HomeMy WebLinkAboutDELTA DENTAL - CONTRACT - RFP - P902 BENEFITS (4)( CrIC
DELTA DENTAU
Delta Dental Plan of Colorado
PART III
GENERAL TERMS AND CONDITIONS
Section 1. TERM OF AGREEMENT - This Agreement shall continue for the period specified in PART
I, ADMINISTRATIVE AGREEMENT.
Section 2. RENEWAL - The Agreement shall be renewed for successive one year periods unless
during any Agreement year either party elects not to renew by giving the other party written
notice of such election at least one hundred twenty (120) days prior to the end of the
current Agreement year. In the event that Delta shall desire to change the rates or other
terms and conditions of this Agreement effective on an Anniversary Date, advice of such
proposed changes shall be given with the notice of renewal.
Section 3. TERMINATION - This Agreement shall be terminated as follows:
a) At the end of the original Term of Agreement provided the required notice of
non -renewal has been given.
b) At the end of any renewal year provided the required notice of non -renewal
is given.
c) In the event any payment due pursuant to PART I, ADMINISTRATIVE
AGREEMENT, Section 4. MONTHLY DUES of this Agreement is not paid
within twenty (20) days of the due date, Delta may give written notice that
payment is due, and if such payment is not received within ten (10) days
after such notice, Delta may at its option, terminate all further obligations.
The date of termination shall be specked by Delta.
d) By election of the Group if Delta defaults in providing the Benefits under the
Agreement and such default is not corrected within sixty (60) days of such
default, the termination date shall be specified by the Group.
e) At any time by either party with sixty (60) days advance written notice.
Section 4. PROCEDURES ON TERMINATION
In the event of termination by Delta as stated in Part III, Section 3, paragraph a,
all Benefits shall terminate and Delta shall be released from all further
obligations of this Contract, however, Delta shall make payment to dentist for
dental services authorized by Delta prior to termination and performed in
reliance of such authorization. Applicant shall remain liable to Delta for the
greater of:
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a. the unpaid payments applicable for the period this Agreement was in
effect prior to termination; or
b. the full amount of all Dentist's statements paid or otherwise
discharged by Delta during the full term of this Contract, plus $7.00
per paid claim (to compensate Delta for its administration for the
dental program), less amounts actually paid by the Group to Delta
during the term of the Agreement.
If Group notifies Delta in writing of its intention to terminate this Agreement as
of any date other than the end of the Agreement Term, such termination shall
be treated as termination for failure to pay the Service Fee, and the notice by
Group of the intention to terminate shall constitute a waiver of notification and
billing by Delta.
In the event of termination of this Agreement for any cause, Delta shall not be
required to authorize services beyond the termination date or to pay for services
provided beyond such termination date, except for the completion of single
procedures started while this Agreement was in effect, which are otherwise
Benefits under the terms of this Agreement.
If on termination of this Agreement for any cause, Group has not paid Fees to
Delta applicable to a period of time before the termination date, Group shall,
within thirty (30) days after termination, remit such portion of the Fees on claims,
if any.
Section 5. REINSTATEMENT
Acceptance by Delta of the proper amount of Service Fee after the termination of
this Agreement and without requiring a new application shall reinstate the Contract
as though it never terminated, unless Delta shall, within five (5) business days of
receipt of such payment, either refund the payment made or issue to Applicant a
new Contract accompanied by written notice stating clearly those respects in which
the new Contract differs from the terminated Agreement in Benefits, coverage, or
otherwise. If Applicant does not approve the new Contract, Delta shall refund the
payment made.
Section 6. GENERAL PROVISIONS
a) Clerical errors or delays in keeping or relating data relative to coverage shall not
validate or invalidate coverage which would otherwise be in force. Upon discovery
of such errors or delays, an equitable adjustment of Service Fees shall be made.
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b) Any notice under this Agreement shall be sufficient if given by either the Applicant
or Delta to the other (or in the case of the Applicant, to its designated agent)
addressed as stated below and shall be effective forty-eight (48) hours after deposit
in the United States mail with postage fully prepaid thereon.
Group: City of Fort Collins
200 West Mountain Ave., Ste A
Fort Collins, CO 80522-0580
DELTA: The Delta Dental Plan of Colorado
Colorado Dental Service Inc.
4582 S. Ulster Street Suite 800
Denver, CO 80237
c) Notice to Covered Persons shall be in writing and sent by regular U.S. mail to their
addresses last shown in the records of Delta. Such notice shall be deemed to be
delivered when deposited in the United States Mail, addressed to the Covered
Person at such address with postage thereon prepaid.
d) No action at law or in equity shall be brought to recover on this Agreement prior to
the expiration of sixty (60) days after final notice of claims has been filed in
accordance with the requirements of this Agreement; nor shall such action be
brought at all unless brought within three (3) years from the date the claim for
benefits was presented to Delta.
e) All statements made by the Group or by an individual shall be deemed
representations and not warranties. No such statement shall be used in defense
to a claim under this Agreement unless it is contained in a written application.
f) This Agreement shall be the entire, full, and complete agreement between Delta
and the Group concerning group dental care. This Agreement may not be orally
amended or changed. This Agreement may at any time be amended and changed
by written agreement between Delta and the Group. Any such amendment shall be
binding on all Covered Persons regardless of the date their coverage became
effective.
g) No agent or employee of Delta has the authority to change the Agreement or its
provisions. No change in the Agreement shall be valid unless approved in writing
by the President of Delta.
h) The Group agrees to permit Delta, by its auditors or other authorized
representatives, upon reasonable advance written notice, to inspect records of the
Group pertinent to eligibility in order to verify the accuracy of lists of Covered
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Persons prepared by the Group and submitted to Delta. Delta agrees to keep all
information regarding the Group confidential.
i) Delta agrees that the Group or its designated representative, upon reasonable
advance written notice, shall have the right of access to all files and records
pertinent to the Group for examination and audit.
j) Any dispute arising out of or relating to this Agreement or the breach thereof
between Delta, a Participating Dentist, and Covered Person or any of them,
including any disagreement with a claim determination made by Delta after
exhaustion of the procedure outlined in PART VII, CONDITIONS UNDER WHICH
BENEFITS SHALL BE PROVIDED, Section 1. Payment of Claims (a) of this
Agreement, shall be settled by arbitration in accordance with the Commercial
Arbitration Rules of the American Arbitration Association, and judgment upon the
award rendered by the Arbitrator(s) may be entered in any Court having jurisdiction
thereof. Arbitration may be initiated by any party to a dispute by giving notice to
each other party two copies of such notice with the American Arbitration Association
and by complying with other applicable provisions of the Association's rules.
k) Delta shall furnish to the Applicant on the Effective Date of this Agreement and at
reasonable times thereafter a directory of Participating Dentists and Preferred
Option Dentists who have agreed to provide services described in this Agreement.
The directory of Preferred Option Dentists shall be furnished by Delta in such
quantities that the Applicant may distribute a copy to each Eligible Employee. It is
understood that the composition of such directory may be subject to change from
time to time, and Delta reserves the right to change the directory without prior notice
to the Applicant, but shall give notice within reasonable time of any provider's
termination or breach of contract, or inability to perform, which will materially and
adversely affect the Applicant. Current information concerning the Participating
Dentist status of any dentist may be obtained by telephoning Delta. The dentists
providing or contracting to provide dental services under this Agreement shall be
solely responsible therefor, and in no case shall Delta or the Applicant be liable for
any act or omission by such dentists, their agents or employees.
