Plans for Small and Mid-Sized Companies · a day, seven days a week, 365 days a year. 877-843-5071 Visit Avalon’s Learning Center to find helpful health information for all Avalon

877-280-0010 — www.avalonhealthcare.comAVAfp04 04/06

Plans for Small and Mid-Sized Companies

1

At Avalon Healthcare we believe that rapid

change is coming in the way Floridians will buy

and use their healthcare insurance. Employers

are looking for better ways to manage healthcare

costs while continuing to provide appropriate

coverage for employees. Consumers are taking

charge of their own healthcare both physically

and financially.

In response to this monumental change,

employers are giving their employees new kinds

of health insurance coverage like the Avalon High

Deductible Focus Health Benefit Plans and Avalon

Focus HSA Health Benefit Plans. With the help

of these new plans they are providing new tools

that allow employees to make personal, educated

healthcare decisions.

Avalon acts both as an insurer and as a conduit

for employers and Members seeking:

The best possible care at an affordable price

Plan designs in tune with today's

healthcare marketplace

Tools to manage care from the consumer

perspective

Important answers to healthcare questions such

as what doctors or hospitals to visit, how claims

are paid and who is responsible for paying

them, and detailed information on new plan

designs and benefits available

How best to plan for future healthcare

spending through health savings tools

such as Health Savings Accounts (HSAs)

The Future is NowAvalon Healthcare offers a variety of PPO health

benefit plan options for any size employer

looking for a logical, affordable approach to

providing health benefits without breaking the

bank. With the help of their brokers, employers

can sign up for Avalon High Deductible Focus

Plans or Avalon Focus HSA plans.

And under Florida law, employers without health

insurance coverage and with less than 50

employees can now offer their employees the

option of buying individual insurance coverage

through their employer. So, individuals seeking

greater personal control of their own healthy

lifestyles can purchase our Avalon IFOCUS

Health Benefit Plans.

For more information on these plans visit:

www.avalonhealthcare.com/individual

877-280-0010 — www.avalonhealthcare.com2

Focusing on the Future of Healthcare

Technology Designed to Help, not Hinder

Technology has changed the way we live and work.

Employers need faster, more economical ways to

manage their business, providing less hassle and

paperwork whenever possible. They want health

insurance products and services that address changing

technology needs yet are simple to manage and

understand. Avalon provides paperless on-line

solutions that are easy to access and navigate.

Services offered on-line include:

Employer application and submission

Hospital, doctor and lab directory searches

Modifying employee coverages

Pharmacy searches and tools

Bill and claims status review

Premium payment options

Access to Health Savings Accounts

for each employee

Outstanding Customer Service is Critical

We know employers and Members don't want to

waste time chasing down outstanding medical

claims or solving protracted billing problems.

They need fast, efficient answers from a real

person, immediately. That's why when you call

Avalon for assistance you are connected to a

live voice.

While Avalon offers a variety of services on-line

we continue to support our employers, producers

and Members through traditional means. Call us.

E-mail us. Send information through the U.S.

mail. We'll respond quickly and with the right

answers. Most importantly, when seeking

service support, brokers, employers and Members

will always get a rapid response to help them

solve problems or answer questions whenever

they call.

Call a Nurse 24-7:

Optum™ Connect24 Services: Access for

all Avalon Members to a toll-free telephone

number to connect to a live nurse 24 hours

a day, seven days a week, 365 days a year.

877-843-5071

Visit Avalon’s Learning Center to find helpful

health information for all Avalon Members.

