Item C25C ounty of M onroe
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BOARD OF COUNTY COMMISSIONERS
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Mayor David Rice, District 4
The FlOnda Key
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Mayor Pro Tem Sylvia J. Murphy, District 5
Danny L. Kolhage, District 1
George Neugent, District 2
Heather Carruthers, District 3
County Commission Meeting
June 20, 2018
Agenda Item Number: C25
Agenda Item Summary #4311
BULK ITEM: Yes DEPARTMENT: Employee Services
TIME APPROXIMATE: STAFF CONTACT: Maria Fernandez- Gonzalez (305)
292 -4448
N/A
AGENDA ITEM WORDING: Approval of one -year policy renewal with Delta Dental Insurance
(1 /l /19- 12/31/19). No rate increase for Low Plan. High Plan rates will increase by 15%
ITEM BACKGROUND:
One -year renewal of the County's agreement with Delta Dental Insurance.
Dental Low Plan: No rate changes.
Dental High Plan: 15% rate increase. Employee Only rate increases $6.34 per month from $42.26 to
$48.60; Employee & Spouse Only rate increases $12.00 per month from $79.97 to $91.97;
Employee & Children Only rate increases $12.95 per month from $86.32 to $99.27; Family
Coverage increases $18.75 per month from $125.02 to $143.77.
The Dental High Plan has almost 500 more enrollees than the Low Plan. With enrollments and
claims experience in the High Plan continuing to rise (SEE ATTACHMENT C & D) an increase in
the High Plan premium is appropriate; From April 2017 to April 2018, claims have exceeded
premiums collected by approximately 5 %. No changes are being made to the dental coverages.
(SEE ATTACHMENT A & B).
May 2015, BOCC approved staff to negotiate a policy with Delta Dental for a two (2) year term
(9/l/15- 12/31/17). October 2017, BOCC approved a one -year renewal with Delta Dental with a
20% premium increase in the High Plan due to high dental utilization and claims experience. Delta
Dental has maintained the Low Plan premium rates unchanged for the past five years, including this
renewal for 2019. The majority of dentists in Monroe County participate in Delta Dental as Premier
Providers in the High Plan. Enrollment in the High Plan (1379) is greater than the Low Plan (893)
primarily because of the dentist in the Premier PPO network. In addition, the High Plan is a much
richer plan with an annual maximum benefit of $5,000 per covered individual and allows $3,000 for
Orthodontics (dependent children only). Delta Dental continues to maintain a strong network in
Monroe County, which provides employees more provider choices.
PREVIOUS RELEVANT BOCC ACTION:
2011 Dental RFP resulted in two -year agreement with United Concordia approved by the BOCC,
October 2011. In 2014, the Employee Benefits Department began to receive numerous complaints
from employees about their dentists leaving the United Concordia network due to lowered
reimbursements. In addition, dentists complained of United Concordia denying claims and
requesting additional documentation. Due to these service and network concerns, a Dental RFP was
done early 2015 resulting in Delta Dental ranked as the 41 vendor. A special Open Enrollment, just
for dental, was held in order for employees /retirees to drop their dental coverage or enroll with Delta
Dental. Delta Dental agreed to credit any deductibles already satisfied for 2015.
CONTRACT /AGREEMENT CHANGES:
15% increase in High Plan premiums
STAFF RECOMMENDATION: Approval for a one -year renewal with Delta Dental (1/1/19
through 12/31/19).
DOCUMENTATION:
RENEWAL FROM DELTA DENTAL
ATTACHMENT A - DED, MAXIMUMS, BENEFIT LEVELS
ATTACHMENT B - SERVICES, LIMITATIONS, EXCLUSIONS
ATTACHMENT C - HIGH PLAN
ATTACHMENT D - LOW PLAN
FINANCIAL IMPACT:
Effective Date: 1/1/2019
Expiration Date: 12/31/2019
Total Dollar Value of Contract:
Total Cost to County: ZERO
Current Year Portion:
Budgeted:
Source of Funds: 100% OF PREMIUMS PAID BY PARTICIPANTS
CPI:
Indirect Costs:
Estimated Ongoing Costs Not Included in above dollar amounts:
Revenue Producing: No If yes, amount:
Grant: No
County Match: No
Insurance Required:
Additional Details:
REVIEWED BY:
Bryan Cook Completed
Assistant County Administrator Christine Hurley
06/05/2018 8:39 AM
Cynthia Hall Completed
Budget and Finance Completed
Maria Slavik Completed
Kathy Peters Completed
Board of County Commissioners Pending
06/05/2018 9:14 AM
Skipped
06/05/2018 9:20 AM
06/05/2018 9:22 AM
06/05/2018 11:14 AM
06/05/2018 11:24 AM
06/20/2018 9:00 AM
-%% % w:d 1tadento1ins_c rri
May 31, 2018
Monroe County Board of County Commissioners
1100 Simonton Street
Key West, 33040
RE: Contract Renewal for Monroe County Board of County Commissioners
Delta Dental PPOI 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:
�07 WPM
Telephone= 88&335-8227
Please keep this renewal letter with your contract documents. [t serves as an amendment to your Delta
Dental Contracts for the rates and contract term.
