claim is made; exceeds those Allowable in a Claim Determination Period. In that case, the benefits of
This Plan will be reduced so that they and the benefits payable under the Other Plans do not total more than those
Allowable Expenses. When the benefits of This Plan are reduced as described above, each benefit is reduced in
proportion. It is then charged against any applicable benefit limit of This Plan.
RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION
Certain facts are needed to apply these rules. The Plan has the right to decide which facts are needed. CompBenefits
Company may get needed facts from, or give them to, any other organization or person. CompBenefits Company
need not tell, or get the consent of, any person to do this. Each person claiming benefits under This Plan must give
CompBenefits Company any facts deemed necessary to pay the claim.
FACILITY OF PAYMENT
A payment made under another Plan may include an amount which should have been paid under This Plan. If it
does, CompBenefits Company may pay that amount to the organization which made that payment. That amount
will then be treated as though it were a benefit paid under This Plan. CompBenefits Company will not have to pay
that amount again. The term "payment made" includes providing benefits in the form of services, in which case,
"payment made" means reasonable cash value of the benefits provided in the form of services.
RIGHT OF RECOVERY
If the amount of the payments made by CompBenefits Company are more than should have paid under this
provision, CompBenefits Company may recover the excess from one or more of: (a) the persons for whom payment
has been made; (b) insurance companies or other organizations providing benefits under another Plan.
CONTRIBUTIONS AND COPAYMENTS
Payments- It is agreed that in order for Member to be eligible for and entitled to receive benefits provided by this
Certificate, The Plan must receive all Contributions in advance. The VisionCare Plan Network Provider must
receive all Copayments for services rendered or materials obtained under the terms of the Plan.
Grace Period- The Contract under which this Certificate is issued has a thirty (30) day grace period. This provision
means that if any required Contribution is not paid on or before the date it is due, it may be paid subsequently during
the grace period. During the grace period, the Contract and this Certificate will stay in force. If full payment is not
received within the thirty (30) day grace period, coverage will be terminated effective the first day of the grace
period. Subscriber will be liable for the cost of all services and materials received during the grace period.
Reinstatement — Subscribers whose coverage is terminated for non - payment of Contributions prior to the expiration
of thirty (30) day grace period only may have their coverage reinstated if a request for reinstatement is submitted by
the Group for consideration by the Plan. The Plan may or may not agree to such request.
CHANGES IN CONTRIBUTIONS AND BENEFITS
Contract Changes- The Plan may increase Copayments or delete, amend, or limit any benefits under the Contract
upon not less than 90 days prior written notice to the Group prior to renewal of the Contract. It is the responsibility
of the Group to notify all Members of any such changes to the Contract.
Premium Changes- Contributions charged by CompBenefits Company for coverage under the Plan may be
changed upon not less than 90 days advance written notice to the Group. It is the responsibility of the Group to
notify all Members of such change in Contributions.
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GROUP NUMBER- VS4753
GENERAL PROVISIONS
Incontestability — In the absence of fraud, all statements made by the Subscriber are considered representations and
not warranties during the first two years of coverage. The Plan may avoid providing coverage at any time if
Subscriber makes a fraudulent statement in a written application.
Conformity with Florida Law- This Certificate shall be interpreted in accordance with the laws of the State of
Florida and any action or claim, including arbitration, shall be brought within the State of Florida. Any statute, act,
ordinance, rule or regulation of any governmental authority with jurisdiction over CompBenefits Company shall
have the effect of amending this Certificate to conform with the minimum requirements thereof. In the event any
portion of this Certificate is held to be void, it shall not affect any other provisions.
Notice of Independent Contractor Relationship — The Plan assumes responsibility of fulfilling the terms of this
Certificate. VisionCare Plan Network Providers are independent contractors, and the Plan cannot be held responsible
for any damages incurred as a result of tort, negligence, breach of contract, or malpractice by a VisionCare Plan
Network Provider for any damage which result from any defective or dangerous condition in or about any facility
which services are rendered or materials are provided hereunder.
Worker's Compensation Act — The coverage under the Contract is not in lieu of and does not affect any
requirement for coverage by any Worker's Compensation Act, or other similar legislation.
SCHEDULE OF BENEFITS
The following vision services and materials are only covered when provided by a VisionCare Plan Network
Provider. The Member is responsible for payment of the applicable Copayment, if any.
Vision Examinations - Each Insured is eligible for a comprehensive eye examination which shall include: 1)
personal and family medical and ocular history; 2) visual acuity (unaided or acuity with present correction); 3)
external exam; 4) pupillary exam; 5) visual field testing (confrontation); 6) internal exam (direct or indirect
ophthalmoscopy recording cup disc ratio, blood vessel status and any abnormalities: 7) biomicroscopy (i.e. cover
test); 8) tonometry; 9) refraction (with recorded visual acuity); 10) extra ocular muscle balance assessment; 11)
diagnosis and treatment plan. We will cover such service once in any 12 month period.
Materials - Where the vision examination shows new lenses or frames or both are necessary for proper visual
health, such Materials will be covered, together with certain services as necessary. Services include, but are not
limited to: (1) prescribing and ordering proper lenses; (2) assisting with selection of frames; (3) verifying accuracy
of finished lenses; (4) proper fitting and adjustments.
Lenses - We will pay for one pair of prescription lenses once in any 12 month period.
Frames - We will pay for a new frame once in any 24 month period. The VisionCare Plan Network Provider will
show the Insured the frames that the Plan covers in full. VisionCare Plan Providers can also order any currently
provided frame that an Insured may find elsewhere. If an Insured selects a frame that costs more than the amount
the Plan covers, the Insured is responsible for the difference in cost.
Contact lenses when necessary — We will pay for one pair of contact lenses under the following circumstances and
only if prior authorization from the Plan is obtained: 1) following cataract surgery without intraocular lens; 2)
correction of extreme visual acuity problems not correctable with glasses; 3) Anisometropia greater than 5.00
diopters and aesthenopia or diplopia, with spectacles; 4) Keratoconus; or 5) monocular aphakia and/or binocular
aphakia where the doctor certifies contact lenses are medically necessary for safety and rehabilitation to a productive
life. Replacement will not be more often than once in any 12 month period and only if prior authorization is
obtained from the Plan. The Copayment is waived.
CBC- Grp- Policy.001
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GROUP NUMBER. VS4753
Contact lenses when elective - Benefits include: (1) The cost of an annual vision examination, subject to the
Copayment; and (2) the cost of contact lenses, any fitting cost and follow -up visit up to a maximum of $105.00, not
subject to the Copayment. This benefit is in lieu of all other benefits and not available when benefits for eyeglasses
are received. Replacement will not be more often than once in any 12 month period.
Co- Payment - An Insured's Co- payment is:
Vision Examination $20
Materials $20
CBC- Grp- Policy.00l
Q (Florida)
GROUP NUMBER: V54753
COMPBENEFITS INSURANCE COMPANY
100 Mansell Court East Roswell, GA 30076 (800) 865 -3676
Group Vision Insurance Policy
POLICYHOLDER:
POLICY NUMBER
POLICY EFFECTIVE DATE:
CONTRACT PERIOD
STATE OF DELIVERY
City of Sanford
VS4753
October 1, 2005
October 1, 2005 — September 31, 2007
Florida
Read Your Policy Carefully
This Policy is a legal contract between the Policyholder and CompBenefits Insurance Company (hereinafter referred
to as "CompBenefits "). The consideration for this contract is the group application and the payment of premiums as
provided hereinafter.
Agreement
This Policy is the entire contract with the Policyholder and CompBenefits. This Policy shall be effective for an
initial term of twenty -four (24) months from the Policy Effective Date and continuing thereafter for periods of
twelve months each until terminated by either party upon 60 days written notice prior to the anniversary date or as
otherwise specified in the Policy. Only authorized officers may make changes for CompBenefits. Such changes
must be in writing and attached to this Policy. CompBenefits reserves the right to amend the Policy from time to
time. CompBenefits will pay, with respect to each Insured, the insurance benefit provided in this Policy. Payment is
subject to the conditions, limitations and exceptions of this Policy. Eligibility requirements to be insured under this
Policy are stated in the section entitled Becoming Insured. This Policy is governed by the laws of the state shown
above.