The Future Requires New Ways of Thinking about Healthcare


4

Information that Educates

Avalon Members can visit the Avalon Learning Center

on the Avalon Healthcare website to gain access to a

multitude of web locations that provide important

information on healthcare, managing and maximizing

healthcare costs and understanding new consumer

savings tools related to the consumer directed Health

Benefit Plans offered by Avalon. They include:

Answers to health information through the

WebMDTM website

Answers and advice on financial information

tied to health savings accounts (HSAs) through

multiple web links including the Federal

Government’s HSA web page and through

HSA Bank

E-mail access to Avalon for questions on

insurance and HSA banking products

Access to the Avalon CareSupport Program

Better CostControls

Avalon Members

are responsible for paying deductibles before

benefits become available. As a Member, you

want to be sure that the care you receive is the

highest quality at an affordable price. With the

Avalon CareSupport Program, we work with our

Members and their providers to help find the most

appropriate care setting at the right price. Your

primary care physician or specialist may be sending

you to a hospital or lab that costs considerably

more for identical services that can be rendered

at a less expensive location with equal or better

outcomes.

Before visiting a lab, hospital or specialist, call us

at: 866-949-5700 to find out how to maximize

your healthcare dollars.

Jack trusts that the doctor has sent him to the rightfacility. But is the price appropriate for the service?How would Jack know?

Jack calls the Avalon CareSupport Program hotline at 866-949-5700 to find out if he is getting the rightdeal for an MRI.

Jack learns that the location to which his doctor hassent him charges $1,400 for an MRI, which is morethan he has in his HSA account.

Jack also learns through the Avalon CareSupportProgram that his doctor has a good relationship withanother location down the street that charges $875for the same service.

The customer support person at the AvalonCareSupport Program helps Jack contact his doctorand move the MRI to the less expensive location, with equal or better outcomes, saving Jack $525.

Jack takes $875 out of his HSA account and pays for the MRI. His out-of-pocket cost is $0.

Here’s an example of how the Avalon CareSupport Program allows Members to become their ownhealth advocate, empowering them to find the best possible care while saving money.

866-949-5700

Jack is 45 years old with a wife and three children. He has an Avalon Focus HSA compatible health benefit plan. It is a $1,250 individual/$2,500 familydeductible plan.

Jack is responsible for his $1,250 deductible but becausehe has a family plan, under HSA rules, the entire $2,500family deductible needs to be reached before any benefits become eligible. Once he and/or his familyreaches the $2,500 deductible, Avalon pays 80% ofcoverage up to his $5,000 out-of-pocket (OOP) limit.

Jack’s employer has given him a pre-taxed amount of$1,250 to put into his HSA. Jack can use the HSA moneyto cover any healthcare needs including deductibles forcoverage, and non-covered services such as eye glasses. Any money not used during the year “rolls over”into the next year.

Jack goes to the doctor and learns that he needs anMRI. His doctor sends him to a nearby location wherethe doctor has “privileges”.

Jack has no idea what an MRI costs.

877-280-0010 — www.avalonhealthcare.com

An HSA is an account that a person can put a

limited amount of money into to save for medical

expenses not covered by their High Deductible

Health Plan (HDHP). HSAs provide security,

flexibility, savings, greater consumer control,

ownership, and the portability to take your account

with you. By having an HSA a person can also gain

certain tax advantages such as tax deductions when

contributing to the account, tax-free earnings

through investments and tax-free withdrawals for

qualified medical expenses. The account can

only be setup:

When an employee has a High Deductible

Health Benefit Plan (HDHP)

If no other first dollar medical coverage

is provided

If a person is not enrolled in Medicare

If a person is not claimed as a dependent on

someone else's tax return

HSAs are portable, meaning that account holders

can keep the HSA if they change jobs, become

unemployed, move to another state or change

marital status.

Contributions to an HSA can be made by both

employers and employees. For Individual HSAs,

the Member is responsible for making their own

contribution. They are easy to open, and Avalon

Healthcare can assist in setting up coverage.

To learn more about

HSAs including answers

to frequently asked questions visit the Avalon

website and click on links to get to the U.S.

Treasury Department's full service website (found

in the Avalon Learning Center) for HSAs or through

HSA Bank.


What is a Health Savings Account (HSA)?

