Item B13M
C ounty of f Monroe
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BOARD OF COUNTY COMMISSIONERS
/� r i � ��
Mayor George Neugent, District 2
The Florida. Ke Se
y
I
Mayor Pro Tern David Rice, District 4
Danny L. Kolhage, District I
Heather Carruthers, District 3
Sylvia J. Murphy, District 5
County Commission Meeting
October 18, 2017
Agenda Item Number: B.13
Agenda Item Summary #3351
BULK ITEM: Yes DEPARTMENT: Employee Services
TIME APPROXIMATE: STAFF CONTACT: Maria Fernandez - Gonzalez (305)
292 -4448
n/a
AGENDA ITEM WORDING: Approval of a one year policy renewal with Delta Dental Insurance
Company (1/1/18 - 12/31/18). Monthly rates for the Low Plan will not be increasing 1/1/18, but the
rates for the High Plan will be increased by 20% effective 1/1/18. (Rates per payday will increase
by: $7.04 for Employee Coverage Only; $13.33 for Employee & Spouse Coverage; $14.39 for
Employee & Children Coverage and $20.84 for Family Coverage.)
ITEM BACKGROUND: Dental RFP done early 2015 resulted in the Selection Committee
recommending Delta Dental as the dental insurance vendor. On May 20, 2015, the BOCC approved
staff to negotiate a policy with Delta Dental Insurance Company for a two (2) year term effective
9/1/15 thru 12/31/17, including signing all necessary documents.
Given that it had only been two years since the last RFP, at the time this policy was discussed, a
renewal quote was requested from Delta Dental vs an RFP. The renewal quote from Delta Dental
was requested early enough that should the renewal rate increases been unreasonable, we had time to
go out to bid.
Initially Delta Dental was quoting a 50% increase in the High Plan due to the high utilization by our
participants in that Plan. Gallagher Benefit Services and EB staff were successful in getting Delta
Dental to quote a rate increase of 20% and no reduction in benefit.
A request will come to the BOCC sometime in 2018 to approve an RFP for dental services.
PREVIOUS RELEVANT BOCC ACTION:
2011 Dental RFP Selection Committee ranked United Concordia #1 and a two (2) year agreement
approved by the BOCC October 2011.
2014 Dental RFP was approved by the BOCC after numerous complaints from employees about the
dentist providers, primarily in Monroe County, leaving the United Concordia network due to a
reduction in payment of services and denial of claims. After review of bids received, the County
Administrator was not satisfied with the RFP and another RFP was distributed early 2015 with Delta
Dental being the #1 ranked vendor.
CONTRACT /AGREEMENT CHANGES:
20% increase in high option plan; no change to rates to low plan.
STAFF RECOMMENDATION: Approval of One year renewal with Delta Dental and
recommend a dental RFP in 2018.
DOCUMENTATION:
One Year Renewal with Delta Dental Insurance Company (1/1/18 - 12/31/18)
Delta Dental PPO Group Dental Insurance Contract 9/1/15 - 12/31/17
FINANCIAL IMPACT:
Effective Date: January 1, 2018
Expiration Date: December 31, 2018
Total Dollar Value of Contract:
Total Cost to County: zero
Current Year Portion:
Budgeted: zero
Source of Funds: 100% of premiums paid by participants
CPI:
Indirect Costs:
Estimated Ongoing Costs Not Included in above dollar amounts:
Revenue Producing:
Grant:
County Match:
Insurance Required:
Additional Details:
If yes, amount:
REVIEWED BY:
Bryan Cook
Completed
Assistant County Administrator Christine Hurley
09/05/2017 10:01 AM
Cynthia Hall
Completed
Budget and Finance
Completed
Maria Slavik
Completed
Kathy Peters
Completed
Board of County Commissioners
Completed
09/01/2017 2:12 PM
Skipped
09/05/2017 11:03 AM
09/05/2017 12:55 PM
09/05/2017 1:08 PM
09/05/2017 2:25 PM
09/20/2017 9:00 AM
v,, � 'It•II�,(?� -ttt�� lit:_ I (, M
August 22, 2017 REVISED
Monroe County Board of County Commissioners
1 100 Simonton Street
Key West, EL 33040
RE: Contract Renewal for Monroe County Board of County Commissioners
Delta Dental PPO' Group# 17858
We appreciate your business and thank you for choosing Delta Dental Insurance Company. Your
employees are among the millions nationwide who trust their smiles to Delta Dental.
We are pleased to present you with your dental plan contract renewal information. We are committed
to providing you with quality plan designs combined with excellent customer service.
When reviewing your dental plan, we considered cost factors related to your group's dental service
utilization and claims experience. Our analysis indicates that an increase in your current rate is
necessary. We have made every attempt to keep this increase as low as possible.
We have calculated your rates based on the employer /employee contribution levels in your contract
remaining the same. If the contribution levels and /or enrollment guidelines have changed or will
change, please notify us immediately, as such a change may affect your renewal rate.
The following is the renewal information for your Delta Dental PPO' dental plan:
Effective Date
Contract Term
% increase
Division # 00001, 00002, 09001
Enrollee Only
Enrollee + Spouse
Enrollee + Children
Family
Delta Dental Insurance Company
relephonc: 800 -521 -2651
Delta Dental of California
lelephonc: 888- 335.8227
Delta Dental Mid - Atlantic Region
Delta Dental of Delaware. Inc.
Delta Dental ofthe District ofColumhia
Delta Dental of New York, Inc.
Delta Dental of l ennsylvania (Maryland)
Delta Dental of West Virginia
I 800- 932 -0783
io
In addition to the rates shown above, Delta Dental agrees to continue to provide coverage in
accordance with the information submitted in its Proposal dated March 9, 2015, particularly with
respect to the information contained in Exhibit D to the Proposal (annual deductibles, annual
maximums, and percentage coverage for Class 1, 11 and 11 services and orthodontics).
Please keep this renewal letter with your contract documents. It serves as an amendment to Your Delta
Dental Contracts for the rates and contract term.
'ro renew your dental plan contract, please follow these steps:
I Review this letter for changes to Your dental plan for January 01, 2018
2) Begin paying the rates outlined in this letter with your new contract term.
Delta Dental Insurance Company
Dick Aracich
Vice President, Eastern Region
The American Dental Association (ADA) annually updates its standard dental procedure coding
system, which is a component of its Code on Dental Procedures and Nomenclature (CDT Code)
reference manual. When the ADA changes the codes, carriers must adopt the changes. We process
claims according to the current CDT reference manual. Changes made to comply with the CDT Code
do not constitute a material change to your dental plan design.
OHCA Notification
Please be informed that consistent with the group application and group contract terns, Delta Dental
considers its relationship with fully insured group health plans as subject to HIPAA's "Organized
Health Care Arrangement" (OHCA) privacy rules as defined in 45 Code of Federal Regulations
(CYK) § 1 64.501 . Functionally, the exchange of enrollment information between Delta Dental and
your group remains the same.
While a Business Associate Agreement is not required between Delta Dental and your fully insured
group health plan within an OFICA, any Protected Health Information (PHI) exchanged or shared
between the entities rernains subject to HIPAA's minimum necessary rule and other privacy rules in
addition to any applicable state laws and regulations governing the disclosure of individually
identifiable health information.
Additionally, confidentiality requirements remain applicable to the exchange of information within an
OHCA.
Delta Dental Insurance Company
1130 Sanctuary Parkway
Alpharetta, Georgia 30009
(770) 641 -5100
(888) 858 -5252
Delta Dental PPOsm Group Dental Insurance Contract
Monroe County Board of County Commissioners , ( "Contractholder") has applied for a group
dentaTinsurance Contract with Delta Dental - insurance Company ("Delta Dental"). The following terms will apply:
Contractholder will pay Delta Dental the monthly Premium stated in this Contract.
When the Contractholder pays the first month's Premium, the term of this Contract will begin at 12:01 a.m.
Standard Time, on the Effective Date listed in Attachment C, Group Variables (Attachment C). The term of
this Contract will end as stated in this Contract at the end of the Contract Term at 12:00 midnight Standard
Time.
III. Contractholder will provide each Primary Enrollee electronic access to a certificate /Evidence of Coverage
booklet supplied by Delta Dental. Delta Dental will also fumish a hard copy to a Primary Enrollee or the
Contractholder upon request. Contractholder will also distribute to its Enrollees any notice from Delta
Dental which may affect their rights under this Contract.
So long as Contractholder pays the Premiums as stated in Article 3, Delta Dental agrees to provide the Benefits
described in this Contract including Attachment A Deductibles, Maximums and Contract Benefit Levels (Attachment
A) and Attachment B Services, Limitations and Exclusions (Attachment B).
This Contract is issued and delivered in the State of Florida and is governed by its laws.
