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HomeMy WebLinkAbout129656 DELTA DENTAL OF COLORADO - CONTRACT - RFP - 7054 BENEFITS DENTALDELTA DENTAL OF COLORADO 4582 South Ulster Street Denver, Colorado 80237 DELTA DENTAL BENEFITS CONTRACT The parties of this Contract are CITY OF FORT COLLINS, herein called the "Group," "Applicant," or "Employer" and Colorado Dental Service Inc., d/b/a Delta Dental of Colorado, herein called "Delta Dental." The attached appendices and riders constitute the entire Contract of the parties and will become binding upon the parties and their respective successors and assigns effective the 1 st day of January, 2010 for a three year period and for successive one-year periods thereafter unless terminated as herein provided. This contract is issued and delivered in the State of Colorado, is governed by the laws of Colorado and is subject to the terms and conditions recited on the subsequent pages of this contract, and may not be changed, altered or terminated except in accordance with Article VII, RENEWAL AND TERMINATION of this Contract. This DECLARATIONS PAGE supersedes any contrary provision of the subsequent sections of this contract. DECLARATION PAGE Group: CITY OF FORT COLLINS Type of Contract: Delta Dental PPO Group Number: 1857 Contract Effective Date: January 1, 2010 Contract Anniversary Date: January 1 st Eligible Class: All permanent active and retired employees. Where two Employees who are spouses and are both eligible for coverage under this contract, they may be enrolled together or separately, but not both. If both parents are covered as employees, children may be covered as dependents under both employees. Dependents of above -mentioned Subscriber are also eligible. 12/16/09, DECLARATION PAGE2010 2.05 CHANGE OF PREMIUM RATES. In the absence of an amendment mutually agreed upon between Applicant and Delta Dental, no change in Premium rates will be made during a Contract Year except as provided in this Article, Section 2.06. 2.06 EFFECT OF PREMIUM TAX CHANGES. If during a Contract Year, any new tax is imposed on Delta Dental by any government agency on the amount of Premium payable under this Contract or the number of persons covered, or if the rate of an existing tax on the amount of Premium or the number of persons covered is increased, the Monthly Premium stated in this Article, Section 2.02 will be increased by the amount of any such new tax or increased tax. 2.07 CLERICAL ERRORS. Clerical errors or delays in maintaining or exchanging data relative to coverage will not validate or invalidate coverage that would otherwise be in force. Upon discovery of such errors or delays, an adjustment of charges will be made. 2.08 GRACE PERIOD. The Contract has a Grace Period extending to the last day of the month during which Premium is due, except for the initial Premium referenced in this Article, Section 2.03. The coverage remains in force during this Grace Period unless terminated by the Group. If the Premium is not paid by the end of the Grace Period, the Contract will terminate as of the last date of the Grace Period. Premiums are due through the last day of the Grace Period, including the Grace Period. 2.09 REFUNDS. Delta Dental must be informed when any Subscriber is no longer eligible. Failure to provide timely notice does not continue a Subscriber's coverage past the time it would otherwise have ended. However, if Delta Dental has been paid Premium on behalf of a Person who is no longer covered, Delta Dental will provide a Premium refund for that person for the period the Premium was paid in error up to a maximum of three months or to the last Contract Anniversary, whichever is less. If any Benefits were paid on behalf of the person after his coverage terminated, the full amount of the Benefits paid in error must be repaid to Delta Dental before any refund of Premium will be provided. Contract Page 6 DDPCO-- C06 ARTICLE III. ELIGIBILITY 3.01 ELIGIBILITY. Any Subscriber who is in an Eligible Class may enroll for coverage under this Contract within 31 days after the completion of the Eligibility Waiting Period or during an Open Enrollment period, if offered by the Employer. a) BECOMING COVERED. Delta Dental must receive enrollment data in a format acceptable to Delta Dental for each Subscriber who wishes to enroll. The enrollment data must be received by Delta Dental within 30 days following an Employee's or Dependent's enrollment. The enrollment data submitted to Delta Dental must include the Subscribers address, gender, social security number, date of birth and effective date. If the Subscriber chooses to enroll his Dependents, each Dependent's name (including surname if different from Employee's), relationship to the Subscriber, address, gender, social security number and date of birth must be submitted. ■ Coverage is effective after the eligibility waiting period as indicated on the Declaration Page, providing the person enrolls for coverage. ■ An Employee may not enroll his eligible Dependents unless he is also enrolled for coverage under the Contract. b) FAILURE TO ENROLL WITHIN CONTRACTUAL TIME FRAME. ■ Late Enrollment. If a Subscriber fails to enroll within the time frame described in Article III, Section 3.01 a, the Subscriber will be considered a Late Enrollee and will receive Benefits as described in Article I for Late Enrollment. ■ Open Enrollment. If a Subscriber fails to enroll within the time frame described in Article III, Section 3.01 a, he may not enroll until the next regularly scheduled Open Enrollment for the Group. ■ Tied -to -Medical. Eligibility for the dental plan will be the same as that required by the medical plan. c) MAINTAINING COVERAGE. The Group will compile and furnish Delta Dental on or prior to the first day of every month a list of any coverage additions, changes, or terminations pertaining to Subscribers. Delta Dental will not be obligated to provide Benefits for any employee or dependent, unless the person is reported upon the list of Subscribers submitted by the Group and the appropriate monthly Premium is made as provided in Article II. Contract Page 7 DDPCO— C06 3.02 EMPLOYEE ELIGIBILITY. Eligible Employees may be enrolled for coverage under the Contract within 31 days of the date the Employee becomes eligible to enroll. a) Any eligible Employees not enrolled as described above or who are enrolled and subsequently dropped from the plan will not be eligible to enroll at a later date, except during Open Enrollment or as a Late Enrollee (depending on the Enrollment Type of the group). b) Any eligible Employees that suffer involuntary loss of coverage through another source will be allowed to enroll with satisfactory proof of coverage loss. Such Employees must be enrolled within 31 days of the loss of coverage. 3.03 DEPENDENT ELIGIBILITY. Dependents of an eligible Employee may be enrolled for coverage under the Contract within 31 days of the latest of the following dates: • the date the Employee becomes eligible to enroll if he has eligible Dependents on that date. Coverage for eligible Dependents is effective on the date the Employee's coverage becomes effective. • the date the Employee first acquires an eligible Dependent. Coverage becomes effective on the first day of the month following this event. • the date the Contract is amended to provide Dependent coverage for the employment classification to which the Employee belongs. Coverage becomes effective on the first day of the month following this event. a) If the group's Enrollment Type is Tied -to -Medical: If enrolling one eligible dependent, all eligible dependents who are enrolled in the medical plan must be enrolled. b) Newly acquired dependents must be added within 31 days of acquisition. If not added during this time: If the group's Enrollment Type is Open Enrollment, the dependent can also be added during the Open Enrollment period. If the group's Enrollment Type is Late Enrollment, a dependent can also be added as a Late Enrollee. c) Any eligible dependents not enrolled as described above or who are enrolled and subsequently dropped from the plan will not be eligible to enroll at a later date, except during Open Enrollment or as a Late Enrollee (depending on the Enrollment Type of the group). d) 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 31 days of the loss of coverage. Contract Page 8 DDPCO-- C06 3.04 TERMINATION OF COVERAGE. A Subscriber's coverage will terminate at the earliest of: • The date Delta Dental receives a written request to terminate coverage; • The date the Subscriber is no longer eligible for coverage; • The date the Contract terminates; • The end of the period for which Premium is paid; • The date the Subscriber enters full-time military service of any country; or • As to any Dependent, the date the person no longer qualifies as a Dependent. Delta Dental must be notified within 60 days if a Dependent or Subscriber is no longer eligible. 