To renew your dental plan contract, please follow these steps:
1) Review this letter for changes to your dental plan for January 01,2019
2) Begin paying the rates outlined in this letter with your new contractterm.
If you have any questions about your renewal, your Account Manager will be happy to help. We
appreciate your continued confidence in Delta Dental. We are proud of our association with you and
look forward to a long and mutually successful relationship.
Sincerely,
Delta Dental Insurance Company
MohammadReza Navid
Group Vice President, Sales
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.
Summary of Contract Amendments to
Monroe County Board of County Commissioners
Delta Dental: PPO'
Delta Dental's retro - termination pglicy for enrollees. As a reminder, Delta Dental's policy is that
enrollment may be adjusted retroactively to the immediately preceding three months plus the current
month billed if no claims have been processed after the requested termination date for the enrollee.
Provider reimbursement. As a reminder, Delta Dental's policy is to reimburse contracted dentists
based on the network payment provisions for the geographic area in which the services are provided
OHCA Notification
Please be informed that consistent with the group application and group contract terms, 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
(C.F.R.) § 164.501. 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 OHCA, any Protected Health Information (PHI) exchanged or shared
between the entities remains 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.
Attachment A
Deductibles, Maximums and Contract Benefit Levels
Contractholder: Monroe County Board of County Commissioners
Group Number: 17858
Effective Date: September 1, 2015
Deductible
per Enrollee each Calendar
Year
per Enrollee each Calendar
Year
$150 per family
each Calendar Year
Deductibles waived for
Orthodontics Services
Deductible Takeover
Annual Maximum
Lifetime Orthodontic
Maximum
Maximum Takeover Credit
Any annual Deductible amount
satisfied by the Enrollees under the
Contractholder's previous dental
care plan from January 1, 2015 to
the Effective Date will be credited
towards the annual Deductible
under the Contract.
$2,000 per Enrollee
each Calendar Year
If an Enrollee switches from the
Low Plan to the High Plan at Open
Enrollment, the Maximum Amount
payable for Benefits will not exceed
the applicable Maximum for the
$1,500 per dependent child
Enrollee to their 26 birthday
Delta Dental will receive credit for
any amount paid under the
Contractholder's previous dental
care plan from January 1, 2015 to
the Effective Date. These amounts
will be credited towards the Annual
Maximum.
Delta Dental will receive credit for
any amount paid under the
Contractholdees previous dental
care plan for Orthodontic Services.
These amounts will be credited
towards the Maximum payable for
Orthodontic Services.
$150 per family
each Calendar Year
agnostic & Preventive and
Orthodontics Services
Any annual Deductible amount
satisfied by the Enrollees under the
Contractholder's previous dental
care plan from January 1, 2015 to
the Effective Date will be credited
towards the annual Deductible
under the Contract.
$5,000 per Enrollee
each Calendar Year
If an Enrollee switches from the
High Plan to the Low Plan at Open
Enrollment, the Maximum Amount
payable for Benefits will not exceed
applicable Maximum for the Low
Plan.
$3,000 per dependent child
Enrollee to their 26"' birthday
Delta Dental will receive credit for
any amount paid under the
Contractholder's previous dental
care plan from January 1, 2015 to
the Effective Date. These amounts
will be credited towards the Annual
Maximum.
Delta Dental will receive credit for
any amount paid under the
Contractholder's previous dental
care plan for Orthodontic Services.
These amounts will be credited
towards the Maximum payable for
Orthodontic Services.
E -51 PPO- A- DM21-1-12 1 17858
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.
E -51 PPO- A- DM2LH2 2 17858
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.
Attachment B
Services, Limitations and Exclusions
Contractholder: Monroe County Board of County Commissioners
Group Number: 17858 Effective Date: September 1, 2015
Description of Dental Services
Delta Dental will pay or otherwise discharge the Contract Benefit Level shown in Attachment A for the following
services:
• Diagnostic and Preventive Services
(1)
Diagnostic:
procedures to aid the Provider in determining required dental
decay).
treatment.