1) Delta will issue to the Group, and the Group will make available to each Eligible
Employee, an evidence of coverage summarizing the benefits to which the
employee is entitled and other provisions of this Agreement. If any amendment of
this Agreement shall materially affect any benefits described in such evidence of
coverage, a corrected evidence of coverage, riders, or inserts showing the change
shall be issued to the Group.
m) Delta, at its own expense, will have the right and opportunity to examine any
individual for whom claim or request for predetermination of benefits is pending
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under this Agreement when and so often as it reasonably may require and to make
an autopsy in case of death where it is not prohibited by law.
n) Where applicable herein, the use of the singular shall include the plural, the plural
the singular, and the use of any gender shall include all genders.
o) This Agreement is not to be construed as satisfying any requirement for coverage
by worker's compensation insurance.
p) The Group shall compile and furnish Delta on or prior to the first day of every month,
commencing on the effective date, a list of all Eligible Employees, showing their
social security numbers, the dates of hire, and if applicable, the location code. The
Group shall also furnish a monthly list of all persons electing continued coverage
pursuant to PART IV, ELIGIBILITY, Section 4. Delta agrees to keep all information
regarding the Group confidential.
q) This agreement shall be construed in accordance with and governed by laws of the
State of Colorado. Delta agrees to comply with all applicable Federal, State and
local laws, rules, regulations or ordinances, and all provisions required thereby to
be included herein, are hereby incorporated by reference. Delta agrees to
indemnify and hold GROUP harmless from any loss, damage or liability resulting
from a violation on the part of Delta of such laws, rules, regulations or ordinances.
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PART IV
ELIGIBILITY
Section 1. ELIGIBLE PERSONS
a) Eligible Employees are defined as follows:
All full-time permanent active employees working a minimum of twenty (20) hours
per week shall become eligible the first day of the month following thirty (30) days
of employment.
Employees who have been absent from work due to strike, lay-off or leave of
absence, and who return to work, will become eligible on the first day of the month
following the return to work, provided the absence does not exceed six (6) months.
If an absence exceeds six (6) months, then such employees shall be considered
newly hired employees in every respect and must fulfill the eligibility requirements
and application of deductibles, maximum benefit payments and waiting periods.
Services provided during the period such employees were not eligible due to strike,
lay-off or leave of absence shall not be covered by this Agreement, unless the
employee or any dependents have elected continued coverage as provided in the
Continued Coverage Option Rider attached hereto.
b) Eligible Dependents are defined as follows:
1) The Eligible Employee's lawful spouse.
2) The Eligible Employee's unmarried children wholly dependent upon the
employee for support and maintenance until the end of the month to which they
attain nineteen (19) years of age or any unmarried children, nineteen (19) years
of age until the end of the month to which they attain twenty-five (25) years who
attend an accredited educational institution on a full-time basis. This includes
any stepchild, foster child, or legally adopted child who lives with the employee
in a regular parent -child relationship.
A covered unmarried child reaching the age of nineteen (19) years may continue to
be eligible as a dependent if he is incapable of self-support because of physical
handicap or mental incapacity that commenced prior to reaching age nineteen (19)
and if he is chiefly dependent on the Eligible Employee for support and
maintenance, provided proof of such handicap or incapacity and dependency is
submitted within thirty-one (31) days after a request by either Delta or Applicant,
and subsequently as may be required by either Delta or the Applicant, but not more
frequently than annually after the handicapped or incapacitated and dependent child
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has attained age twenty-one (21). Upon failure to submit such required proof or to
permit such an examination, or when the child ceases to be so incapacitated,
coverage with respect to such child shall cease.
No one may be covered as a dependent and also as an employee. If both parents
are covered as employees, children may be covered as dependents under both
employees.
Persons in active military service will not be considered as Eligible Dependents.
"Dependent" also means any child for whom the employee or spouse is responsible
for medical or other health care benefits under a Qualified Medical Child Support
Order.
Section 2. ENROLLMENT OF DEPENDENTS
a) You must select the same level of dependent coverage as chosen for medical
coverage.
b) Newly acquired dependents who are enrolled in the medical plan provided by this
employer must be enrolled within thirty-one (31) days of acquisition. Newborn
children must be enrolled within thirty-one (31) days of birth.
c) Any eligible dependents that suffer involuntary loss of coverage through another
source will be allowed to enroll with satisfactory proof of coverage loss. Such
dependents must be enrolled within thirty-one (31) days of the loss of coverage and
must be enrolled in the medical plan provided by this employer.
Section 3. EFFECTIVE DATE OF INDIVIDUAL COVERAGE
a) Coverage for Eligible Employees becomes effective the first day of the month
coincident with or next following the date such persons become eligible as defined
in PART IV, ELIGIBILITY, Section 1. ELIGIBLE PERSONS.
b) Coverage for Eligible Dependents becomes effective on the date the employee's
coverage becomes effective. Dependents acquired after the employee effective
date shall become eligible on the first day of the month following attainment of
dependent status.
Section 4. TERMINATION OF INDIVIDUAL COVERAGE
a) Coverage for Enrolled Eligible Employees will terminate on the earliest date of the
following:
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1) The last day of the month that eligibility is terminated in accordance with the
eligibility rules of this Agreement, unless the Eligible Employee elects continued
coverage under the Continued Coverage Option Rider.
2) The last day of the month for which Service Fees have been paid.
3) The day this Agreement is terminated.
b) Coverage for enrolled eligible dependents will terminate on the earliest of the
following:
1) The day the Enrolled Eligible Employee's coverage under which they are
covered terminates in accordance with the above.
2) The last day of the month during which the enrolled eligible dependent ceases
to be eligible in accordance with the eligibility rules of this Agreement unless
continued coverage is elected by or on behalf of any dependent under the
Continued Coverage Option Rider.
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PART V
BENEFITS, LIMITATIONS AND EXCLUSIONS
Subject to the limitations and exclusions hereinafter set forth, the following completed dental services
are Benefits when provided by a dentist (or other person legally permitted to perform such services by
authority of license) and are determined under the standards of generally accepted dental practice to be
necessary. THE SPECIFIC DENTAL PROCEDURES ARE SET FORTH IN APPENDIX A - COVERED
SERVICES.
Section 1. DIAGNOSTIC, PREVENTIVE AND ADJUNCTIVE BENEFITS
Delta shall pay or otherwise discharge Eighty Percent (80%) of the Dentist's Usual,
Customary and Reasonable fees or the fees actually charged, whichever is less, or
One Hundred Percent (100%) of the Preferred Option Dentist's Fees for the following
Covered Services:
a) Diagnostic - certain services performed to assist the dentist in evaluating the
existing conditions and determining the dental care required. Appendix A, Section
I.
Preventive - certain services performed to prevent the occurrence of dental
abnormalities or disease. Appendix A, Section II.
Adjunctive - certain additional services including emergency palliative treatment
performed as a temporary measure which does not effect a definite cure. Appendix
A, Section IX.
b) Limitations on Diagnostic, Preventive and Adjunctive Benefits:
1) Benefits for oral examinations and prophylaxis treatment shall not be provided
more than twice each in any twelve-month period except for special need as
determined by Delta. Allowance separate from the allowance for oral
examination shall not be made for diagnosis, treatment planning or consultation
by the treating dentist, which for purposes of this Agreement, are considered
components of a complete examination service.
2) Topical fluoride application is a benefit only through age fifteen (15) and only
once in twelve (12) months.
3) Benefit for full mouth x-rays is made only after sixty (60) months have elapsed
following any prior provision of payment for full mouth x-rays under any Delta
program. Benefit for supplementary bite -wing individual x-rays is provided on
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request by the dentist, but not more than once every twelve (12) months while
the patient is under any Delta program. A panoramic survey (which may include
bitewing x-rays and/or periapical) is considered a full mouth x-ray for purposes
of this Agreement. Total allowance for individual periapical and/or bitewing x-
rays shall not exceed allowance for full mouth x-rays. Exception to this Limitation
may be made in documented cases of special need, but only as determined by
DELTA.