Certificates
CompBenefits will furnish a Certificate for each Insured person which will contain the benefits provided by this
Policy.
Incorporation Provision
The provisions of the attached Certificate and all rider(s) issued to amend this Policy after the effective dates are
made a part of this Policy. This Policy was signed by the Policyholder on the Group Application form. We sign here
on behalf of CompBenefits.
President & COO
CBC- Grp- Policy.001
1 (Florida)
GROUP NUMBERS VS4753
COMPBENEFITS INSURANCE COMPANY
100 Mansell Court East Roswell, GA 30076 (800) 865 -3676
CERTIFICATE
OF
GROUP VISION INSURANCE
This Certificate outlines the features of the Group Vision Insurance Policy issued to the Policyholder by
CompBenefits Insurance Company (hereinafter referred to as "CompBenefits "). Read it carefully to become familiar
with Your coverage. In this Certificate, the masculine pronouns include both masculine and feminine gender unless
the context indicates otherwise. Your coverage may be terminated or amended in whole or in part under the terms
and provisions of the Policy.
If you should have any questions, or to obtain coverage information or assistance in resolving complaints, please call
(800) 865 -3676.
Signed for CompBenefits Insurance Company
President & COO
CBC- Grp- Policy.001
(Florida)
GROUP NUMBER: V54753
TABLE OF CONTENTS
Section I- Definitions ............................................... ............................... Z
Section II- Becoming Insured ..................................... ............................... 3
Section III- Procedures for Using Benefits ...................... ............................... 3
Section IV- Limitations and Exclusions ...............................................
Section V- Coordination With Other Benefits ......................................
Section VI- Premiums .............................................. ............................... 6
SectionVII- Claims ................................................ ...............................
Section VIII - Notice of Continuation of Group Health Coverage Rights (COBRA) ...... 7
Section IX- General Provisions ................................... ............................... 9
SECTION I - DEFINITIONS
Copayment- means the amount an Insured is required to pay when a covered service is rendered or covered
Materials are purchased.
Dependent- means any of the following persons:
1. Your spouse;
2. Your child;
a) from birth to age 19 and dependent upon You for support
b) 19 years of age through the end of the calendar year in which the child reaches the age of 25 years of
age, if dependent upon You for support and a full -time or part -time student or residing in your
household; or
c) at least 19 years of age and:
i. primarily dependent upon You for support because of mental or physical handicap;
ii. was incapacitated and insured under Policy on his 19 birthday; and
iii. continues to be incapacitated beyond his W birthday.
A child also includes adopted children, as well as stepchildren, children placed in court- ordered custody,
including foster children, living with You in a parent -child relationship.
Group- means the aggregate of individuals eligible to be covered under the Policy. Group also refers to the
subgroup participating under the Policy for the benefit of its group members.
Insured- means You and Your Dependent(s) covered under the Policy.
Materials- means lenses, frame and contact lenses covered under the Policy.
Policy- means the Policy issued to the Policyholder.
Policyholder — means the Group to whom the Policy has been issued.
Schedule of Benefits - means the listing of benefits showing what is paid.
"You" and "Your" means the Certificateholder.
"We ", "Our ", "Us ", and "Plan" means CompBenefits.
CBC- Grp- Policy.001
2 (Florida)
GROUPNUMBER: VS4753
SECTION II - BECOMING INSURED
Your Coverage Begins- You and Your Dependents are covered at 12:01 a.m. on the later of:
1. The first of the month following the date first eligible for coverage;
2. The date We accept Your enrollment, if You are not enrolled within 30 days of becoming eligible;
3. The date You first acquire a new Dependent;
4- The date We accept a Dependent's enrollment, if he is not enrolled within 30 days of becoming
eligible.
Newborn Child- A child born to You or a covered Dependent is covered from the moment of birth for 30 days. If
timely notice is given, Plan may not charge an additional premium for coverage of the newborn child for duration of
the notice period. If timely notice is not given, Plan may charge an additional premium from the date of birth. If
notice is given within 60 days of the birth of the child, Plan may not deny coverage for a child due to the failure of
the Plan to timely notify the Plan of the birth the child.
Adopted Children, Foster Children- Benefits applicable to Your Dependent children also apply to an adopted
child, court - ordered child or foster child placed in compliance with chapter 63, from the moment of placement in
Your residence. 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 You prior to the birth of the child, whether or not the agreement is
enforceable. This section does not require coverage for an adopted child who is not ultimately placed in Your
residence in compliance with chapter 63.
You must notify Us of the birth or placement of the adopted child not less than 30 days after the birth or placement
in Your residence of a child adopted by You. If timely notice is given, We may not charge an additional premium
for coverage of the child for the duration of the notice period. If timely notice is not given, We may charge an
additional premium from the date of birth or placement. If notice is given within 60 days of the birth or placement of
the child, We may not deny coverage for the child due to Your failure to timely notify Us of the birth or placement
of the child.
Your Coverage Ends- Coverage for You and/or Your Dependent will end at 12:01 a.m. on the earlier of
1. On the date the Policyholder tells Us that You and/or Your Dependent cease to be eligible for coverage;
2. The last day of the month in which Your Dependent is no longer a Dependent as defined;
3. Subject to the Grace Period provision, the last day of the month for which a premium has been paid; or
4. The date coverage ends for any class or Group to which You belong; or
5. The date the Policy ends.
If Your coverage ends it will not prejudice any existing claim. If service is being rendered at the time coverage ends
for an Insured, We will continue to reimburse for such service to completion, but in no event beyond a 3 -month
period following the date coverage ended.
SECTION III - PROCEDURES FOR USING BENEFITS
The Insured may receive covered services and Materials from a licensed Optometrist or Ophthalmologist of his
choice. The Insured may pay the provider in full for any service and/or Materials at the time the service is rendered
or the Materials are provided and then submit to Us an itemized statement of charges. We will reimburse covered
services and Materials only up to the allowance, as shown in the Schedule of Benefits. The Insured is responsible for
the costs and fees associated with covered services or Materials in excess of the allowance as shown in the Schedule
of Benefits, and any services or materials NOT covered by the Policy. Determination of benefits under this Plan
will be affected if a covered service or Material was provided under another vision plan.
CBC- Grp- Policy.001
3 (Florida)
GROUP NUMBER: VS4753
SECTION IV- LIMITATIONS AND EXCLUSIONS
Limitations - In no event will coverage exceed the lesser of:
I. The actual cost of covered services or Materials;
2. The limits of the Policy, shown in the Schedule of Benefits; or
3. The allowance as shown in the Schedule of Benefits.
Materials covered by the Policy that are lost or broken will only be replaced at normal intervals as provided for in
the Schedule of Benefits.
We will pay only for the basic cost for lenses and frames covered by the Policy. The Insured is responsible for extras
selected, including but not limited to:
I. Blended lenses;
2. Progressive multifocal lenses;
3. Photochromatic lenses; tinted lenses, sunglasses, prescription and plano;
4. Coating of lens or lenses;
5. Laminating of lens or lenses;
6. Groove, Drill or Notch, and Roll and Polish;
unless otherwise specifically listed as a covered benefit in the Schedule of Benefits.
Exclusions - We will not cover:
1. Orthoptic or vision training and any associated supplemental testing;
2. Two pair of glasses, in lieu of bifocals, trifocals or progressives;
3. Medical or surgical treatment of the eyes;
4. Any services and/or materials required by an Employer as a condition of employment;
5. Any injury or illness paid under any Workers' Compensation or similar law;
6. Sub - normal vision aids, aniseikonic lenses or non - prescription lenses;
7. Charges incurred after: (a) the Policy ends; or (b) the Insured's coverage under the Policy ends,
except as stated in the Policy.
8. Experimental or non - conventional treatment or device;
9. Contact lenses, except as specifically covered by the Policy;
10. Hi Index, aspheric and non - aspheric styles
It. Oversized 61 and above lens or lenses;
12. Cosmetic items, unless otherwise specifically listed as a covered benefit in the Schedule of
Benefits.