(2)
Preventive:
cleaning (periodontal cleaning in the presence of inflamed gums is
(8) Specialist
opinion or advice requested by the general dentist.
considered to be a Basic Benefit for payment purposes), topical
application of fluoride solutions.
(3)
Palliative:
emergency treatment to relieve pain.
• Basic
Services
(1)
Oral Surgery:
extractions and other surgical procedures (including pre- and post-
operative care).
(2)
General Anesthesia
when administered by a Provider for covered Oral Surgery or
or IV Sedation:
selected endodontic and periodontal surgical procedures.
(3)
Endodontics:
treatment of diseases and injuries of the tooth pulp.
(4)
Periodontics:
treatment of gums and bones supporting teeth.
(5)
Sealants:
topically applied acrylic, plastic or composite materials used to seal
developmental grooves and pits in permanent molars for the
purpose of preventing decay.
(6) Restorative:
amalgam and resin -based composite restorations (fillings) and
prefabricated crowns for treatment of carious lesions (visible
destruction of hard tooth structure resulting from the process of
decay).
(7) Denture Repairs:
repair to partial or complete dentures, including rebase procedures
and relining.
(8) Specialist
opinion or advice requested by the general dentist.
Consultations:
• Major Services
(1) Crowns and treatment of carious lesions (visible decay of the hard tooth structure)
Inlays/Onlays: when teeth cannot be restored with amalgam or resin -based
composites.
(2) Prosthodontics: procedures for construction of fixed bridges, partial or complete
dentures and the repair of fixed bridges.
• Orthodontic Services
Procedures performed by a Provider using appliances to treat malocclusion of teeth and /or jaws which
significantly interferes with their function.
• Note on additional Benefits during pregnancy
When an Enrollee is pregnant, Delta Dental will pay for additional services to help improve the oral 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 -FL 1 17858
Limitations
(1) Services that are more expensive than the form of treatment customarily provided under accepted dental
practice standards are called "Optional Services ". Optional Services also include the use of specialized
techniques instead of standard procedures.
Examples of Optional Services:
a) a crown where a filling would restore the tooth;
b) an inlaylonlay instead of an amalgam restoration;
c) porcelain, resin or similar materials for crowns placed on a maxillary second or third molar, or on any
mandibular molar (an allowance will be made for a porcelain fused to high noble metal crown); or
d) an overdenture instead of denture.
If an Enrollee receives Optional Services, an altemate Benefit will be allowed, which means Delta Dental
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.
(2) Exam and cleaning limitations
a) Delta Dental will pay for oral examinations (except after hours exams and exams for observation) and
cleanings (including periodontal cleanings in the presence of inflamed gums or any combination
thereof) no more than twice in a 12 month period.
b) A full mouth debridement is allowed once in a lifetime and counts toward the cleaning frequency in the
year provided.
c) Delta Dental will pay for up to two (2) additional periodontal cleanings or Procedure Codes that include
periodontal cleanings during any Calendar Year if Enrollees have a previous history of periodontal
therapy. Note that periodontal cleanings and full mouth debridement are covered as a Basic Benefit,
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.
(3) X-ray limitations:
a) Delta Dental will limit the total reimbursable amount to the Providers Accepted Fee for a complete
intraoral series when the fees for any combination of intraoral x -rays in a single treatment series meet
or exceed the Accepted Fee for a complete intraoral series.
b) When a panoramic film is submitted with supplemental film(s), Delta Dental will limit the total
reimbursable amount to the Provider's Accepted Fee for a complete intraoral series.
c) If a panoramic film is taken in conjunction with an intraoral complete series, Delta Dental considers the
panoramic film to be included in the complete series.
d) A complete intraoral series and panoramic film are each limited to once every 60 months.
e) Bitewing x -rays are limited to once in a 6 month period when provided to Enrollees under age 14 and
once in a 12 month period for Enrollees age 14 and over. Bitewings of any type are disallowed within
12 months of a full mouth series unless warranted by special circumstances.
(4) Topical application of fluoride solutions is limited to Enrollees to age 19 and no more than twice in a
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) Recementation of space maintainer is limited to once per lifetime.
c) 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
Provider /Providers office.
(6) Pulp vitality tests are allowed once per day when definitive treatment is not performed.
(7) Cephalometric x -rays, orallfacial photographic images and diagnostic casts are covered once per lifetime
only when Orthodontic Services are covered. If Orthodontic Services are covered, see Limitations as age
limits may apply. However, 3D x -rays are not a covered benefit.