3.05 INVOLUNTARY LOSS OF COVERAGE DUE TO STRIKE, LEAVE OF ABSENCE OR LAYOFF. An Employee who loses his coverage because of an absence from work due to strike, lay-off or leave of absence, and who returns to work within 6 months of the date on which the absence began, will become eligible to re -enroll for coverage on the first day of the month following his return to work. If the Employee's absence exceeds 6 months, then he will be considered a new Employee in every respect and must fulfill the eligibility requirements that apply to new Employees and all Contract provisions relating to the Deductible, Coinsurance, Contract Year Maximum, and Waiting Periods, if any, will apply to him as if he had not been previously covered. The following exception applies: Delta Dental of Colorado complies with all regulations 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, will not be covered by this Contract, unless the Employee or any Dependent elects continued coverage as provided in the Article Vill or according to USERRA where applicable. 3.06 INVOLUNTARY LOSS OF "OTHER COVERAGE". Any person not enrolled for the Benefits provided under this Contract who involuntarily loses his Other Coverage (i.e., dental insurance through another source) will be allowed to enroll with satisfactory proof of the loss of such Other Coverage. Such persons must be enrolled within 31 days of the loss of the Other Coverage. Coverage is effective the first day of the month following enrollment. Contract Page 9 DDPCO— C06 3.07 VOLUNTARY TERMINATION OF COVERAGE. For those groups offering Open Enrollment, any Subscriber who chooses voluntarily to terminate his coverage will not be eligible to re -enroll until the next regularly scheduled Open Enrollment for the Group that occurs after the date on which coverage for the person was voluntarily terminated. For those groups not offering Open Enrollment, a Subscriber who voluntarily terminates coverage and chooses to re -enroll will be considered a Late Enrollee and subject to the requirements of Late Enrollment. 3.08 REVIEW OF RECORDS. In accordance with applicable local, state and federal laws, the applicant will permit Delta Dental, by its auditors or other authorized representatives, on reasonable advance written notice, to inspect records of Applicant in order to verify the accuracy of lists of Subscribers prepared by Applicant and submitted to Delta Dental and to verify Applicant's compliance with Article II. ARTICLE IV. COORDINATION OF BENEFITS 4.01 DEFINITIONS. Coordination of Benefits: Means taking other Plans into account when paying Benefits. Plan: Any Plan that provides benefits or Services for dental care expenses on a group or individual basis. This includes group and blanket insurance, self -insured and prepaid plans, automobile fault or no-fault insurance and government plans (except Medicaid). Primary Coverage: Coverage that has the first responsibility for paying a claim. The Primary Coverage must pay up to its full liability. Secondary Coverage: Coverage responsible for paying a claim after the Primary Coverage has paid up to its full liability. 4.02 WHEN COORDINATION OF BENEFITS APPLIES. Coordination of Benefits will apply when a Subscriber has coverage under more than one Plan. The Benefits of this Plan will be coordinated with the other Plan(s). 4.03 RULES FOR COORDINATION OF BENEFITS The rules for the order of benefit payment are summarized below. The Plan covering a Subscriber as an Employee will be primary over the policy or program covering a Subscriber as a Dependent. Dependent children's benefit payment determination will be as follows: o The Plan of the parent whose birthday (excluding year of birth) occurs earlier in a year will be primary, or; o If the parents are separated or divorced, the Plan of the parent who is ordered by court decree to take financial responsibility for dental expenses will be primary, or; Contract Page 10 DDPCO-- C06 o The Plan of the parent with custody is Primary and if the custodial parent has remarried, the step -parent's Plan is Secondary and the Plan of the parent without custody pays third. If the above rules do not establish an order of benefit payment, the Plan that has covered the Person for the longer period of time will be Primary except that the Plan covering the Person as a laid -off or retired employee or Dependent of such Person will be considered Secondary to any other Plan covering the Person. Any group Plan that does not contain a Coordination of Benefits provision is automatically primary. If this Plan is Primary, this Plan will 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 will not exceed 100% of the allowable expense or this Plan's maximum benefit. ARTICLE V. CONDITIONS UNDER WHICH BENEFITS WILL BE PROVIDED 5.01 PAYMENT OF CLAIMS. 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 Contract, including any attached Appendix, Amendment, or Rider. To submit the expenses to Delta Dental for consideration, the Service must be identified in terms of the American Dental Association Current Dental Terminology (Code on Dental Procedures and Nomenclature). 5.02 APPEAL OF AN ADVERSE DETERMINATION OF A CLAIM. A. Internal Appeal Process - First Level Appeals If a Subscriber is dissatisfied with any adverse determination, a request for appeal may be submitted in writing within 180 days of the date of the original Explanation of Benefits to: Delta Dental of Colorado Appeal Analyst PO BOX 172528 Denver, CO 80217-2528 A Subscriber may submit additional documentation in support of the appeal. Appeal requests will be reviewed by a Dentist and a clinical peer of the same or similar specialty as would typically manage the case being reviewed. The Dentist and the clinical peer will not have been involved in the initial adverse determination. Contract Page 11 DDPCO— C06 A written appeal decision will be issued to the Subscriber that explains the decision and the rationale for the decision. The appeal decision will be issued within 15 calendar days for pre -service denials and within 20 working days for post -service denials. B. Internal Appeal Process - Second Level Appeals If the Subscriber remains dissatisfied with the outcome of the First Level Appeal decision, a request for a Second Level Appeal may be submitted. The request must be received within 30 days of the First Level Appeal decision and must be submitted to the address noted in 5.02 A. Additional documentation supporting the Second Level Appeal request may be submitted. This appeal will be evaluated by a review panel consisting of three people, two of whom are Dentists. The appeal panel will not have been involved in the case previously. The Subscriber, or a designated representative, may request to appear before the review panel either in person or by conference call. A Second Level Appeal decision will be issued within 5 days of the date of the review panel's decision. C. Internal Appeal Process - Expedited Appeals Subscribers may request expedited reviews of adverse determinations in situations where the time frame of the standard review procedures would seriously jeopardize the life or health of the Subscriber, would jeopardize the Subscriber's ability to regain maximum function, or, for persons with a disability, create an imminent and substantial limitation on their existing ability to live independently. Expedited review decisions will be issued within 72 hours of the review being commenced. D. Independent External Review (Not available for Self -Funded or Federal Groups) If a Subscriber remains dissatisfied with the outcome of the Second Level Appeal decision, an Independent External Review may be requested. Requests must be received in writing within 60 days of the Second Level Appeal decision and addressed to the Appeals Analyst at the address in 5.02 A. Requests must include a completed extended review request form from the Division of Insurance and a signed consent authorizing Delta Dental to disclose protected health information pertinent to the external review. The Subscriber will be notified of the External Review Decision within 1 day of its receipt by Delta Dental. Contract Page 12 DDPCO-- C06 5.03 CLAIMS FROM NON -PARTICIPATING DENTISTS. Payment for Completed Covered Services provided by a Non -Participating Dentist will be based on the non -participating Maximum Plan Allowance. The Subscriber will be responsible for the full cost of Service. 5.04 CLAIMS FROM PARTICIPATING DENTISTS. Payment for Completed Covered Services provided by a Participating Dentist will be made directly to the Dentist. If the Participating Dentist charges more for a Service than Delta Dental allows, that amount is not chargeable to the patient. 5.05 TIME LIMIT FOR SUBMISSION OF CLAIM. Delta Dental will not be obligated to pay claims submitted more than 15 months after the date the Service is Completed. If a claim is denied due to a Participating Dentist's failure to make timely submission, the Subscriber will not be liable to such Dentist for the amount which would have been payable by Delta Dental. 5.06 AVAILABILITY OF DENTIST. While a Subscriber may elect the Service of any licensed Dentist, neither Delta Dental nor Applicant undertakes to guarantee the availability of any particular Dentist. 