Information provided by the U.S. Department of Treasury. (2005)

This chart indicates how much money a Member can put into an HSA to offset healthcare costs not covered by their HSA compatible HDHP Plan.


The Avalon Healthcare website offers Members

complete access to Avalon’s product and service

offerings from:

Finding the right doctor, hospital, dentist or

pharmacy immediately

Connection to the places that help educate

Members on today’s rapidly changing

healthcare market

Complete review of Avalon HDHP and

HSA options and what they mean to

the consumer

Real time review of claims that are pending or

paid through Member-secure and employer-

secure web locations

On-line review of a personalized and secure

HSA through HSA Bank

Avalon Members can choose between two high-quality, low cost, dental plans, each providing covered benefits for traditional preventive care and discounted fees for allother services. Working with our Dental provider,MCNA Dental, Members have access to twodental plans that provide no deductibles tomeet, no limits on dental services received and no restrictions due to age or pre-existingconditions.

MCNA Dental Plan 1This more economical plan includes comprehensive preventive care including:

One routine cleaning per year

Free exams

Free X-rays

Discounts on all other procedures

25% off on all Orthodontics, Periodontics, Endodontics, Oral Surgery, and Pedodontics

MCNA Dental Plan 2This plan includes comprehensive preventive care including:

Two routine cleanings per year

Free exams

Free X-rays

Discounts on all other procedures

25% off on all Orthodontics, Periodontics, Endodontics, Oral Surgery, and Pedodontics

Dental Plan Options

ADDITIONAL TOOLS & PRODUCTS

On-line Services to Help MembersBetter Manage Their Own Care

www.avalonhealthcare.com

Plan deductibles starting at $1,000

Office co-pay visits are $25 per visit

Attractive coinsurance options

Co-pay pharmacy plans

On-line support services such as doctor, hospital and pharmacy directories

A live voice to answer questions

Plan deductibles starting from $2,000 to $5,000

Deductibles and coinsurance for office visits, hospital stays and urgent care

Co-pay pharmacy plans

Attractive coinsurance options

HRA compatible



PPO plan designs starting at a $1,250 deductible

Compatible with a third party administered HSA

Tax advantage option through the employer with the setup of an HSA

One stop setup and management of HSA through Avalon



AVALON HEALTHCARE PPO FOCUS HEALTH BENEFIT PLAN OPTIONS

Avalon Focus Co-Pay Benefit Plans:

Avalon Focus HSACompatible Benefit Plans:

Avalon Focus High Deductible Plans:

AV

ALO

N F

OC

US

(GRO

UP)

PLA

NS A

VA

LON

FOC

US (G

ROU

P) PLAN

S

To get a live customer service person:

Brokers call: 877-280-0010

Employers and Members call:

866-469-2347

Office hours: 8:00 am - 6:00 pm EST.