4) X-rays and other specific and/or usual diagnostic services associated with
determination of the need for treatment covered by an Amendment or Rider may
be covered only under terms of such Amendment or Rider and only when such
an Amendment or Rider is made a part of this Agreement but only when such
services are included in such Amendment or Rider.
5) Payment of a separate charge for examination shall not be made when
performed in conjunction with any covered Adjunctive Service.
6) Benefit for Covered Diagnostic Services may be applied toward the cost of
special diagnostic services or techniques and the patient shall be responsible
for the portion of the dentist's fee in excess of the Delta allowance.
7) Benefit for space maintainers shall only be made for premature loss of primary
(deciduous) teeth for children through age thirteen (13).
8) Sealant Benefits are described as topically applied resin, composite or other
material used to seal developmental grooves and pits in teeth for the purpose
of preventing dental decay and are available only to Covered Persons under the
age of fifteen (15).
9) Sealant Benefits include the application of sealants only to intact occlusal
surfaces of permanent molar teeth when those teeth have no caries (decay) and
no restorations on any surface.
10) Separate benefit shall not be made for any preparation or conditioning of the
tooth or any other procedure associated with sealant application.
11) Sealant Benefits do not include any repair or replacement of a sealant on any
tooth within thirty-six (36) months of its application under this Contract. Such
repair or replacement is considered included in the fee for the initial placement
of the sealant.
12) Payment of Benefits for Adjunctive Services provided in relation to or as a result
of another category of Covered Services, or Covered Services provided under
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I
rt APPLICATION FOR PREFERRED PROVIDER OPTION PLAN
MADE TO
DELTA DENTAL PLAN OF COLORADO
4582 S. ULSTER STREET PARKWAY, SUITE 800
DENVER, COLORADO 80237
Name of Group City of Fort Collins Phone (970) 221-6828
Address 200 West Mountain Avenue Ste A
Fort Collins Colorado 80522-0580
Contact for
Eligibility Laurie Harvey Title Benefits Administrator
Nature of Business Government Proposed Effective Date January 1, 1997
PROGRAM DESCRIPTION #1857 (Comprehensive Plan)
DPO STD DPO STD
A. Diagnostic, Preventive F. Special Restorative 60 % 50 %
and Adjunctive Services 100 % 80 %
B. Basic Restorative
C. Oral Surgery
D. Endodontics
E. Periodontics
80 % 60 %
80—% 60 %
80 % 60 %
80 % 60 %
Annual Maximum $ 1,000.00 per person
G. Prosthodontics
OPTIONAL SERVICES
60 % 50 %
H. Orthodontic Care 50 % 50 %
Lifetime Maximum $1.000 $1.000
Age Limitation 19 or 25 if full-time student
Deductible Amount $ 25.00 - DPO PROVIDER Annual X Family Aggregate $ 50.00
Deductible Amount $ 25.00 NON-DPO PROVIDER Annual X Family Aggregate $ 50.00
Deductible Applies to: DPO: B.C.D.E.F.G NON-DPO: A. B, C.D.E.F G
ELIGIBILITY RULES
All present and future employees shall become eligible on the first day of the month,
a. following the date of employment, or
b. X following the completion of thrity (30) days of employment.
The minimum number of hours worked per week to establish eligibility shall be 20 hours.
Dependent Coverage: Yes x No _ Children to Age 19 Students to Age 25
any Amendment or Rider, shall be made at a percentage no greater than the
related category of Covered Services or Amendment or Rider.
Section 2. BASIC RESTORATIVE BENEFITS
Delta shall pay or otherwise discharge Sixty Percent (60%) of the dentist's Usual,
Customary and Reasonable fees or the fees actually charged, whichever is less, or
Eighty Percent (80%) of the Preferred Option Dentist's Fees for the following Covered
Services:
a) Basic Restorative - amalgam restorations (fillings) on posterior teeth, intraorally
cured resin or plastic restorations (fillings) on anterior teeth and preformed shell
crowns for treatment of carious lesions (visible destruction of hard tooth
structure resulting from the process of dental decay or loss of tooth structure due
to fracture). Appendix A, Section III -A.
b) Limitations on Basic Restorative Benefits
1) Benefit for the same Covered Basic Restorative Service shall not be provided
more than once in any twelve (12) month period.
2) Allowance for amalgam or intraorally cured resin or plastic restorations may be
made toward the cost of more expensive procedures or materials selected, and
the patient shall be responsible for the portion of the dentist's fee in excess of
the Delta allowance.
Section 3. ORAL SURGERY ENDODONTIC AND PERIODONTIC BENEFITS
Delta shall pay or otherwise discharge Sixty Percent (60%) of the dentist's Usual,
Customary and Reasonable fees or the fees actually charged, whichever is less, or
Eighty Percent (80%) of the Preferred Option Dentist's Fees for the following Covered
Services:
a) Oral Surgery - extractions and certain other surgical services and associated
covered anesthesia and/or related covered services. Appendix A, Section Vill
and IX.
Endodontic - certain services for treatment of non -vital tooth pulp. Appendix A,
Section IV.
Periodontic - certain services for treatment of gums and bone supporting teeth.
Appendix A, Section V.
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b) Limitations on Endodontic and Periodontic Benefits
1) Unless special need is documented, benefit for Covered Surgical Periodontic
Services shall not be provided more than once in any thirty-six (36) month period
and for Covered Adjunctive Periodontic Services not more than once in a
twenty-four (24) month period while the patient is an Covered Person.
2) Benefit for pulpotomy/pulpectomy shall be made only for primary (deciduous)
teeth.
3) No Benefits shall be provided for teeth retained in relation to an overdenture.
4) Nonsurgical periodontal procedures which include any component of prophylaxis
are limited to Part V, Section 1.,b), paragraph 1).
Section 4. SPECIAL RESTORATIVE BENEFITS
Delta shall pay or otherwise discharge Fifty Percent (50%) of the dentist's Usual,
Customary and Reasonable fees or the fees actually charged, whichever is less, or
Sixty Percent (60%) of the Preferred Option Dentist's Fees for the following Covered
Services.
a) Special Restorative - crowns, jackets, cast, fused or other laboratory processed
restorations (except preformed shell crowns) for treatment of carious lesions
(visible destruction of hard tooth structure resulting from the process of dental
decay) or significant loss of tooth structure due to fracture which cannot be
restored with amalgam or intraorally cured resin restorations. Appendix A,
Section III-B.
b) Limitations on Special Restorative Benefit
1) In the event that more than one such restoration is used to restore a tooth,
allowance shall not exceed the Covered Amount for a Single Covered Service.
2) Benefit for placement of Special Restorative Services will be made only after
sixty (60) months have elapsed following any prior provisions of these
procedures or any prior provision of Covered Prosthodontic Services involving
the same teeth.
3) Benefit for Special Restorative Services shall not be made for these services
when provided for children under twelve (12) years of age.
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4) A patient shall be eligible for Special Restorative Benefits immediately following
enrollment under this Agreement.
5) No Benefits shall be provided for teeth retained in relation to an overdenture.
Section 5. PROSTHODONTIC BENEFITS
Delta shall pay or otherwise discharge Fifty Percent (50%) of the dentist's Usual,
Customary and Reasonable fees or of the fees actually charged, whichever is less, or
Sixty Percent (60%) of the Preferred Option Dentist's Fees for the following Covered
Services:
a) Prosthodontic - certain services for construction or repair of fixed bridges, and
removable partial and complete dentures to replace completely extracted or
missing natural permanent teeth, or natural permanent teeth missing from their
normal functioning position in the dental arch. Appendix A, Section VI and VII.
b) Limitations on Prosthodontic Benefits:
1) Benefit for replacement of prosthodontic appliances will be made only
after sixty (60) months have elapsed following any prior provisions of
such appliances, subject to individual consideration determined by Delta
where there is such extensive loss of remaining teeth or change in
supporting tissues that the existing appliance cannot be made
satisfactory. Benefits for replacement will be made for a prosthodontic
appliance more than sixty (60) months old or one not provided under this
Delta Agreement only if it is unsatisfactory and cannot be made
satisfactory.