5.07 RIGHT TO INFORMATION AND RECORDS. Delta Dental has the right to receive information and records related to the examination or treatment of a Subscriber from any Dentist. Delta Dental may require a Subscriber be examined by a dental consultant retained by Delta Dental. Delta Dental will maintain such information and records in a confidential manner in accordance with federal and state law. 5.08 EXTENDED COVERAGE. Delta Dental's responsibility to pay for Covered Services for a Person will end if anyone has terminated this Contract or if the Person ceases to be a Subscriber under the terms of the Contract. Delta Dental will cover no further care or Services with the following exception: If the Subscriber has a Covered Service that is Started while still covered under the Contract, but the Covered Service is Completed after Delta Dental no longer covers the Person, Delta Dental will pay Benefits for the Covered Service as follows: • No benefit is payable if the Covered Service is Started after the day the Person's coverage ends • Benefits are payable only in the amount that would have been payable and subject to the same terms and conditions of the Contract that would have applied if the Person's coverage was still in effect; • Benefits are payable only if the Covered Service is Completed within 60 days after the date the Person's coverage ended. Contract Page 13 DDPCO— C06 5.09 PRE-TREATMENT ESTIMATE. Before beginning a course of treatment for which the charge is expected to be $400 or more, a description of that course of treatment may be submitted to Delta Dental before treatment is begun. Delta Dental will provide an estimate of the Benefits payable for the planned course of treatment of a Subscriber. Pre-treatment estimates are not required and are provided as a Service to the Subscriber and Dentist in order to allow for appropriate planning. 5.10 SUBROGATION. Delta Dental is entitled to enforce by its direct suit, or as co - plaintiff with a Subscriber, the Subscriber's claim against any third party to the extent of Benefits paid for, or on behalf of, a Subscriber by Delta Dental. When Delta Dental provides benefit payments for injuries sustained by a Subscriber and the Subscriber subsequently obtains a settlement from a third party which includes such costs, the Subscriber is obligated to refund to Delta Dental the amount equal to the benefit payment made to, or on behalf of, the Subscriber. ARTICLE VI. GENERAL TERMS AND CONDITIONS 6.01 NOTICES. Any notice under this Contract will be sufficient if given by either the Applicant or Delta Dental to the other (or in the case of the Applicant, to its Designated Agent) and will be effective upon the date of mailing. 6.02 NOTICES TO SUBSCRIBERS. Notice to a Subscriber will be in writing and sent by regular US mail to the current address noted in Delta Dental's records. Notices will be sent via electronic media, if agreed upon by both Delta Dental and the Subscriber. 6.03 LEGAL ACTION. No action at law or in equity may be filed in order to recover on this Contract prior to the expiration of 60 days after final notice of claim has been filed in accordance with the requirements of this Contract. 6.04 REPRESENTATIONS. All statements made by the Group or by an individual will be deemed representations and not warranties. 6.05 ENTIRE CONTRACT; AMENDMENTS. This Contract will be the entire, full, and complete agreement between Delta Dental and the Group concerning group dental care. This Contract may not be orally amended or changed. This Contract may at any time be amended and changed by written agreement between Delta Dental and the Group. Any such amendment will be binding on all Subscribers regardless of the date their coverage became effective or the date treatment was Started. 6.06 CONTRACT CHANGES. No agent or employee of Delta Dental has the authority to change the Contract or waive any of its provisions. No change in the Contract will be valid unless approved in writing by an authorized Delta Dental employee. Contract Page 14 DDPCO-- C06 6.07 GROUP'S ACCESS TO RECORDS. Delta Dental agrees that the Group or its designated representative, upon reasonable advance written notice, will have the right of access to all files and records pertinent to the Group for examination in accordance with federal and state laws. 6.08 SETTLEMENT OF DISPUTES. Any dispute arising out of or relating to this Contract or the breach thereof between Delta Dental, a Participating Dentist, and Subscriber or any of them, including any disagreement with a claim determination made by Delta Dental after exhaustion of the appeals process procedure outlined in ARTICLE V. CONDITIONS UNDER WHICH BENEFITS will BE PROVIDED Section 5.02, APPEAL OF AN ADVERSE DETERMINATION OF A CLAIM, will 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 party, by filing two copies of such notice with the American Arbitration Association and by complying with other applicable provisions of the Association's rule. 6.09 PARTICIPATING DENTIST. Delta Dental will make reasonable efforts to make available to the Applicant, a listing of Participating Dentists who have agreed to provide Services described in this Contract. This listing may be available in a variety of formats. It is understood that the composition of such directory may be subject to change from time to time, and Delta Dental reserves the right to change the listing without prior notice to the Applicant. The Dentists providing or contracting to provide dental Services under this Contract will be solely responsible, and in no case will Delta Dental or the Applicant be liable for any act or omission by such Dentists, their agents or employees. Dentists who participate with Delta Dental are independent contractors. They are neither agents nor employees of Delta Dental, nor is Delta Dental an agent or employee of any Participating Dentist. Delta Dental will not be responsible for any claim or demand on account of damages arising out of, or in any way connected with, any injuries suffered by a Subscriber while receiving care from any Participating provider or in any Participating provider's facilities. 6.10 EMPLOYEE BENEFIT BOOKLET. Delta Dental will issue to the Group, and the Group will make available to each Subscriber, an Employee Benefit Booklet summarizing the Benefits and other provisions of this Contract. If any amendment to this Contract will materially affect any Benefits described in such booklet, a corrected Employee Benefit Booklet or inserts showing the change will be issued to the Group. 6.11 PHYSICAL EXAMINATION. Delta Dental, at its own expense, will have the right and opportunity to examine any individual for whom claim or request for pre - estimation of Benefits is pending under this Contract. Contract Page 15 DDPCO— C06 Enrollment Type The enrollment type is Open Enrollment. Open Enrollment means a period of time each Contract Year occurring prior to the Anniversary Date during which eligible Employees may choose to enroll themselves and/or their eligible Dependents in the Plan. Coverage will become effective on the Group's Anniversary Date. Eligible Retirees and their eligible Dependents with coverage at the time of retirement may elect to continue coverage in this plan. Once coverage is terminated, it may not be reinstated. Eligibility Waiting Period: Active employees working the minimum number of hours as required by the employer will become eligible for enrollment as determined by the City of Fort Collins. Child Dependent Age Limit is to the end of the month in which they attain age 19, Full - Time Student Age Limit is to the end of the month in which they attain age 25. Individual Calendar Year Deductible: $25 deductible per person per calendar year limited to a maximum deductible of $50 per family per calendar year on Basic and Major Covered Services. Individual Calendar Year Maximum: $2,000 Individual Calendar Year Maximum on Diagnostic & Preventive, Basic, and Major Benefits. Delta Dental's payment for Orthodontic Benefits will not exceed a lifetime maximum of $1,500 per eligible person. 12/16/09, DECLARATION PAGE2010 6.12 GENDER. The use of the singular will include the plural, the plural the singular, and the use of any gender will include all genders. 6.13 OBLIGATIONS. 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 the City Council of the city of Fort Collins, in its discretion. 6.14 NON-DISCRIMINATION. Delta Dental does not discriminate against individuals based on health factors for benefits or premium rates. These health factors include: health status, medical condition (including both physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability and disability. ARTICLE VII. RENEWAL AND TERMINATION 7.01 RENEWAL. The Contract will be renewed for successive one-year periods unless during any Contract Year either party elects not to renew by giving the other party written notice of such election at least 120 days prior to the end of the current Contract year. In the event that there are changes to the terms and conditions, other than rates, of this Contract effective on an Anniversary Date, Delta Dental will provide notice of such proposed changes in writing no fewer than 120 days in advance of the renewal. 