Delta Dental Insurance Company
Anthony S. Barth, President
This Contract Contains a Deductible Provision
ENT -51 PPO -FL -C 1 17858
tr_\ I4 ** IK0*I`i t &l
ARTICLE 1- DEFINITIONS
ARTICLE 2 - ELIGIBILITY AND ENROLLMENT
ARTICLE 3 - MONTHLY PREMIUMS
ARTICLE 4 - CONDITIONS UNDER WHICH BENEFITS WILL BE PROVIDED
ARTICLE 5 - GENERAL PROVISIONS
ARTICLE 6 - TERMINATION AND RENEWAL
ARTICLE 7 - ATTACHMENTS
I
ENT -51 PPO -FL -C 2 17858
ARTICLE 1-DEFINITIONS
Terms when capitalized indhiaduounnanthavedefinedmeaningo.givennitherindhesechonbeloworwdhin#his
Contract's sections.
1�01 Accepted Fee — theamounttheettendingPnzvider agrees to accept as payment in full for services
rendered. The Accepted Fee for a Non-Delta Dental Provider is said Provider's Submitted Fee.
1�02 Benefits -- the amounts that Delta Dental will pay for covered dental services under this Contract.
1.03 Calendar Year — the 12 months of the year from January 1 through December 31.
1.04 Claim Form -- the standard form used to file a claim or request a Pre-Treatment Estimate.
1.05 Contract -- this agreement between Delta Dental and the Contractholder, including the attachments listed
in Article 7.
1.06 ContnactBenefitLevei — the percentage of the Maximum Contract Allowance that Delta Dental will pay
after the Deductible has been satisfied aa shown in Attachment A.
1.07 Contractholder -- the employer, union or other organization or group as named herein contracting to
obtain Benefits.
1.08 Contract Term the period during which this Contract is in effect, as shown in Attachment C.
1.08 Contract Year the 16 months starting on the Effective Date and each subsequent 12 month period
thereafter.
1.10 Deductible -- a dollar amount that an Enrollee and/or the Enrollee's family (for family coverage) must pay
for certain covered services before Delta Dental begins paying Benefits.
1.11 Delta Dental PnmmniormProvider Provider) —a Provider who contracts with Delta Dental orany
other member company of the Delta Dental Plans Association and agrees toaccept th Delta D ta|
Premier Contracted Fee as payment in full for covered services provided under a plan. A Premier Provider
also agrees ho comply with Delta Danba|'a administrative guidelines.
1.12 Delta Dental Premier Contracted Fee — thefeeforooch Single Procedure that m Premier Provider has
contractually agreed to accept eo payment in full for covered services,
1.13 Delta Dental PPOom Provider (PPO Pruv|dmr) — aPnoviderwhocontnaotmwith Delta Dental Insurance
Company o/ any other member company of the Delta Dental Plans Association and agrees to accept the
Delta Dental PPO Contracted Fee os payment in full for covered services provided under oPPDdental
plan. A PPD Provider also agrees to comply with Oa|to Dente|'o administrative guidelines.
1.14 Delta Dental PpO Contracted Fee — the fee for each Single Procedure that ePPO Provider has
contractually agreed to accept oa payment in full for covered services.
115 Dependent Enrollee —en Eligible Dependent enrolled to receive Benefits.
1.16 Effective Date -- the original date the Contract starts, as shown in Attachment C.
1.17 Eligible Oependent — adependentofan Eligible Employee eligible for Benefits under Article 2.
1.18 Eligible Employee — any employee or retiree eligible for Benefits under Article 2.
1.19 Ennm|iee — anBigib|eEmployee ("Primary Enrollee") or an Eligible Dependent ("Dependent Enrollee")
enrolled to receive Benefitm^
1.20 Enrollee's Effective Date of Coverage -- the date the Contractholder reports coverage will begin for each
Primary Enrollee and each Dependent Enrollee.
ENT-51 PPO-FL-C 3 17858
121 Maximum Contract Allowance the reimbursement under the Enrollee's benefit plan against which Delta
Dental calculates payment and the Enrollee's financial obligation. Subject to adjustment for extreme
difficulty or unusual circumstances, the Maximum Contract Allowance for services provided:
Low Plan
• byePP0 Provider is the lesser of the Provider's Submitted Fee ov the Delta Dental PPOContracted
Fee.
• bvaPremier Provider is the lesser of the Provider's Submitted Fee or the Delta Dental PR]
Contracted Fee for a PP[) Provider in the same geographic anea.
• by a Non-Delta Dental Provider is the lesser of the Provider's Submitted Fee or the Delta Dental PPO
Contracted Fee for aPPO Provider in the same geographic area.
High Plan
• by a PPO Provider is the lesser of the Provider's Submitted Fee or the Delta Dental PPO Contracted
Fee.
• by a Premier Provider is the lesser of the Provider's Submitted Fee or the Delta Dental Premier
Contracted Fee.
• by a Non-Delta Dental Provider is the lesser of the Provider's Submitted Fee or the Program
1.22 Non-Delta Dental Provider -- a Provider who is not a PPO Provider or a Premier Provider and who is not
contractually bound to abide by Delta Denta|'o administrative guidelines.
123 Open Enrollment Period — themonths of the year during which employees may change coverage for the
next Contract Year.
1.24 Patient — Enndleesfinonoia|obligation calculated an the difference between the amount m�
shown the Fee and the portion shown ae "Delta Dental Pays" on the claims statement when a p~
claim '"processed. o�
125 Pre-Treatment Estimate — unestimotionofthmalbwableEenefitsunderdhis Contract for the services �
proposed, assuming the person is an eligible Enrollee.
1.26 Premium — theemounts payable by the Contractholder monthly as provided in Attachment C.
1.27 PrimaryEnro|lee —anBk]ibkaEmployeeenndledindheplantonaoaive Benefits; may also be referred ho
as "Enrollee".
1.28 Procedure Code —the Current Dental Terminology' (COT) number assigned to a Single Procedure by the
American Dental Association.
1.29 Program Allowance -- the amount determined for a set percentile level of all charges for such services by
Providers with similar professional atandingintheeamegeognaphica|arem. Program Allowances may differ
based on the Provider's contracting status.
1.30 Provider -- a person licensed to practice dentistry when and where services are performed. A Provider
shall also include a dental partnemhip, dental professional corporation or dental clinic.
U1 Qualifying Status Change aohan i
• marital status (marr divorce, legal separation, annulment ordeedh);
• number of dependents (a child's birth, adoption of a child, placement of child for adoption, addition of a
step or foster child or death ofachi|d};
• employment status (change in ) t status uf Enrollee orBigib|e Dependent);
• dependent child ceases to satisfy eligibility requirements;
• neomenma child moves);
• e court order requiring dependent coverage; or
• any other current or future election changes permitted by Internal Revenue Code Section 125.
1,32 Single Prooedure — adentalpmoedure that is assigned a separate Procedure Code.
ENT-51 PPO-FL-C 4 17858
1.33 SFmuse - mperoon related tome partner of the Primary Enrollee:
• as defined and as may be required to be treated as a Spouse by the laws of the state where this
Contract is ' .
• as defined and ae may berequired tobo treated asaSpouse by the laws of the state where the
Primary Enrollee resides; and
• as may be recognized by the Contractholder.
1.34 Submitted Fee - theamont that the Provider bills and enters onm claim for m specific procedure.
ARTICLE 2' ELIGIBILITY AND ENROLLMENT
101 Reporting
Delta Dental processes eligibility eu reported by the Contractholder, On or before the Effective Date,
Contractholder will furnish to Delta Dental, in writing or via electronic format as agreed by Delta Dental and
the Contractholder, a listing of eligible Primary Enrollees and Dependent Enrollees. Electronic format may
be file transmissions, Delta Dental's web tool or a combination of the two. The listing shall include but not
be limited to the:
• PhmaryEnroUeeo'and Dependent Enrollees': names, Enrollee |D numbers, Enrollee's Effective Date of
Coverage, dates of birth, addresses and gender;
• Dependent Enrollees' dependent status; and
• Primary Enrollees' location, ifapplicable.
The eligibility list shall include all Eligible Employees | the Eligible Employee waives coverage or
enrolls in on alternate dental plan offered byContracthoNer. The eligibility list may also include retired
employees.
Thereafter, before the tenth day of each month, Contractholder must furnish to Delta Dental in the format
�
agreed to above, a listing indicating specific additions, changes or terminations made during the prior �
month. An Enrollee remains enrolled until the Contractholder notifies Delta Dental of the termination, If the
Primary Enrollee loses coverage or makes any change that affects an Enrollee's eligibility, Contractholder
must promptly notify Delta Dental of such change. `-
Contractholder will notify Delta Dental in writing or in electronic media uf any requests for Premium
adjustments for Enrollees who should have been terminated in the event Delta Dental was not previously
notified of the termination(s). Retroactivity will be adjusted up to the immediately preceding three (3)
months plus the current billing month.
Delta Dental will not make any payment fo services provided tnen Enrollee who |s not reported toDelta
Dental as an Enrollee under this Contract when the service is provided. Also, Delta Dental may not pay
Benefits for an Enrollee if Premiums are not paid for the month in which dental services are rendered. Delta
Dental shall not be obligated to recover claims paid to a Provider ama result nfContnaotho|der'm retroactive
eligibility adjustments. The Contractholder agrees to reimburse Delta Dental for any erroneous claim
payments made by Delta Dental as result cf incorrect eligibility reporting by the Coninactho|der.