8

SUMMARY OF HDHP PLAN OFFERINGS

A - 1A - 2

B - 1B - 2

C - 1C - 2C - 3C - 4C - 5

D - 1D - 2D - 3D - 4D - 5D - 6

E - 1E - 2E - 3E - 4E - 5E - 6E - 7E - 8

F - 1F - 2F - 3F - 4F - 5F - 6F - 7F - 8

$1,000$1,000

$1,500$1,500

$2,000$2,000$2,000$2,000$2,000

$2,500$2,500$2,500$2,500$2,500$2,500

$3,000$3,000$3,000$3,000$3,000$3,000$3,000$3,000

$5,000$5,000$5,000$5,000$5,000$5,000$5,000$5,000

$2,000$2,000

$3,000$3,000

$4,000$4,000$4,000$4,000$4,000

$5,000$5,000$5,000$5,000$5,000$5,000

$6,000$6,000$6,000$6,000$6,000$6,000$6,000$6,000

$10,000$10,000$10,000$10,000$10,000$10,000$10,000$10,000

90%80%

80%70%

100%80%70%60%60%

100%80%70%70%60%60%

100%100%80%80%70%70%60%60%

100%100%80%80%70%70%60%60%

70%60%

60%50%

80%60%50%40%40%

80%60%50%50%40%40%

80%80%60%60%50%50%40%40%

80%80%60%60%50%50%40%40%

$1,500$2,000

$2,000$2,500

$0$2,000$3,000$4,000$4,000

$0$2,500$3,500$3,500$4,500$4,500

$0$0

$3,000$3,000$4,000$4,000$5,000$5,000

$0$0

$5,000$5,000$6,000$6,000$7,000$7,000

$5,000$6,000

$7,000$8,000

$6,000$8,000

$10,000$12,000$12,000

$7,000$10,000$12,000$12,000$14,000$14,000

$10,000$10,000$12,000$12,000$14,000$14,000$16,000$16,000

$18,000$18,000$20,000$20,000$22,000$22,000$24,000$24,000

$3,000$4,000

$4,000$5,000

$2,000$4,000$6,000$8,000$8,000

$2,000$5,000$7,000$7,000$9,000$9,000

$4,000$4,000$6,000$6,000$8,000$8,000

$10,000$10,000

$8,000$8,000

$10,000$10,000$12,000$12,000$14,000$14,000

$2,500$3,000

$3,500$4,000

$2,000$4,000$5,000$6,000$6,000

$2,500$5,000$6,000$6,000$7,000$7,000

$3,000$3,000$6,000$6,000$7,000$7,000$8,000$8,000

$5,000$5,000

$10,000$10,000$11,000$11,000$12,000$12,000

$25$25

$25$25

$25$25$25$25N/A

$25$25$25N/A$25N/A

$25N/A$25N/A$25N/A$25N/A

$25N/A$25N/A$25N/A$25N/A

BENEFITPreventive Care

Inpatient Care

Other

Riders

Adult Annual Physical ExamWell Child Care (to age 16)Well Woman CareMammography Exams (based on established guidelines)

$25 Co-pay - Deductible Waived$25 Co-pay - Deductible Waived$25 Co-pay - Deductible Waived

Covered at 100%

$25 Co-payDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and Coinsurance

Deductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and Coinsurance

Deductible and CoinsuranceDeductible and CoinsuranceDeductible and Coinsurance


Deductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and Coinsurance


$25 OB-GYN VisitDeductible and Coinsurance

See Rider SummarySee Rider SummarySee Rider Summary

$5 Million

Coinsurance - Deductible Waived Coinsurance - Deductible WaivedCoinsurance - Deductible Waived

Covered at 100%

PCP Office VisitsSpecialist Office VisitsEmergency Room (based on guidelines)3

Diagnostic X-Ray and LabComplex Imaging (MRI, MRA, CAT, PET)4

Surgery, Pre-Surgical TestingSecond Surgical OpinionsAllergy Testing and TreatmentChiropractic Care (15 visits/calendar year)Outpatient Rehab Services (60 visits/calendar year)4

Inpatient Hospital (semi-private room)4

Surgery, Surgical Assistant, Anesthesia 4

Skilled Nursing Facility (30 days/calendar year)4

Home Health Care (30 visits/calendar year)4

Durable Medical Equipment ($2,000 maximum/calendar year)4

Orthotics and Prosthetics ($2,000 maximum/calendar year)4

Maternity4

Ambulance Services for non-emergency transport ($2,000 per calendar year)4

Lifetime Maximum

Mental/Nervous Alcohol & Substance Abuse Prescription Drugs (administered through MedcoTM)

Member Pays Member PaysIN-NETWORK1 OUT-OF-NETWORK2

Office/Outpatient Care

1. Network varies by region. 2. Out-of-network services are those from a provider that does not participate in one of Avalon’s regional networks. 3. Must notify Avalon Medical Management within 24 hours or reasonably thereafter.4. These services require pre-certification from Avalon. Please call (866) 469-2347. Failure to pre-certify

prior to receiving services will result in a reduction in benefits by 50% of the allowed amount. NOTE: All benefit cost-sharing subject to the Allowance as defined in the Plan.