SECTION V- COORDINATION WITH OTHER BENEFITS
1. APPLICABILITY.
This Coordination With Other Benefits provision applies to This Plan when You or Your covered dependents have
vision care coverage under more than one Plan. For the purposes of this section only, 'Plan" and "This Plan" are
defined below. If this provision applies, the Order of Benefit Determination Rules should be looked at first. Those
rules determine whether the benefits of This Plan are determined before or after those of another Plan. The benefits
of This Plan (a) will not be reduced when, under the Order of Benefit Determination Rules, This Plan determines its
benefits before another Plan; but (b) may be reduced when, under the Order of Benefit Determination Rules, another
Plan determines its benefits first. The above reduction is described in Section 4, Effect on the Benefits of This Plan.
2. DEFINITIONS.
A 'Plan" is any group insurance or group type insurance, whether insured or uninsured, which provides benefits for,
or because of, vision care or treatment. This also includes 1) group or group -type coverage through HMOs and
other prepayment, group practice and individual practice plans; and 2) group coverage under labor- management
trusteed plans, union welfare plans, employer organization plans, employee benefit organization plans or self insured
CeC- cry- Poricy.00]
4 (F7odaa)
GROUP NUMBER: VS4753
employee benefit plans. It does not include school accident type coverages, coverage under any governmental plan
required or provided by law, or any state plan under Medicaid. Each contract or other arrangement for coverage is a
separate Plan. Also, if an arrangement has two parts and coordination applies only to one of the two, each of the
parts is a separate Plan.
"This Plan" means this Policy.
"Primary Plan"/"Secondary Plan ". The Order of Benefit Determination Rules state whether This Plan is a Primary
Plan or Secondary Plan as to another Plan covering the person. When This Plan is a Primary Plan, its benefits are
determined before those of the other Plan and without considering the other Plan's benefits. When This Plan is a
Secondary Plan, its benefits are determined after those of the other Plan and may be reduced because of the other
Plan's benefits. When there are more than two Plans covering the person, This Plan may be a Primary Plan as to one
or more other Plans, and may be a Secondary Plan as to a different Plan or Plans.
"Allowable Expenses" means the allowed amount as shown in the Schedule of Benefits.
"Claim Determination Period" means a benefit year. However it does not include any part of a year during which a
person has no coverage under This Plan, or any part of a year before the date this provision or a similar provision
takes effect.
3. ORDER OF BENEFIT DETERMINATION RULES.
This Plan determines its order of benefits using the first of the following rules which applies:
(a) The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a
dependent) are determined before those of the Plan which covers the person as a dependent; except that if the
person is also a Medicare beneficiary, Medicare is secondary to the Plan covering the person as a dependent and
primary to the Plan covering the person as other than a dependent, then the benefits of the Plan covering the
person as a dependent are determined before those of the Plan covering that person as other than a dependent.
Except in the case of legal separation or divorce (further described below), when This Plan and another Plan
cover the same child as a dependent of different persons, called "parents ":
(1) the benefits of the Plan of the parent whose birthday falls earlier in a year are determined before those of
the Plan of the parent whose birthday falls later in that year; but
(2) if both parents have the same birthday, the benefits of the Plan which covered the parent longer are
determined before those of the Plan which covered the other parent for a shorter period of time. However,
if the other Plan does not have the rule described immediately above, and if, as a result, the Plans do not
agree on the Order of Benefits, the rule in the other Plan will determine the order of benefits.
(b) If two or more Plans cover a person as a dependent child of divorced or separated parents, benefits for the child
are determined in this order: (1) first, the Plan of the parent with custody of the child; (2) then, the Plan of the
spouse of the parent with custody of the child; and (3) finally, the Plan of the parent not having custody of the
child. However, if the specific terms of a court decree state that one of the parents is responsible for the health
care expenses of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has
actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply
with respect to any Claim Determination Period or Plan Year during which any benefits are actually paid or
provided before the entity has that actual knowledge.
(c) The benefits of a Plan which covers a person as an employee who is neither laid off, retired or continuing
coverage under a right of continuation (or as a dependent of the person) are determined before those of a Plan
which covers that person as a laid off, retired or continuing coverage (or as a dependent of that person). If the
other flan does not have this rule, and if, as a result, the Plans do not agree on the Order of Benefits, this rule is
ignored.(d)If none of the above rules determines the Order of Benefits, the benefits of the Plan which covered
an employee, member, or subscriber longer are determined before those of the Plan which covered that person
for the shorter time.
CBC- Grp- Policy .001 5 (Florida)
GROUP NUMBER: VS4753
4. EFFECT ON THE BENEFITS OF THIS PLAN
This section applies when, in accordance with Section 3. Order of Benefit Determination Rules, This Plan is a
Secondary Plan to one or more other Plans. In the event the benefits of This Plan may be reduced under this section.
Such other Plan or Plans are referred to as 'the Other Plans ".
The benefits of This Plan will be reduced when the sum of: (a) the benefits that would be payable for the Allowable
Expenses under This Plan in the absence of this provision; and (b) the benefits that would be payable for the
Allowable Expenses under the other plans, in the absence of provisions with a purpose like that of this provision,
whether or not claim is made; exceeds those Allowable in a Claim Determination Period. In that case, the benefits of
This Plan will be reduced so that they and the benefits payable under the Other Plans do not total more than those
Allowable Expenses. When the benefits of This Plan are reduced as described above, each benefit is reduced in
proportion. It is then charged against any applicable benefit limit of This Plan.
5. RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION.
Certain facts are needed to apply these rules. CompBenefits has the right to decide which facts are needed.
CompBenefits may get needed facts from, or give them to, any other organization or person. CompBenefits need not
tell, or get the consent of, any person to do this. Each person claiming benefits under This Plan must give
CompBenefits any facts deemed necessary to pay the claim.
6. FACILITY OF PAYMENT.
A payment made under another Plan may include an amount which should have been paid under This Plan. If it
does, CompBenefits may pay that amount to the organization which made that payment. That amount will then be
treated as though it were a benefit paid under This Plan. CompBenefits will not have to pay that amount again. The
term "payment made" includes providing benefits in the form of services, in which case, "payment made" means
reasonable cash value of the benefits provided in the form of services.
7. ERRORS RELATED TO YOUR COVERAGE.
The Plan has the right to correct benefit payments made in error. Providers and/or You have the responsibility to
return any overpayments to the Plan. The Plan has the responsibility to make additional payment if any
underpayments have been made.
SECTION VI- PREMIUMS
Premium Payments - All premiums are payable in advance for coverage under the Policy on the first day of each
calendar month in accordance with the premium rate schedules of CompBenefits in effect for each premium due
date.
Grace Periods - A grace period of 31 days is allowed for payment of each premium due after the first premium,
during such grace period the Policy shall continue in force, unless the Group has given the Plan written notice of
discontinuance in advance of the date of discontinuance and in accordance with the terms of the Policy. If any
premium is not paid prior to the end of the grace period, the coverage to which the premium applies will lapse at the
end of the grace period. We will charge a pro -rata premium for the time coverage under the Policy remained in force
for any Group during such grace period.
Change in Premiums - Premiums are payable to CompBenefits or Our authorized agent. Premiums may be
increased for a Policy period on the anniversary date of the Policy. Notice of the maximum amount of a premium
increase will be mailed to the Policyholder not less than 90 days prior to the anniversary of the Policy period.
Reinstatement - If any renewal premium is not paid within the time granted the Policyholder for payment, a
subsequent acceptance of premium by CompBenefits or by any agent authorized by CompBenefits to accept such
premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy;
provided, that if CompBenefits or such agent requires an application for reinstatement and issues a conditional
receipt for the premium tendered, the Policy will be reinstated upon approval of such application by CompBenefits,
or lacking approval, upon the forty -fifth day following the date of such conditional receipt unless CompBenefits has
CBC- Grp- Poticy.001 6 (Florida)
GROUP NUMBER: VS4753
previously notified the Policyholder in writing of its disapproval of such application. The reinstated policy shall
cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due
to such sickness as may begin more than ten (10) days after such date. In all other respects, the Policyholder and
CompBenefits shall have the same rights thereunder as they had under the Policy immediately before the due date of
the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the
reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which
premium has not been previously paid, but not to any period more than sixty (60) days prior to the date of
reinstatement.
Termination - This Policy may be terminated if CompBenefits elects to discontinue offering this type of group
insurance coverage by this form of Policy or if CompBenefits elects to discontinue all types of coverage, in
accordance with applicable state and federal laws. You will receive at least one hundred - eighty (180) days advance
notice prior to such discontinuance. Unless otherwise permitted under state law, except for nonpayment of the
required premium or the failure to meet continued underwriting standards, CompBenefits will not terminate this
Policy prior to the first anniversary date of the Effective Date of the Policy as specified herein. Termination by
CompBenefits will be without prejudice to any expenses originating prior to the effective date of termination.