2�02 Contractholder will permit Delta Dental to audit Contractholder's records to confirm compliance with Articles
2 and 3. Delta Dental will give Contractholder written notice within a reasonable time before the audit date.
2.03 Eligible Employees
An employee wmrkingeminimumof2Ghoumperweakbecomese|iQib|eonwhichevarim|ater.the
Effective Date oron the 60 days from the date of hire.
2.04 Eligible Dependents
• Dependents are the Primary Enrollee's Spouse and dependent children from birth to the end of the
month of their 26mbirthday.
• Children include natural children, stepchi|dnon, foster children, adopted chi|dren, children placed for
adoption, custodial children, children for which the employee haob appointed | | guardian and
newborn children, including a newborn child of a covered dependent child and children of a partner as
recognized by the Contractholder. Children/students must be dependent upon the Primary Enrollee for
support and maintenance. The dependents of Primary Enrollees are eligible to enroll on the same date
that the employee, of whom they are a dependent, becomes a Primary Enrollee. Newborn children,
including a newborn child of a covered dependent child or a newborn child where a written agreement
to adopt has been entered into prior to birth, are eligible from the moment of birth. Adopted children,
foster children and custodial children are eligible from the moment of placement in the Enrollee's
residence. Notice of birth, adoption placement, foster home placement or other custodial placement of
ENT-51PPO-FL-C 5 17858
child with Enrollee must be received within 31 days of the birth or placement. If notice of birth or
adoption is received within the 31 day notice period, no additional premiums are due during the notice
period. If notice is received within 60 days of the birth or adoption placement instead of 31 days,
coverage will be effective from the date of birth or placement, but the Enrollee must pay any additional
Premium from the date of birth or placement. Eligibility for a newborn child of covered dependent child
terminates 18 months after the birth of the newborn. Later-acquired dependents become eligible as
soon as they acquire dependent status.
An overage dependent child may be eligible if:
1 ) he/she is incapable of self-sustaining employment because of a physically or mentally disabling
injury, illness or condition that began prior to reaching the limiting age;
2) he/she is chiefly dependent on the eligible employee for support; and
3) proof of dependent's disability is provided within 31 days of request. Such requests will not be
made more than once a year following a two year period after this dependent reaches the limiting
age. Enrollment will continue as long as the dependent relies on the eligible employee for support
because of a physically or mentally disabling injury, illness or condition that began before he/she
reached the limiting age.
Dependents on active military duty are not eligible.
2.05 Enrollment of Eligible
• If the Primary Enrollee must contribute any portion of the cost of coverage, then Eligible Employees
must enroll to be covered under the plan. Enrollment must be within 31 days after first becoming
eligible or during an Open Enrollment Period. Coverage cannot be dropped or changed other than
during an Open Enrollment Period or because of a Qualifying Status Change.
• If the Primary Enrollee is paying all or a portion of the cost for coverage for Dependent Enrollees in the
manner elected by the Contractholder and approved by Delta Dental, then Eligible Dependents must
be enrolled within 31 days after the date becoming eligible or during an Open Enrollment Period. If
notice of a birth or adoption is received within the 31 day notice period, no additional premiums are due
during the notice period. If notice is received within 60 days of a birth or adoption placement instead of
31 days, coverage will be effective from the date of birth or placement, but the Enrollee must pay any
additional Premium from the date of birth or placement. Coverage may not be changed at any time
other than during an Open Enrollment Period or if there is a Qualifying Status Change.
• All Eligible Dependents must be enrolled as Dependent Enrollees if dependent coverage is elected.
• * child who m eligible ssa Primary Enrollee and o dependent can be insured unoe this Contract oaa
Primary Enrollee nro Dependent Enrollee but not both at the same time.
2.08 Except for en employee absent from work due buo leave of absence approved bvth Contractholder
governed byuthe "Family m Medical Leave Act of 1993 (r.L. /o3.a),an Enrollee will not oe covered for any
dental services received while a Primary Enrollee ison strike, lay-off r leave ofabsence. CVntrectho|der
must inform Delta Dental of any change in eligibility as required under section 2.01.
Benefits for such Primary Enrollee and his/her Eli ib| Dependents will resume as follows:
• |f coverage isneactivatedintheoameCa|endorYaar.Oeduotib|eoandmeximumovvi||remumeaeifthe
Primary Enrollee were never gone.
• If coverage is reactivated in a different Calendar Year, new Deductibles and maximums will apply.
Coverage will resume the date the Primary Enrollee returns bo work, provided the Contnactho|dersubmits
the request to Delta Dental that coverage bareactivated.
If an employee is rehired within the same Calendar Year, Deductibles and maximums will resume am|fthe
Primary Enrollee was never gone.
2.07 A Primary Enrollee loses coverage on the day of termination of emplo t when he/she |ano|ongeren
Eligible Member of the Contractholder or the day this Contract is terminated. Dependent Enrollees lose
coverage along with the Primary Enrollee or the last day of the month when dependent status is lost.
Termination of Benefits on Voluntary Loss of Eligibility
Delta Dental will not pay for Benefits for any services received by o person who is cd an Enrollee at the
time oftreatment except for covered dental services incurred when the person was covered if such
procedure is completed within 90 days of the Enrollee's voluntary termination of coverage. A dental service
ie incurred aafollows:
• for en appliance (or change bzanapp|ianoe).adthebmetheimprausioniamade;
• for a crown, bridge or cast restoration, at the time the tooth or teeth are prepared;
• for root canal therapy, at the time the pulp chamber ie opened; and
• for all other dental services, at the time the service is performed or the supply furnished,
ENT-51 PPO-FL-C 6 17858
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2.08 Extension of Benefits
In the case of services provided to an Enrollee at the termination of this Contract, an Extension of Benefits in
the form cf reimbursed expenses will apply if:
• the dental services were recommended in writing and commenced while the policy was in effect by the
Provider tn the Enrollee while the person was covered by this Contract.
• the dental services were for procedures other than routine examinations, prophylaxis, x-rays, sealants or
orthodontic services.
• the dental services were performed within 90 days after the Enrollee's coverage ceased under this
Contract and the termination of coverage did not occur as a result of the Enrollee's, or, in the case of a
dependent child, the child's parent's voluntary termination ofcoverage.
The extension of benefits terminates upon the earlier of:
• the SO-dey period specified in the above third bullet item; or
• the date the person becomes covered under o succeeding policy
K coverage or services for the dental procedures referred hoin the above first bullet item are excluded bythe
succeeding contract through the use of an elimination period, the person is not covered by the succeeding
contract and the Extension of Benefits does not terminate.
All contractual Limitations, Exclusions orreduut� kj have reductions ~�
had the coverage on the not bynninobad during the Extension of Benefits. ~' ~ ~ dental
�0
2�09 Continued Coverage Under USERRA
Ao required under the Uniformed Services Employment and Reemp (USERRA).
if a Primary Enrollee is covered by this Contract on the date his or her USERRA leave of absence begins,
the Primary Enrollee may continue dental coverage for himself or herself and any covered dependents. ~~
Continuation ofcovero d USE�<RA may not extend b ndtheeadierot 24 months beginning on
the date the leave ofa p~
coverage o�
-- _ ^^
required by USERRA For leave beyond 31 days, the Premium for of
coverage will be the same as for COBRA coverage.
� .
210 Continuation of Coverage Under COBRA
When the Eligible Employees of a Contractholder are covered under COBRA (the Consolidated Omnibus
Budget Reconciliation Act of 1985), then in consideration of the payments specified in Article 3, Delta
Dental agrees to provide the Benefits to Enrollees who elect continued coverage pursuant to this section,
continuation of coverage is required to be offered under COBRA;
the Enrollee requests the continuation within the time frame allowed;
the Contractholder notifies Delta Dental that the Enrollee has elected to continue coverage under
Delta Dental receives the required Premium for the continued coverage; and
this Contract stays in force.
Delta Dental does not assume any of the obligations required by COBRA of the Contractholder or any
employer (including the obligation to notify potential beneficiaries of their rights or options under COBRA).
ARTICLE 3— MONTHLY PREMIUMS
3.01 Contractholder will remit to Delta Dental or its Third Party Administrator the Premium in the amount and
manner shown in Attachment C for all Primary Enrollees and Dependent Enrollees,
Oe|bs Dental will process eligibility as reported by the Contractho|der.
For enrollment additions, Controotho|derwiU remit a full month's Premium for Enrollees whose coverage is
effective on the first through the fifteenth calendar day of a month. Premiums are not due to Delta Dental
for Enrollees who are enrolled on the sixteenth through the last day of a month.
For enrollment terminations, Contnactho|der will remit a full month's Premium for Enrollees whose coverage
is terminated on the sixteenth through the last calendar day of respective month. Premiums are not due
to Delta Dental for Enrollees whose enrollment is terminated on the first through the fifteenth day of a
month.