2) Benefit for a covered prosthodontic appliance shall be made only after
sixty (60) months have elapsed following any prior payment of covered
Special Restorative Benefit for the same teeth.
3) Delta will pay the applicable percentage of the dentist's fee for a standard
cast base metal and/or acrylic partial denture or a standard complete
denture, up to a maximum fee allowance for a standard denture. (A
"standard" complete or partial denture is defined as a removable
prosthodontic appliance provided to replace missing natural, permanent
teeth and which is constructed using accepted and conventional
procedures and materials). The portion of the dentist's fee in excess of
the Delta allowance for any denture and/or related service for which a
charge is made which exceeds this allowance is considered the
responsibility of the patient.
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4) Removable temporary partial dentures are a benefit only when anterior
teeth are missing. An allowance limited to the Covered Amount for a
removable appliance may be made toward the cost of other procedures
performed and the patient is responsible for the portion of the dentist's
fee in excess of the Delta allowance.
5) Benefit based on the cost of a covered standard removable partial
denture may be made toward the cost of implants and appliances
constructed in association therewith. If benefit is made for such an
appliance, benefit will not be made or any replacement within sixty (60)
months thereafter.
6) Benefit for reline or rebase of a prosthodontic appliance will be made only
once in any thirty-six (36) month period.
7) A patient shall be eligible for Prosthodontic Benefits immediately following
enrollment under this Agreement.
8) Fixed bridges and/or cast metal framework partial dentures are not a
benefit for persons under age sixteen (16).
9) Fixed and removable Prosthodontic appliances are not a benefit in the
same arch except in cases of special need as determined by Delta.
Allowance will be limited to that for a removable appliance.
10) Allowance in cases using overdenture appliances shall be limited to
allowance for standard appliances.
Section 6. GENERAL LIMITATIONS - ALL SERVICES
a) If an Covered Person selects a service that is not provided for under the terms
of this Agreement or specialized techniques rather than standard services, Delta
will pay the applicable percentage of the fee for the least costly commonly
performed Covered Service and the patient is responsible for the remainder of
the dentist's fee.
b) When services involving veneers, facings, or any other cosmetic services
posterior to the first molar are provided, allowance shall be limited to the
Covered Amount for Covered Service without veneers, facings or cosmetic
component, or the service actually performed, whichever is less. The patient is
responsible for the remainder of the Dentist's fee.
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c) If the expenses to be incurred for the performance of Covered Services (except
Covered Diagnostic and Emergency Services) which can reasonably be
expected to total Four Hundred Dollars ($400.00) or more, those expenses may
be paid, provided Delta agrees through Predetermination prior to the
performance of the service, to accept those expenses as Covered Services. If
Delta does not so agree through Predetermination, or if a description of the
procedures to be performed and an estimate of the Dentist's charges are not
submitted in advance, then the amount of expenses included as Covered
Services will be determined by Delta, taking into account alternate procedures,
services, or courses of treatment based upon professionally endorsed standards
of dental care.
d) Local anesthesia is considered a component of any procedure in which it is
used.
e) The Covered Amount for a Covered Service started but not completed shall be
limited to the amount determined by Delta.
i A temporary dental service will be considered an integral part of a complete
dental service rather than a separate service, and separate payment shall not
be made for a temporary service unless otherwise included as a Covered
Service of this Agreement.
g) Allowance for assistant surgeon when determined by Delta to be a Covered
Benefit shall not exceed 20% of the surgeon's fee for the same Covered
Service.
Section 7. EXCLUSIONS - The following services are not benefits
a) Services for injuries or conditions which are compensable under Worker's
Compensation or employer's liability laws, no-fault auto insurance, or services
which are provided to the Covered Person by any federal or state government
agency or are provided without cost to the Covered Person by any municipality,
county or other political subdivision, or any services for which the Covered
Person would have no obligation to pay in absence of this coverage, except as
such exclusion may be prohibited by law, such as Medicaid.
b) Any Covered Service or any portion thereof started during any period when the
person was not eligible for such service under this Agreement.
c) Services for treatment of congenital (present at birth) or developmental
(following birth) malformations, except intraoral dental services for treatment of
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a condition which is related to or developed as a result of cleft lip and/or cleft
palate, unless otherwise included as a Covered Service of this Agreement.
d) Services for cosmetic reasons.
e) Services for restoring tooth structure lost from wear or for any services related
to protecting, altering, correcting, stabilizing, rebuilding or maintaining teeth due
to improper alignment, occlusion or contour or for periodontal stabilization.
f) Habit appliances, night guards, occlusal guards, athletic mouth guards and
gnathological (jaw function) services, bite registration or analysis, or any related
services (except as covered under provisions of an Amendment or Rider).
g) Pre -medication, analgesia, hypnosis or any other patient management services
(except covered anesthetic services).
h) Charges for prescription drugs.
i) Experimental procedures, or any procedures other than those Covered Services
for which the prognosis is good. Any procedures done in anticipation of future
need (except Covered Preventive Services).
j) Hospital costs and any additional fees charged by the dentist or hospital for
hospital services, visits, or charges for use of any facility.
k) Anesthesia other than general anesthesia, intravenous sedation or analgesia
administered in connection with Covered Oral Surgery Services. (See PART V,
BENEFITS, LIMITATIONS AND EXCLUSIONS, Section 3. Oral Surgery).
I) Extraoral grafts (grafting of tissues or other substances from outside the mouth
to or into oral tissues), augmentations or implants and/or any associated
appliances. Removal of implants or any services associated therewith.
m) Orthodontic services including any related diagnostic, preventive or interceptive
services (surgical and other treatment of malalignment of teeth and/or jaws)
except as covered under provisions of an Orthodontic Amendment or Rider.
Myofunctional therapy or speech therapy.
n) Services for the treatment of any disturbances of the temporomandibular joint
(jaw joint) facial pain, or any related conditions, including any related diagnostic,
preventive or interceptive services (except as covered under provisions of an
Amendment or Rider).
24
o) Services not performed in accordance with the laws of the State of Colorado,
services performed by any person other than a person authorized by license to
perform such services, or services performed to treat any condition, other than
an oral or dental disease, malformation, abnormality or condition.
p) Oral hygiene instructions or dietary instructions.
q) Completion of forms, providing diagnostic information or records, or duplication
of x-rays or other records.
r) Replacement of lost, stolen or damaged appliances.
s) Preparation for placement or replacement, removal or repair, or any other
procedure related in any way to any procedure or service not included in
Covered Services.
t) Any services not specifically included in Covered Services.
u) Services to the extent that payment for which under this Agreement is prohibited
by any law of the jurisdiction in which the Covered Person resides at the time the
expenses are incurred.
v) Services for which charges would not have been made if this coverage had not
existed, except for services as provided under Medicaid.
w) Services for which legal payment obligations have been reduced due to a
professional or courtesy discount, or for services by a relative as the provider.
x) Services which result from an act of declared or undeclared war or armed
aggression.
y) Services which result, whether the insured person is sane or insane, from an
intentionally self-inflicted injury or sickness.
z) Charges for failure to keep a scheduled visit with your Dentist.
aa) Any payable expense under any other group or individual plan, medical or dental
plan, whether claimed or not.