This section does not apply to a termination for nonpayment of premium by the Policyholder. In the event that the
Policyholder fails in a timely manner to pay premiums, the Policy will terminate on the expiration date of the grace
period.
SECTION VII - CLAIMS
Notice of Claim - Written notice of claim must be given to Us within 60 -days after the occurrence or
commencement of loss covered by the Policy, or as soon thereafter as reasonably possible. Notice given by or on
behalf of You or Your beneficiary to Us at P.O. Box 30349, Tampa, FL 33630 -3349, or to Our authorized agent,
with information sufficient to identify the Insured, shall be deemed notice to Us.
Claim Forms - You can get the forms You need for claiming benefits by calling Us at (800) 865 -3676 or writing Us
at P.O. Box 30349, Tampa, FL 33630 -3349. If the forms are not sent to You before the expiration of 15 days after
the giving of notice, You shall be deemed to have complied with the requirements of the Policy as to proof of loss
upon submitting, within the time fixed in the Policy for filing proof of loss, written proof covering the occurrence,
character. and extent of the loss for which claim is made.
Time of Payment of Claims - Indemnities payable under this Policy for any loss, other than loss for which the
Policy provides any periodic payment, will be paid immediately upon receipt of due written proof of such loss.
Subject to due written proof of loss, all accrued indemnities for loss for which the Policy provides periodic payment
will be paid monthly and any balance remaining unpaid upon the termination of liability will be paid immediately
upon receipt of due written proof.
Proof of Loss — Written proof of loss must be furnished to Us at P.O. Box 30349, Tampa, FL 33630 -3349 in the
case of claim for loss for which the Policy provides any periodic payment contingent upon continuing loss within
90 -days after the termination period for which We are liable and, in the case of claim for any other loss, within 90-
days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce
any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon
as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time
proof is otherwise required.
Legal Action - No action at law or in equity shall be brought to recover on the Policy prior to the expiration of 60
days after written proof of loss has been furnished in accordance with the requirements of the Policy. No such action
shall be brought after the expiration of the applicable statute of limitations from the time written proof of loss is
required to be furnished.
CBC-0rp- Policy.001 '� (Florida)
GROUP NUMBER: VS4753
SECTION VIII- NOTICE OF CONTINUATION OF GROUP HEALTH
COVERAGE RIGHTS (COBRA) FOR GROUPS SIZE 20 OR MORE
If Your insurance terminates in accordance with the other terms of this Policy, it will be reinstated as of the date of
termination if You elect to continue the insurance in force as described in this section. You may elect to continue
insurance if You are currently insured under this Policy, and if such insurance is terminating due to any of the
following Qualifying Events:
1. Termination of Your employment (for reasons other than gross misconduct);
2. Reduction of work hours including lay -off;
3. Death of the Certificateholder;
4. Divorce or legal separation;
5. A child ceases to be a dependent as defined in this Policy;
6. The Policyholder files for a Chapter 11 bankruptcy petition, and as a result to this You suffer a
loss of coverage under Your retiree coverage.
The maximum continuation of coverage period with respect to a reason described above is: (1) 18 months with
respect to 1 or 2 above. However, if You are disabled as determined under Title II or XVI of the Social Security Act
at the time of the Qualifying Event or any time during the first 60 days of continuation coverage, then You and any
other non - disabled eligible individuals will be eligible for an additional 11 months; (2) 36 months with respect to 3,
4 or 5 above; (3) With respect to 6 above, lifetime coverage for You, whereas Your Dependents will be covered
until the earlier of: (a) Your death; or (b) death of the Dependent. If, while insurance is being continued, further
qualifying events occur which would entitle You to again elect continuation, the total period of continuation may not
exceed 36 months from the date the initial continuation commenced, other than the coverage due to bankruptcy
filing as described above.
It is Your responsibility to notify the Policyholder of the occurrence of a Qualifying Event other than termination of
employment or reduction in work hours. You must notify the Policyholder within 60 days.
It is the responsibility of the Policyholder to provide You with written notice of Your right to continue coverage
under this Section. Such notice will also contain the amount of monthly premium You must pay to continue
coverage and the time and manner in which such payments must be made.
To continue coverage under this Policy You must notify the Policyholder of Your election within 60 days of the
latest of: (1) the date of Qualifying Event; (2) the date of the loss of coverage; or (3) The date the Policyholder
sends notice of the right to continue coverage.
Payment for the cost of insurance for the period preceding the election must be made to the Policyholder within 45
days after the date of such election. Subsequent payments are to be made to the Policyholder in the manner
described by the Policyholder in the notice. The Policyholder will remit the payments to CompBenefits.
Continuation of insurance will terminate at the earliest of the following dates: (1) The end of the maximum
continuation of coverage period; (2) The last day of the period of coverage for which premiums have been paid, if
You fail to make a premium payment when due; (3) Your becoming covered under another group vision care plan as
employee, spouse or dependent child; however, coverage will continue for a pre- existing condition for which
treatment has already commenced and which is excluded or limited by the other group vision plan; (4)
Discontinuance of this vision care benefit provision; or (5) The date Your employer ceases to provide any group
vision plan.
SECTION IX- GENERAL PROVISIONS
Representations and Warranties - All statements made by any Insured or the Group are deemed representations
and not warranties. No statement made by any person insured may be used in any contest unless a copy of the
instrument containing the statement is or has been furnished to You, or in the event of Your death or incapacity,
Your beneficiary or personal representative.
CBC-Grp- Policy.001 g (Florida)
GROUP NUMBER: VS4753
Worker's Compensation Act - The coverage under the Policy is not in lieu of and does not affect any requirement
for coverage by any Worker's Compensation Act, or other similar legislation.
Conformity with State Statutes - Any provision of the Policy which, on its effective date, is in conflict with the
statutes of the state in which the Insured resides on such date is hereby amended to conform to the minimum
requirements of such statutes.
Time Limit on Certain Defenses - After the Policy has been in force for a period of two (2) years during the
lifetime of the Insured, excluding any period during which the Insured is disabled, it shall become incontestable as
to the statements contained in the application.
SCHEDULE OF BENEFITS
The following vision services and materials are covered up to the Allowance shown below after deduction of
the applicable copayment, if any.
Vision Examinations - Each Insured is eligible for a comprehensive eye examination which shall include: 1)
personal and family medical and ocular history; 2) visual acuity (unaided or acuity with present correction); 3)
external exam; 4) papillary exam; 5) visual field testing (confrontation); 6) internal exam (direct or indirect
ophthalmoscopy recording cup disc ratio, blood vessel status and any abnormalities: 7) biomicroscopy (i.e. cover
test); 8) tonometry; 9) refraction (with recorded visual acuity); 10) extra ocular muscle balance assessment; 11)
diagnosis and treatment plan. We will cover such service once in any 12 month period.
Materials - Where the vision examination shows new lenses or frames or both are necessary for proper visual
health, such Materials will be covered, together with certain services as necessary. Services .include, but are not
limited to: (1) prescribing and ordering proper lenses; (2) assisting with selection of frames; (3) verifying accuracy
of finished lenses; (4) proper fitting and adjustments.
Lenses - One pair of prescription lenses once in any 12 month period.
Frames - One new frame once in any 24 month period.
Contact lenses when necessary — One pair of contact lenses under the following circumstances and only if prior
authorization from the Plan is obtained: 1) following cataract surgery without intraocular lens; 2) correction of
extreme visual acuity problems not correctable with glasses; 3) Anisometropia greater than 5.00 diopters and
aesthenopia or diplopia, with spectacles; 4) Keratoconus; or 5) monocular aphakia and/or binocular aphakia where
the doctor certifies contact lenses are medically necessary for safety and rehabilitation to a productive life.
Replacement will not be more often than once in any 12 month period and only if prior authorization is obtained
from the Plan. The Copayment is waived.
Contact lenses when elective - Benefits include: (1) The cost of an annual vision examination, subject to the
Copayment and (2) the cost of contact lenses, any fitting cost and follow -up visit up to a maximum of $105.00, not
subject to the Copayment. This benefit is in lieu of all other benefits and not available when benefits for eyeglasses
are received. Replacement will not be more often than once in any 12 month period.