ENT-51 PPO-FL-C 7 17858
3.02 Contractholder will pay all Premiums, including the first month's Premium, to Delta Dental within 60 days
following the first calendar day of the applicable month of coverage. This 60 day period includes a 30 day
grace period. This Contract will continue in force during this period. However, if the Premium remains
unpaid at the end of this period, Delta Dental may terminate this Contract in accordance with the notice
requirements of section 6.01.
3.03 Delta Dental will not be responsible or liable for any incorrect, incomplete, obsolete nr unreadable data or
information supplied to Delta Dental including, but not limited to, eligibility and enrollment information.
3.04 Delta Dental may change the rate of monthly Premium whenever this Contract iu amended ae stated in
section 3.05/ur whenever the Contracthn|dar requests a change in Benefits. Any change in Premium shall
not go into effect during o Contract Term unless ConbncthoNer and Delta Dental agree in writing, except
as provided in section 3,OG, 3.06.
105 Premiums are based on the number ofcovered employees at the beginning of each Contract Term. Kthe
Contnaotho|derreports a 15 percent edddi reduction in the b of covered Ph Enrollees for
three (3) months in a row, Delta Dental may propose a choice of changes in Premiums or Benefits to
remedy the increase in cost per person which may result from the difference in the number of enrolled
employees. Within 45 days, Contrecthok1er will select one cf the choices b ritta notice to Delta Dental
|fContoantho|der fails todoso, Delta Dental may select one nf the choices bywritten notice to
Contractholder. This Contract will be modified for all dental services predetermined and paid after notice.
3,06 If during the Contract Term any new nr increased tax is imposed ho Delta Dental
under this Contract, the amount stated in Attachment C will be increase by the amount of any such new or
increased taxes.
ARTICLE 4- CONDIT UNDER WHICH BENEFITS WILL BE PROVIDED
4.01 Delta Dental will pay Benefits for dental services described in Attachment B when provided by a Provider
and when necessary and customary under generally accepted dental practice standards. Claims
processed in accordance with Delta Dental's standard processing policies. The processing policies may be
revised from time to time; therefore, Delta Dental shall use the processing policies that are in effect at the
time the claim is processed. Delta Dental may use dentists (dental consultants) to review treatment plans,
diagnostic materials and/or prescribed treatments to determine generally accepted dental practices and to
determine if treatment has a favorable prognosis. Limitations and exclusions will be applied for the period
the person is an Enrollee under any Delta Dental program or prior dental care program provided by the
Contractholder subject to receipt of such information from the Contractholder or at the time a claim is
submitted. Additional waiting periods, if any, are shown in Attachment A. If an Enrollee receives dental
services from a Provider outside the state of Florida, the Provider will be reimbursed according to Delta
Dental's network payment provisions for said state according to the terms of this Contract.
If primary dental procedure includes component procedures that are performed at the i the
primary procedure, the component procedures are considered t be rtof the h oed for
purposes cx determining the benefit payable under this Contract. |f the Provider bills separately forthe
primary procedure and each of its component parts, the total benefit payable for all related charges will be
limited to the maximum benefit payable for the primary procedure.
4.02 Delta Dental's provision of Benefits is limited to the applicable portion of the Provider's fees or allowances
specified in Attachment A. The Enrollee is responsible for paying the balance of any fees or allowances
known as the "Enrollee Coinsurance". Contractholder has chosen to require Enrollee Coinsurances under
this program as a method of sharing the costs of providing dental Benefits between Contractholder and
Enrollees. If the Provider discounts, waives or rebates any portion of the Enrollee Coinsurance to the
Enrollee, Delta Dental will be obligated to provide as Benefits only the applicable percentages of the
Provider's fees or allowances reduced by the amount of such Enrollee Coinsurance fees or allowances that
are discounted, waived or rebated.
ENT-51 PPO-FL-C 8 17858
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4,03 Deductible
As shown on Attachment /\ Delta Dental will not pay Benefits for the Deductible amount of the Maxmum
Contract Allowance for services received each Calendar Year by an Enrollee. The annual maximum
Deductible per family, if any, is shown in Attachment A. Only fees an Enrollee pays for covered services
that are described in Attachment B will count toward the Deductible.
4,04 Maximum
Amox Amount" or "Maximum")
pay toward the cost of dental care. Enrollees must satisfy costs above this amount. Delta Dental will pay
the Maximum Amount(s), if applicable, shown in Attachments A for Benefits under this Contract.
4.05 Choice ofa Provider
Enrollees may choose e Provider from Delta Oenta|'a panel ofPPO and Premier Providers orEnrollees
may choose Non-Delta Dental Provider. A list ofPPO and Premier Providers can be obtained at Delta
Den(a|'swebmite(de|tedento|ina.uom). Providers are regularly added too/ deleted from the list. Enrollees
are responsible for verifying whether the selected Provider is a PPO Provider or a Premier Provider.
AddhionaUy. Enrollees should always confirm with the Provider's office that a listed Provide/ is still o
participating PPO Provider or Premier Provider. Delta Dental does not guarantee that any particular
Provider will be available.
PPOPmvider
Selecting PPC}Provider potentially allows #he greatest reduction in E leea
since this select group of Providers will provide dental Benefits at a charge which has been contractually
agreed upon.
Premier Provider
A Premier Provider has not agreed to the features of the PPO program; however, Enrollees may still
receive dental care at a lower cost than if Enrollees use a Non-Delta Dental Provider.
Non-Delta Dental Provider
If a Provider iae Non-Delta Dental Provider, the amount charged to Enrollees may be above that accepted
by the PPO Providers or Premier Providers. For m Non-Delta Dental Provider, the Accepted Fee imthe
Provider's Submitted Fee.
Additional Obligations of Delta Dental Providers:
• The PPO Provider or Premier Provider must accept assignment of Benefits, meaning these Providers
will be paid directly by Delta Dental after satisfaction of the Deductible and Enrollee Coinsurance, and
the Enrollee does not have to pay all the dental charges while at the dental office and then submit the
claim for reimbursement.
• The PP{] Provider or Premier Provider will complete the dental Claim Form and submit htoDelta
Dental for reimbursement.
• The PP[> Provider or Premier Provider will accept contracted fees aa payment in full for covered
services and will not balance bill if there is a difference between Submitted Fees and contracted fees.
4.08 Coordination of Benefits
Delta Dental coordinates the Benefits under this Contract with an Enrollee's benefits under any other group
or pre-paid plan or insurance policy designed to fully integrate with other policies. If this Contract is the
"primary" plan, Delta Dental will not reduce Benefits. If this is the "secondary" plan, Delta Dental may
reduce Benefits otherwise payable under this Contract so that the total benefits paid or provided by all
plans do not exceed 100 percent of total allowable expense.
Order uf Benefit Determination Rules
The following rules determine which plan is the "primary"
( The plan covering the Enrollee as an employee io primary over m plan covering the Enrollee as a
dependent.
( The plan covering the Enrollee aann employee primary over o plan which covers the insured
person aso dependent; that: if the insured person is | Medicare beneficiary, and ama
result of the rule established by Title XVIII of the Social Security Act and implementing regulations,
Medicare is:
a) Secondary to the plan covering the insured person uoa dependent and
b) Primary to the plan covering the insured person as other than a dependent (e.g. a retired
employee),
then the benefits of the plan covering the insured person as a dependent are determined before
those of the plan covering that insured person ao other than adependent.
ENT-51 PPO-FL-C 9 17858
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(3) Except as stated in paragraph (4), when this plan and another plan cover the same child as a
dependent of different persons, called parents:
a) 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
b) If both parents have the same birthday, the benefits of the plan which covered one parent
longer are determined before those of the plan which covered the other parent for a shorter
period of time.
c) However, if the other plan does not have the birthday rule described above, but instead has a
rule based on the gender of the parent, 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.
(4) In the case of a dependent child of legally separated or divorced parents, the plan covering the
Enrollee as a dependent of the parent with legal custody, or as a dependent of the custodial
parent's Spouse (i.e. step - parent) will be primary over the plan covering the Enrollee as a
dependent of the parent without legal custody. If there is a court decree which would otherwise
establish financial responsibility for the health care expenses with respect to the child, the benefits
of a plan which covers the child as a dependent of the parent with such financial responsibility will
be determined before the benefits of any other policy which covers the child as a dependent child.
(5) If the specific terms of a court decree state that the parents will share joint custody, without stating
that one of the parents is responsible for the health care expenses of the child, the plans covering
the child will follow the order of benefit determination rules outlined in paragraph (3).
(6) The benefits of a plan which covers an insured person as an employee who is neither laid -off nor
retired are determined before those of a plan which covers that insured person as a laid -off or
retired employee. The same would hold true if an insured person is a dependent of a person
covered as a retiree or an employee. 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 (6) is ignored.
(7) If an insured person whose coverage is provided under a right of continuation pursuant to federal
or state law also is covered under another plan, the following will be the order of benefit
determination:
a) First, the benefits of a plan covering the insured person as an employee or Primary Enrollee (or
as that insured person's dependent);
b) Second, the benefits under the continuation coverage.
If the other plan does not have the rule described above, and if, as a result, the plans do not
agree on the order of benefits, this rule is ignored.