7.02 TERMINATION. This Contract will be terminated as follows: a) By either the Group or Delta Dental at the end of the original Contract or at the end of any renewal year, provided the required notice of non -renewal is given. b) In the event any Premium due as stated in Article II of this Contract is not paid within 20 days of the due date, Delta Dental may give notice that payment is due, and if such payment is not received by the last day of the Grace Period, as referenced in Article II, Section 2.08, Delta Dental may terminate all further obligations. c) By election of the Group if Delta Dental defaults in providing the Benefits under the Contract and such default is not corrected within 60 days of such default. d) By election of Delta Dental in the event enrollment of Subscribers falls below 75% of the total number of eligible Employees as of the Contract Effective Date. Delta Dental may, at its option, terminate or propose to the Group alternative adjustment in rates, Benefits, or copayments necessary to correct adverse group experience that could result from such reduction in size. Within 30 days, the Group will select an alternative by written notice to Delta Dental. If an alternative is not selected, Delta Dental may terminate this Contract. Contract Page 16 DDPCO-- C06 e) Upon written notification by Group of its intention to terminate this Contract as of any date other than the end of the Contract Term. The termination date will be the last day of the month during which Delta Dental received the Group's written notification of intent to terminate. f) By election of Delta Dental in the event the number of enrolled Employees drops below the required minimum number of 10 enrolled Employees. Delta Dental may, at its option, terminate or propose to the Group alternative adjustment in rates, Benefits, or copayments necessary to correct adverse group experience that could result from such reduction in size. Within 30 days, the Group will select an alternative by written notice to Delta Dental. If an alternative is not selected, Delta Dental may terminate this Contract. g) By election of Delta Dental in the event of fraud or misrepresentation by the Applicant, or with respect to coverage of a Subscriber, fraud or misrepresentation by the Subscriber or such person's representative. 7.03 In the event of termination by Delta Dental as stated in Article VII, Section 7.02, all Benefits will terminate and Delta Dental will be released from all further obligations of this Contract, effective on the last day of the month in which written notice of termination is given; provided Premium is received through that period. Delta Dental will make payment for Services Started while a person was covered under the Contract but Completed after the person's coverage ends pursuant to Article V, Section 5.08, Extended Coverage. 7.04 If on termination of this Contract for any cause Group has not paid Premiums to Delta Dental applicable to a period of time up to and including the termination date, Group will, within 30 days after termination, remit such Premium to Delta Dental. 7.05 REINSTATEMENT. Delta Dental, in its sole discretion, may reinstate a Contract that has terminated due to non-payment of Premium. If Delta Dental does reinstate a Contract, the following rules will apply: a) All Premiums then due and unpaid must be paid, including the Premium for the Grace Period; and b) Interest on past due Premiums must be paid at a rate of 1.5% per month or the maximum allowed in the state of jurisdiction if less; and c) Delta Dental may review the claim experience for the group and, based on its analysis, offer to reinstate the group at a different Premium rate than was in force at the time the Contract lapsed; and d) A Contract Reinstatement Fee of $50.00 must be paid. Contract Page 17 DDPCO— C06 ARTICLE VIII. CONTINUATION COVERAGE 8.01 COBRA (Consolidated Omnibus Budget Reconcilation Act of 1985) applies to Groups with 20 or more employees. Subscribers may be eligible to continue coverage under COBRA. The benefits will be the same as the benefits active Employees receive. The Subscriber will be responsible for the entire Premium amount, which cannot exceed 102% of the cost to the plan for a similarly situated active individual. Qualifying events determine eligibility for COBRA coverage and the length of continuation. Termination of service for any reason except gross misconduct is a qualifying event, as well as a reduction in hours. Coverage can be continued for 18 months for these qualifying events. For a covered Dependent, a qualifying event includes termination of the Employee's service, the Employee becoming entitled to Medicare, and the Employee's death, divorce, or legal separation. The date a Dependent no longer meets the definition of Dependent is also a qualifying event. Coverage can be continued for 36 months after the initial qualifying event. When the qualifying event is termination of the Employee's service, COBRA coverage may be extended for a Subscriber who qualifies for Social Security disability benefits. However, the Subscriber's disability must have existed on the date of the qualifying event or began within the first 60 days of COBRA coverage. When a qualifying event occurs, the employer must give the Subscriber the necessary COBRA election form. This must be completed and returned to the employer within 60 days of the determination and before the end of the initial 18- month COBRA coverage period in order to extend COBRA coverage to 29 months. COBRA Continuation coverage will be effective the first day of the month following termination of coverage. Within 60 days of the coverage termination, the Group must supply eligibility, premium, and initial expected length of COBRA coverage to Delta Dental in order for the Subscriber's benefits to continue. Should the Subscriber's COBRA status change, the Group must notify Delta Dental within 30 days of the change. COBRA Continuation coverage will terminate on the earliest of the following: a) the last day of the month in which COBRA Continuation ends; b) the day the Contract terminates; c) the last day of the month that premium has been paid; d) the day the person becomes entitled to Medicare; e) the day the person becomes eligible for coverage under another group plan. Contract Page 18 DDPCO-- C06 RIDERS and APPENDICES RIDERS and APPENDICES ASC Rider A. Delete Item 1.27, in ARTICLE I — DEFINITIONS and replace it with the following Item 1.27. 1.27 SERVICE FEE means the amount of money paid to Delta Dental for each Employee to purchase the Administrative Services provided by this Contract, as provided in Article II. CLAIMS REIMBURSEMENT means the amount of money the Group must pay Delta Dental for the total amount of Dentists' statements paid or otherwise discharged by Delta Dental for services rendered for all Subscribers. B. Delete ARTICLE II — MONTHLY PREMIUM and replace it with ARTICLE II — SERVICE FEE AND MONTHLY CLAIMS REIMBURSEMENT ARTICLE 11— SERVICE FEE AND MONTHLY CLAIMS REIMBURSEMENT 2.01 CLAIMS REIMBURSEMENT Claims Reimbursement - On the 2"d 12ch and 22"d day or the last business day closest to such date of each month, Delta Dental will notify the Group of the total amount of Dentists' statements paid or otherwise discharged by Delta Dental for services rendered. Using one of the options described below, a prompt transfer of funds is made to Delta Dental to cover such disbursements as they become due and payable upon receipt of said notification. a) Automated Clearing House Transfer (ACH Transfer) Once the Group is notified of the total claims paid, Delta Dental has authorization from the Group to initiate an electronic transfer of funds from the Group's account to cover the total claims paid by Delta Dental. The ACH Transfer will occur 2 business days following the Group's receipt of the total claims paid by Delta Dental. b) Wire Transfer Once the Group is notified of the total claims paid, the Group initiates the electronic transfer of funds from their account to cover the total claims paid by Delta Dental. The electronic fund transfer must be completed within 5 business days of the Group receiving the invoice. 2.02 MONTHLY SERVICE FEE The Monthly Service Fee for each Employee is as noted on the Declaration Page. The Group agrees to remit to Delta Dental during the Contract Term a monthly Service Fee for each subscriber. This is due and payable on the 15th day of each month for the previous month's Service fee. 2.03 SERVICE FEE AND CLAIMS REIMBURSEMENT AT TERMINATION. In the event this Contract terminates for any reason, the Applicant will be liable for all Service Fees due but unpaid, as well as Claims Reimbursement. 2.04 CHANGE OF SERVICE FEE. In the absence of an amendment mutually agreed upon between Applicant and Delta, no change in the Service Fee will be made ASC Rider during a Contract Year. Furthermore, no modification will be made that is inconsistent with the rates section of the Declaration Page. 2.05 CLERICAL ERRORS. Clerical errors or delays in maintaining or exchanging data relative to coverage will not validate or invalidate coverage that would otherwise be in force. Upon discovery of such errors or delays, an adjustment of charges will be made. 2.06 GRACE PERIOD. Service Fee. The Contract has a Grace Period of 15 days after the due date of the Service Fee bill. Claims Reimbursement. The Contract has a Grace Period extending to the following bill of claims reimbursement. When Delta Dental has notified the Group of the total claims paid on the 2"d , the grace period is until the 12th day of the month; when Delta Dental has notified the Group of the total claims paid on the 12th, the grace period is until the 22"d day of the month; and when Delta Dental has notified the Group of the total claims paid on the 22"d calendar day, the grace period is until the 2"d of the following month. The coverage remains in force during this Grace Period unless terminated by the Group. If either the Service Fee or Claims Reimbursement are not paid by the end of the Grace Period, the Contract will be placed on a hold status, where no claims will be paid and no eligibility will be guaranteed. If the Group does not pay after this Grace period, they may be terminated as of the last date of the earliest Grace Period at the discretion of Delta Dental. Service Fees and Claim Reimbursement are due through the last day of the Grace Period, including the Grace Period. 