25
PART VI
DEDUCTIBLE, MAXIMUM AMOUNT AND COORDINATION OF BENEFITS
Section 1. DEDUCTIBLE
Delta shall not be obligated to pay, in whole or in part, the first twenty five ($25.00) of
fees for Benefits received by a Covered Person during the calendar year of the
Agreement. Fees shall be computed on the basis of the dentist's Usual, Customary
and Reasonable fee (or the Prevailing Fee, if applicable). If a patient received services
from a Preferred Option Dentist, the deductible will not apply to Diagnostic, Preventive,
and Orthodontic Services. The deductible will apply to all services except Orthodontics
for those receiving services from a Non -Preferred Option Dentist. The $25.00 annual
deductible is limited to $50.00 per family.
Section 2. MAXIMUM BENEFIT PAYMENT
Delta will pay up to a maximum of One Thousand Dollars ($1,000.00) per calendar year
for each Covered Person.
Section 3. COORDINATION OF BENEFITS
a) If an Covered Person is entitled to coverage under two or more plans, then the
benefits of this Agreement shall be coordinated with other plan benefits.
"PLAN" means any plan providing dental care benefits under group, blanket or
franchise coverage; or service type plans or other group pre -paid plans; or coverage
under any governmental plan or required by laws; or "No -Fault" motor vehicle
insurance.
b) Order of Benefit Determination if the other coverage is by a dental insurance
policy or prepaid dental care program:
1) The policy or program covering the patient as an employee shall be primary over
the policy or program covering the patient as a dependent;
2) For dependent children's expenses the order of benefit determination shall be
as follows:
(a) The policy of the parent whose birthday (excluding year of birth) occurs
earlier in the year shall be primary, or;
26
(b) If the parents are separated or divorced, the policy of the parent who is
ordered by court decree to take financial responsibility for dental
expenses shall be primary, or;
(c) The policy of the parent with custody is primary and if said parent has
remarried, the step -parent's plan is secondary and the plan of the parent
without custody pays third.
3) If the above rules do not establish an order of benefit determination, the plan
that has covered the person for the longer period of time shall be primary with
the following exception:
The plan covering the person as a laid -off or retired employee or dependent of
such person, shall be determined after the benefits of any other plan covering
the person or employee.
4) Any group plan that does not contain a coordination of benefits provision is
automatically primary.
If this plan is primary as provided above, this plan shall provide Benefits without regard to benefits
provided by any other plan. If this plan is secondary, this plan will provide benefits which together with
the other plan(s) will not exceed 100% of the covered dental expense or this plan's maximum benefit
whichever is less.
27
PART VII
_CONDITIONS UNDER WHICH BENEFITS
SHALL BE PROVIDED
Section 1. PAYMENT OF CLAIMS
a) "Covered Services will not include, and no payment will be made for expenses
incurred for the performance of any dental service not provided for in this
Agreement, including any attached Appendix, Amendment, or Rider, unless
Delta agrees to accept such expenses as covered services. To submit the
expenses to Delta for consideration, the dental service must be identified in
terms of the American Dental Association Uniform Code on Dental Procedures
and Nomenclature and/or by narrative description. If expenses incurred for a
dental service not provided for in this Agreement are accepted by Delta, the
Benefit for the dental service will be determined by Delta and will be consistent
with those for dental services listed in this Appendix and in PART V, BENEFITS,
LIMITATIONS AND EXCLUSIONS.
In any event, expenses incurred for dental services which do not have uniform
professional endorsement will not be accepted by Delta as Covered Services.
b) The Employer, or his designee(s) shall have authority for determination of
Benefits in any case involving disputed Benefits. The Covered Person may
appeal this determination by filing a written notice with the Dental Director, in
which event the matter may be submitted to the Executive Committee of Delta
for determination of Benefits. Any matter relating to the necessity,
appropriateness or adequacy of covered services provided or to be provided
under this Agreement may be referred to a peer review committee of the
appropriate dental society or association which will accept jurisdiction and Delta
agrees to be bound by the decision of such a peer review committee.
c) Payment for completed Covered Services:
1) provided by a Participating Dentist or a Preferred Option Dentist shall be made
directly to the Dentist upon receipt of claim or claims signed by the Dentist for
such services.
2) provided by a dentist who is not a Participating Dentist or a Preferred Option
Dentist shall be made to the Eligible Employee upon receipt of claim or claims
signed by the dentist for such services and shall not be assignable. Since Delta
does not pay a non -participating dentist, the Covered Person shall be liable to
the dentist for the cost of service.
28
Specify classes of ineligible employees, if any hourly
CENSUS DATA
A. Total number of enrolled employees
B. Total number of eligible employees 1200
OTHER INFORMATION
Name of Previous Dental Carrier National Dental Health
Number of years with previous carrier 5 years
Percentage of employer contribution for: Employee
Dependent
Initial term of proposed Contract Two Year
Name of Broker _ The Segal Company Tax I.D.# or SS#
Address 6300 S. Syracuse Way Suite 200 Phone 303-714-9900
Englewood, Colorado 80111
MONTHLY PREMIUMS*
$2.55 per eligible plus paid claims
*Final premiums will be subject to the employees enrolled on the effective date of the Contract.
The proposed effective date for ithis group dental plan is January 1. 1997 . It is
agreed that the Group Contract will not become effective unless and until this application is approved
and accepted by the Delta Dental Plan of Colorado. An estimated payment of $ has
been tendered toward the first month's premium under the Contract applied for herein.
It is understood that this applicaticAwill be made a part of the Contract between Delta Dental Plan
and the Group. Executed this j� day of 193 at t 75 C�
Colorado.
GROUP NAME:
City of Fort Collins
Authorized signature:
Title: `n-L--5
ACCEPTED:
DELTA DENTAL PLAN OF COLORADO
President
3) provided by a dentist in another state or country shall be made directly to the
dentist, unless assigned to the employee, upon receipt of claim or claims signed
by the dentist for such services.
4) Delta shall not be obligated to pay claims submitted more than fifteen (15)
months after the date of providing the service. If a claim is denied due to a
Participating Dentist's failure to make timely submission, the Covered Person
shall not be liable to such dentist for the amount which would have been payable
by Delta.
Section 2. EXTENDED COVERAGE
All Benefits shall terminate for any Covered Person in the event that this Contract is
terminated or such person ceases to be eligible under the terms of this Contract, and no
further care or services shall be provided under this plan except completion of any single
procedure in progress, where work has commenced prior to termination of coverage.
Delta shall authorize Attending Dentist's Statement for Benefits when satisfied from the
Attending Dentist's Statement and other data that:
a. the patient is a Covered Person hereunder, provided, however, that Delta may
determine such eligibility on the basis of the most current list of Eligible Employees
received by Delta;
b. the services proposed are Benefits under this Contract; and
c. the total fee to be charged for such services to both Delta and Covered Person do
not exceed the dentist's Usual, Customary and Reasonable fees. Such
authorization shall be for a reasonable period up to a maximum of sixty (60) days,
but shall not be required to extend beyond termination of the patient's eligibility and
may be revoked upon notice of such termination. In no event shall an authorization
period extend beyond the termination date of this Agreement.
Delta shall make no payment for any services provided to a patient who is not a
Covered Person hereunder at the time of providing the service, except to the extent of
services provided during unrevoked period of authorization issued by Delta pursuant to
Part III, section 7, r and Part IV of this Agreement, and except for completion of single
procedures which were commenced at the time a patient was eligible or was entitled
Benefits by reason of such authorization. Applicant shall reimburse Delta for any
erroneous payments made as a result of incorrect eligibility reporting by Applicant.
29
Section 3. AVAILABILITY OF DENTIST
While an Covered Person may elect the service of any licensed dentist, neither
Delta nor Applicant undertakes to guarantee the availability of any particular
dentist.
As a condition precedent to determination of benefits hereunder, Delta shall be
entitled to receive, to such extent as may be lawful, from any attending or
examining dentist, or from any attending or examining dentist, or from hospitals
or clinics in which a dentist's care is provided, such information and records
relating to attendance to or examination of or treatment proposed or provided to
an Covered Person as may be required by Delta in the administration of such
claims, or to require that an Covered Person be examined by a dental consultant
retained by Delta in or near his community or residence; provided, however, that
Delta shall in every case hold such information and records as confidential.