(8) If none of the above rules determine the order of benefits, the benefits of the plan which covered an
employee longer are determined before those of the plan which covered that insured person for the
shorter term.
(9) When determination cannot be made in accordance with the above, the benefits of a plan that is a
medical plan covering dental as a benefit shall be primary to a dental -only plan.
4.07 Clinical Examination
Before approving a claim, Delta Dental may obtain, to such extent as may be lawful, from any Provider, or
from hospitals in which a Provider's care is provided, such information and records relating to an Enrollee
as Delta Dental may require to administer the claim. Delta Dental may also require that an Enrollee be
examined by a dental consultant retained by Delta Dental at Delta Dental's expense in or near his/her
community or residence. Such information and records will be kept confidential in accordance with all
applicable laws and regulations.
4.08 Notice of Claim Forms
Delta Dental will furnish to any Provider or Enrollee, on request, a Claim Form to make a claim for payment
of Benefits. To make a claim, the Claim Form must be completed and signed by the Provider who
performed the services and by the Enrollee (or the parent or guardian of a minor) and submitted to Delta
Dental at the address shown thereon. If Delta Dental does not furnish the Claim Form within 15 days after
requested by a Provider or Enrollee, the requirements for proof of loss set forth in section 4.10 of this
Contract will be deemed to have been complied with upon the submission to Delta Dental within the time
established in said section for filing proof of loss, of written proof covering the occurrence, the character
and the extent of the loss for which claim is made. Enrollees and Providers may download a Claim Form
from Delta Dental's website.
4.09 Pre - Treatment Estimate
A Provider may file a Claim Form before treatment, showing the services to be provided to an Enrollee.
Delta Dental will estimate the amount of Benefits payable under this Contract for the listed services.
Benefits will be processed according to the terms of this Contract when the treatment is performed. Pre -
Treatment Estimates are valid for 365 days unless other services are received after the date of the Pre -
Treatment Estimate, or until an earlier occurrence of any one of the following events:
• the date this Contract terminates;
ENT -51 PPO -FL -C 10 17858
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• the date Benefits under this Contract are amended if services in the Pre-Treatment Estimate are part of
the amendment;
• the date the Enrollee's coverage ends; or
• the date the Provider's agreement with Delta Dental ends.
410 Written Notice mf Claim/Proof ofLoss
Delta Dental must be given a written notice of claim, sometimes referred to as a written proof of loss, within
12 months after the date of the loss and must include information regarding other group coverage if
applicable. If it is not reasonably possible bo give written proof in the time ired the } i will not ba
reduced or denied solely for this reason, pnzvidad proof iafiled as soon as reasonably possible. In any
event, proof of |oee must be given no later than one (1) year from such time (unless the claimant was
legally incapacitated).
4.11 Time of Payment
Claims payable under this Contract for any loss other than for which this Contract provides any periodic
payment will be processed (paid or denied):
• within 45 days after receipt of due written proof of such loss. If additional information is requested to
process the claim, Delta Dental will notify the Primary Enrollee and the Provider within 45 days of
written proof of loss; and
• within 60 days after the requested information is received for any disputed portion of the claim.
Claims not processed (paid or denied) within 120 days of receipt are subject to a charge of 10 percent
interest per annum. Subject to due written proof of loss, all accrued indemnities for loss for which the
Contract provides periodic payment will be paid monthly.
4,12 C|ehns Appeal
Delta Denta|wiU ���������r���/�d�������bm���� �
'--`-- m�
Claim Form, whole or in stating the �
receiving a notice of denial to request an appeal or grievance by writing to Delta Dental giving reasons why
they believe the denial was wrong. The Enrollee and his/her Provider may also ask Delta Dental to �
examine any additional information provided that may support the appeal or grievance.
Send your appeal or grievance to Delta Dental at the address shown below: ~-
Delta Dental Insurance Company
P.O. Box 1809
Alpharetta, GA 30023
Delta Dental will send the Enrollee a written acknowledgment within fifteen (1
appeal or grievance. Delta Dental will make a full and fair review and may ask for more documents during
this review if needed. The review will take into account all comments, documents, records or other
information, regardless of whether such information was submitted or considered initially, If the review is of
a denial based in whole or in part on lack of dental necessity, experimental treatment or clinical judgment in
applying the terms of this Contract, Delta Dental shall consult with a dentist who has appropriate training
and experience. The review will be conducted for us by a person who is neither the individual who made
the claim denial that is subject to the review, nor the subordinate of such individual. Delta Dental will send
the Enrollee a decision within 30 days after receipt of the Enrollee's appeal or grievance.
If the Enrollee believes he/she needs further review of their
his/her state regulatory agency if applicable. If the group health plan is subject to the Employee Retirement
Income Security Act of 1974 (ERISA), the Enrollee may contact the U.S. Department of Labor, Employee
Benefits Security Administration (EBSA) for further review of the claim or if the Enrollee has questions
about the rights under ERISA. The Enrollee may also bring a civil action under Section 502(a) of ERISA.
The address of the U.S. Department of Labor is: U.S. Department of Labor, Employee Benefits Security
Administration (EBSA), 200 Constitution Avenue, N.W. Washington, D.C. 202M
413 To Whom Benefits Are Paid
Payment for services provided bya PPO Provider ora Premier Provider will be made directly tothe
Provider. Any other payments provided by this Contract will be made to the Primary Enrollee | the
Primary Enrollee requests when filing proof of loss that the payment be made directly to the Provider
providing the services. All Benefits not paid to the Provider will be payable to the Primary Enrollee, to
his/her estate, or /vuxalternate recipient mu directed u order except that n the person ma minor or
otherwise not competent bo give avalid release. Benefits may ba payable ho his/her parent, guardian or
other person actually supporting him/her.
ENT-51 PPO-FL'C 11 17858
4]4 No change in Benefits will become effective during a Contract Term unless Contractholder and Delta
Dental agree in writing.
ARTICLE 6-GENERAL PROVISIONS
5.01 Entire Contract: Changes
This Contract, including the attachments listed in Article 7 is the entire agreement between the parties. No
agent has authority to change this Contract or waive any of its provisions. No change in this Contract will
be valid unless approved byan executive officer of Delta Dental.
5.02 Severability
If any part of this Contract oren amendment ofdis found byo court or other authority tobe illegal, void or
not enforceable, all other portions of this Contract will remain in full force and effect.
5.03 Conformity with Prevailing Laws
All legal questions about this Contract will bogoverned by the state of Florida where this Contract was
entered into and ishobe performed. Any part of this Contract which conflicts with the laws of Florida o/
federal law is hereby amended to conform to the minimum requirements of such laws.
5.04 Misstatements on Application; Effect
In the absence of fraud or intentional misrepresentation of material fact in applying for or procuring
coverage under the terms of this Contract, all statements made by the Contractholder will be deemed
representations and not warranties. No such statement will be used in defense to a claim under this
Contract, unless it is contained in a written instrument signed by the Contractholder, a copy of which has
been furnished to such Contractholder.
5.05 Legal Actions
No action at law or in equity will be brought to recover on this Contract before 60 days after written proof of
loss has been filed in accordance with requirements ofthioContrnc.Noouchactionmaybebroughtafter
the expiration of the applicable statute of limitations from the time written proof of loss is required to be
given.
5.06 Not in Lieu of Workers' Compensation
This Contract is not in lieu of and does not affect any requirements for coverage by workers' compensation
insurance.
5.07 Certificate ofInsurance
Delta Dental will issue to the Contractholder an electronic file of Coverage
booklet summarizing the Benefits to which Enrollees are entitled and to whom Benefits are payable. Each
Primary Enrollee will have electronic access to the certificate. Delta Dental will also furnish a hard copy to a
Primary Enrollee or the Contractholder upon request. The certificate is not assignable and the Benefits are
not assignable prior to a claim. If any amendment to this Contract will materially affect any Benefits
described in the certificate, new certificates or amendments showing the change will be issued.
5.08 Publications About Program
ConreuUholder and Delta Dental agree bo consult aeis reasonably all material published or
distributed about this Contract. No material will be published or distributed which conflicts with the terms of
this Contract.
6.09 Provider Relationships
Cordranthnk]er and Delta Dental agree to permit and encourage the nohao io | relationship between
Provider and Enrollee to be maintained without interference. Any PPO, Premier or Non-Delta Dental
Provider, including Provider | associated with or employed dental
services to Enrollees does so as an independent contractor and shall be solely responsible for dental
advice and for performance of dental services, or lack thereof, to the Enrollee.
5.10 Notice; Where Directed
All formal notices under this Contract must Le in writing and sent by email, facsimile
Sb�eemail, overnight d�kmrysen�ceor �ne|��ery.NodcebyUnhad States r�ai|�will be effective 48
hours after mailing with fully pre-paid postage.
Contractholder shall designate in writing on the application a representative for purposes of receiving
notices from Delta Dental under this Contract. Contractholder may change its representative at any time
with 30 days written notice to Delta Dental. The Contractholder's representative shall disseminate notices
to the Enrollees within 30 days of receipt.