This is a benefit summary. It is intended for informational purposes only, and doesnot represent a full description of benefits provided. For a complete description of

benefits and exclusions, please refer to the insurance policy certificate and schedule of benefits.

COVERAGE - Family Deductibles and OOP Maximums are equal to 2.0 times the Individual Coverage Amounts.

OUT-OF-NETWORKFOCUS

PLANSDEDUCTIBLE DEDUCTIBLECOINSURANCE COINSURANCE

PCPCO-PAY

IN-NETWORKCOINS OOP MAX COINS OOP MAX

ANNUAL OOPMAX

ANNUAL OOPMAX

9

SUMMARY OF HSA ELIGIBLE PLANS

FOCUS HSA PLANS FOR GROUPS WITH 2 - 50 ELIGIBLE EMPLOYEES

HSA - A1

HSA - B1

HSA - C1HSA - C2HSA - C3

HSA - D1HSA - D2

HSA - E1HSA - E2

HSA - F1

$1,250

$1,500

$2,000$2,000$2,000

$2,500$2,500

$3,000$3,000

$5,000

$1,250

$2,000

$0$2,000$3,000

$0$2,500

$0$2,000

$0

$2,500

$3,500

$2,000$4,000$5,000

$2,500$5,000

$3,000$5,000

$5,000

$2,500

$3,000

$4,000$4,000$4,000

$5,000$5,000

$6,000$6,000

$10,000

$2,500

$4,000

$2,000$4,000$6,000

$2,000$5,000

$2,000$4,000

$2,000

$5,000

$7,000

$6,000$8,000

$10,000

$7,000$10,000

$8,000$10,000

$12,000

Ded & Coins

Ded & Coins

Deductible

Ded & Coins

Ded & Coins

Deductible

Ded & Coins

Deductible

Ded & Coins

Deductible

80%

70%

100%80%70%

100%80%

100%80%

100%

60%

50%

80%60%50%

80%60%

80%60%

60%

OUT-OF-NETWORKIN-NETWORK

BENEFIT

Adult Annual Physical ExamWell Child Care (to age 16)Well Woman CareMammography Exams (based on established guidelines)

Deductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & Coinsurance

Deductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & Coinsurance

Deductible & CoinsuranceDeductible & CoinsuranceDeductible & Coinsurance


Deductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & Coinsurance


$25 OB-GYN VisitDeductible & Coinsurance

Coinsurance - Deductible WaivedCoinsurance - Deductible WaivedCoinsurance - Deductible Waived

Covered at 100%

$25 Co-Pay - Deductible Waived$25 Co-Pay - Deductible Waived $25 Co-Pay - Deductible Waived

Covered at 100%

PCP Office VisitsSpecialist Office VisitsEmergency Room (based on guidelines)3

Diagnostic X-Ray and LabComplex Imaging (MRI, MRA, CAT, PET)4

Surgery, Pre-Surgical TestingSecond Surgical OpinionsAllergy Testing & TreatmentChiropractic Care (15 visits/calendar year)Outpatient Rehab Services (60 visits/calendar year)4

Inpatient Hospital (semi-private room)4

Surgery, Surgical Assistant, Anesthesia4

Skilled Nursing Facility (30 days/calendar year)4

Home Health Care (30 visits/calendar year)4

Durable Medical Equipment ($2,000 maximum/calendar year)4

Orthotics and Prosthetics ($2,000 maximum/calendar year)4

Maternity4

Ambulance Services for non-emergency transp. ($2,000 per calendar year)4

Lifetime Maximum

OUT-OF-NETWORK2IN-NETWORK1

FOCUS

PLANSDEDUCTIBLE DEDUCTIBLECOINSURANCE COINSURANCE COINS OOP MAXCOINS OOP MAX

ANNUAL OOPMAX

PCP PROVISIONS

ANNUAL OOP MAX

Preventive Care Member PaysMember Pays

See Rider SummarySee Rider SummarySee Rider Summary

$5 Million

Mental/Nervous Alcohol & Substance Abuse Prescription Drugs (administered through MedcoTM)