(8) Sealants are limited as follows:
a) to permanent first molars through age eight (8) and to permanent second molars through age 15 if
they are without caries (decay) or restorations on the occlusal surface.
b) repair or replacement of a Sealant on any tooth within 36 months of its application is included in the
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 -FL 2 17858
(10) Delta Dental will not cover replacement of an amalgam within 12 months 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 if the
service is provided by the same Provider/Provider office. Replacement restorations within 24 months are
included in the fee for the original restoration.
(11) Protective restorations (sedative fillings) are allowed once per tooth per lifetime when definitive treatment
is not performed on the same date of service.
(12) Prefabricated crowns are allowed on baby (deciduous) teeth and permanent teeth up to age 16.
(13) Therapeutic pulpotomy is limited to once per lifetime for baby (deciduous) teeth only and is considered
palliative treatment for permanent teeth.
(14) Root canal therapy and pulpal therapy (resorbable filling) are limited to once in a lifetime. Retreatment of
root canal therapy by the same Provider/Provider office is limited to once in a lifetime and is considered
part of the original procedure.
(15) Apexification is only benefited on permanent teeth with incomplete root canal development or for the
repair of a perforation. Apexification visits have a lifetime limit per tooth of one (1) initial visit, four (4)
interim visits and one (1) final visit to age 19.
(16) Retreatment of apical surgery by the same Provider/Provider office within 24 months is considered part of
the original procedure.
(17) Pin retention is covered not more than once in any 24 -month period.
(18) Palliative treatment is covered per visit, not per tooth, and the fee includes all treatment provided other
than required x -rays or select Diagnostic procedures.
(19) Periodontal limitations:
a) Benefits for periodontal scaling and root planing 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 same quadrant is limited to once in every 24 -month period and includes
any surgical re -entry or scaling and root planing.
c) Periodontal services, including bone replacement grafts, guided tissue regeneration, graft procedures
and biological materials to aid in soft and osseous tissue regeneration are only covered for the
treatment of natural teeth and are not covered when submitted in conjunction with extractions,
periradicular surgery, 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
periodontal surgery.
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.
(21) The following Oral Surgery procedure is limited to age 19 or orthodontic limiting age: transseptal
fiberotomy /supra crestal fiberotomy, by report.
(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
eruption of impacted tooth, and surgical repositioning of teeth.
(23) Crowns and Inlays/Onlays are limited to Enrollees age 12 and older and are covered not more often than
once in any 60 month period except when Delta Dental determines the existing Crown or Inlay /Onlay is
not satisfactory and cannot be made satisfactory because the tooth involved has experienced extensive
loss or changes to tooth structure or supporting tissues.
(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 60 month period.
(25) Core buildup, including any pins, are covered not more than once in any 60 month period.
(26) Post and core services are covered not more than once in any 60 month period.
ENT -51 LE -FL 3 17858
(27) Crown repairs are covered not more than twice in any 60 month period.
(28) 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 60 month period.
(29) Prosthodontic 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 a removable partial denture are placed in the same arch in the same
treatment episode, only the partial denture will be a Benefit.
(31) Recementation of Crowns, Inlays/Onlays or bridges is 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) months, payment will be limited to one (1) recementation in a lifetime by the same
Provider /Provider office.
(32) Delta Dental limits payment for dentures to a standard 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 any adjustments and relines for the first six (6) months after placement.
a) Denture rebase is limited to one (1) per arch in a 24 -month period and includes any relining and
adjustments for six (6) months following placement.
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
(2) per arch in a Calendar Year and relining is limited to one (1) per arch in a six (6) month period.
c) Tissue conditioning is limited to two (2) per arch in a 12 -month period. However, tissue conditioning is
not allowed as a separate Benefit when performed on the same day as a denture, reline or rebase
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.
(34) 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 to repair or replace any orthodontic appliance received under this plan.
d) Benefits are not paid for orthodontic retreatment procedures.
e) Benefits for Orthodontic Services are limited to dependent child Enrollees to their 26th birthday.
Exclusions
Delta Dental does not pay Benefits for:
(1) 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 or procedures for purely cosmetic reasons.
(3) maxillofacial prosthetics.
(4) provisional and/or temporary restorations (except an interim 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 for congenital (hereditary) or developmental (following birth) malformations, including but not
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 to stabilize teeth, treatment to restore tooth structure lost from wear, erosion, or abrasion or
treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion. Examples
include but are not limited to: equilibration, periodontal splinting, complete occlusal adjustments or Night
Guards/Occlusal guards and abfraction.
(7) any Single Procedure provided prior to the date the Enrollee became eligible for services under this plan.