ENT-51PPO-FL-C 12 17858
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5A1 Indemnification
Contractholder will indemnify, defend and hold harmless Delta Dental, its directors, officers,
agents and affiliated companies against any and all claims, demands, liabilities, costs, damages and
causes of action or administrative proceedings whatsoever, including reasonable attorney's fees, arising
from Contractholder's negligent performance or non-performance of its obligations under this Agreement.
Delta Dental will indemnKy, defend and hold harmless C mdractho|derond its employees d agents,
against any and all claims, demands, liabilities, costs, damages and causes of action or administrative
proceedings whatsoever, including reasonable attorney's fees,uriaingfromDe|baDenta[aneU||gant
performance or non-performance of its obligations under this Agreement.
5.12 Time Limit on Certain Defenses
After this Contract has been in force for two (2) years from the Effective Date, no statement made by the
Contractholder will be used to void this Contract. No statement by an Enrollee with respect to the Enrollee's
insurability, will be used to reduce or deny a claim or contest the validity of insurance for such Enrollee after
that person's coverage has been in effect two (2) years or more during his or her lifetime.
5.13 Compliance with Administrative Simplification, Security and Privacy Regulations
Contractholder and Delta Dental shall comply in all respects with applicable federal, state and local laws
and regulations relating to administrative simplification, security and privacy of individually identifiable
Enrollee information including executing a Business Associate Addendum as required by Health Insurance
Portability and Accountability Act of 1996 ("HIPAX). The Contractholder and Delta Dental agree that this
Contract shall incorporate terms as necessary and as applicable to execute the required agreements (i.e.
business associate agreement) to comply with federal regulations issued under the HIPAA, HITECH Act or
to comply with any other enacted administrative simplifications, security or privacy laws or regulations.
5.14 Impossibility of Performance
Neither h ll be liable to th h be deemed to be in breach of this Contract for any failure or
delay in performance arising out of causes beyond its reasonable control. Such causes are strictly limited
to include outm of God orofa public enemy, exp|osion, firea, or unusually severe weather. Dates and times
of performance shall be extended to the extent of the delays excused by this paragraph, provided that the
party whose performance is affected notifies the other promptly of the existence and nature of the delay.
5.15 Third Party Administrator (''TPA")
Delta Dental may use the services ofa TPA, duly registered under applicable state law, bu provide services
under this Contract. Any TPA providing such services or receiving such information shall enter into a
separate Business Associate Agreement with Delta Dental providing that the TPA shall meet HIPAA and
HITECH requirements for the preservation of protected health information of Enrollees.
516 Holding
Delta Dental is a member of the Insurance Holding Company
"Enterprise"). There are service agreements between and among the controlled member companies of the
Enterprise. Delta Dental is a party to some of these service agreements, and it is expected that the
services, which include certain ministerial tasks, will continue to be performed by these controlled member
companies, which operate under strict confidentiality and/or business associate agreements. All such
service agreements have been approved by the respective regulatory agencies.
517 Mutual Confidentiality
Contractholder and Delta Dental agree to maintain confidential information using the same degree ofoare
(which shall bano less than reasonable ea each uses to protect its own confidential info at| of
similar nature and to use confidential information only for specified purposes. Confidential information
includes any information which the owner deems confidential, whether marked as confidential or otherwise
clearly identifiable as confidential and includes information not generally known by the public or by parties
which are competitive with or otherwise in an industry, trade or business similar to the owner of the
confidential information. The recipient of confidential information shall notify the owner of any unauthorized
disclosure or breach of confidentiality as soon as possible after discovery and without unreasonable delay.
5.18 Trademarks; Service Marks
Unless specifically allowed in this Contract, neither party shall ueetheneme.tredemarks.servimmmarkmor
other proprietary branding of the other party without the advance written approval of the other party.
5.10 Automated Information Line
CondnacthoNmrund Enrollees may coeso Oebo Dnnta'o automated information line od8OO-521-2G51 on a
regular business day to obtain Enrollee eligibility Benefits, group Benefit or claim status information or
to speak tna Customer Service Representative for assistance, including resolution ofcomplaints,
ENT-51 PPO-FL-C 13 17858
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520 New Enrollees
New eligible Enrollees may be added in accordance with the terms of this Contract under section 2.05.
ARTICLE 6- TERMINATION AND RENEWAL
&01 This Contract may be terminated only as follows:
• ByContnaotho|der upon 3O days written notice at any time.
• By Delta Dental,
( upon GO days written notice ifContusctho|der fails hofurnish Delta Dental a list ofall Enrollees as
required under section 2.O1;or
( upon GO days written notice if Contnaotho|der fails to permit Delta Dental to inspect Controctho|de/a
records ae called for under section 2.O2; or
(3) upon 31 days written notice if Contractholder fails to pay Premiums, in the amount and manner
required by Article 3.
• By Delta Dental, upon 60 days advance written notice if the Contractholder reports fewer than the
Minimum Number of Primary Enrollees shown inAttachment C for three (3) consecutive months,
• By Delta Dental at the end ofm Contract Term upon GO days written notice.
6.02 If this Contract is terminated under 6.01, Contractholder will owe Delta Dental unpaid Premiums due before
this Contract was terminated,
8,03 Delta Dental will not be required to do Pre-Treatment Estimates if this Contract is terminated for any cause
nor will Delta Dental be required to pay for services performed beyond the termination date except for
completion of Single Procedures commenced while this Contract was in effect as stated in Section 2.08.
6.04 Delta Dental will provide 120 days advance written renewal notice prior to the end of the initial or any
subsequent Contract Terms indicating if Premiums and/or Benefits will remain the same or change. The
Con ractholder's payment of the Premium indicated in the renewal notice for the new Contract Term will
signify the Contractholder's acceptance of the renewal. If the Contractholder fails to provide written
notification to Delta Dental of non-renewal by the date indicated in the renewal letter and/or does not the Premiums ind�abadin the renewal noboewdhthe new Conb�
this o�
Contract under section 6.01 second bullet, item (3). �n
ARTICLE 7'ATTACHMENTS ~-
These documents are attached to this Contract and mode a part of it:
Attachment Deductibles, Maximums and Contract Benefit Levels
Attachment Services, Limitations and Exclusions
Attachment Group Variables
ENT-51 PPO-FL-C 14 17858
B.13.b
Attachment A
Deductibles, Maximums and Contract Benefit Levels
Contractholder: Monroe County Board of County Commissioners
Group Number: 17858 Effective Date: September 1, 2015
_— ... ....... _.... ... ... .. ............
_ ...... �
Deductibles & Maximums
- - - --
Annual Deductible
$50 per Enrollee each Calendar
$50 per Enrollee each Calendar
Year
Year
$150 per family
$150 per family
each Calendar Year
each Calendar Year
Deductibles waived for
Diagnostic & Preventive and
9
Dia
Diagnostic & Preventive and
9
Orthodontics Services
Orthodontics Services
Deductible Takeover
Any annual Deductible amount
Any annual Deductible amount
satisfied by the Enrollees under the
satisfied by the Enrollees under the
Contractholder's previous dental
Contractholder's previous dental
care plan from January 1, 2015 to
care plan from January 1, 2015 to
the Effective Date will be credited
the Effective Date will be credited
towards the annual Deductible
towards the annual Deductible
under the Contract.
under the Contract.
Annual Maximum
$2,000 per Enrollee
$5,000 per Enrollee
each Calendar Year
each Calendar Year
If an Enrollee switches from the
If an Enrollee switches from the
Low Plan to the High Plan at Open
High Plan to the Low Plan at Open
Enrollment, the Maximum Amount
Enrollment, the Maximum Amount
payable for Benefits will not exceed
payable for Benefits will not exceed
the applicable Maximum for the
applicable Maximum for the Low
High Plan.
Plan.
Lifetime Orthodontic
$1,500 per dependent child
$3,000 per dependent child
Maximum
Enrollee to their 26 birthday
Enrollee to their 26 birthday
Maximum Takeover Credit
Delta Dental will receive credit for
Delta Dental will receive credit for
any amount paid under the
any amount paid under the
Contractholder's previous dental
Contractholder's previous dental
care plan from January 1, 2015 to
care plan from January 1, 2015 to
t he Effective Date. These amounts
the Effective Date. These amounts
will be credited towards the Annual
will be credited towards the Annual
Maximum.
Maximum.
Delta Dental will receive credit for
Delta Dental will receive credit for
any amount paid under the
any amount paid under the
Contractholder's previous dental
Contractholder's previous dental
care plan for Orthodontic Services.
care plan for Orthodontic Services.
These amounts will be credited
These amounts will be credited
towards the Maximum payable for
towards the Maximum payable for
Orthodontic Services.
Orthodontic Services.
E -51 PPO- A- DM2LH2 1 17858
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B.13.b
Low Plan
t Reimbursement is based on PPO Contracted Fees for PPO Providers, PPO Contracted Fees for
Premier Providers and PPO Contracted Fees for Non -Delta Dental Providers.
High Plan
t Reimbursement is based on PPO Contracted Fees for PPO Providers, Premier Contracted Fees for
Premier Providers and Program Allowance for Non -Delta Dental Providers.