Section 5. CLAIM FORMS
Delta shall prepare and furnish to each Participating Dentist and to any other
Dentist or Covered Person on request a standard form to complete and submit
to Delta at the address shown herein.
Delta shall advise Participating Dentists as follows:
a. to complete and submit a standardized Attending Dentist's Statement (ADS),
prior to providing service, showing the Covered Person's dental needs and
the treatment necessary in the professional judgement of the Dentist.
b. to notify the patient of all actions taken by Delta with respect to such
Attending Dentist's Statement, and
c. that such ADS need not be submitted prior to providing of services in the
case of emergency service or in the case of brief routine procedures
normally completed in one appointment.
Section 5. SUBROGATION. Delta is entitled to enforce by its direct suit, or as co -plaintiff with
Eligible Employee, the Covered Person's claim against any third party to the extent of
benefit paid for, or on behalf of Eligible Employee by Delta. When Delta provides
benefit payments for injuries sustained by an Eligible Employee and the Eligible
Employee subsequently obtains a settlement from a third party which includes such
costs, the Eligible Employee is obligated to refund to Delta the amount equal to the
30
benefit payment made to, or on behalf of the Eligible Employee. The Eligible Employee
shall, upon request, execute and deliver such instrument or papers as may be required
and do whatever else is necessary to carry out this provision.
31
APPENDIX A - COVERED SERVICES
Covered Services include only those specific procedures listed
under each category. They do not include any or all procedures
which could be considered to fall under each category. Subject to
all contract limitations and exclusions.
I. Diagnostic
Clinical Oral Examinations
Initial
Periodic
Emergency
Radiographs
Complete Series (full mouth) -
Intraoral/Panoramic
Intraoral or Extraoral, Dental, Single
Film
Bitewings - not in addition to Complete
Series
Sialography
Cephalometric - only in conjunction with
covered orthodontic services
TMJ survey - single procedure including
all necessary films - only in
conjunction with covered TMJ/MPD
services
Tests and Laboratory Services
Diagnostic Casts - not in conjunction with
denture
Histopathologic Examination (microscopic
examination of biopsy specimen)
Pulp vitality tests - not in conjunction
with examination
II. Preventive
Dental Prophylaxis - to include removal of all
deposits and/or stains, and polishing as
a single complete service
Topical Fluoride Treatment - single office
procedure (through age fifteen (15) only)
Space Maintainer - passive appliance, including
recementation - primary teeth only
Sealants - topically applied resin, composite or other
material used to seal developmental grooves
and pits in teeth for purpose of preventing
dental decay
III. Restorative (to include tooth preparation, any special
preparations, bases, liners, conditioning, finishing, polishing
or other related procedures as components of a single
complete service)
A. Restorative - Basic
Amalgam Restorations
One, two, three surface
four or more surface
Silicate Restorations - per tooth
Resin Restorations (filled or unfilled) -
anterior teeth
One, two, three surface
Four or more surface or incisal angle
Prefabricated Crown (resin or stainless
steel)
Sedative Filling - not in conjunction with
other restoration on same tooth
Pin Retention - per tooth, in addition to
Amalgam or Resin Restoration
Temporary (fractured tooth) - not in
conjunction with any laboratory
processed restoration
B. Restorative - Special
Crown - single restoration - metal and/or
porcelain or resin - laboratory
Onlay - metal or porcelain - includes
inlay component as a single
restoration
Recementation
Crown/Onlay repair
IV. Endodontics - excluding final restoration
Pulp Cap - direct - exposed pulp only
Pulpotomy or Pulpectomy - primary teeth only
Appendix A Page 2
Root Canal Therapy - with open/drain - single
procedure
One, two, three canal
Four or more canal
Apexification or Recalcification
Periapical Services
Apicoectomy - with or without retrograde
filling and/or apical curettage -
single procedure
Root Amputation - not in addition to
hemisection
Hemisection - with removal of any roots -
single procedure
V. Periodontics
Surgical Services
Gingivectomy or Gingivoplasty
Gingival Curettage - to include root
planing per quadrant - with or
without flap entry - single procedure
Osseous Surgery
Osseous Graft
Pedicle or Free Soft Tissue Graft
Apically Repositioned Flap Procedure
Adjunctive Services
Root Planing - per quadrant - not in
addition to curettage - to include
scaling/polishing as a single
complete service
Other Periodontal Services
Periodontal maintenance following active
therapy - single procedure
Unscheduled dressing change
VI. Prosthodontics - Removable - not to include noble metal
components
Complete Dentures - except overdentures
Partial Dentures - except overdentures
Adjust, Repair, Reline or Rebase Complete or
Partial Denture
Temporary Partial Denture - anterior teeth only
Tissue Conditioning - per denture unit - single
procedure
Appendix A Page 3
VII. Prosthodontics - Fixed
Bridge Pontics - metal or resin/porcelain with
metal
Bridge Retainers
Crown - metal or resin/porcelain with
metal
Cast Metal - for acid etch bridge
Recement or repair bridge
Vill. Oral Surgery
Extractions - including exposed residual roots
Surgical Extractions - including submerged
tooth fragments
Alveoloplasty - surgical preparation for
denture
Vestibuloplasty (ridge extension for denture) -
secondary epithelialization only - not to include grafts,
implants, augmentations, or any tissue reattachment
except mucosa
Excision of Oral Inflammatory Lesion, Tumor,
Cyst, Neoplasm, Exostosis, Hyperplastic Tissue or
Pericoronal Gingiva
Incision and Drainage - soft tissue - itraoral or extraoral -
oral lesion only
Treatment of Fractures - maxilla, mandible,
alveolus
Other Surgical Procedures
Maxillary sinusotomy or Fistula Closure
Removal of foreign body or sequestrum
Tooth Reimplantation and/or stabilization of
tooth or alveolus following trauma
Exposure of Tooth - aid eruption or
orthodontics
Frenulectomy or transseptal fiberotomy
Biopsy of Oral Tissue - soft or hard
Treatment of salivary gland or duct
Repair of traumatic wound
IX. Adjunctive General Services
Palliative (emergency) treatment - minor
procedure
Anesthesia and related services except local
anesthesia - only in conjunction with
Appendix A Page 4
covered oral surgery (VIII. Oral Surgery,
above)
General Anesthesia
Intravenous Sedation - in lieu of general
anesthesia associated with covered
oral surgery
Analgesia - in lieu of general anesthesia
with covered oral surgery
Desensitize root surface - except restoration
Treatment of unusual postsurgical complication
- following covered surgical service only
Consultation (other than practitioner providing
treatment) - when requested by
attending dentist or Delta
Appendix A Page 5
In consideration of the payments specified in PART I, ADMINISTRATIVE AGREEMENT Section 3.,
of the attached Agreement, and subject to all terms and conditions thereof, except as herein otherwise
specified, Delta agrees to provide Orthodontic Benefits as follows:
1) COVERED ORTHODONTICS are defined as the services provided by a licensed dentist
involving orthognathic surgery or appliance therapy for movement of teeth and post-
treatment retention for treatment of malalignment of teeth and/or jaws including any
related diagnostic, preventive or interceptive services except extraction of teeth.
2) Delta will pay or otherwise discharge Fifty Percent (50%) of the lesser of the Covered
Amount or the fees actually charged and received by Participating Dentists, or Fifty
Percent (50%) of the Preferred Option Dentist's Fees. Allowance shall be based on
total case fee to include active treatment and post treatment retention or stabilization
and all payments shall be on a periodic basis, in accordance with the dentist's proposed
period of active treatment. Separate benefit shall not be made for post treatment
stabilization.