1. Network varies by region. 2. Out-of-network services are those from a provider that does not participate in one of Avalon’s regional networks. 3. Must notify Avalon Medical Management within 24 hours or reasonably thereafter.4. These services require pre-certification from Avalon. Please call (866) 469-2347. Failure to pre-certify

prior to receiving services will result in a reduction in benefits by 50% of the allowed amount. NOTE: All benefit cost-sharing subject to the Allowance as defined in the Plan.

This is a benefit summary. It is intended for informational purposes only, and doesnot represent a full description of benefits provided. For a complete description of

benefits and exclusions, please refer to the insurance policy certificate and schedule of benefits.

COVERAGE - Family Deductibles and OOP Maximums are equal to 2.0 times the Individual Coverage Amounts.

Inpatient Care

Other

Riders

Office/Outpatient Care

10

SUMMARY OF DRUG RIDERS OPTIONAL BENEFIT RIDERS AVAILABLE WITH FOCUS HEALTH BENEFIT PLANS FOR GROUPS WITH 2 - 50 ELIGIBLE EMPLOYEES

123456789

1011121314

$0$0$0

$500$750

$1,000$1,250$1,500$1,750$2,000$2,000$2,500$3,000$5,000

$10$15$20$20$20$20$20$20$20$20$35$35$35$35

$30$50$60$60$60$60$60$60$60$60$90$90$90$90

$50$75

$100$100$100$100$100$100$100$100$200$200$200$200

$25.00$37.50$50.00$50.00$50.00$50.00$50.00$50.00$50.00$50.00$87.50$87.50$87.50$87.50

$125.00$187.50$250.00$250.00$250.00$250.00$250.00$250.00$250.00$250.00$500.00$500.00$500.00$500.00

$75$125$150$150$150$150$150$150$150$150$225$225$225$225

www.avalonhealthcare.com

FOCUS

PLANDEDUCTIBLE

NETWORKGENERIC

MAIL ORDERGENERIC

MAIL ORDERFORMULARY

MAIL ORDERNON-FORMULARY

NETWORKFORMULARY

NETWORK NON-FORMULARY

ABCDEF

$1,250$1,500$2,000$2,500$3,000$5,000

$20$20$20$20$20$20

$60$60$60$60$60$60

$100$100$100$100$100$100

$50$50$50$50$50$50

$250.00$250.00$250.00$250.00$250.00$250.00

$150$150$150$150$150$150

HSA

PLAN DEDUCTIBLE NETWORK

GENERICMAIL ORDER

GENERICMAIL ORDERFORMULARY

MAIL ORDERNON-FORMULARY

NETWORKFORMULARY

In-Patient Services:Limitation: 30 days per calendar year

Out-Patient Services:Limitation: $1,000 per calendar year

In-Patient Services:Limitation: $2,000 per per lifetime, combined w/out-Patient Services

Out-Patient Services:Limitation: 44 visits per calendar year

Plan Deductible & Coinsurance








MENTAL HEALTH

ALCOHOL & SUBSTANCE ABUSE

OUT-OF-NETWORK

OUT-OF-NETWORK

IN-NETWORK

IN-NETWORK

BENEFIT

BENEFIT

Notes on RX Plans:Core Plans -

Any Rx Rider may be purchased with any health benefit plan.The deductible applies to retail (in-network), mail order and out-of-network charges.The Rx deductibles exist as separate from medical deductibles.There is no OOP max for Rx cost.Co-pays will not count towards the medical deductible.

HSA Plans - The elected Rider must have the same deductible as the health benefit plan.

Medical Claims and Rx Claims contribute towards the health benefit plan deductible.

The Plan in-network deductible and OOP applies to retail (in-network) and mail order Rx.