Allowance — Vision Benefits will be reimbursed according to the following schedule:
Vision Examination
$35
Single Vision Lens
$25
Bifocal Lens
$40
Trifocal Lens
$60
Lenticular Lens
$100
Contact Lenses when elective
Exam +$105
Contact Lenses when necessary
$210
Frame
$45
CDC- Grp-Poticy.001 9 (Florida)
GROUP NUMBER: VS4753
09/19/05 MON 15:09 FAX 4072405452 C 0 M P B E N E F I T S 004
COMPBENEFITS INSURANCE COMPANY S -3
APPLICATION FOR GROUP VISIONCARE PLAN
To avoid unnecessary correspondence and delay, please complete all applicable questions.
GROUP INFORMATION
Phan Purchased: Core 13 Sac. 125 ID Employee CorelDependem See_ 125 ❑ Value Plan ❑
1. Full Legal Name of Proposed Group _ City Of Sanford
(es d Is to appear on porky)
Taraayerl.D.il 59 -6000 425 Nature Of Business or SIC Code Muni -gill
Address ARK AVE
R/ P 788
City Sanfom _ State FL Zip 32772 -1786 Phone( 407) 330 -5625
Person in Charge She man Title HR Director Fax (407)
2 Contact for Billing Information JoM R'ms-M
inc ft HR AnaWSt Phone ( 407) 330 -5026 `�
• VWOnCare Plan to BIII Group ❑ 4 Please provide us with one of the fdlowing: Enmllment Cards El list of Covered Employees Q
-m-
• Group to Self -Bill 13 -) Please provide ua With one of the foAovring monthly; List of Covered Employees ❑ Disk O Email
Efgibl@y Contact Jovice R "miss -McCOV hl Analyst Phone ( 407) 33Q�8
3. Eligible Employee$ (any wmkisions must be based upon coni-( —o13—
ditions pertalelrhg to employment)
(500)All full4lme active employees who work at lead U& hours per week
[ ] Omer (describe In detail)
4. Wartig period: New employee$ will be eligible on the first day of the month follumn 30 day
of full-time employment. Present employees who have satisfied this m" period 8 re eligible on the effective date of this cwerage.
5. Total number Of eligible emPbye&% ` Total number of employees 500
6. K vision coverage Is volradary, What Is the Section 125 plan anniversary date? Oc 1
7. Dependents covered? O YES ❑ NO Through IRC section 125? ID YES ❑ NO
Other informltton VISION PASS WITH ID CARD ANDJD CARDS MAI D lb EE'S HO
PTG SET UP FOR JOYCE RIGGINS- MCCOY (EMAIL RIGCtN`e�rl SANFORD.FL.US I FAX 4073305806 FECTIVE 10/
PLAN DETAILS
B. •Plan Frequency: Ehmm eve ,ry a . months Lenses every 12 nronths Frame every
24 momlts
CoWymerrt Exam 3 20 Material $ 20 • Elective contact lens allowance: $ �1(�
Monthly cosz $ 4Q per empkya a $ 10.78 cer emolOM otus som S 1 oz4 per emolovee pus r Ilefrero 510 tit) er (army
AGREEMENT
The kffvdwsigned group hereby applies for vision care through Vsioncere Plan, It Is understood and agreed that:
A- The group wig cover all current erns future eligible employees as defined above.
e. Coverage terminates for empfoyeeW&Tendents On the last day of the month in which employment terminates.
C. Group will continue this agreement in force for a minimum of two years from the effective ,
D. Group will submit monthly premiums due and payable directly to VisionCaze Plan with a single remittance by the I & of each month.
This plan Vail become effective on the 1' day of October M provided that all of the folimin
g has been completed prier to this effective date:
A. Application has been submitted to and accepted V - Care PfarL
B. vales ca e Plan fi.n s led a list of ag nor W $ew* number, bkl h date. and which employees have dependent coverage
C. A check fm fast month's coverage is inchrded hereWit h. J
This application signed this (�7 day of
Gmup /Employer C Senfmd
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VisionCare Plan
Administrative
Guide
V i r V CompBenefits
Plan Administered by CompBenefits
www.compbenefits.com
Table of Contents
Introduction /Contact Numbers 2
Enrollment Procedures 2 -4
Termination of Coverage 4
Billing Procedures 5 -6
Reconciling Your Payment 7
Member Access 7 -10
Plan Benefits 11
Limitations & Exclusions 12 -13
HIPPA Information 14 -16
Frequently Asked Questions 17 -18
Sales Office Locations 19
Introduction
Welcome to the CompBenefits family of clients. We are pleased that you have chosen
VisionCare Plan to provide and administer vision benefits for your employees. We take
our responsibility seriously and will do everything in our power to ensure that service
levels meet your expectations.
This guide is designed to assist you in the administration of the benefit program by
providing a handy reference to procedures and contacts in our company. We have kept it
as brief as possible to enable you to have a quick reference.
Please note that this guide is for reference and guidance only and may be amended from
time to time. All administrative policies are established by CompBenefits and can only be
changed with written permission from CompBenefits. The information in this guide does
not in any way change or alter the provisions or benefits contained in the policy,
certificates or benefit schedules.
Contact Numbers
VisionCare Plan Home Office
Phone: (800) 749-5855 or (813)289 -2020
Fax: (813) 349-5855
Address: 1511 N. Westshore Blvd. Suite 1000
Tampa, FL 33607
Non— Network Claims can be mailed to:
VisionCare Plan -- VCP Claims
1511 N. Westshore Blvd. Suite 1000
Tampa, FL 33607
Administration/Operations for Group Administrators
(800) 749 -5855
Member Services for Employees: (800) 865 -3676
Enrollment Procedures
Initial Enrollment
During the initial enrollment process all eligible employees and their dependents may enroll in
the plan. The effective date of their coverage will be the effective date of your plan.
Eligible employees may enroll after the initial enrollment period only for the following reasons:
I . New employees upon satisfying eligibility requirements defined by the Employer;
2. Newly acquired dependent(s) [spouse or child(ren)];
1 Individuals who become eligible due to a qualifying event,
4. Change of status (divorce, etc.); or
5. Annual open enrollment.
All employees will become effective on the first day of the next month.
Terms of Enrollment
All members must remain enrolled in the plan until an open enrollment period, except in the
following situations:
1. The subscriber voluntarily or involuntarily terminates employment with the
employer;
2. The subscriber's employment status changes to such an extent that he /she is no
longer eligible for benefit coverage as determined by the Employer's eligibility
rules;
3. The dependent reaches the limited age (Please refer to the group policy /
certificate for the dependent age limit) or
4. The member experiences a qualifying event.
Open Enrollment
Open enrollment is conducted annually, prior to the anniversary date of the contract.
VisionCare Plan will notify you 2 -3 months prior to the contract anniversary date of the
renewal terms for your policy. The open enrollment should be held at this time. The
following changes are allowed during open enrollment and are effective on the plan's
renewal date:
1. New enrollment for eligible employees not previously enrolled;
2. Enrollment for dependents not previously enrolled; or
3. Termination of coverage for subscribers and /or their dependents.
Employee / Subscriber Change Form
The following actions require completion of an employee/ subscriber change form *:
I. Employee name change;
2. Add dependent coverage;
3. Add dependent child(ren);
4. Terminate dependent spouse;
5. Terminate dependent child(ren);
6. Terminate all coverage;
7. Address change; or
8. Changing plans during an open enrollment.
* Signature by employee and date required.
Change forms must be submitted to VisionCare Plan no later than the 15` day of each
month to be effective on the I" day of the next month. Changes that are made after the
15` of the month will be processed as soon as possible but, may not be effective the 0
of the next month. Example: A change made on the 20 of April would become effective
on the 1" of June.
3
New Employees
New employees may be added to the group once they become eligible. Eligibility will be based
on the criteria that we have agreed upon. Applications received on or before the 15 of the month
will be processed to appear in our system by the I" of the next month. Employees must enroll
within 30 days of becoming eligible or wait until your next group open enrollment period.