(8) prescribed drugs, medication, pain killers, antimicrobial agents, or experimental/investigational
procedures.
(9) charges for anesthesia, other than General Anesthesia and IV Sedation administered by a Provider in
connection with covered Oral Surgery or selected Endodontic and Periodontal surgical procedures. Local
anesthesia and regionallor trigeminal bloc anesthesia are not separately payable procedures.
(10) extraoral grafts (grafting of tissues from outside the mouth to oral tissues).
(11) laboratory processed crowns for Enrollees under age 12.
(12) fixed bridges and removable partials for Enrollees under age 16.
(13) interim implants and endodontic endosseous implant.
(14) indirectly fabricated resin -based Inlays/Onlays.
(15) charges by any hospital or other surgical or treatment facility and any additional fees charged by the
Provider for treatment in any such facility.
(16) treatment by someone other than a Provider or a person who by law may work under a Provider's direct
supervision.
(17) charges incurred for oral hygiene instruction, a plaque control program, preventive control programs
including home care times, dietary instruction, x -ray duplications, cancer screening, tobacco counseling
or broken appointments.
(18) dental practice administrative services including, but not limited to, preparation of claims, any non -
treatment phase of dentistry such 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
cotton swabs, gauze, bibs, masks or relaxation techniques such as music.
(19) procedures having a questionable prognosis based on a dental consultant's professional review of the
submitted documentation.
(20) any tax imposed (or incurred) by a government, state or other 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.
(21) Deductibles, amounts over plan maximums and /or any service not covered under the dental plan.
(22) 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 is processed.
(23) services for Orthodontic treatment (treatment of malocclusion of teeth and /or jaws) except as provided
under the Orthodontic Services section, if applicable.
(24) services for any disturbance of the Temporomandibular (jaw) Joints (TMJ) or associated musculature,
nerves and other tissues) except as provided under the TMJ Benefit section, if applicable.
(25) missed and/or cancelled appointments.
ENT -51 LE -FL 5 17858
ATTACHMENT C
GROUP VARIABLES
for
Monroe County Board of County Commssloners
17858
Effective Date: September 1, 2015
Contract Term: September 1, 2015 thru December 31, 2017
Termination IMinimurn Number of Primary Enrollees):
ess t an nmary Enrollees.
Premiums:
Monthly Amount:
Low Plan
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
$104.18
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.
ENT -51GV FL 9 17858
Delta Dental Insurance Company
1130 Sanctuary Parkway
Alpharetta, Georgia 30009
(770) 641 -5100
(888) 858 -5252
Delta Dental PPOsm Group Dental Insurance Contract
Monroe Coun Board of Coun Commissioners , ( "Contractholder') has applied for a group
cFental insurance Contract with e a Dental Insurance Company ("Delta Dental"). The following terms will apply:
I. Contractholder will pay Delta Dental the monthly Premium stated in this Contract.
II. 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
Q�Wkwmnv
Anthony S. Barth, President
This Contract Contains a Deductible Provision
ENT -51 PPO -FL -C 1 17858
TABLE OF CONTENTS
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
ENT -51 PPO -FL -C 2 17858
ARTICLE 1 - DEFINITIONS
Terms when capitalized in this document have defined meanings, given either in the section below or within this
Contract's sections.
1.01 Accepted Fee — the amount the attending Provider 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 Contract Benefit Level — the percentage of the Maximum Contract Allowance that Delta Dental will pay
after the Deductible has been satisfied as 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.
1.09 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 Premiere Provider (Premier Provider) -- a Provider who contracts with Delta Dental or any
other member company of the Delta Dental Plans Association and agrees to accept the Delta Dental
Premier Contracted Fee as payment in full for covered services provided under a plan. A Premier Provider
also agrees to comply with Delta Dental's administrative guidelines.
1.12 Delta Dental Premier Contracted Fee -- the fee for each Single Procedure that a Premier Provider has
contractually agreed to accept as payment in full for covered services.
1.13 Delta Dental PPOsm Provider (PPO Provider) — a Provider who contracts with Delta Dental Insurance
Company or any other member company of the Delta Dental Plans Association and agrees to accept the
Delta Dental PPO Contracted Fee as payment in full for covered services provided under a PPO dental
plan. A PPO Provider also agrees to comply with Delta Dental's administrative guidelines.
1.14 Delta Dental PPO Contracted Fee — the fee for each Single Procedure that a PPO Provider has
contractually agreed to accept as payment in full for covered services.