2.07 TIMELY NOTICE. Delta Dental must be informed when any Subscriber is no longer eligible. Failure to provide timely notice does not continue a Subscriber's coverage past the time it would otherwise have ended. C. Delete Item 7.02 in ARTICLE VII — RENEWAL AND TERMINATION and replace it with the following Item 7.02 7.02 TERMINATION. This Contract will be terminated as follows: a) By either the Group or Delta Dental at the end of the original Contract or at the end of any renewal year, provided the required notice of non -renewal is given. b) In the event any Service Fee due as stated in Article II of this Contract is not paid within 20 days of the due date, Delta Dental may give notice that payment is due, and if such payment is not received by the last day of the Grace Period, as referenced in Article II, Section 2.06, Delta Dental may terminate all further obligations. ASC Rider c) In the event any Claims Reimbursement due as stated in Article II of this Contract is not paid within 10 business days of the due date, Delta Dental may give notice that payment is due, and if such payment is not received by the last day of the Grace Period, as referenced in Article II, Section 2.06, Delta Dental may terminate all further obligations. d) By election of the Group if Delta Dental defaults in providing the Benefits under the Contract and such default is not corrected within 60 days of notice of such default. e) By election of Delta Dental in the event enrollment of Subscribers changes by 10% or more from the minimum enrollment requirements included on Delta Dental's proposal.. Delta Dental may, at its option, terminate or propose to the Group alternative adjustment in rates, Benefits, or copayments. Within 30 days, the Group will select an alternative by written notice to Delta Dental. If an alternative is not selected, Delta Dental may terminate this Contract. f) Upon written notification by the Group of its intention to terminate this Contract as of any date other than the end of the Contract Term. The termination date will be the last day of the month during which Delta Dental received the Group's written notification of intent to terminate. g) By election of Delta Dental in the event of fraud or misrepresentation by the Applicant, or with respect to coverage of a Subscriber, fraud or misrepresentation by the Subscriber or such person's representative. In the event this Agreement terminates as stated, the Group will remain liable to Delta Dental for the full amount of the Dentists' statements paid or otherwise discharged by Delta Dental for services rendered and incurred under this Contract prior to the termination date. In addition, the Group will be and remain liable to Delta Dental for a period of 12 months following the termination date for the full amount of Dentist's statements paid or otherwise discharged by Delta Dental for services rendered according to ARTICLE V, CONDITIONS UNDER WHICH BENEFITS WILL BE PROVIDED, 5.03 and 5.04. D. Delete Item 7.03 in ARTICLE VII — RENEWAL AND TERMINATION and replace it with the following Item 7.03. 7.03 PROCEDURES ON TERMINATION a) In the event of termination of this Agreement in accordance with the provisions of Article VII, Section 7.02, no Subscriber will, on or after the date on which the termination takes effect, be entitled to any further benefit payments hereunder and Group will indemnify and hold Delta Dental harmless with respect to any claims by or with respect to Subscribers for further benefit payments hereunder without regard to the date on which the dental claims were incurred. ASC Rider However, Delta Dental will have the right to process Dentists' statements for payment where each of the following terms are met, provided that any Claims Reimbursement and Service Fees owed Delta Dental have been paid: 1. the Dentist's statement is first received by Delta Dental within 12 months of the termination date of this Agreement according to ARTICLE V, CONDITIONS UNDER WHICH BENEFITS WILL BE PROVIDED, 5.03 and 5.04; 2. the date of service reported on the Dentist's statement was within 12 months of the date the claim was first received by Delta; 3. the date of service reported on the Dentist's statement was no later than the termination date of this Agreement. b) In the event of termination by Delta Dental, all Benefits will terminate and Delta Dental will be released from all further obligations of this Agreement, effective on the last day of the month in which written notice of termination is given; provided, however, that Delta Dental will make payments for dental services for Extended Benefits. Applicant will remain liable to Delta Dental for: 1. the unpaid payments applicable for the period this Agreement was in effect prior to termination; and 2. the full amount of all Dentist's statements paid or otherwise discharged by Delta Dental after the termination date but incurred during the full Term of this Contract. 3. In the event of termination of this Agreement for any cause, Delta Dental will not be required 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, provided that any Claims Reimbursement and Service Fees owed Delta Dental have been paid. E. Delete Item 7.04 in ARTICLE VII — RENEWAL AND TERMINATION and replace it with the following Item 7.04. 7.04 If on termination of this Contract for any cause Group has not paid Service Fee and/or Claims Reimbursement to Delta Dental applicable to a period of time up to and including the termination date Group will, within 30 days after termination, remit such to Delta. F. Delete Item 7.05 in ARTICLE VII — REINSTATEMENT. Delta Dental PPO Delta Dental Benefits Rider A. Add Item 1.35 and 1.36, in ARTICLE I — DEFINITIONS 1.35 Delta Dental PPO is a preferred provider plan. PPO Dentists provide services at the PPO Discounted Fee Schedule. 1.36 PPO Dentist's Allowable Fee means the fee from the PPO Discounted Fee Schedule that the PPO Dentist has contractually agreed with Delta Dental to accept for treatment under this program, or the fee actually charged, whichever is less, for a single procedure. B. Delete and replace Item 1.10, in ARTICLE I — DEFINITIONS. 1.10 Covered Amount means: ■ For PPO Dentists, the lesser of the PPO Dentist's Allowable fee or the fee actually charged. ■ For Premier Participating Dentists, the lesser of the Premier Maximum Plan Allowance, or the fee actually charged. ■ For all other Dentists, the lesser of the Premier Maximum Plan Allowance, or the fee actually charged. Covered Services: Rates: Delta Dental Premier or PPO Dentist *Non -Participating Dentist Plan Pays / Patient Pays Plan Pays / Patient Pays Diagnostic & Preventive Benefits Diagnostic & Preventive Services 100% 0% 80% 20% Dental X-Rays 100% 0% 80% 20% Sealants 100% 0% 80% 20% Basic Benefits (Oral Surgery & Endodontics) Oral Surgery Services 80% 20% 80% 20% Endodontic Services 80% 20% 80% 20% All Other Basic Benefits Periodontic Services 80% 20% 60% 40% Basic Restorative Services 80% 20% 60% 40% Major Benefits Relines and Repairs 60% 40% 50% 50% Special Restorative Services 60% 40% 50% 50% Prosthodontic Services 60% 40% 50% 50% Orthodontic Benefits Orthodontic Services 50% 50% 50% 50% Orthodontia is a covered benefit for dependent children to age 19, and Full -Time Students to age 25. See Delta Dental Benefits Rider DDCO-006Spec and the ORTHODONTIC RIDER for details of all benefits. * Important: Non -Participating Dentists are allowed to balance bill. Employees and/or Dependents are responsible for the difference between the non -participating Maximum Plan Allowance and the full fee charged by the Dentist. Administrative Service Fee: Composite - $4.05 per month per Employee This Administrative Service Fee is contingent upon total enrollment of all eligible employees, in accordance with the eligibility provisions in Article III. This Administrative Service Fee is guaranteed at the above amount for the next three year period with a cap of 3% for the fourth and fifth year of this contract. The Administrative Service Fee is due the first day of each month, and as further described in Article II. The Monthly Claims Reimbursement Due Date is the 2nd, 12th, and 22nd day or the last business day closest to such date of each month and as further described in Article II. 12/16/09, DECLARATION PAGE2010 Delta Dental Benefits Rider DDCO — C06spec BENEFITS, LIMITATIONS AND EXCLUSIONS C.01 Subject to the limitations and exclusions included in this Contract, the 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 and appropriate. Benefits will be determined (even if no monies are paid) based on the terms of this Contract and Delta Dental's Processing Guidelines. C.02 DIAGNOSTIC, PREVENTIVE AND ADJUNCTIVE BENEFITS. Delta Dental will pay that percentage noted on the Contract Declaration Page of the Maximum Plan Allowance for the following Covered Services. Diagnostic — certain Services performed to assist the Dentist in evaluating the existing conditions and determining the dental care required. Preventive — certain Services performed to prevent the occurrence of dental abnormalities or disease. Adjunctive —certain additional Services including emergency palliative treatment performed as a temporary measure that does not affect a definite cure. C.03 Limitations on