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Contract Benefit Levels
Dental Service Category
Dena Dental
Delta 'Dental
Delta Dental
Delta Dental
PP"
Premier and
PPO
Premier and
Providerst
Non -Della
Providers
Neon- Delta
Dental
Dental
Prooviderst
Providerst
Delta Dental will pay or otherwise discharge the Contract Benefit Level shown below for the following services:
Diagnostic and Preventive
100%
100%
100%
100%
Services
Basic Services
90%
80%
90%
90%
Major Services
60%
50%
60%
60%
Orthodontic Services
50%
50%
50%
50%
Low Plan
t Reimbursement is based on PPO Contracted Fees for PPO Providers, PPO Contracted Fees for
Premier Providers and PPO Contracted Fees for Non -Delta Dental Providers.
High Plan
t Reimbursement is based on PPO Contracted Fees for PPO Providers, Premier Contracted Fees for
Premier Providers and Program Allowance for Non -Delta Dental Providers.
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Attachment B
Services, Limitations and Exclusions
Monroe County Board of County Commissioners
Group Number: 17858 Effective Date: September 1.2O15
Description of Dental Services
Delta Dental will pay or otherwise discharge the Contract Benefit Level shown in Attachment A for the following
* Diagnostic and Preventive Services
(
Diagnostic:
procedures Uo aid the Provider in determining required dental
(
Preventive:
cleaning (periodontal cleaning in the presence of inflamed gums ia
considered hoboa Basic Benefit for payment purpoaeo).topical
application of fluoride solutions.
(
Palliative:
emergency treatment ho relieve pain.
� Basic
Services
(
Oral Surgery:
extractions and other surgical procedures (including pre- and post-
operative cana).
(
General Anesthesia
when administered byn Provider for covered Oral Surgery or
mr|VSedation:
selected endodondo and periodontal surgical procedures.
(3)
Endodonhoa:
treatment of diseases and injuries of the tooth pulp.
(
Periodontics:
treatment of gums and bones supporting teeth.
(S)
Sealants:
topically applied acrylic, plastic orcomposite materials used to seal
developmental grooves and pits in permanent molars for the
purpose of preventing decay.
(6) Restorative: and
prefabricated crowns for treatment of carious lesions (visible
destruction of hard tooth structure resulting from the process of
(7) Denture Repairs: repair to partial or complete danburem, including nehmae procedures
and relining.
( Specialist opinion or advice requested by the general dentist.
° Major Services
( Crowns and treatment of carious lesions decay of the hard tooth structure)
|nlays/Onlaye: when teeth cannot be restored with amalgam or resin-based
composites.
( Pnoehodon(iuu: procedures for construction of fixed bhdgam, partial or complete
dentures and the repair of fixed bridges.
�
Orthodontic Services
Procedures performed b Provider using appliances to treat malocclusion of teeth and/or jaws which
significantly interferes with their function.
0 Note on additional Benefits during pregnancy
When en Enrollee /s pregnant, Delta Dental will pay for additional services to help improve the l health
of the Enrollee during the pregnancy. The additional services each Calendar Year while the Enrollee is
covered under the Contract include one (1) additional oral exam and either one (1) additional routine
cleaning; or one (1) additional periodontal scaling and root planing per quadrant; or one (1) additional
periodontal maintenance procedure. Written confirmation of the pregnancy must be provided by the
Enrollee or her Provider when the claim is submitted.
ENT-51 LE-FIL 1 17858
Limitation
(1) Services that are more expensive th the form uftreatment customarily provided under accepted dental
practice standards are called "Optional Services". Optional Services also include the use ofspecialized m
techniques instead of standard procedures. >
Examples ofOptional Services:
�nro�n where af0�gvvou|d restore - .
b) an i |
u) porcelain, resin or similar materials for crowns placed onm maxillary second or third molar, oronany �
mandibular molar (an allowance will be made for a porcelain fused to high noble metal crown); or �
d} enovendentune instead ufdenture. 0
�
If an Enrollee receives Optional Services, an alternate Benefit will be allowed, which means Delta Dental w =
will base Benefits on the lower cost of the customary service or standard practice instead of on the higher
cost of the Optional Service. The Enrollee will be responsible for the difference between the higher cost of
the Optional Service and the lower cost of the customary service or standard procedure. CL
( Exam and cleaning limitations
a) Delta Dental will pay for oral examinations after )and �
cleanings (including peh d nta|o|eaningointhepnaoanoecfinflemadgummorenyoomb|nadion
thereof) no more than twice ina12 month period.
b) A full mouth debridement is allowed once in a lifetime and counts toward the cleaning frequency in the �
emr id d ~�
~ . ��
u) Delta Dental i|| for e
periodontal cleanings during any Calendar Year if Enrollees have a previous history of periodontal Z
therapy. Note that periodontal cleanings and full mouth debridement are covered as a Basic Benefit, R:
and routine cleanings are covered as a Diagnostic and Preventive Benefit. See note on additional
Benefits during pregnancy.
d) Caries risk assessments are allowed once in 36 months for Enrollees age three (3) to 19. ~~
( X-ray limitations: T-
e) Delta Dental will limit the total reimbursable amount to the Provider's Accepted Fee for a complete
|ntroona| series when the fees for any combination ofintnaonal x-rays in e single treatment series meet r*
or exceed the Accepted Fee for a complete intnaona| series. .
b) When a panoramic film io submitted with supplemental 5|m( ) Delta Dental will limit th total w»
reimbursable amount to the Provider's Accepted Fee for a complete intraoral series.
d If a panoramic fi| is taken in bh an intraoral complete series, Delta Dental considers the m�
panoramic film to be included in the complete series. T
d) A complete |ntnaons| series and panoramic film are each limited toonce every 60 months.
a} Bitewing x-rays are limited to once mo6 month period when provided to Enrollees under age 14and
once ino12 month period for Enrollees age 14 and over. Bitowingmof any type are disallowed within 0
12 months ofa full mouth series unless warranted by special circumstances. U
( Topical application offluohdeso|ubonaio|imitedboEnroUeeotoage1Aandnomorethonhwioeino �
Calendar Year. �
(5) Space maintainer limitations:
a) Space maintainer is limited to the initial appliance once every three (3) years for Enrollees under age
19.
b) Renementadion of space i toi is limited to once per lifetime.
o) The removal of a fixed space maintainer is considered to be included in the fee for the space
maintainer; however, an exception is made if the removal is performed by a different
Prov|der/Provider'eofficm.
(6) Pulp vitality tests are allowed once per day when definitive treatment im not performed.
(7) lifetime
only Services are covered. xOrthodontic Services are covered, see Limitations aaage
limits may apply. However, 3D x-rays are not a covered benefit.
( Sealants are limited esfollows:
a) to permanent first molars through 15 if
they are without caries (decay) or restorations on the occlusal surface.
W repair or replacement of a Sealant on any tooth within 36 months of its application is included inthe
fee for the original placement.
(9) Specialist Consultations, screenings of patients, and assessments of patients are limited to once per
lifetime per Provider and count toward the oral exam frequency.
ENT-51 LE-FIL 2 17858
( Delta Dental will of an amalgam within 12 month of treatment if the service is
provided by the same Provider/Provider office. Replacement restorations within 12 months are included in
the fee for the original restoration.
Delta Dental will not cover replacement of prefabricated crowns within 24 months of treatment ifthe >
service is provided by the same Provider/Provider office. Replacement restorations within 24 months are
included in the fee for the original restoration.
( Protective restorations (sedative fi||ingo are
' �
ia not performed on the same date of service. m
�
( Prefabricated crowns are allowed on baby (deciduous) teeth and permanent teeth up to age 16. �
( Therapeutic | oto is limited to once per lifetime for baby (deciduous) teeth only and is considered 4- 0
palliative treatment for permanent teeth.
( Root canal therapy and pulpal th (resorbable filling) are limited toonce in a lifetime. Redreatmentof °
root canal thenep by the same Provide�Pnovidero�ceio limited bz once ina|ifeUme and ioconsidered
��
part of the original procedure.
(15) Apexification is only benefited on permanent teeth with incomplete root canal development or for the s�
repair ofa perforation. ApexifioaUonvioitohoveaUfetime|imitpertoothcfone(1)inihm|visd.four(4)
interim visits and one (1) final visit hoage 19. �
�
�
(1G)Retnaetmentof apical surgery by the same Pnzvd�Pnovdero�oew� �
within
the original procedure.
( Pin retention is covered not more than once in any 24-mnnth period.
( Palliative treatment iacovered per visit, not per tooth, and the fee includes all treatment provided other ~~
than required x-rays or select Diagnostic procedures. p~
T
(19) Periodontal limitations:
a) Benefits for periodontal 000Ungandnootp}enin in the same quadrant are limited to once in every 24-
month period. See note on additional Benefits during pregnancy. .
b) Periodontal surgery in the me quadrant i limited to once in every 24-month period and includes w»
any surgical re-entry or scaling and root planing. z�
C) Periodontal services, including bone replacement grafts, guided tissue regeneration, graft procedures m�
and biological mmberio|mtooidinaoftendoosemuodesuenagenenetionaneonlycoveredforthe
treatment of natural teeth and are not covered when submitted in conjunction with extractions,
perinadiuu|orourOery. ridge augmentation or implants.
d) If in the same quadrant, scaling and root planing must be performed at least six (6) weeks prior to the 0
periodontal s U
e) Cleanings (regular and periodontal) and full mouth debridement are subject to a 30 day wait following
periodontal scaling and root planing if performed by the same Provider office.