Renewals
Coverage for employees and their dependents is automatically renewed upon each annual open
enrollment period unless a written request for termination is submitted to VisionCare Plan
Enrollment Materials
Please contact your local Account Manager for the following materials:
1. Enrollment packets;
2. Updated Provider Directories;
3. Enrollment Forms;
4. Employee /subscriber change forms:
5. Claim Forms;
6. Benefit Plan Design; or
7. Certificates of Coverage.
Enrollment packets are available which include an application, Schedule of Benefits, and updated
Provider Directory. Requests may be made through your local Account Manager.
Termination of Coverage
Coverage must remain in -force for the full month, with termination being the last day of
the month. VisionCare Plan must be notified of the termination by the 15' of the month
for coverage to terminate at the end of the month. At no time will VisionCare Plan
provide more than 60 days back credit for retroactive terminations submitted in the
current month.
Consolidated Omnibus Reconciliation ACT (COBRA)
VisionCare Plan will continue benefits in accordance with COBRA requirements as
administered by your company.
Once COBRA coverage is elected, the Administrator must collect the monthly premiums
from the individual and remit to VisionCare Plan. Upon receipt of the premiums,
VisionCare Plan will reinstate the individual back to the date of termination and continue
coverage as stipulated by COBRA requirements. Reinstatement will only be allowed up
to 180 days from the date of the qualifying event.
4
Billing Procedures
Invoices are mailed no later than the last day of each month. Included will be:
• An original copy of the invoice; or
• A bar coded return envelope.
It is important to review the first invoice to confirm the accuracy. Listed below for your
convenience is an explanation for each item on the invoice.
1. Your group account number
2. Coverage month for the current invoice
3. Your group's name and address
4. Certificate number for each covered subscriber
5. Names of each covered subscriber
6. Coverage period for each covered subscriber
7. Premium amount for each covered subscriber
8. Type ofplan for covered subscriber
9. Original effective date of coverage for each covered subscriber
10. Total premium for current invoice
11. Adjustments made to current invoice, if any
12. Current monthly premium due after adjustments
13. Total premium due. This includes the monthly adjusted
premium, past due premium and pending payments
14. Total number of subscribers on your group account
15. Due date for premium payment
16. Mailing address to send the premium remittance
See sample invoice on next page with above numbers referenced.
Invoice
EE Only II
Unreconciled Cash
EE + 1 3
Balance
(1)Croup Number
3639
Cun'ent Month Premium
(10) 246 -30
Desk Code
P
Total (14) 17
Administrative Fee
(2) For Month of
July, 2003
(12) 24630
(3) ABC COMPANY, INC.
Please Pay this amount
Invoice Number
000895136
ATTN. JOHN MANSELL
Payment Due
06
4100 SMITH ROAD
Agent k
99179
FRIENDLY, GEORGIA 30076
Agent Name
Reynolds, Julia C
Cvrg Prem
Bff
Cobra Certificate
Subscriber or Buyer
Prd Amt
Plan
Date
(4) 000 -00 -0001 (5)
SUBSCRIBER NAME
(6) 7/03 (7) 4 70
(8) PP (9) 04/97
000 -00 -0002
SUBSCRIBER NAME
7/03 10.50
PP
04/97
000 -00 -0003
SUBSCRIBER NAME
7/03 10.50
PP
08/97
000 -00 -0004
SUBSCRIBER NAME
7/03 10.50
PP
08/98
000 -00 -0005
SUBSCRIBER NAME
7/03 2470
PP
04/98
000 -00 -0006
SUBSCRIBER NAME
7/03 1800
PP
08/97
C 000 -00 -0007
SUBSCRIBER NAME
7/03 1800
PP
04/99
000-00 -0008
SUBSCRIBER NAME
7/03 10.50
PP
08/99
00000 -0009
SUBSCRIBER NAME
7103 10.50
PP
04100
000 -00 -0010
SUBSCRIBER NAME
7/03 10.50
PP
04/99
000 -00 -0011
SUBSCRIBER NAME
7/03 10.50
PP
II /01
000 -00 -0012
SUBSCRIBER NAME
7/03 10.50
PP
04/00
000 -00 -0013
SUBSCRIBER NAME
7/03 1800
PP
04/02
C 000 -00 -0014
SUBSCRIBER NAME
7/03 1050
PP
04/02
000 -00 -0015
SUBSCRIBER NAME
7/03 2470
PP
04/02
000 -00 -0016
SUBSCRIBER NAME
7/03 1050
PP
04/02
000 -00 -0017
SUBSCRIBER NAME
7/03 1050
PP
1 P98
'Previous Balance
EE Only II
Unreconciled Cash
EE + 1 3
Balance
Family 3
Cun'ent Month Premium
(10) 246 -30
Current Adjustments
(11)
Total (14) 17
Administrative Fee
Current Total Due
(12) 24630
Please Pay this amount
(13) 246.30
HOW YOU CAN REACH US
For benefit questions, please call
Member Services at (800) 342-
5209.
For benefit questions, please call
Account Services at (800) 342-
5209.
If you have special needs, please
call your billing representative, John
Doe at (800) 342 -5209 ext. 7812.
If no changes, detach and return bottom portion of invoice with your remittance_ If changes shown, adjust
the total premium and mail this entire form back to Complienefus with your remittance.
Check here if changes are shown on the back of this form. 0
ABC COMPANY, INC.
ATTNcJOHN MANSELL
4100 SMITH ROAD
FRIENDLY. GEORGIA 30076
MAKE CHECK PAYABLE TO.
(16) CompBenefits
PO Box 769849
Roswell, GA 30076 -8230
Group Number 3639
Desk Code P
For Month of July, 2003
Invoice Number 000895136
Payment Due (15) 06/15.'03
Check Number
Check Amount
I
Reconciling Your Payment
To cancel any employee on the invoice:
I. Complete the membership changes section found on
the back of page one of your invoice;
2. Strike through the individual's name with a single line, and
3. Note the date the certificate is to be cancelled (always on I" day of the
month).
To add new employees:
1. New applications for the month should be noted in the membership
changes section on the back of the invoice. Please include the additional
amount in your premium check.
Overpayments and credits should be noted on the invoice when you return it and you will
receive credit on the next invoice.
All refund requests must be submitted in writing listing the employee name and premium
amount to be refunded.
A copy of the invoice must accompany the premium payment.
Member Access
To access care, plan members are required to:
1. Request and obtain a personalized benefit form from VisionCare Plan;
2. Choose either a network or non - network doctor and set up an appointment for an
examination. (Members may only choose a non - network doctor if your plan
includes coverage for doctors outside the VisionCare Plan network. Members
may only receive partial reimbursement for expenses incurred Jrom a non -
network doctor.), and
3. Deliver the benefit form to the network doctor and pay any
plan co- payment at the time of the initial visit.
•'
Pay a non - network doctor's fees at the time of their visit and
send the benefit form to VisionCare Plan along with an itemized receipt for services
rendered.
The following steps outline the way to access your VisionCare Plan.
7
The Benefit Form
Plan members must request and obtain a benefit form prior to making an appointment for
their eye exam. To request a benefit form, plan members may call Member Services at
(800) 865 -3676, access the VisionCare Plan web -site at www.compbenefits.com fax in a
request to (800) 421 -0100 or mail a request card to VisionCare Plan at 1511 N.
Westshore Blvd. Ste 1000 Tampa FL 33607. At the time eligibility is verified, the
Member Services Representative will also verify past services to ensure the member is
covered for current services. Upon confirmation of eligibility a benefit form will be
issued and mailed directly to the plan member.
Member Access
The Benefit Form Continued.
Upon request, a current network provider directory will be included with the benefit
form. This form is valid for 60 days. Should the form expire prior to usage, the plan
member may request a replacement by returning the expired form to VisionCare Plan. If
the form is misplaced or destroyed the plan member must forward a brief explanation of
its disposition along with the request for a replacement. A replacement form will be
issued promptly by Member Services after re- verifying eligibility.
Eligibility
If an employee does not appear on the eligibility roster, Enrollment Services will attempt
to verify coverage through the member's employer. In the case where an employee is
determined to be ineligible, a notice will be sent to the member informing them of his or
her ineligibility. A plan benefit form can be issued when the employee becomes eligible
and again requests a form through Member Services.