1.15 Dependent Enrollee — an Eligible Dependent enrolled to receive Benefits.
1.16 Effective Date — the original date the Contract starts, as shown in Attachment C.
1.17 Eligible Dependent — a dependent of an Eligible Employee eligible for Benefits under Article 2.
1.18 Eligible Employee — any employee or retiree eligible for Benefits under Article 2.
1.19 Enrollee — an Eligible Employee ( "Primary Enrollee ") or an Eligible Dependent ("Dependent Enrollee ")
enrolled to receive Benefits".
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
1.21 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
• 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 PPO
Contracted Fee for a PPO Provider in the same geographic area.
• by a Non -Delta Dental Provider is the lesser of the Provider's Submitted Fee or the Delta Dental PPO
Contracted Fee for a PPO 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 Providers Submitted Fee or the Program
Allowance.
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 Dental's administrative guidelines.
1.23 Open Enrollment Period -- the months of the year during which employees may change coverage for the
next Contract Year.
1.24 Patient Pays — Enrollee's financial obligation for services calculated as the difference between the amount
shown as the Accepted Fee and the portion shown as "Delta Dental Pays" on the claims statement when a
claim is processed.
1.25 Pre - Treatment Estimate -- an estimation of the allowable Benefits under this Contract for the services
proposed, assuming the person is an eligible Enrollee.
1.26 Premium -- the amounts payable by the Contractholder monthly as provided in Attachment C.
1.27 Primary Enrollee — an Eligible Employee enrolled in the plan to receive Benefits; may also be referred to
as "Enrollee ".
1.28 Procedure Code — the Current Dental Terminology* (CDT) 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 standing in the same geographical area. 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 partnership, dental professional corporation or dental clinic.
1.31 Qualifying Status Change — a change in:
• marital status (marriage, divorce, legal separation, annulment or death);
• 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 of a child);
• employment status (change in employment status of Enrollee or Eligible Dependent);
• dependent child ceases to satisfy eligibility requirements;
• residence (Enrollee, dependent Spouse or child moves);
• a court order requiring dependent coverage; or
• any other current or future election changes permitted by Intemal Revenue Code Section 125.
1.32 Single Procedure -- a dental procedure that is assigned a separate Procedure Code.
ENT -51 PPO -FL -C 4 17858
1.33 Spouse — a person related to or a 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 issued and delivered;
• as defined and as may be required to be treated as a Spouse by the laws of the state where the
Primary Enrollee resides; and
• as may be recognized by the Contractholder.
1.34 Submitted Fee — the amount that the Provider bills and enters on a claim for a specific procedure.
ARTICLE 2 - ELIGIBILITY AND ENROLLMENT
2.01 Reporting
Delta Dental processes eligibility as 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:
• Primary Enrollees' and Dependent Enrollees': names, Enrollee ID numbers, Enrollee's Effective Date of
Coverage, dates of birth, addresses and gender,
• Dependent Enrollees' dependent status; and
• Primary Enrollees' location, if applicable.
The eligibility list shall include all Eligible Employees unless the Eligible Employee waives coverage or
enrolls in an alternate dental plan offered by Contractholder. 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 of 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 for services provided to an Enrollee who is not reported to Delta
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 as a result of Contractholders retroactive
eligibility adjustments. The Contractholder agrees to reimburse Delta Dental for any erroneous claim
payments made by Delta Dental as a result of incorrect eligibility reporting by the Contractholder.
2.02 Contractholder will permit Delta Dental to audit Contractholders 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 working a minimum of 25 hours per week becomes eligible on whichever is later, the
Effective Date or on 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 26th birthday.
• Children include natural children, stepchildren, foster children, adopted children, children placed for
adoption, custodial children, children for which the employee has been appointed legal 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 -51 PPO -FL -C 5 17858
a 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 newbom. 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 Employees and Eligible Dependents
• 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 0; cement, 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 the;nden is a Qualifying Status Change.
• All Eligible Dependents must be enrolled as Depende Enrollees if dependent coverage is elected.
• A child who is eligible as a Primary Enrollee and a det can be insured under this Contract as a
Primary Enrollee or a Dependent Enrollee but not botat the same time.
2.06 Except for an employee absent from work due to a leave of absence approved by the Contractholder or
governed by the "Family & Medical Leave Act of 1993" (P.L. 103.3), an Enrollee will not be covered for any
dental services received while a Primary Enrollee is on strike, lay-off or leave of absence. Contractholder
must inform Delta Dental of any change in eligibility as required under section 2.01.
Benefits for such Primary Enrollee and his/her Eligible Dependents will resume as follows:
• If coverage is reactivated in the same Calendar Year, Deductibles and maximums will resume as if the
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 to work, provided the Contractholder submits
the request to Delta Dental that coverage be reactivated.