(20) Oral Surgery services are covered once in a lifetime except removal of cysts and lesions and incision and �
drainage procedures, which are covered once in the same day. JS
(21) The following Oral Surgery procedure is limited to age 19 or orthodontic limiting age: transseptal �
fibenohzmy/aupraoneatu|fibendomy. by report. x�
(22) The following Oral Surgery procedures are limited to age 19 (or orthodontic limiting age) provided
Orthodontic Services are covered: surgical access of an unerupted tooth, placement of device to facilitate L_
eruption of impacted tooth, and surgical repositioning nfteeth. ~~
0.
(23) Crowns and Inlays/Onlays are limited to Enrollees age 12 and older and are covered not more often than CL
once in any 60 month period except when Delta Dental determines the existing Crown or Inlay/Onlay ie
not satisfactory and cannot be made satisfactory because the tooth involved has experienced extensive
loss or changes hn tooth structure or supporting tissues. m
(24) When an alternate Benefit of an amalgam is allowed for inlays/ onlays, they are limited to Enrollees age
12 and older and are covered not more than once in any SO month period. �
( Core bui|dup, including any pins, are covered not more than once in any 60 month period.
( Post and core services are covered not more than once in any SO month period. Ja
ENT-51 LE-FL 3 17858
(27) Crown repairs are covered not more than twice in any 6O month period.
(20 Denture Repairs are covered not more than once in any six (6) month period except for fixed Denture
Repairs which are covered not more than twice in any GO month period.
(29)pmnthmjontio appliances, that were provided under any Delta Dental program will be replaced only after
60 months have passed, except when Delta Dental determines that there is such extensive loss of
remaining teeth or change in supporting tissue that the existing fixed bridge or denture cannot be made
satisfactory. Fixed prosthodontic appliances are limited to Enrollees age 16 and older. Replacement of a
prosthodontic appliance not provided under a Delta Dental program will be made if Delta Dental
determines it is unsatisfactory and cannot be made satisfactory.
(30) When a posterior fixed bridge and aremovable partial denture are placed in the same arch in the same
treatment episode, only the partial denture will bamBenefit.
(31) Recementation of included in the fee for the Crown, Inlay/Onlay or
bridge when performed by the same Provider/Provider office within six (6) months of the initial placement.
After six (6) payment will be limited to one (1)naoemenbsinnina lifetime by the same
Provider/Provideroffiue.
(32) Delta Dental limits payment for dentures dard partial or complete denture (Enrollee Coinsurances
apply), A standard denture means a removable appliance to replace missing natural, permanent teeth that
is made from acceptable materials by conventional means and includes routine post delivery care
including �
o) Denture base is limited to one (1) per arch in a 24-month period and includes any relining and Z
adjustments for six (6) months following placement. R:
b Dentures, removable partial dentures and relines include adjustments for six (6) months following
installation. After the initial six (6) months of an adjustment or reline, adjustments are limited to two 0
(2) per arch in a Calendar Year and relining is limited to one (1) per arch in a six (6) month period.
o) Tissue conditioning is limited to two (2) per arch in a 12-month period. However, tissue conditioning is p~
not allowed as a separate Benefit when performed on the same day as a denture, reline or rebase T-
service.
d) Recementation of fixed partial dentures is limited to once in a lifetime.
(33) Delta Dental will not pay for implants (artificial teeth implanted into or on bone or gums), their removal or
other associated procedures, but Delta Dental will credit the cost of a pontic or standard complete or
partial denture toward the cost of the implant associated appliance, i.e., the implant supported crown or
denture. The implant appliance is not covered.
(]4) Limitations on Orthodontic Services
a) The maximum amount payable for each Enrollee is shown in Attachment A.
b) Orthodontic Benefits will be provided in two (2) payments after the person becomes covered, (the
initial payment at the banding date and the second in 12 months); however, for treatment plans of
less than $500 or when the treatment plan is 12 months or less, one (1) payment will be made.
c) Benefits are not paid bo repair or replace any orthodontic appliance received under this plan.
d) Benefits are not paid for orthodontic retreatmentprocedures.
e) Benefits for Orthodontic Services are limited to dependent child Enrollees to their 26th birthday.
Exclusions
Delta Dental does not pay Benefits for:
( treatment of injuries or illness covered by workers' compensation or employers' liability laws; services
received without cost from any federal, state or local agency, unless this exclusion is prohibited by law
(2) cosmetic surgery cx procedures for purely cosmetic reasons.
(3) maxi|lofacialpmathetkcs,
(4) restorations removable partial denture to replace
extracted anterior permanent teeth during the healing period for children 16 years of age or under.
Provisional and/or temporary restorations are not separately payable procedures and are included in the
fee for completed service.
(5) services bn congenital (hereddo
limited to cleft palate, upper and lower jaw malformations, enamel hypoplasia (lack of development),
fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), except those
services provided to newborn children for medically diagnosed congenital defects or birth abnormalities
ENT-51 LE-FL 4 17858
(6) treatment bu stabilize teeth, treatment to restore tooth structure lost from wear, erosion, or abrasion nr
treatment bu rebuild or maintain chewing surfaces due bz teeth out of alignment o'ocd
include but are not limited to: equilibration, periodontal op|inUng, complete occlusal adjustments orNight
Guards/Occlusal guards and obfnanion.
(7) any Single Procedure provided prior to the date the Enrollee became eligible for services under this plan.
( prescribed drugs, medication, pain killers, antimicrobial agents, or experimental/investigational
procedures.
( charges for anesthesia, other than General Anesthesia and IV Sedation administered by a Provider in
connection with covered Oral Surgery ur selected Endodondc and Periodontal surgical procedures. Local
anesthesia and regional/or trigerninal bloc anesthesia are not separately payable procedures.
( extraoral grafts (grafting of tissues from outside the mouth to oral tissues).
(11) laboratory processed crowns for Enrollees under age 12.
( fixed bridges and removable partials for Enrollees under age 1G.
( interim implants and andodonticendoaeeoueimplant.
( indirectly fabricated resin-based |n|aye/C)n|oya.
( charges by any hospital or other surgical or treatment facility and any additional fees charged by the
Provider for treatment in any such facility.
( treatment by someone other than a Provider or a person who by law may work under a Provider's direct
supervision.
( charges incurred for oral hygiene instruction, a plaque control program, preventive controlp~
dietary including home care times, '
or broken appointments.
duplications, screening, -
( dental practice administrative services including, but not limited to, preparation of claims, any non-
treatment phasecfdenbot h as provision of an antiseptic environment, sterilization of equipment or '
infection control, or any ancillary materials used during the routine course of providing treatment such as z�
cotton swabs, gauze, bibs, masks or relaxation techniques such aamusic.
( procedures having a questionable prognosis based ona dental consultant's professional review ofthe
submitted documentation.
(20) any tax imposed incurred) state orother entity, in connection with any fees charged
for Benefits provided under the Contract, will be the responsibility of the Enrollee and not a covered
Benefit.
( Deductibles, amounts over plan maximums and/or any service not covered under the dental plan.
( services covered under the dental plan but exceed Benefit limitations or are not in accordance with
processing policies in effect at the time the claim ioprocessed.
( services for Orthodontic treatment (treatment of malocclusion of teeth and/or jaws) except as provided
under the Orthodontic Services section, ifapplicable.
( services for any disturbance of the Tam dibu|or(jew)Joinio(TK8J)oreeeooietedmuscu|edure.
nerves and other tissues) except as provided under the TMJ Benefit section, if applicable,
( missed and/or cancelled appointments.
ENT-51 LE-FL 5 17858
ATTACHMENT C
GROUP VARIABLES
for
Monroe County Board of County Commssioners
17858
Effective Date: September 1, 2016
Contract Term: September 1, 2015 thru December 31, 2017
Termination (Minimum Number of Primary Enrollees):
Less than 91 Primary Enrollees.
Premiums:
Monthly Amount:
Low Plan
r
I High Plan
Per Primary Enrollee:
$25.86
$35.22
Per Primary Enrollee and Spouse:
$48.94
$66.64
Per Primary Enrollee and Child(ren):
$52.81
$71.93
Per Primary Enrollee and Family:
$76.51
$10418
Premiums are to be remitted to:
Delta Dental Insurance Company
P.O. Box 7564
San Francisco, CA 94120-7564
Payment Breakdown:
Primary Enrollee shall pay: 100% for Primary Enrollee
100% for Dependent Enrollees
Contractholder may charge persons electing continued coverage pursuant to Title X of P.L. 99 as permitted by law
i
ENT-51 GV-FL 1 17858