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01/01/1985 to 12/31/1987MONROE COUNTY DENTAL HEALTH, INC. L -- I TABLE OF CONTENTS Page 1. TERM OF CONTRACT . . . . . . . . . . 1 2. ELIGIBILITY, EFFECTIVE DATE. . . . . . . 1 3. RATES . . . . . . . . . . . . . . . . . 1 4. COVERED BENEFITS AND ANNUAL PATIENT CHARGE SCHEDULE 2 5. OWNER . . . . . . . . . . . . . . . . 3 6. DEPENDENT DEFINED. . . . . . . . . . . 3 7. IDENTIFICATION . . . . . . . . . . . . . 3 8. RESPONSIBtLITY FOR SERVICE . . . . . . 3 9. FACILITIES . . . . . . . . . . . . . . 3 10. SCOPE OF SERVICE . . . . . . . . . . . . 3 11. HOSPITALIZATION . . . . . . . . . . . 3 12. RENEWALS . . . . . . . . . . . . . . . 3 13, CONVERSIONS . . ... . . . . . . . . . . 3 14. CHARGES FOR BROKEN APPOINTMENTS. . . 3 15. GRIEVANCE PROCEDURE . . . . . . . . . 4 16. LIMITATIONS . . . . . . . . . . . . . . 4 17. EXCLUSIONS . . . . . . . . . . . . . . . 4 18. BOOKS AND RECORDS . . . . . . . . . . 4- 19. COMPLIANCE WITH LAW . . . . . ... . . . 4 20. SIGNATURES AND -SEALS . . . . . . . . . 4 dental r"Maltm, Inc. TERM OF CONTRACT The contract will be in effect for three (3) years. effective beginning January 1, 1985 and expiring December 31, 198T. Each individual contract will continue in effect for three (3) years except that individual subscribers can, for exceptional and compelling reasons, withdraw from the plan by paying all costs for services rendered which exceed the amount of total fees received by DHI and co- payments paid to providers. 2. ELIGIBILITY, EFFECTIVE DATE The effective date of coverage of the Group under the Dental Plan shall be the first day of the month following receipt of appropriate rates by the Dental Corp. Present employees actively at work will be eligible upon completion of service. Future employees will be eligible, if they are actively at work, upon completion of 3. RATES service. Individual Individual+ One Dependent Family (maximum 4) Family (5 or over) Annual $ 129.96 $ 235.44 s 325.80 $ 373.80 Monthly $ t,9.62 17 9-' S - � __q9. 91 In consideration of the services to be rendered or made available to the covered persons by the Dental Corp., the monthly rate is payable on the 25th of the month preceding the month of coverage. On or before 25th, the employer will furnish the dental plan with a listing of persons to be covered under the plan eTTecti ebeTJanuary 1St. On January 25th and the 25th of each month thereafter for the term of the contract, employer will furnish the dental plan with an exception list indicating employees to be added to the plan and their dependents, employees to be deleted from the plan, and any changes in type of coverage for the next month. The rate structure is guaranteed for the term of the contract except under pressures of an inflationary rate in excess of 6% per year. Seventy-five (75) days before each anniversary date of the contract, DHI will submit a comparison of the most recent monthly Consumer Price Index published with that for the same month of the preceding year. If that comparison indicates an increase in excess of 6%. then DHI will absorb the first 6% of this increase and only the percentage amount in excess of 8% will be added to the rate structure. As an example, if the current year's CPI exceeds the CPI for the same month of the prior year by 16%. DHI would absorb the first 6% of the increase and only the difference, i.e., 10%, would be passed on. to the Owner. The co -payment schedule of the dental plan will be reviewed at the end of each calendar year and adjusted to reflect rates currently in effect statewide as approved by the Florida State Insurance Commission. It shall then be guaranteed from the first of the succeeding year until the end of that calendar year. — 1 — 4. COVERED BENEFITS AND 198 $ PATIENT CHARGE SCHEDULE The benefits provided under the Dental Plan will be according to the following schedule. Certain services are subject to a Patient Charge as listed in the schedule. (A Patient Charge is defined as an additional amount subscriber or dependent shall pay the participating dentist directly). DHI Patient Charge DIAGNOSTIC/PREVENTIVE Consultation..... NO CHARGE Oral Examination -Initial..... NO CHARGE Oral Examination -Periodic NO CHARGE Oral Cancer Examination .. NO CHARG E X-Rays-Complete Series (14 or more films) NO CHARGE including bite -wings if indicated NO CHARGE X-Rays-Single NO CHARGE X-Rays-Each Additional NO CHARGE X-Rays-Bite-wing NO CHARGE X-Rays-Panoramic NO CHARGE Diagnostic Casts or Models NO CHARGE Prophylaxis - Adult - Every Six Months NO CHARGE Prophylaxis With Fluoride -Child - Every Six Months NO CHARGE Topical Application of Fluoride IAnnually l NO CHARGE Additional Prophylaxis $ 15.00 Preventive Care Training NO CHARGE Sealant (Per Quadrant) NO CHARGE RESTORATIVE (Fillings) Amalgam -Primary I Surface .. ... .. ... NO CHARGE Amalgam -Primary 2 Surface .............. NO CHARGE Amalgam -Primary 3 Surface .. NO CHARGE Amalgam -Adult 1 Surface NO CHARGE Amalgam -Adult 2 Surface NO CHARGE Amalgam --Adult :1 Surface ......... NO CHARGE Amalgam -Adult 4 Surface .. I ..... .. NO CHARGE Composite -I Surface ... NO CHARGE Composite-2 Surface ........ NO CHARGE Composite-3 Surface . ........ NO CHARGE Bonding (Facing. Per Tooth) .............. $ 60.00 Inlay -Gold $150.00 Sedative Filling NO CHARGE CROWNS (Caps -Single Restorations Only) Crown, Temporary NO CHARGE Crown, Plastic ................. .. $ 25.00 Crown, Porcelain .................. $175.00 Crown, Porcelain Fused to Metal .. .. .. $175.00 Crown, Full Cast $175.00 Crown, Stainless Steel (Pedo) .... ..... .... NO CHARGE Post Required for Crown $ 70.00 Recement Inlays I I ...... .......... NO CHARGE Recement Crowns ............ I ...... NO CHARGE CROWN AND BRIDGE (Fixed Bridge Tooth Replacement► Pontic, Porcelain Fused to Metal (per unit) $175.00 (UP TO 6 UNITS -More than 6 units requires complex rehabilitation and additional charge) Recement Bridge. . NO CH A RG E CROWN AND BRIDGE (Fixed Bridge Abutments) Crown, Porcelain Fused to Metal..... .. $175.00 Replace Broken Facing ... ........ NO CHARGE ENDODONTICS (Root Canal Therapy) Endo Consultation NO CHARGE Single Root Canal' NO CHARGE Bi-Root Canal' $110.00 Tri-Root Canal' $165.00 Four -Root Canal and/or More Complicated Procedures $165.00 Pulp Cap, NO CHARGE Vitaf Pulpotomy, NO CHARGE Apicoectomy .. NO CHARGE *(Excluding Final Restorations) PERIODONTICS Perio Consultation. NO CHARGE Perio Examination and Treatment Plan...... $ 35.00 Root Planing and Curettage Per Quadrant .. ........ .. . .... .. $ 40.00 Full Mouth .... .......... .......... $155.00 Prophylaxis-Perio Analysis .......... .... $ 25.00 Gingival Curettage (Per Procedure)..... ..... $ 40.00 Gingivectomy or Gingivoplasty IPer Quadrant). . ......... ........ ... $110.00 Perio Osseous Surgery (Per Quadrant) ...... . $210.00 Gingival Graft (Per Procedure).......... .. $165.00 Occlusal Adjustment/ Limited ............... $ 25.00 Occlusal Equilibration/Complete (Per Visit)..... $ 55.00 DHI Patient Charge A-Splint(2-6 teeth) .... .. . . . $55.00-$165.00 Night Guard ISoft Acrylic) ....... ......... S 40.00 Night Guard IHard Acrylic) ................. "$165.00 PROSTHODONTICS Removable Tooth Replacement -Dentures Partial Upper, Without Clasps. ........ $ 45.00 Partial Lower, Without Clasps.. I I $ 45.00 Partial Upper -Chrome Casting, Acrylic, Two Clasps $175.00 Partial Lower -Chrome Casting, Acrylic, Two Clasps $175.00 Partial Denture Designed -Chrome, Specific Design, Any Number of Clasps ... $265.00 Complete Upper Denture ... $175.Q0 Complete Lower Denture $175.00 Immediate Denture (does not include reline charge) $175.00 Cosmetic Denture (Upper or Lower) $265.00 REPAIRS TO PROSTHETICS Repair broken complete denture, no teeth damage NO CHARGE Repair broken complete denture and replace one broken tooth NO CHARGE Replace additional teeth, each tooth. ........ NO CHARGE Replace one tooth on denture NO CHARGE Add tooth to partial denture to replace extracted tooth NO CHARGE Replace broken clasp with new clasp on denture NO CHARGE DENTURE RELINING Reline Upper or Lower Complete Denture -Office. NO CHARGE Reline Upper or Lower Partial Denture -Office . NO CHARGE Reline or Rebase Upper or Lower Complete Denture -Laboratory $ 55.00 Reline or Rebase Upper or Lower Partial Denture - Laboratory $ 55.00 ORAL SURGERY Oral Surgery Consultation NO CHARGE Extraction. Single Primary Tooth NO CHARGE Extraction. Each Add'I Primary Tooth NO CHARGE Extraction. Single Permanent Tooth. .. NO CHARGE Extraction. Each Add'► Permanent Tooth. NO CHARGE Surgical Extraction Erupted Tooth NO CHARGE Surgical Removal Impaction: Soft tissue impaction NO CHARGE Partial bony impaction NO CHARGE Full bony impaction $ 70.00 Complicated Surgical Extractions NO CHARGE Surgical Removal Root Tip -Root Recovery. NO CHARGE Alveoloplasty (Per Quadrant) NO CHARGE Implant U C R Biopsy NO CHARGE. Surgical Excision of Cyst NO CHARGE Removal of Exostosis. NO CHARGE Surgical Incision and Drainage NO CHARGE Frenectomy NO CHARGE Oral Antral Fistual Closure NO CHARGE Antral Root Recovery Tooth Replantation...... NO CHARGE Surgical Exposure of Impacted or Unerupted Tooth for Orthodontic Reasons.... ....... NO CHARGE Post Operative Treatment .. .... NO CHARGE ORTHODONTICS Ortho Consultation........ NO CHARGE Ortho Treatment Plan (Records and Models)_ .. $ 35.00 Orthodontic Therapy: The orthodontic fee for a normal 24-month fully -banded case for children ........ .. ............. $1,550.00 (where a cooperating orthodontist is available) Space Maintainer -Fixed Band. ... .. I I I NO CHARGE Ortho Retainer ....... ... .... ....... U C R MISCELLANEOUS/OTHER SERVICES Emergency Visit- Palliative 'Treatment of Dental Pain ............................ NO CHARGE Broken Appointment -less than 24 hours notice. (per 15 minute appointment)... ............ $ 10.00 All other procedures not listed are at dentists' usual, customary, and reasonable (UCR) fees. The DHI Patient Charge Schedule will be reviewed at the end of each calendar year and adjusted to reflect rates currently in effect statewide as approved by the appropriate state insurance commission and shall then be guaranteed until the end of that calendar year (i.e. the Patient Charge Schedule for 1985will be in effect from January 1, 198-- until December 31, 1988- ). The Patient Charge Schedule is valid at the specialist's office when the patient has been referred by the DHI general dentist. - 2 - SCHEDULE - V85 5. OWNER The Owner, as described in this contract, is an Employer, Labor Union, or other recognized Group in accordance with applicable regulations, rulings or orders of the appropriate State Department of Insurance, if any. 6. DEPENDENT DEFINED A dependent of any employee or member is any person, belgw age nineteen (age twenty-three in the case of a full-time student at an accredited institution of learning), who is a son or daughter or a stepson or stepdaughter, or dependent as defined by IRS, of the employee or member and is a member of the household of the employee or member. H(,wever, the attainment of such limiting age shall not operate to terminate the coverage of such child while the child is and continues to be both: 1) Incapable of self-sustaining employment by reason of mental retardation or physical handicap and 2) Chiefly dependent upon the employee or member for support and maintenance, provided proof of such incapacity and dependency is furnished to DHI by the participant within thirty-one days of the child's attainment of the limit- ing age and subsequently as may be required by the insurer or corporation, but not more frequently than annually after the two-year period following the child's attainment of the limiting age. 7. IDENTIFICATION All individual subscribers will be provided with an identification card which should be retained at all times and available for presentation upon visits to the Dental Corp. 8. RESPONSIBILITY FOR SERVICE The Dental Corp. will provide dental services hereunder in accordance with recognized standards of sound dental practice. The Dental Corp. shall be sole judge of what professional services are required and the dental procedures to be used and also the need for referral of covered persons to an outside specialist or a dentist not under contract with the Dental Corp. 9. FACILITIES All dental services to be rendered to the members and dependents shall be performed at the Dental Corp. facilities for specified specialty offices when referred by general dentist). The Dental Corp. maintains its facilities for the provision or ordinary and customary dental treatment at locations convenient to the subscribers. The contract holder and his family must be treated at the same facility. 10. SCOPE OF SERVICE The Dental Corp. shall not be obligated to render any service other than through its own employees, contractors, or other designees. 11. HOSPITALIZATION In the event that it is necessary for a patient to be hospitalized, the cost of hospitalization shall be borne by the patient. The Dental Plan covers treatment of the teeth, the gums (other than tumors), and other associated structures primarily in con- nection with the treatment of teeth at the hospital. 12. RENEWALS The individual subscriber may renew coverage in the Dental Plan at the rates then prevailing under the Master contract. '13. CONVERSIONS Any employee or member of the Group who terminates his employment or membership may obtain toverage under an individual Dental Plan. This individual contract and any succeeding renewals would be at the then prevailing conversion rates. 