If an employee is rehired within the same Calendar Year, Deductibles and maximums will resume as if the
Primary Enrollee was never gone.
2.07 A Primary Enrollee loses coverage on the day of termination of employment, when he /she is no longer an
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 a person who is not an Enrollee at the
time of treatment 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
is incurred as follows:
• for an appliance (or change to an appliance), at the time the impression is made;
• 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 is 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
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 of reimbursed expenses will apply if:
• the dental services were recommended in writing and commenced while the policy was in effect by the
Provider to 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 of coverage.
The extension of benefits terminates upon the earlier of:
• the 90-day period specified in the above third bullet item; or
• the date the person becomes covered under a succeeding policy
If coverage or services for the dental procedures referred to in the above first bullet item are excluded by the
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 or reductions that would have applied to the specific dental services
had the coverage on the person not terminated apply during the Extension of Benefits.
2.09 Continued Coverage Under USERRA
As required under the Uniformed Services Employment and Reemployment Rights Act of 1994 ( 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 of coverage under USERRA may not extend beyond the earlier of: 24 months beginning on
the date the leave of absence begins or the date the Primary Enrollee fails to return to work within the time
required by USERRA. For USERRA leave that extends beyond 31 days, the Premium for continuation of
coverage will be the same as for COBRA coverage.
2.10 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,
provided:
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
COBRA;
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.
Delta Dental will process eligibility as reported by the Contractholder.
For enrollment additions, Contractholder will 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, Contractholder will remit a full month's Premium for Enrollees whose coverage
is terminated on the sixteenth through the last calendar day of a 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 or 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 is amended as stated in
section 3.05, or whenever the Contractholder requests a change in Benefits. Any change in Premium shall
not go into effect during a Contract Term unless Contractholder and Delta Dental agree in writing, except
as provided in section 3.05, 3.06.
3.05 Premiums are based on the number of covered employees at the beginning of each Contract Term. If the
Contractholder reports a 15 percent addition or reduction in the number of covered Primary 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, Contractholder will select one of the choices by written notice to Delta Dental.
If Contractholder fails to do so, Delta Dental may select one of the choices by written notice to
Contractholder. This Contract will be modified for all dental services predetermined and paid after notice.
3.06 If during the Contract Tenn any new or increased tax is imposed on the amounts payable to 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 - CONDITIONS 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 shall be
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 a primary dental procedure includes component procedures that are performed at the same time as the
primary procedure, the component procedures are considered to be part of the primary procedure for
purposes of determining the benefit payable under this Contract. If the Provider bills separately for the
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 ortion 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 a 17858
4.03 Deductible
As shown on Attachment A, Delta Dental will not pay Benefits for the Deductible amount of the Maximum
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
A maximum amount ( "Maximum Amount" or "Maximum') is the maximum dollar amount Delta Dental will
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 of a Provider
Enrollees may choose a Provider from Delta Dental's panel of PPO and Premier Providers or Enrollees
may choose a Non -Delta Dental Provider. A list of PPO and Premier Providers can be obtained at Delta
Dental's website (deltadentalins.com). Providers are regularly added to or deleted from the list. Enrollees
are responsible for verifying whether the selected Provider is a PPO Provider or a Premier Provider.
Additionally, Enrollees should always confirm with the Provider's office that a listed Provider is still a
participating PPO Provider or Premier Provider. Delta Dental does not guarantee that any particular
Provider will be available.
PPO Provider
Selecting a PPO Provider potentially allows the greatest reduction in Enrollees' out -of- pocket expenses,
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 is a Non -Delta Dental Provider, the amount charged to Enrollees may be above that accepted
by the PPO Providers or Premier Providers. For a Non -Delta Dental Provider, the Accepted Fee is the
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 PPO Provider or Premier Provider will complete the dental Claim Form and submit it to Delta
Dental for reimbursement.
• The PPO Provider or Premier Provider will accept contracted fees as payment in full for covered
services and will not balance bill if there is a difference between Submitted Fees and contracted fees.
4.06 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 of Benefit Determination Rules:
The following rules determine which plan is the 'primary" plan:
(1) The plan covering the Enrollee as an employee is primary over a plan covering the Enrollee as a
dependent.
(2) The plan covering the Enrollee as an employee is primary over a plan which covers the insured
person as a dependent; except that: if the insured person is also a Medicare beneficiary, and as a
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 as a dependent and
b) Primary to the plan covering the insured personas 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 as other than a dependent.
ENT -51 PPO -FL -C 9 17858
(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
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
a the date the Provider's agreement with Delta Dental ends.