3) The maximum amount payable by Delta for all Orthodontics rendered to each Covered
Person shall be One Thousand Dollars ($1,000.00) per lifetime and the limitations on
the maximum amount payable during the calendar year, if any, specified in the attached
Contract shall not apply to Orthodontics.
4) EXCLUSIONS AND LIMITATIONS: In addition to the Exclusions and Limitations stated
in PART V., BENEFITS. LIMITATIONS AND EXCLUSIONS, or the attached Contract
the following exclusions and limitations shall apply to Orthodontic Benefits:
a) Replacement or repair of appliances is not a covered service.
b) Orthodontic care provided in the treatment of periodontal cases or cases
involving treatment or repositioning of the temporomandibular joint or related
conditions is not a covered service.
c) The obligation of Delta to make periodic payments for an Orthodontic treatment
plan shall cease upon termination of treatment for any reason prior to completion
of the case.
d) The obligation of Delta to make periodic payments for an Orthodontic treatment
plan begun prior to the eligibility date of the patient shall commence with the first
payment due following the patient eligibility date. The above mentioned
maximum amount payable will apply fully to this and subsequent payment.
e) The obligation of Delta to make periodic payments for an Orthodontic treatment
plan shall cease upon termination of the covered person's eligibility.
fi Only dependent children under age nineteen (19) and dependent students under
age twenty-five (25) are eligible for Orthodontic Services.
5) EXTENDED COVERAGE: The extended coverage provision stated in PART VII,
CONDITIONS UNDER WHICH BENEFITS SHALL BE PROVIDED, Section 2.,
EXTENDED COVERAGE does not apply to Orthodontic Benefits.
PART I
DELTA DENTAL PLAN OF COLORADO
DELTA GROUP #1857
Section 1. PARTIES - The parties to this Agreement are CITY OF FORT COLLINS, herein called the
"Group," "Applicant," or "Employer" and Colorado Dental Service Inc., a not for profit
Colorado Corporation, d/b/a Delta Dental Plan of Colorado, herein called "Delta".
Section 2. TERM - The term of the Agreement is from January 1, 1997 to December 31, 1998 and for
successive one-year periods thereafter unless terminated as herein provided.
Section 3. SERVICE FEE AND CLAIMS REIMBURSEMENT -On the tenth (10th), twentieth (20th),
and thirtieth (30th) day or the last business day closest to such date of each month, Delta
will notify the Group of the total claims paid for the specified period. The Group will make
a prompt transfer of funds to Delta to cover such disbursements as they become due and
payable upon receipt of said notification. In addition, the Group agrees to reimburse to
Delta a monthly Service Fee of $2.55 per eligible employee.
Section 4. Changes - This Agreement may not be changed, altered or terminated except in
accordance with PART III, GENERAL TERMS AND CONDITIONS, of this Agreement.
Section 5. BENEFITS - Delta will provide to the Enrolled Eligible Employees and their enrolled eligible
dependents the Benefits as described in PART V, BENEFITS, LIMITATIONS AND
EXCLUSIONS of this Agreement.
Section 6. AGREEMENT - The Group's Application, PART I, ADMINISTRATIVE AGREEMENT;
PART II, DEFINITIONS; PART III, GENERAL TERMS AND CONDITIONS; PART IV,
ELIGIBILITY; PART V, BENEFITS, LIMITATIONS AND EXCLUSIONS; PART VI,
DEDUCTIBLE, MAXIMUM AMOUNT AND COORDINATION OF BENEFITS: PART VII,
CONDITIONS UNDER WHICH BENEFITS SHALL BE PROVIDED; and the attached
appendices and riders constitute the entire Contract of the parties. The Agreement is
binding upon the parties and their respective successors and assigns.
3
CONTINUED COVERAGE OPTION RIDER
In consideration of the payment specified in PART I, PREFERRED OPTION ADMINISTRATIVE
AGREEMENT, Section 3. of the Contract, and subject to all of the terms and conditions thereof, Delta
agrees to provide benefits to persons who elect continued coverage pursuant to this Rider.
1. For the purposes of this Rider, each of the following shall constitute a "Qualifying Event":
(a) Termination of an Eligible Employee's employment with the Group (other than for gross
misconduct), or a reduction in the number of hours worked by the Eligible Employee to less
than the minimum number of hours required under PART II, DEFINITIONS, Section 8. of
the attached Contract.
(b) Death of an Eligible Employee.
(c) Divorce or legal separation from an Eligible Employee.
(d) An Eligible Employee becoming entitled to Medicare benefits.
(e) A dependent child ceasing to meet the definition of a dependent child contained in PART
1, DEFINITIONS, Section 8. of the attached Contract.
2. Eligible Employees whose coverage under this program is terminated by reason of Qualifying
Event described in paragraph 1. (a) of this Rider may elect to continue coverage for themselves
and their Eligible Dependents for up to eighteen (18) months following the month in which the
Qualifying Event occurs.
3. Eligible Dependents whose coverage under this program is terminated by reason of any of the
Qualifying Events described in paragraph 1. (b) through (e) of this Rider may elect to continue
their coverage for up to thirty-six (36) months following the month in which the Qualifying Event
occurs.
4. After COBRA coverage begins, the Employee may add a newborn child, an adopted child or a
child who has been placed with the Employee for adoption and for whom the Employee has
financial responsibility. The Employee must notify the employer in writing within 31 days of the
birth or placement in order to add the child to the COBRA coverage. A child born, adopted or
placed for adoption and enrolled as indicated will have the same COBRA rights as any other
dependents covered by the plan before the event that triggered COBRA coverage.
5. Any Eligible Employee or Eligible Dependent who is Eligible for COBRA continuation coverage
who is disabled and determined to be Eligible for social security disability benefits at the time of
termination of employment or reduction of hours may elect to extend coverage for themselves and
their dependents for up to an additional eleven (11) months following the eighteen (18) month
extension allowed for the initial Qualifying Event. This right also applies if the Eligible Employee
or Eligible Dependent is totally and permanently disabled within 60 days after termination of the
employee's employment or reduction of hours. The employee or dependent must notify the
employer in writing of the Social Security disability determination within 60 days of the date it is
issued, and before the end of the initial 18 month COBRA coverage period. The employee or
dependent must also notify the employer within 30 days of the date of any final determination by
the Social Security Administration that the employee or dependent is no longer disabled.
6. Eligible Employees or Eligible Dependent whose coverage under this Continued Coverage Option
Rider would otherwise terminate due to their becoming covered under another group plan, may
continue coverage under this Rider if the new group plan would exclude coverage for a pre-
existing condition. Coverage under this Rider may be continued until the earlier of:
(a) The end of the Maximum Period of coverage for which the initial Qualifying Event provided
coverage; or
(b) The date on which the pre-existing condition becomes covered under the new group plan.
The new plan must count the months for which the Qualified Beneficiary had coverage under
COBRA for the pre-existing condition.
7. If a Qualifying Event described in paragraph 1. (b),(c),(d) or (e) occurs during the eighteen (18)
months after the date of the Qualifying Event described in paragraph 1. (a), a Qualified
Beneficiary may continue coverage until thirty-six (36) months after the initial Qualifying Event.
8. In the case of a Qualifying Event as described in paragraph 1. of this Rider, a Qualified
Beneficiary must notify the Employer within sixty (60) days of the occurrence of the Qualifying
Event. The Employer will then have fourteen days (14) to provide the Qualified Beneficiary with
information concerning continuation coverage and rates. The Qualified Beneficiary will then have
sixty (60) days to elect to continue coverage. The first monthly payment must be received by the
Employer within forty-five (45) days of the date the Qualified Beneficiary elects to continue
coverage; the payment must include all monthly payments due at that time. If notice by the
Employee is not received by the Employer within sixty (60) days of the Qualifying Event, the
otherwise Qualified Beneficiary will not be eligible for continuation coverage.