The Plan out-of-network deductible and OOP applies to out-of-network charges.Rx subject to 50% of allowance.

Once Plan in-network deductible is met, co-pays do not count toward the Plan in-network OOP maximum.

NETWORKNON-FORMULARY

This is a benefit summary. It is intended for informational purposes only, and does not represent a full description of benefits provided. For a complete description of benefits and exclusions, please refer to the insurance policy certificate and schedule of benefits.

11

AGENT GUIDELINESFor Groups with 2 to 50 Eligible Employees


Agent Guidelines for Avalon Group Health Benefit Plans

Census data must be provided on all eligible, including COBRA eligible employees. Include name, date of birth, date of

hire, gender, dependent status, and residence zip code.

An eligible employee is an employee who works full-time, having a normal work week of 25 or more hours per week, and

who has met any applicable waiting-period requirements.

Eligible employees include self-employed individuals, sole proprietors, partners of a partnership or independent

contractors, if they are actively engaged on a full-time basis in the small employer's business and included as employees

under a health care plan contract of a small employer.

Part-time, temporary, or substitute employees are not eligible.

Groups with 2-5 eligible employees: 100% of eligibles, counting those covered under another health plan sponsored

by the employer and excluding those with qualifying existing coverage, must participate in Avalon's plan.

Groups with more than 5 eligible employees require 75% participation, counting those covered under another health plan

sponsored by the employer and excluding those with qualifying existing coverage, must participate in Avalon's plan.

Employees waiving due to spousal coverage must complete the waiver section and provide proof of coverage

by providing a copy of the I.D. card.

Employer contribution must equal 50% of employee premium.

Individual coverage is not a valid waiver, unless subscriber is a current Avalon individual Member.

Eligible dependents include an employee's spouse and unmarried children up to the age of 19. Unmarried child(ren)

includes natural, stepchildren, foster, legally adopted children, proposed adoptive children, and a child under court order.

Coverage for dependent children may be extended until the end of the calendar year in which the child attains the age of

25. The child must be dependent upon the employee for support and residing with the employee, or attending school on

a regular basis.

Groups with 10 to 50 eligible employees may offer a dual option. This is when more than one Avalon medical plan is

offered to Members, an employer offers two Avalon medical plans to the employees. Each of the dual option plans has

a minimum of 5 subscribers.

Avalon will underwrite at the employer level for companies enrolling 21 – 50 employees. The employer (or lead benefits

administrator) will state to the best of his/her knowledge answers to a number of questions regarding the health status of

the company’s employees.

Avalon will underwrite using individual medical applications for groups enrolling 20 or fewer employees.

Cases will be issued as quoted, offered a reduced premium or a premium increase based on the medical statements collect-

ed by either the employer or employees. The maximum increase or decrease from standard rates on new groups is 15%.

Documentation that will allow Avalon to determine whether the group qualifies as a Florida Small Group will be required

at the time of application. Please review the Case Submission Checklist for all required information.

The group effective date must be the 1st of the month.


Avalon Healthcare, Inc.

Rocky Point Centre

3030 North Rocky Point Drive West

Suite # 800

Tampa, Florida 33607

Florida based Avalon Healthcare is an innovative health insurance company offering consumer directed Health Benefit Plans to employers and individuals whoneed affordable healthcare and live and work in Florida.

Avalon is poised to meet the rapid changes in the Florida group health insurance market through the development of innovative new products: in and out-of-network High Deductible PPO Health Benefit Plans wrapped around Health SavingsAccounts (HSAs) and Health Reimbursement Accounts (HRAs). We call theseHealth Benefit Plans Avalon "Focus Plans" because they clearly focus on the needsof employers, employees and individuals.

Avalon Healthcare, Inc.12

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Plans for Small and Mid-Sized Companies · a day, seven days a week, 365 days a year. 877-843-5071 Visit Avalon’s Learning Center to find helpful health information for all Avalon