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HomeMy WebLinkAboutDELTA DENTAL WILLIAM MERCER - CONTRACT - RFP - P692 BENEFITS (2)AMENDMENT TO AGREEMENT GROUP #1857 The Agreement dated January 1 1999 as amended between CITY OF FORT COLLINS and DELTA DENTAL PLAN OF COLORADO is hereby further amended effective January 1 2002 as follows 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 82 per eligible employee PART IV ELIGIBILITY Section 1 ELIGIBLE PERSONS All full-time permanent active employees working a minimum of twenty (20) hour 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 The following exception applies Delta Dental Plan of Colorado complies with all regulation related to the Uniformed Services Employment and Reemployment Rights Act (USERRA) for employees called to active duty in the uniformed services Employees who return to active employment are eligible to enroll as if there had been no leave of absence for uniformed service provided they are still in an eligible class of employee as defined by the group In addition, USERRA allows for employees to elect continuation of coverage when coverage would otherwise terminate due to an absence to serve in the uniformed services Services provided while an employee is not eligible due to their leave of absence, shall not be covered by this Contract unless the employee or any dependent elects continued coverage as provided in the Continued Coverage Option Rider attached hereto or according to USERRA where applicable 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 isan 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 Retirees 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 workdays all ofthe 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 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 Section 18 RETIREE means an Employee who has ten (10) or more years of eligible service completed with the Employer in a classified position or an unclassified management position, and who is eligible to file without penalty for receipt of retirement benefits and who has been covered under the Plan continuously and immediately prior to retirement for twelve (12) consecutive months, or who is totally and permanently disabled and has ten (10) or more years of eligible service completed with the Employer in a classified position or unclassified management position and has exhausted his/her COBRA continuation period ,,y PART III Section 1 TERMS OF AGREEMENT This Agreement shall continue for the period specified in Part I ADMINISTRATIVE AGREEMENT Section 2 RENEWAL The Agreement shall be renewed for four 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 any such proposed changes shall be given to writing no fewer than sixty (60) days in advance of the of 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 MONTH 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 specified 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 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 a the unpaid payments applicable for the period this Agreement was in effect prior to termination or 7 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 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 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 mad with postage fully prepaid thereon Group City of Fort Collins 200 West Mountain Ave Ste A Fort Collins CO 80522-0580 f3 DELTA The Delta Dental Plan of Colorado Colorado Dental Service Inc 4582 South Ulster Street Suite 800 Denver CO 80237 c) Notice to Covered Persons shall be In writing and sent by regular U S mad to their addresses last shown in the records of Delta Such notice shall be deemed to be delivered when deposited in the United States Mad addressed to the Covered Person at such address with postage thereon prepaid d) No action at law or inequity 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 Persons prepared by the Group and submitted to Delta Delta agrees to keep all information regarding the Group confidential 1) 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 UO 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 parry 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 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 10 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 constructed 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 r) All obligations of the City of Fort Collins hereunder are expressly contingent upon the annual appropriation of funds sufficient and intended to carry out the same by t City Council of the city of Fort Collins in its discretion /) 11 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 subsequentlyas may be required by either Delta or the Applicant but not more frequently than annually afterthe handicapped or incapacitated and dependent child 12 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 c) Eligible Retirees are covered as follows All Retirees and their eligible Dependents with coverage at the time of retirement may elect to continue coverage in that plan or switch to the other plan available to the Group After this time coverage must remain under the same plan Once coverage is terminated it may not be reinstated 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 anothersource 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 13 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 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 dependentswdl 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 14 PART VI DEDUCTIBLE, MAXIMUM AMOUNT AND COORDINATION OF BENEFITS Section 2 MAXIMUM BENEFIT PAYMENT Delta will pay up to a maximum of One Thousand Five Hundred ($1,500 00) per calendar year for each Covered Person PART VII CONDITIONS UNDER WHICH BENEFITS SHALL BE PROVIDED Section 1 PAYMENT OF CLAIMS b) Appeal of a Claim Denied in Whole or in Part 1) Internal Appeal i) With the exception of a claim appeal that qualifies for Independent External Review 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 within one hundred and eighty (180) days by filing a written notice with the Dental Director of Delta Dental Any written communication should include documents or records in support of the claim Delta may submit the matter to Delta's Executive Committee of the Board of Trustees for determination of Benefits 2) Appeal to request an Independent External Review (only available on qualified claims) i) In addition to the Internal