4.10 Written Notice of Claim /Proof of Loss
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 to give written proof in the time required, the claim will not be
reduced or denied solely for this reason, provided proof is filed as soon as reasonably possible. In any
event, proof of loss 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 Claims Appeal
Delta Dental will notify the Enrollee and his/her Provider if Benefits are denied for services submitted on a
Claim Form, in whole or in part, stating the reason(s) for denial. The Enrollee has at least 180 days after
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 (15) days upon receipt of the
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 appeal or grievance, he/she may contact
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. 20210.
4.13 To Whom Benefits Are Paid
Payment for services provided by a PPO Provider or a Premier Provider will be made directly to the
Provider. Any other payments provided by this Contract will be made to the Primary Enrollee unless the
Primary Enrollee requests when filing proof of loss that the payment be made directly to the Provider
pproviding the services. All Benefits not paid to the Provider will be payable to the Primary Enrollee, to
his/her estate, or to an alternate recipient as directed by court order except that if the person is a minor or
otherwise not competent to give a valid release, Benefits may be payable to his/her parent, guardian or
other person actually supporting him/her.
......:..:
ENT -51 PPO -FL -C 11 17858
4.14 No change in Benefits will become effective during a Contract Term unless Contractholder and Delta
Dental agree in writing.
ARTICLE 5 - 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 by an executive officer of Delta Dental.
5.02 Severability
If any part of this Contract or an amendment of it is found by a court or other authority to be 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 be governed by the state of Florida where this Contract was
entered into and is to be performed. Any part of this Contract which conflicts with the laws of Florida or
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 of this Contract. No such action may be brought after
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 of Insurance
Delta Dental will issue to the Contractholder an electronic file containing a certificate/Evidence 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
Contractholder and Delta Dental agree to consult as is reasonably practical on all material published or
distributed about this Contract. No material will be published or distributed which conflicts with the terms of
this Contract.
5.09 Provider Relationships
Contractholder and Delta Dental agree to permit and encourage the professional relationship between
Provider and Enrollee to be maintained without interference. Any PPO, Premier or Non -Delta Dental
Provider, including any Provider or employee associated with or employed by them, who provides 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 be in writing and sent by email, facsimile (fax), first -class United
States mail, overnight delivery service or personal delivery. Notice by United States mail 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 -51 PPO -FL -C 12 17858
5.11 Indemnification
Contractholder will indemnify, defend and hold harmless Delta Dental, its directors, officers, employees,
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 indemnify, defend and hold harmless Contractholder and its employees and agents,
against any and all claims, demands, liabilities, costs, damages and causes of action or administrative
proceedings whatsoever, including reasonable attorney's fees, arising from Delta Dental's negligent
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 ( "HIPAA "). 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 party shall be liable to the other or 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 acts of God or of a public enemy, explosion, fires, 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 of a TPA, duly registered under applicable state law, to 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.
5.16 Holding Company
Delta Dental is a member of the Insurance Holding Company System of Delta Dental of California (the
"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.
5.17 Mutual Confidentiality
Contractholder and Delta Dental agree to maintain confidential information using the same degree of care
(which shall be no less than reasonable care) as each uses to protect its own confidential information of a
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 use the name, trademarks, service marks or
other proprietary branding of the other party without the advance written approval of the other party.
5.19 Automated Information Line
Contractholder and Enrollees may access Delta Dental's automated information line at 800- 521 -2651 on a
regular business day to obtain Enrollee eligibility and Benefits, group Benefit or claim status information or
to speak to a Customer Service Representative for assistance, including resolution of complaints.
ENT -51 PPO -FL -C 13 17858
5.20 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
6.01 This Contract may be terminated only as follows:
• By Contractholder upon 30 days written notice at any time.
• By Delta Dental,
(1) upon 60 days written notice if Contractholder fails to fumish Delta Dental a list of all Enrollees as
required under section 2.01; or
(2) upon 60 days written notice if Contractholder fails to permit Delta Dental to inspect Contractholder's
records as called for under section 2.02; 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 in Attachment C for three (3) consecutive months.
• By Delta Dental at the end of a Contract Terre upon 60 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.
6.03 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
Contractholder'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 pay
the Premiums indicated in the renewal notice with the new Contract Term, Delta Dental will terminate this
Contract under section 6.01 second bullet, item (3).
ARTICLE 7 -ATTACHMENTS
These documents are attached to this Contract and made a part of it:
Attachment A Deductibles, Maximums and Contract Benefit Levels
Attachment B Services, Limitations and Exclusions
Attachment C Group Variables
ENT -51 PPO -FL -C 14 17858
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