9. Continuation coverage elected by a person under this Rider shall also be effective as of the first
day of the month following the applicable Qualifying Event described in paragraph 1. above.
However, benefits shall not be available to a person electing continuation coverage before the
group furnishes Delta with the data about such person required in PART III, GENERAL TERMS
AND CONDITIONS, Section 6. "(q)" of the Contract, along with all dues then currently payable for
such person as stated in PART I. PREFERRED OPTION ADMINISTRATIVE AGREEMENT,
Section 3. of the Contract..
10. Continuation coverage as provided under paragraph 1. of this Rider will terminate on the earliest
of the following dates, as applicable:
(a) The period of continuation coverage specified in paragraphs 2. through 6. expires.
(b) This Contract terminates.
(c) The Group fails to pay dues for the person as specified in PART I, PREFERRED OPTION
ADMINISTRATIVE AGREEMENT, Section 3. of the Contract.
(d) The person becomes entitled to Medicare coverage.
(e) The person becomes enrolled for dental benefits under another group dental plan as an
employee or dependent.
Section 7. SIGNATURES - When accepted by the President of Delta Dental Plan of Colorado and the
Authorized Officer of the Group, this Agreement becomes binding and effective as of
January 1, 1997.
Countersigned:
DELTA DENTAL PLAN OF COLORADO
BY J t2o
President
ON 713A2 7
Accepted:
CITY OF FORT COLLINS
BY
Title:
ON 9
ARTI
DEFINITIONS
For the purpose of this Agreement, the following definitions shall apply:
Section 1. APPLICANT means the Group or Employer for whose members or employees dental
benefits are being provided.
Section 2. ADMINISTRATIVE AGREEMENT means this agreement referenced in PART I, Section
6., between DELTA and the Applicant including the application of the Applicant for this
Agreement and the attached appendices and riders, if any. This Agreement constitutes
the entire agreement between the parties.
Section 3. PARTICIPATING AND NON -PARTICIPATING DENTIST
a) Participating Dentist means a dentist who is licensed to practice by the State of
Colorado, has executed a Participating Dentist Agreement with Delta, and agrees
to render dental care to Covered Persons in accordance with standard terms and
conditions applicable to Dentist participation in Delta prepaid dental care programs
as established by the Board of Trustees of Delta.
b) Non -Participating Dentists means a dentist licensed to practice by the State of
Colorado who has not executed a Participating Dentist Agreement with Delta.
Section 4. PREFERRED OPTION DENTIST means a dentist licensed to practice by the State of
Colorado who meets the criteria for the DELTA Preferred Option program and has made
a special agreement with Delta to participate in that program.
Section 5. COVERED SERVICES means the dental procedures as set forth in Appendix A - Covered
Services, attached hereto and made a part of this Agreement.
Section 6. BENEFITS means those dental services which are available under the terms of this
Agreement as specified in PART V, BENEFITS, LIMITATIONS AND EXCLUSIONS.
Section 7. Each of the words in the term USUAL. CUSTOMARY AND REASONABLE as used herein
shall have the following meanings:
a) USUAL: A "usual fee" for a private patient is a fee charged or offered and received
by an individual dentist or group of dentists; i.e., his/her or their own usual fee.
However, if a dentist or group of dentists charge a lower fee to patient(s) who are
members of any individual or group dental care program for the same or similar
5
service or procedure, the "usual fee" shall be deemed to be the lowest fee charged
or offered and received.
The "usual fee" shall not be affected by fees accepted for patients covered by non-commercial
programs funded by public or charitable funds primarily intended to assist the poor or
disadvantaged or those occasional instances where professional courtesy discounts are given or
fees waived or discounted in case of financial hardship.
Fees which are established by a bona fide arm's length agreement between a participating dentist
and any third -party payor under a prepayment, insurance or health care service corporation
program shall r� be considered to "regularly" or "usually" charge and therefore, shall D_Qt affect
a participating dentist's "usual fee." If so requested by Delta, it shall be the responsibility of the
participating dentist to document the existence of a "bona fide arm's length agreement" between
the dentist and such third -party payor, in order for the dentist's fees charged to such payor to be
considered to be not "regularly or usually charged." This interpretation shall not be construed to
alter the following well established policies of Delta:
1. The fee considered to be the participating dentist's usual fee for a particular
dental procedure shall in no event be more than the lowest fee charged or
offered and received by the same dentist or group of dentists for prepayment or
indemnity insurance healthcare service corporation programs, except as
specified immediately above, or for uninsured patients.
2. Fees which are advertised shall be made available to Delta -eligible patients if
lower than the participating dentist's accepted filed fees.
3. Offers, arrangements, or agreements by which a participating dentist waives any
or all of the co -payment or deductible chargeable under the terms of a dental
prepayment, insurance, or healthcare service corporation program shall be
considered in determining what constitutes the dentist's "usual fee."
b) CUSTOMARY: A fee is customary when it is within the range of usual fees
charged and received by Participating Dentists within the same geographic
area for the same Covered Service.
c) REASONABLE: A fee is reasonable if it is usual and customary, or if it falls
above customary if it is justifiable considering special circumstances, or
extraordinary difficulty of the case in question.
Section 8. PREVAILING FEE is the fee for a single procedure which satisfies the majority of dentists
in Colorado, and is determined by Delta based upon confidential fee listings from
Participating Dentists (the 51st percentile).
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Section 9. PREFERRED OPTION DENTIST'S FEE means the fee which the Preferred Option dentist
has contractually agreed with Delta to accept for treating Covered Persons under this
program, or the fee actually charged, whichever is less, for a single procedure.
Section 10. COVERED AMOUNT
a) Payment for completed Covered Services provided by a Participating Dentist
will be based upon the Participating Dentist's Usual and Customary fee or
the fees actually charged, whichever is less.
b) Payment for completed Covered Services provided by a dentist who is not
a Participating Dentist will be based upon the Non -Participating Dentist's fee
not to exceed the Prevailing Fee charged by Participating Dentists.
Section 11. ELIGIBLE DEPENDENT UNIT is the group of Eligible Dependents, as defined in PART IV,
ELIGIBILITY hereof, attributable to an Eligible Employee, as defined in said PART IV.
Section 12. ENROLLED EMPLOYEE, or ENROLLED ELIGIBLE EMPLOYEE, is an Eligible Employee,
as defined in PART IV, ELIGIBILITY hereof, enrolled as a member or employee of the
Group, and covered by the Group Dental Care Plan provided in accordance with this
Agreement.
Section 13. COVERED PERSON means enrolled eligible employees and enrolled eligible dependents
or a person ceasing to be eligible who elects continued coverage as provided in PART IV,
ELIGIBILITY, and for whom the appropriate monthly payment specified in PART I,
ADMINISTRATIVE AGREEMENT, Section 4. is received.
Section 14. AGREEMENT YEAR is the 365-successive-day period (or, if a February 29 is
encompassed, the 366-successive-day period) beginning on the day and month set forth
in this Agreement, PART I, Section 2.
Section 15. ANNIVERSARY DATE shall be the first day of each Agreement Year subsequent to the
initial Agreement Year.
Section 16. ACTIVE for purposes of PART IV, ELIGIBILITY, Section 1. ELIGIBLE PERSONS, means
performing in the customary manner on the Group's scheduled work days, all of the regular
duties of the employee's employment with the Group either at one of the Group's business
establishments or at some location to which the Group's business requires the employee
to travel. An employee will be considered active on a day which is not one of the Group's
scheduled work days only if he was performing in the customary manner all of the regular
duties of his employment on the next preceding scheduled work day.
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Section 17. PREDETERMINATION means review by Delta of a dentist's statement, including
diagnostic material, describing his planned treatment and expected charges for the
purpose of determining benefits available under the terms of this Agreement.
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