Diagnostic, Preventive and Adjunctive Benefits a) Benefits for oral examinations and prophylaxis (adult and child) treatment (and/or any procedure that includes any component of prophylaxis) will not be provided more than twice in any 12-month period. A separate benefit is provided once in a 12-month period for an emergency evaluation. For payment purposes, an adult prophylaxis is not a benefit for persons under age 14. Diagnosis, treatment planning or consultation by the treating Dentist (or other person legally permitted to perform such Services by authority of license) are considered components of a complete oral examination. b) Topical fluoride application is a benefit only through age 15 and only once in 12 months. c) Benefit for full mouth x-rays is made only after 60 months have elapsed following any prior provision of payment for full mouth x-rays under this Delta Dental plan unless documentation of special need is provided. Benefit for supplementary bitewing individual x-rays is provided once every 12 months while the patient is under this Delta Dental plan. A panoramic survey (which may include bitewing x-rays and/or periapical x-rays) is considered a full mouth x-ray for purposes of this Contract. Total allowance for individual periapical x-rays, intraoral occlusal x-rays, extraoral x-rays and/or bitewing x- rays performed on the same day will not exceed the allowance for full mouth x-rays. Delta Dental Benefits Rider DDCO — C06spec d) Benefit for space maintainers will only be made for appliances to maintain space for eruption of permanent posterior teeth in cases of premature loss of primary (deciduous) teeth through age 13. e) Adjunctive Services related to another category of Covered Services will be paid at the same percentage as the related category of Covered Services. f) Benefits for sealants are limited to one time per tooth in any 36 consecutive month period. Benefit is allowed only for the occlusal surface of decay -free and previously unrestored permanent molars for children through age 14. There is no separate benefit for preparation or conditioning of the tooth or any other procedure associated with the sealant application. C.04 BASIC BENEFITS. Delta Dental will pay that percentage noted on the Contract Declaration Page of the Maximum Plan Allowance for the following Covered Services. Basic Restorative - amalgam restorations (metal fillings) on posterior teeth, or resin -based composite restorations (white/plastic fillings) on anterior teeth and preformed shell crowns for treatment of carious lesions (decay) which result in visible destruction of hard tooth structure or loss of tooth structure due to fracture. Oral Surgery - extractions and certain other surgical Services and associated covered anesthesia and/or related Covered Services. Endodontic - certain Services for treatment of non -vital tooth pulp resulting from disease or trauma. Periodontic - certain Services for treatment of gums and bone supporting teeth. C.05 Limitations on Basic Benefits a) Benefit for the same Covered Basic Restorative Service will not be provided more than once in any 12-month period. b) Allowance for amalgam restorations (on posterior teeth) or resin -based composite restorations (on anterior teeth) may be made toward the cost of more expensive procedures or materials selected. The patient will be responsible for the portion of the Dentist's fee in excess of the Delta Dental allowance. c) No Benefits will be provided for treatment of teeth retained in relation to an overdenture. Delta Dental Benefits Rider DDCO — C06spec d) Benefit for the same Covered Surgical Periodontic Services will not be provided more than once in any 36-month period. Benefit for the same Covered Non -Surgical Periodontic Services will not be provided more than once in any 24-month period. e) Benefit for pulpotomy/pulpectomy will be made only for primary (deciduous) teeth. f) Periodontal maintenance procedures which include any component of prophylaxis are limited to Delta Dental Benefits Rider DDPCO — C, Section C.03, paragraph a. g) A course of treatment for apexification/recalcification (initial, interim, and final visits) is a benefit once per tooth. h) Allowance for assistant surgeon when determined by Delta Dental to be a Covered Service will not exceed 20% of the surgeon's fee for the same Covered Service. i) If this plan includes a late enrollment provision, Late Enrollees added to the dental plan will be required to be continuously enrolled in the dental plan for a consecutive 12-month period prior to being eligible for Basic Benefits. C.06 MAJOR BENEFITS. Delta Dental will pay that percentage noted on the Contract Declaration Page of the Maximum Plan Allowance for the following Covered Services: Special Restorative - crowns, jackets, cast, fused or other laboratory processed restorations (except preformed shell crowns) for treatment of carious lesions (decay) which result in visible destruction of hard tooth structure or loss of tooth structure due to fracture which cannot be restored with amalgam or resin -based composite restorations. Other Special Restorative - buildups (which may or may not include a post) for treatment of carious lesions (decay) which result in visible destruction of hard tooth structure or loss of tooth structure due to fracture which cannot be restored with amalgam or resin -based composite restorations. Prosthodontic - Services for construction or repair of fixed bridges (fixed partial dentures), cast based metal or acrylic removable partial and acrylic complete dentures, and removable temporary partial dentures to replace completely extracted or avulsed natural permanent teeth. Delta Dental Benefits Rider DDCO — C06spec C.07 Limitations on Major Benefits- Special Restorative and Other Special Restorative a) When two or more similar restorations are used to restore a tooth, allowance will not exceed the Covered Amount for the most inclusive Covered Service. b) Benefit for placement of Special Restorative Services will not be provided more than once in any 60-month period involving restorations of the same tooth. This includes any prior provision of Covered Prosthodontic Services involving the same teeth. c) Benefit for placement of Other Special Restorative Services will not be provided more than once in any 60-month period involving restorations of the same tooth. d) Any laboratory processed Special Restorative Service or Other Special Restorative Service (except preformed shell crowns) is not a benefit for children under the age of 12. e) No Benefits will be provided for treatment of teeth retained in relation to an overdenture. f) Allowance for Special Restorative Services posterior to the first molar will be limited to the allowance for a full metal restoration. The patient will be responsible for the portion of the Dentist's fee in excess of the Delta Dental allowance. g) Allowance for inlays will be limited to the allowance for an amalgam filling on back teeth or resin -based composite on front teeth for the same number of surfaces. The patient will be responsible for the portion of the Dentist's fee in excess of the Delta Dental allowance. h) If this plan includes a late enrollment provision, Late Enrollees added to the dental plan will be required to be continuously enrolled in the dental plan for a consecutive 12-month period prior to being eligible for Special Restorative and Other Special Restorative Benefits. C.08 Limitations on Major Benefits- Prosthodontic a) Benefit for replacement of prosthodontic appliances will not be provided more than once in any 60-month period. For removable partial dentures, the 60- month time limitation is not applicable when there is loss of an anchor tooth. b) Benefit for placement of prosthodontic Services will not be provided more than once in any 60-month period involving restorations of the same tooth. This includes any prior benefits of Special Restorative Services involving the same teeth. Delta Dental Benefits Rider DDCO — C06spec c) Allowance for cast based metal or acrylic removable partials and acrylic complete dentures may be made towards the cost of more expensive procedures or materials selected and the patient will be responsible for the portion of the Dentist's fee in excess of the Delta Dental allowance. d) Removable temporary partial dentures are a benefit to replace missing permanent anterior teeth. Allowance may be made toward the cost of more expensive procedures or materials selected and the patient will be responsible for the portion of the Dentist's fee in excess of the Delta Dental allowance. e) Alternate Benefit of a cast based metal removable partial or an acrylic complete denture may be made toward the restorative phase of implant procedures. Alternate Benefit will be paid according to the time limitations listed in Delta Denta I Benefits Rider DDPCO — C, Section C.07, Prosthodontic items a & b. f) Fixed bridges (fixed partial dentures) and/or cast metal framework partial dentures (removable partial dentures) are not a benefit for persons under age 16. g) Fixed and removable prosthodontic appliances are not a benefit in the same arch. Allowance will be limited to the allowance for a removable appliance. Exception will be made when the fixed bridge (fixed partial denture) replaces anterior teeth. h) Benefit for reline or rebase of a prosthodontic appliance will be made only once in any 36-month period. Reline or rebase of