The benefit form must be presented at the time of the initial visit. Upon failure to do so,
the member will be considered a private patient and may be charged the provider's usual
and customary fees. The member will be required to pay the full fee at the time of service
and submit an itemized receipt for reimbursement according to the non - network schedule
of reimbursement for your plan. The difference in the VisionCare Plan. network provider
fees and the private pay fees charged by the physician will not be reimbursed. Any exam
or material co- payment applicable to the plan will be deducted from the reimbursement.
(If your plan does not include non - network reimbursements, no payment will be made to
the member.)
8
Network Doctors
By choosing a network doctor, members are assured of quality care through a doctor that has
been approved by the VisionCare Plan Credentialing Committee. Network doctors must abide
by stringent criteria and agree to ongoing evaluations. After the examination, the member
simply signs the benefit form acknowledging services and materials received. That is the only
paperwork the member will encounter. The network doctor's office will file the claim for
payment.
DASH — Direct Access System Handling
An alternative to the benefit form system. This system alleviates the need for the benefit form
prior to making an appointment with the doctor. Upon enrolling in VisionCare Plan, the
member will receive their Certificate of Coverage and Member ID card. This card will not
only serve as identification but also describes how to access benefits as a DASH member in
six easy steps.
1. Before scheduling an appointment for eye care, the member would choose a doctor
from the list of doctors. This can be done from the list of doctors or, access the
VisionCare Plan web -site for a list of all active doctors. Call the selected doctor and
make an appointment.
2. When setting that appointment the member should identify themselves as a VisionCare
Plan member and provide the following information:
• The subscriber's name,
• The patient's name;
• The subscriber's Ill number:
• Policy number (group number); and
• Name of the subscriber's employer.
3. The doctor will schedule the appointment and verify eligibility and
benefits before the visit.
4. Upon your visit, show your ID card and sign the VisionCare Plan form provided by
the doctor at your initial visit. You'll pay any co- payments and/or the cost of any
upgrades at that time.
S. The doctor will provide you with a complete eye exam, and when necessary, order
prescribed eyeglasses or contact lenses from a VisionCare Plan approved lab. The
doctor also checks for accuracy and 6t.
6. VisionCare Plan pays the doctor directly for his or her professional
services. It's that easy!
9
Non - Network Doctors
Because VisionCare Plan offers the members a choice, members may opt to see a non-
network doctor if they prefer. Not all plans include coverage for non- network doctors. The
member must obtain a benefit form in the standard manner. When visiting a non - network
doctor, the member will pay the full amount of the doctor's regular charges for services and
materials. The member will then submit the benefit form along with the doctor's itemized
receipt to VisionCare Plan for reimbursement. Benefits are paid according to the plans out -
of- network schedule allowances. VisionCare Plan sends reimbursement payments directly to
the member.
Co- payments
Many of VisionCare Plan's contracts include a co- payment that the
plan member is responsible for paying. Co- payment amounts are
stated in the contract. The co- payment amount will also appear on
the benefit form issued to the plan member at the time they seek
service. When a plan member sees a network doctor and pays the
co- payments, the plan member will carry no further financial
obligation unless they choose upgrades or cosmetic options that are
not included in the plan benefits (sales tax may apply). Any
applicable co- payments will be deducted from the members
reimbursement for all non - network claims as well.
Extra Charges
If a plan member chooses any of the following options for which the network doctor has not
received authorization from VisionCare Plan, the plan member will be responsible for the
extra charges. These charges will, however, be provided at a reduced cost. At the time of the
visit, the network doctor will explain the specific charges that may be incurred for these items,
which include:
• Oversized, coated or faceted lenses;
• Blended or progressive lenses;
• Tinted or photochromic lenses (except pink #1 & # 2);
• A frame that exceeds the contracted plan wholesale allowance; or
• Other cosmetic items.
10
Plan Benefits
The plan provides a complete analysis of the eyes and related structures to determine vision
problems other than abnormalities.
A vision exam typically includes:
• Patient's history;
• Visual acuity;
• External examination;
• Pupillary examination;
• Visual field testing;
• Internal examination;
• Biomicroscopy;
• Tonometry;
• Refraction;
• Extra ocular muscle balance assessment; and
• Diagnosis and treatment plan
Frames
VisionCare Plan covers a wide range of frames, with an allowance designed to include the
most popular styles. VisionCare Plan encompasses a wholesale frame allowance. For
example, if your plan includes a frame allowance of $40.00, it typically retails from $80.00 to
$100.00. Plan members may also choose frames that exceed the limit and pay the difference
on a wholesale cost basis (the difference between wholesale allowance and actual wholesale
cost multiplied by two) making virtually every frame on the market available to VisionCare
Plan members at a reduced cost.
Lenses
The plan covers any lenses needed for patient's visual welfare as determined by the network
doctor. Certain lenses such as those described in the "Limitations" are cosmetic in nature, and
not necessary for the visual welfare of the patient and are not covered. The extra cost of these
cosmetic options must be paid by the patient.
Contact lenses when elective
We will cover the combined cost of an annual exam and contact lenses up to a maximum of
your contracted "Elective Contact Lens Allowance ". Payment will be in lieu of the lens and
frame benefits.
Contact lenses when necessary
VisionCare Plan will pay for one pair of contact lenses under the following circumstances and
only if prior authorization from VisionCare Plan has been obtained:
• Following cataract surgery without intraocular lens,
• Correction of extreme visual acuity problems not correctable with glasses;
• Anisometropia greater than 5.0 diopters and ae.sthenopia or diplopia, with spectacles;
Keratoconus; or
• Monocular aphakia and /or binocular aphakia where the doctor certifies contact lenses
are medically necessary for safety and rehabilitation to a productive life.
Replacement will not be more often than once in any 12 -month period and only if prior
authorization is obtained from VisionCare Plan. The co- payment is waived.
Limitations and Exclusions
Limitations
In no event will coverage exceed the lesser of
• The actual cost of covered services or materials;
• The limits of the policy, shown in the Schedule of Benefits, or
• The allowance as shown in the Schedule of Benefits.
Materials covered by the policy that are lost or broken will only be replaced at normal
intervals as provided for in the Schedule of Benefits.
We will pay only the cost for lenses and frames covered by the policy. The insured is
responsible for extras selected including, but not limited to, the following; unless otherwise
specifically listed as a covered benefit in the schedule of benefits:
• Blended lenses;
• Progressive multi -focal lenses;
• Photochromic lenses, tinted lenses, sunglasses, prescription and piano;
• Laminating of lens or lenses; or
• Groove, drill or notch, and roll and polish.
12
Exciusions
We will not cover:
• Orthoptic or vision training and any associated supplemental testing;
• Two pair of glasses, in lieu of bifocals or trifocals;
• Medical or surgical treatment to eyes;
• Any services and/or materials required by an employer as a condition of employment;
• Any injury or illness covered under any Workers Compensation or similar law;
• Sub - normal vision aids, aniseikonic lenses or non - prescription lenses;
• Charges incurred after:
o The policy ends
o The insured's coverage under the policy ends; except as stated in the policy;
• Experimental or non - conventional treatment or device;
• Contact lenses except as specifically covered by the policy;
• 1 I Index, aspheric and non - aspheric style;
• Oversized 61 and above lens or lenses: or
• Cosmetic items, unless otherwise specifically listed as a covered benefit in the schedule of
benefits.
13
Important HIPAA Information for Groups and Benefits Administrators
The following information is provided as a courtesy to our groups to address frequently asked
questions about HIPAA and is not intended as interpretive or legal advice.
The new privacy protections required by the Health Insurance Portability and Accountability
Act ( "HIPAA ") is changing the way health plans manage, use and disclose an individual's
health - related information. These changes will affect the availability and amount of
information that groups and group benefits administrators will be able to receive from health
carriers, such as CompBenefits. The information provided below will help you better
understand what these changes will be and how they may affect you and your ability to
receive certain kinds of information.
The HIPAA privacy rule provides the first comprehensive federal protection for the privacy of
an individual's health information. You will hear this referred to as the individual's
"Protected Health Information" or "PHI ". The privacy rule gives individuals more control
over their PHI and it sets boundaries on the use and disclosure of their PHI. Additionally, it
establishes safeguards that must be achieved to protect the privacy of protected health
information and it holds violators accountable with civil and criminal penalties that can be
imposed if they violate an individual's privacy rights.