Appeal procedures outlined above Covered Persons have certain rights under Colorado Division of Insurance Regulation 4-2-21 Covered Persons may request an Independent External Review of a claim when the above Internal Appeal procedures result in a final denial AND that final denial is based on one of the following reasons • medical necessity, • effectiveness • efficiency, • experimental, or • investigational 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 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) 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 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 M1 bitewmg x-rays and/or penapical) is considered a full mouth x-ray for purposes of this Agreement Total allowance for individual penapical 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) Benefitfor 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 underthe 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 canes (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 any Amendment or Rider shall be made at a percentage no greater than the related category of Covered Services or Amendment or Rider i[: Section 2 BASIC 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) 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 mtraorally 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 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) Oral Surgery - extractions and certain other surgical services and associated covered anesthesia and/or related covered services Appendix A Section VIII and IX End odontic -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 b) Limitations on Endodontic and Penodontic 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 17 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 penodontal procedures which include any component of prophylaxis are limited to Part V Section 1 b) paragraph 1) Section 4 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 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 less 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 estenses imate of the Dentist's charges are not submitted in advance then the amount of exp 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 f) 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 M Section 5 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 mtraoral dental services for treatment of 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) iE 1) 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/orjaws) except as covered under provisions of an Orthodontic Amendment or Rider Myofunctional therapy or speech therapy n) Services forthe treatment of any disturbances of the temporomandibularloint Oawjoint) facial pain or any related conditions including any related diagnostic, preventive or interceptive services (except as covered under provisions of an Amendment or Rider) 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 forwhich underthis Agreement is prohibited by any law of thejunsdiction 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 20 y) Services which result whether the insured person is sane or insane from an intentionally self-inflicted injury or sickness z) Any payable expense under any other group or individual plan medical or dental plan whether claimed or not aa) Charges for failure to keep a scheduled visit with your Dentist bb) Charges for Special Restorative are not covered expenses cc) Charges for Prosthodontics are not covered expenses 21 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 Dollars ($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 Preferred Option Dentist's Fees by a Preferred Option Dentist and the Covered Amount for all other Dentists If a patient received seances from a Preferred Option Dentist or a Non -Preferred Option Dentist, the deductible will not apply to Diagnostic and Preventive Services The Twenty -Five Dollar ($25 00) annual deductible is limited to Fifty Dollars ($50 00) per family Section 2 MAXIMUM BENEFIT PAYMENT Delta will pay up to a maximum of Four Hundred Dollars ($400 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 both) occurs earlier in the year shall be primary or 22 (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 23 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 24 n) When a claim qualifies for External Review, Delta will mad the Covered Person a notice that explains their rights to request an Independent External Review of the denied claim In addition to the notice the Covered Person will receive the required form for submitting this request ORTHODONTIC BENEFIT RIDER 3) The maximum amount payable by Delta for all Orthodontics rendered to each Covered Person shall be One Thousand Five Hundred Dollars ($1 500 00) per lifetime and the limitations on the maximum amount payable during the calendar ear if any specified in the attached Contract shall not apply to Orthodontic All other provisions of this Agreement shall remain as previously stated DELTA DENTAL PLAN OF COLORADO By Authorized Signature On December_5, 2001 DATED JANUARY 1 2002 CITY OF FORT COLLINS By T� ��'� /U2 Dom' I�d2G ssfsA On 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 maybe 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 PartI II section 7 rand 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 25 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 Section 4 RIGHT TO INFORMATION AND RECORDS 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 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 26 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 surrey - 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 11 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 11 Preventive (Cont) 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) - antenor 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 IV Endodontics - excluding final restoration Pulp Cap - direct - exposed pulp only Pulpotomy or Pulpectomy - primary teeth only Root Canal Therapy - with open/drain - single procedure One two three canal Four or more canal Apexification or Recalcification Penapical 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 Appendix A Page 2 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 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 - etraoral 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 Appendix A Page 3 VI Oral Surgery (Cont) Frenulectomy or transseptal fiberotomy Biopsy