a prosthodontic appliance at the time of insertion and/or within 6 months following insertion by the same Dentist is considered a component of the appliance and separate payment will not be made for such reline or rebase. Reline or rebase of an immediate denture is a covered benefit at any time, subject to the limitation of one in 36 months. i) If this plan includes a late enrollment provision, Late Enrollees added to the dental plan will be required to be continuously enrolled in the dental plan for a consecutive 12-month period prior to being eligible for Prosthodontic Benefits. C.09 GENERAL LIMITATIONS - ALL SERVICES a) Pre- and post -operative procedures are considered part of any associated Covered Service. Benefit will be limited to the Covered Amount for the Covered Service. b) Local anesthesia is considered part of any associated Covered Service. Benefit will be limited to the Covered Amount for the Covered Service. Delta Dental Benefits Rider DDCO — C06spec c) The Covered Amount for a Covered Service Started but not Completed will be limited to the amount determined by Delta Dental. d) A temporary dental Service is considered part of any complete Covered Service. Benefits will be limited to the Covered Amount for the complete Covered Service, unless the temporary Service is specifically included as a Covered Service of this Contract. C.10 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, or Services which are provided to the Subscriber by any federal or state government agency or are provided without cost to the Subscriber by any municipality, county or other political subdivision, or any Services for which the Subscriber would have no obligation to pay in absence of this coverage, except as such exclusion may be prohibited by law. b) Any Covered Service Started when the person was not eligible for such Service under this Contract. c) Services for treatment of congenital (present at birth) or developmental (following birth) malformations, except intraoral 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 Contract. d) Services for cosmetic reasons. e) Services for restoring tooth structure lost from wear, erosion, attrition, abrasion or abfraction. f) Services related to protecting, altering, correcting, stabilizing, rebuilding or maintaining teeth due to improper alignment, occlusion or contour. g) Services related to periodontal stabilization of teeth. h) Habit appliances, night guards, occlusal guards, athletic mouth guards and gnathological (jaw function) Services, bite registration or analysis, or any related Services. i) Pre -medication, analgesia, hypnosis or any other patient management Services (except covered anesthetic Services). j) Charges for prescription drugs. k) Any Experimental or Investigational Procedures. Delta Dental Benefits Rider DDCO — C06spec 1) Services that may otherwise have been covered, but due to the patient's underlying condition would not prove successful to improve the oral health of the patient. m) Any procedures done in anticipation of future need (except Covered Preventive Services). n) Hospital costs and any additional fees charged by the Dentist or hospital for hospital services or visits, or charges for use of any facility. o) Any anesthesia service not specifically included in Covered Services. p) Intraoral grafts when done in areas where a tooth/teeth are not present. q) 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 associated Services. r) Orthodontic Services including any related diagnostic, preventive or interceptive Services (surgical and other treatment of malalignment of teeth and/or jaws), unless noted as a benefit on the Contract Declaration Page. s) Myofunctional therapy or speech therapy. t) Services for the treatment of any disturbances of the temporomandibular joint (TMJ), facial pain, or any related conditions, including any related diagnostic, preventive or interceptive Services, unless noted as a benefit on the Contract Declaration Page. u) Services not performed in accordance with the laws of the State in which Services are rendered, 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. v) Oral hygiene instructions or dietary instructions. w) Completion of forms, providing diagnostic information or records, or duplication of x-rays or other records. x) Replacement of lost, stolen or damaged appliances. y) Repair of appliances altered by someone other than a Dentist. z) Any Services including any associated Services or procedures not specifically included in Covered Services. Delta Dental Benefits Rider DDCO — C06spec aa) Services for which charges would not have been made if this coverage had not existed, except for Services as provided under Medicaid. bb) Missed appointment charges. cc) Preventive control programs, including home care items. dd) Plaque control programs. ee) Self-inflicted injuries. ff) Bone grafting when done in the same site as a tooth extraction, implant, apicoectomy or hemisection. Orthodontic Rider DDCO-A/B/C 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 interceptive services. (Extraction of teeth is covered under Oral Surgery Benefits.) Delta Dental will pay that percentage stated on the Contract Declaration Page of the Maximum Plan Allowance for Covered Orthodontic Services up to the maximum amount stated on the Contract Declaration Page. Allowance will be based on total case fees to include active treatment and post treatment retention or stabilization and all payments will be on a periodic basis, in accordance with the dentist's proposed period of active treatment. Separate benefit will not be made for post treatment stabilization. In addition to the Exclusions and Limitations stated in the Benefit Rider, the following exclusions and limitations will apply to Orthodontic Benefits. EXCLUSIONS AND LIMITATIONS: a) No benefits will be provided for 1. Replacement or repair of appliances. 2. Orthodontic care provided in the treatment of periodontal cases or cases involving treatment or repositioning of the temporomandibular joint or related conditions. b) The obligation of Delta Dental to make periodic payments for an Orthodontic treatment plan will cease upon termination of treatment for any reason prior to completion of the case, or upon termination of the Subscriber's eligibility. c) The obligation of Delta Dental to make periodic payments for an Orthodontic treatment plan begun prior to the eligibility date of the patient will commence with the first payment due following the patient eligibility date. The maximum benefit will be determined based upon the prior carrier's payment history. d) If this plan includes a late enrollment provision, Late Enrollees added to the dental plan will be required to be continuously enrolled in the dental plan for a consecutive 12-month period prior to being eligible for Orthodontic Benefits. PERFORMANCE GUARANTEE Colorado counties without PPO or Premier Providers are Bent, Crowley, Custer, Gilpin, Hinsdale, Jackson, Kiowa, Mineral, Phillips, Rio Blanco, Saguache, San Juan, San Miguel and Sedgwick. Riders or Appendices Attached Countersigned: Delta Dental of Colorado Signature December 16, 2009 Date Accepted: CITY OF FORT COLLINS #1857 r Sig tur I Date 12/16/09, DECLARATION PAGE2010 w d ''GwD V/ O {Q V A C d m 0 0 0 0 0 0 E E 0c m m v m ar m c ° c o c a) m @ J a @ .E E o m J @ .E >, m c $ n E o :E:-n E O m'm c �.4 c �.� c �.4 c �.0 c 3.0 c 3 0 o f 0 J y .0 C C @ N C m C N C[2 m N C@ m N C m y C U C a) @ E V C a1 D @ )a O a) O ' ° .0 O .c o O C o O C o O .0 O 'c O 7 0 U O 7 0 U N )A V VA O a @ a N @ a N @ a N @ o a N @ o a N @ N N fA O 6e fA O 6% J C O L ° U@ N @ c c o E 7 N 0 YO a) C - N U �. N C m L 3 Y 7 0 a C >� C ° a °) E m N@ v N m u >� > N L a) v L U Coa) > @ @ U) m y N a @ C @° V! 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Na Ea C d ary C a-0 is O C_ E ° E 3 N O N y m 3 0 0 3 'o N C J a) vt 3 U N H J N •�..� aa). = N J � a c °' a m E E a Q E E Q E E LL E E o) a@i E a m oc E ~ Q' 3 v W ARTICLE I. DEFINITIONS For the purpose of this Contract, the following definitions will apply: 1.1 ALTERNATE BENEFIT Alternate benefit means that benefit allowed for the least -costly, commonly accepted Service or supply that could be used to treat a dental problem for which there are other, more costly treatment options that the Subscriber selects. 1.2 APPLICANT means the Group or Employer for whose Employees dental benefits are being provided. 1.3 BENEFITS means those dental Services that are available under the terms of this Contract as specified in the Benefits Rider, BENEFITS, LIMITATIONS and EXCLUSIONS. 1.4 COINSURANCE means the percentage of a Covered Amount which is payable by Delta Dental. The Coinsurance for each type of Covered Service is noted on the Declaration Page. The Coinsurance applicable to a Subscriber will vary depending upon the type of dental Service. 1.5 COMPLETED means: • For Root Canal Therapy: On the date the canals are permanently filled. • For Fixed Bridges (fixed partial dentures), Crowns, Inlays, Onlays, and other laboratory prepared restorations: On the date the restoration is cemented in place. • For Dentures and Partial Dentures (removable partial dentures): On the date that the final appliance is first inserted in the mouth. • For all other Services, on the date the procedure is Started. For benefit payment purposes, the date Completed will be considered as the date when a Covered Service is incurred. 