14. CHARGES FOR BROKEN APPOINTMENTS All covered persons shall pay a charge as set forth in the Benefit Schedule for each and every appointment broken which was made for him. — 3 — 15. GRIEVANCE PROCEDURE Almost all minor controversies can be handled on a personal level by the provider or the plan administrator. In the event satisfaction is not achieved, a Board of Arbitration will be consulted The Board of Arbitration shall be composed of three members. One member shall be appointed by the Dental Corp, the second shall be appointed by the Owner, and these two members shall agree upon a third who shall chair the arbitration. If they cannot agree on a third member, the local Dental Society shall be asked to select a member. If the grievance is of a strictly professional nature, all three members must be dent- ists. Arbitration will be binding on all parties. If either party shall fail to cooperate in the arbitration process, the other party may employ legal means to compel compliance. 16. LIMITATIONS The services included in the Dental Plan are limited to the extent set forth herein. (A) X-RAYS — Complete mouth x-rays will be provided as necessary. (B) EMERGENCY OR ACCIDENT — In the case of accident or emergency involving acute pain or a condition requiring immediate treatment occurring 50 miles from home and the nearest DHI facility, except where hospitalization is re- quired, the Dental Plan covers the cost of all dentally necessary diagnostic and therapeutic procedures administered by any dentist up to a maximum of $50 for each accident or emergency. 17. EXCLUSIONS Services under the Dental Plan specifically do not cover any condition caused by or resulting from: (A) Injuries or contusions as to which benefits exist under Workmen's Compensation, occupational disease, or similar law or act; nor (B) Conditions as to which dental treatment is provided by a Federal or State government agency or is provided without cost to the Owner or any covered person by any political subdivisions or governmental authority, including any treat- ment provided without charge to members or ex -members of the Armed Forces of the United States; nor (C) Any injury or contusion arising out of any condition which is intentionally self-inflicted; nor (D) Declared or undeclared war or act thereof; nor (E) Service in the Armed Forces of any country or international authority; nor (F) Any condition as to which services, treatment, or supplies of any kind are furnished or paid for under Title XVIII of the Social Security Act, as amended; nor (G) Services with respect to congenital mouth malformations; nor (H) Cosmetic dentistry or cosmetic dental surgery; nor (1) Self-administered prescription drugs, and the administration of a general anesthesia; nor W) Partial dentures for covered persons under eighteen years of age. In the event that any covered person shall receive payment from any insurer in respect of any condition for which coverage was available under this agreement and for which treatment was provided hereunder, then the covered person shall be liable for the amount of such payment to the dental provider. Other than the exclusions defined in this section, there are no other exclusions or pre-existing condition exclusions. 18. BOOKS AND RECORDS The Dental Corp, shall arrange for the installation and maintenance of dental records in accordance with accepted professional standards and dental, accounting and internal control practice. 19. COMPLIANCE WITH LAW This agreement is intended to comply with the appropriate State Statutes. The terms and provisions hereof shall be interpreted to the extent possible to render them consistent with the Statutes and the rules and regulations thereof promul- gated by the appropriate State Department of Insurance. This Agreement and the rates required to be paid hereunder are subject to amendment and adjustment as required by the Act and the rules and regulations thereunder promulgated by the State Department of Insurance. 20. SIGNATURES AND SEALS DENTAL HEALTH, INC. BY: (SEAL) ATTEST: (SEAL) MONROE COUNTY MONROE COUNTY — WING 3 PUBLIC SECURITY BUILDING STOCK ISLAND, KEY WEST, FL 33040 AGREED: See Attached for Signatures (SEAL) DATE: November 6, 1986 DATE: cdlQntsl rwai i, Inc. O 1981 D.H.I. —4— The foregoing contract between Dental Hq0th, Inc. and Monroe County is approved and accepted by the foll w' g departm s: Board of County Commissions Office of Tax Collector Office of Property Appraisor Office of Sheriff Office of the Clerk BY: TITLE BY: TITLE Dental Heal t DATE BY: TLs- ATTESTED BY: DATE: ,, 2162B d c fn AnAAS 6