of Oral Tissue - soft or hard Treatment of salivary gland or duct Repair of traumatic wound VII Adjunctive General Services Palliative (emergency) treatment - minor procedure Anesthesia and related services except local anesthesia - only in conjunction with 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 4 CONTINUED COVERAGE OPTION RIDER In consideration of the payment specified in PART I, PREFERRED OPTION ADMINISTRATIVE AGREEMENT, Section 3 of the Agreement 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 IV, ELIGIBILITY, Section 1 a) of the attached Agreement (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 IV, ELIGIBILITY, Section 1 , b) of the attached Agreement 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 thirty-one (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 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 dependent is totally and permanently disabled at any time during the first sixty (60) days of continuation coverage The employee or dependent must notify the employer in writing of the Social Security disability determination within sixty (60) days of the date it is issued and before the end of the initial eighteen (18) month COBRA coverage period The employee or dependent must also notify the employer within thirty (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 maybe 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 (14) days 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 (p)" of the Agreement along with all dues then currently payable for such person as stated in PART I. PREFERRED OPTION ADMINISTRATIVE AGREEMENT, Section 3 of the Agreement 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 7 expires (b) This Agreement terminates (c) The Group fails to pay dues for the person as specified in PART I, PREFERRED OPTION ADMINISTRATIVE AGREEMENT, Section 3 of the Agreement (d) The person becomes entitled to Medicare coverage (e) After election of COBRA the person becomes first enrolled for dental benefits under another group dental plan as an employee or dependent except as described in paragraph 6 above AMENDMENT TO AGREEMENT GROUP #1858 The Agreement dated January 1 1999 as amended between CITY OF FORT COLLINS and DELTA DENTAL PLAN OF COLORADO is hereby further amended effective January 1 2002 as follows 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 82 per eligible employee PART IV ELIGIBILITY Section 1 ELIGIBLE PERSONS All full-time permanent active employees working a minimum of twenty (20) hour 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 The following exception applies Delta Dental Plan of Colorado complies with all regulation related to the Uniformed Services Employment and Reemployment Rights Act (USERRA) for employees called to active duty in the uniformed services Employees who return to active employment are eligible to enroll as if there had been no leave of absence for uniformed service provided they are still in an eligible class of employee as defined by the group In addition, USERRA allows for employees to elect continuation of coverage when coverage would otherwise terminate due to an absence to serve in the uniformed services Services provided while an employee is not eligible, due to their leave of absence, shall not be covered by this Contract, unless the employee or any dependent elects continued coverage as provided in the Continued Coverage Option Rider attached hereto or according to USERRA where applicable PART VII CONDITIONS UNDER WHICH BENEFITS SHALL BE PROVIDED Section 1 PAYMENT OF CLAIMS b) Appeal of a Claim Denied in Whole or in Part 1) Internal Appeal i) With the exception of a claim appeal that qualifies for Independent External Review 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 within one hundred and eighty (180) days by filing a written notice with the Dental Director of Delta Dental Any written communication should include documents or records in support of the claim Delta may submit the matter to Delta's Executive Committee of the Board of Trustees for determination of Benefits 2) Appeal to request an Independent External Review (only available on qualified claims) i) In addition to the Internal Appeal procedures outlined above Covered Persons have certain rights under Colorado Division of Insurance Regulation 4-2-21 Covered Persons may request an Independent External Review of a claim when the above Internal Appeal procedures result in a final denial AND that final denial is based on one of the following reasons • medical necessity • effectiveness • efficiency • experimental, or • investigational iQ When a claim qualifies for External Review, Delta will mail the Covered Person a notice that explains their rights to request an Independent External Review of the denied claim In addition to the notice the Covered Person will receive the required form for submitting this request All other provisions of this Agreement shall remain as previously stated DELTA DENTAL PLAN OF COLORADO By -��,-- Authorized Signature On December 5. 2001 DATED JANUARY 1 2002 CITY OF FORT COLLINS B 7 Ttle �rrZ�L-rp•z O� v2C�i�4 SZnJI�'1' f2�5kr467 On q/o Z, PART I PREFERRED OPTION ADMINISTRATIVE AGREEMENT DELTA DENTAL PLAN OF COLORADO DELTA GROUP #1858 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 1999 to December 31, 1999 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 AGREEMENT-PARTI ADMINISTRATIVE AGREEMENT PARTII 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 1 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 1999 Countersigned Accepted DELTA DENTAL PLAN OF CCOLD O CITY OF FORT COLLINS , n C� BY e" ez��6 BY /President Title t nk CC 10(-ACHA-5Pu l9 d- yes ('- nej fc4 , CA�.c� ON 212-/ ON I �r/S 2 p;,proved As 7o Form l/�•��_" t;,,t City rn PART II 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 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 6 COVERED SERVICES means the dental procedures as set forth in AppendixA - 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 CUSTOMARYAND 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 service or procedure the ' usual fee shall be deemed to be the lowest fee charged or offered and received K 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 not be considered to "regularly" or "usually" charge and therefore shall not 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 forthe 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) 0