Depending on the type of information you request from us, certain certifications or
authorizations may be required under HIPAA before we can release such information to
you. As a general rule, when you request information from us that contains an
individual's PHI, you will be required to provide us with some type of certification or
authorization depending on the type of request. Whether or not your request will require
you to provide a certification or authorization will depend upon whether your request is
for summary information, plan administration functions, or other type of request.
(NOTE: Information regarding enrollment, disenrollment or participation is not subject to these
requirements.)
You may receive "summary information" from us for the purpose of obtaining premium
bids or when modifying, amending, or terminating the group health plan, without any
type of authorization or certification. HIPAA defines "summary information" as
information that summarizes claims history, claims expenses, or types of claims
experienced by individuals for whom the plan sponsor has provided health benefits under
a group health plan, provided that specified identifiers (i.e. those identifiers that could
identify an individual, including, but not limited to, name, address, social security
number, etc.) are omitted.
If you request an individual's PHI for the purposes of "plan administration functions" that
you perform as the plan sponsor, we can provide you with such PHI without authorization
from the individual, if, and only if, you provide us with written certification that your plan
documents have been amended as required under HIPAA. If you wish to receive an
individual's PHI from us for plan administration functions, your written certification to us
must state that your plan documents have been amended to incorporate the following
provisions and that you agree to:
14
a) not use or further disclose PHI other than as permitted or required by the
plan documents or as required by law;
b) ensure that any subcontractors or agents to whom the plan sponsor
provides PHI agree to the same restrictions;
C) not use or disclose the PHI for employment- related actions;
d) report to group health plan any use or disclosure that is inconsistent with
the plan documents or HIPAA regulation;
C) make the individual's PHI accessible to the individual;
f) allow individuals to amend their information;
g) provide an accounting of its disclosures;
h) make its practices available to the Secretary of HHS for determining
compliance;
i) return and destroy all PHI when no longer needed, if feasible; and
j.) ensure that firewalls have been established. (Note: the firewalls must
identify the employees or classes of employees or other
persons under the plan sponsor's control who will have access to PHI.)
It is important to note that "plan administration functions" are defined by HIPAA to only
include quality assurance, claims processing, auditing, monitoring, and management of
carve -out plans. Plan administration functions do not include any employment - related
functions or functions in connection with any other benefits or benefit plans, and we are
not permitted under HIPAA to disclose information for such purposes absent an
authorization from the individual.
All other requests for an individual's PHI will require that you provide us with written
authorization from the individual to prior to release of such PHI. This includes instances
where the individual has asked you to advocate on his /her behalf in benefit disputes,
claims issues and grievances and appeals. In order for an authorization to be a valid
authorization, it must be written in plain language and must contain the following core
elements:
I ) a description of the information to be used or disclosed that identifies the
information in a specific and meaningful fashion;
2) the name or other specific identification of the person(s) or class of persons
authorized to make the use /disclosure;
3) the name or other specific identification of the person(s) or class of persons to
whom the covered entity may make the requested use /disclosure;
4) a description of each purpose of the requested use or disclosure. (The statement
"at the request of the individual" is a sufficient description of the purpose when an
individual initiates the authorization and does not, or elects not to, provide a
statement the purpose."
5) the authorization's expiration date or an expiration event that relates to the
individual or to the purpose or use of the requested disclosure;
6) a statement of the individual's right to revoke the authorization in writing and exceptions to the
right, along with a description of how the individual may revoke;
15
7) a statement that information used or disclosed under the authorization may be
subject to re- disclosure by the recipient and no longer protected;
8) the signature of the individual and the date signed; and
9) a description of the personal representative's authority to sign, if applicable.
Further, a copy of the signed authorization must be given to the individual. An
authorization is not valid if. I) the expiration date has passed or the expiration event has
occurred; 2) the authorization was not filled out completely; 3) the authorization was
revoked; 4) the authorization lacks a required element; or 5) any material information in
the authorization is known to be false.
We appreciate your business and hope that this information has been helpful in your
understanding of the additional measures that are being put into place as part of our
commitment to ensuring the privacy and confidentiality of your group members protected
health information in compliance with HIPAA requirements.
If you should have any questions, please do not hesitate to contact our Privacy Officer at
(770) 998 -8936 or e-mail at P rig -acyO
0
Frequently Asked Questions
Q. What do I do if my bill is wrong?
A. Contact your Billing Representative. Their name and extension
is listed on your bill.
Q. Who do I call if an employee did not receive their
benefit form
A. Contact Member Services at (800) 865 -3676.
Q. I need enrollment materials. How do I get
them?
A. Contact your local Account Manager.
Q. Who do I call if I have questions about my plan?
A. Your primary contact should be your Account Manager
however, you can always contact Administration
Operations in our Tampa office at (800) 749 -5855.
Just follow the prompts.
Q. I changed brokers. Do I need to do anything?
A. Yes. Anytime you make a change to your agent, you need to
supply a letter to your Account Manager on your company's
letter head advising us of the date the change will take effect and
who your new agent will be.
17
Q. How do I add and terminate employees from VisionCare Plan?
A. You have several options:
• Make the corrections directly on your bill and send them in with your
payment; or
• Fax them to our Premium Administration Department at (813) 281 -0554,
Q. I am having an enrollment fair and would like a
representative from VisionCare to be there.
Who do I call?
A. Contact your Account Manager in advance to see if he /she will
be available to attend. The more advance notice the better the
chance that their schedule will be free.
Q. What is the address to which I send my payment
and what do you need me to send with my check?
A. The mailing address is P.O Box 917388 — Orlando, FL 32891-
7388. Please include a detailed explanation of your payment.
If you receive a bill from VisionCare Plan, you can include a copy with any necessary
changes made on the back. If you do not receive a bill and "self bill', please include
backup for payment by member and premiums paid for each.
W
Regional Sales Offices
Alabama
Illirwis
2204 Lakeshore Or
200 W Jackson Boulevard
Corporate 8180 Coorate Park Drive
SWe t00
9" Floor
Suite 202
Birmingham, AL 352096701
Chicago, IL 60606
Cincinnati, OR 45242
Phone (205) 879 7374
Phone .(312)261 -6200
Phone - (513)489.6550
BM) 8799374
(000)83] -2341
(000)45691635
Fax (205)B79 -530]
Fax (312)42] -9558
Fax (513) 489 7003
Florida
Indian,
2772 NW 43rd Street
3850 Priority Way 5. Drive
Ohio
5wie C
Suite 222
Rock side Square
Gainesville FL 326 06
Indianapolis, IN 46240
Suite 0Kks ide Rwd
Road
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Phone: (317) 581-]001
3
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Independence end
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Fax (l52) 37t -90
3719055
Fax ( 17 501 7060
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Phone
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( 55
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Fax (216 (216)5201559
520.1
Miami. F133126 -2034
Street
Tennesse e
Phone. 13o5)262393J3
Sure 320 Building
. uJdin 10
Overland Park, NS 66213 -2665
105 Weslpark Dive
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Fax
Phone 8519532
Suite 450
19 5)26 2106
30
(5)269 -2106
IBM 456 -1629
Brentwood, TN 3]02]
Fax (9t3851 -4563
Phone.(615)371-
Citadel lnterne6onal Building
(800)261 -5881
Fax
5950
59501iazelline rva6onal D.
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(615)3]1 -5445
Suite 520
1 Spite Bishop lane
32822
100
Texas
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(88 894 2985
893 381
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S. 1000 1000
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Tampa. FL 33689 4591
Mlssowf
Phone : I8t 2892020
1650 Des Peres Road
Suite 207
2929 B1ldrpark
(800) 749-5855
St Louis, MO 63131
Suite 314
Fax (613)281 -0956
Phone (314)821 -0163
Nousmn. T% ]]042
(800)456 -164]
one (7132184 -]011
Ceoroia
Fax 1314)821 -6540
(BWJ679 -7883
Two Securities Center
Fax (713) TEN .9440
3500 Piedmont Rd
Suite 345
North Carolina
85 NE
Atlanta, CA W305 -1532
130 Edinburgh South
Long 410
Phone (404) 365 0074
Suite 107
Boger Atrmrn Bldg.
Suite 603
Cary, NC 27511
Phone (919)380926]
San Antonio T %78216
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Fax ax ( 4044)) 2 233 3 2Jfi6
(B00)542 1146
Phone .(210)979 3940
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