1.6 The CONTRACT ANNIVERSARY DATE or ANNIVERSARY DATE is noted on the declaration page of this Contract and will be defined as the first day of each Contract Year subsequent to the initial Contract Year. 1.7 CONTRACT means this agreement between Delta Dental and the Applicant including the attached appendices, exhibits and riders, if any. This Contract constitutes the entire agreement between the parties. 1.8 CONTRACT TERM means the period of time from the Effective Date of the Contract until it is terminated in accordance with the provisions of Article VII. 1.9 CONTRACT YEAR is the 365-successive-day period (or, if a February 29 is encompassed, the 366-successive-day period) beginning on the Effective Date set forth in this Contract, and successive one-year periods thereafter unless terminated. Contract Page 1 DDPCO— C06 1.10 COVERED AMOUNT means ■ For Premier Dentists, the lesser of the Premier Maximum Plan Allowance, or the fee actually charged. ■ For all other Dentists, the lesser of the non -participating Maximum Plan Allowance, or the fee actually charged. 1.11 COVERED SERVICES means those Services and supplies covered pursuant to the terms of this Contract. Benefits for all Covered Services are subject to the limitations and exclusions noted in this Contract. 1.12 DEDUCTIBLE means the portion of the Covered Amount for certain Covered Services which must be paid in full for each Subscriber before any Benefits are payable. The amount of the Deductible is noted on the Declaration Page. If there is a maximum amount that a family must pay in Deductibles, that will also be noted on the Declaration Page. 1.13 DENTIST means an individual licensed to practice dentistry at the time and in the place Services are provided. 1.14 DEPENDENT means • the Employee's lawful spouse, including common law spouse; • an unmarried dependent child under the Dependent Age Limit noted on the Contract Declaration Page; • an unmarried dependent child who is a full-time student enrolled in an accredited school, college, or university, and who is under the Student Age Limit noted on the Declaration Page. • an unmarried covered dependent child who reaches the Child Dependent Age Limit noted on the Declaration Page, is incapable of self-support because of physical handicap or mental incapacity that began before reaching the Dependent Age Limit, and is chiefly dependent on the Employee for support and maintenance. Delta Dental may annually request a copy of the court - ordered guardianship as proof of such handicap or incapacity and dependency. Upon failure to submit such required proof, or when the child is no longer incapacitated, coverage will terminate. Eligible Dependent children include stepchildren, court -ordered guardianship, adopted children, QMCSO, and foster children, provided such children live with the Employee in a regular parent -child relationship and are dependent on the eligible Employee for support and maintenance. If the child does not live with the Employee in a regular parent -child relationship, the Employee must be legally responsible for the provision of health care for the child. No one may be covered as a Dependent and also as an Employee under this Contract. If both parents are covered as Employees, children may be covered as Dependents of one parent only. Persons in active military service will not be considered as eligible Dependents. Contract Page 2 DDPCO-- C06 1.15 EFFECTIVE DATE is the date on which coverage begins under the Contract. 1.16 ELIGIBLE CLASS is a category of Employees who are eligible for coverage under the Contract. A list of Eligible Classes is noted on the Declaration Page. 1.17 ELIGIBILITY WAITING PERIOD means a specified period of employment that an Employee must complete before becoming eligible for coverage under the Contract. The length of the Eligibility Waiting Period is chosen by the Applicant and may differ for different Eligible Classes. The Eligibility Waiting Period, if any, is noted on the Declaration Page and in Article III, Section 3.02 and 3.05 . 1.18 EMPLOYEE means someone who works at a minimum the number of hours as defined by the Employer. 1.19 EXPERIMENTAL OR INVESTIGATIONAL PROCEDURES means those services or supplies that are not generally accepted in the dental community as being safe and effective, as defined by Delta Dental. 1.20 GROUP means the Applicant or Employer for whose Employees dental benefits are being provided. 1.21 LATE ENROLLMENT means enrollment occurring after the period of initial eligibility. Any Late Enrollee must be continuously enrolled for a period of 12 consecutive months before Covered Services other than the ones noted on the Declaration Page become payable under the Contract. The exceptions to this rule are: a) an Employee or Dependent who involuntarily loses coverage through another group insurance plan. (Involuntary loss of coverage is defined as loss due to death, divorce, loss of job, or termination of benefits by the employer.) Such Employee or Dependent will be allowed to enroll within 31 days of the loss of coverage with satisfactory proof of coverage loss and will not be considered a Late Enrollee upon enrollment. b) a dependent child under age 3 may be added on any anniversary until the anniversary on or following the date the dependent child turns age 3. Such child will not be considered a Late Enrollee upon enrollment. If the Applicant has chosen Late Enrollment, then the option will be noted on the Declaration Page. 1.22 MAXIMUM PLAN ALLOWANCE means the maximum allowable amount as determined by Delta Dental for a procedure. Delta Dental evaluates these amounts twice annually, and may increase or decrease fees for any given procedure. 1.23 NECESSARY means a Service that is required by, and appropriate for treatment of, the Subscriber's dental condition according to generally accepted standards of dental care as determined by Delta Dental. Contract Page 3 DDPCO— C06 1.24 NON -PARTICIPATING DENTIST means a licensed Dentist who is not currently contracted with Delta Dental as a Participating Dentist. 1.25 OPEN ENROLLMENT means a period of time each Contract Year occurring prior to the Anniversary Date during which eligible Employees may choose to enroll themselves and/or their eligible Dependents in the Plan, or change from one coverage option to another if the Contract issued to the Group permits them to do so. Coverage will become effective on the Applicant's Anniversary Date. If the Applicant has chosen an Open Enrollment period, then the option will be noted on the Declaration Page. 1.26 PARTICIPATING DENTIST means a licensed Dentist who is currently contracted with Delta Dental. Premier Participating Dentist means a Dentist licensed to practice who has executed a Premier Participating Dentist Agreement with Delta Dental. PPO Participating Dentist means a Dentist licensed to practice who has executed a PPO Dentist Agreement with Delta Dental. 1.27 PREMIUM means the amount of money paid for each Subscriber to purchase the Benefits provided by this Contract, as provided in Article II. 1.28 PRE-TREATMENT ESTIMATE is a service offered by Delta Dental to review 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 Contract. 1.29 RETIREE means an Employee who has 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 12 consecutive moths; or who is totally and permanently disabled and has 10 or more years of eligible service completed with the Employer in a classified position or unclassified management position and has exhausted his COBRA continuation period. 1.30 SERVICE means a procedure or supply that is provided by a Dentist in connection with the dental care of a Person. 1.31 STARTED means • For Full Dentures or Partial Dentures (removable partial dentures): The date the final impression is taken. • For Fixed Bridges (fixed partial dentures), Crowns, Inlays, Onlays and other laboratory prepared restorations: The date the teeth are first prepared (i.e., drilled down) to receive the restoration. Contract Page 4 DDPCO— C06 For Root Canal Therapy: The date the pulp chamber is first opened. For Periodontal Surgery: The date the surgery is actually performed. For All Other Services: The date the Service is performed. 1.32 SUBSCRIBER means: • an Employee or Dependent who is eligible to be covered under this Contract pursuant to Article III, is enrolled for the Group Dental Benefits provided in accordance with this Contract, and for whom the appropriate monthly Premium specified in Article II is received; or • a person ceasing to be eligible who elects continued coverage as provided in Article VIII, is enrolled for the Group Dental Benefits provided in accordance with this Contract and for whom the appropriate monthly Premium specified in Article II is received. 1.33 TIED -TO -MEDICAL means the Applicant has packaged the dental benefits with the medical plan that the Applicant offers. Only those who enroll for medical coverage will be considered Subscribers under a dental Contract that is tied -to - medical. If the Applicant has chosen Tied -To -Medical, then the option will be noted on the Declaration Page 1.34 WAITING PERIOD means a period of time starting on a Subscriber's Effective Date (the date that Person's coverage under the Contract began) before Benefits for certain Services become payable. If a Covered Service is Completed before the Waiting Period for that Service ends, that Service is not covered under the Contract. If a Person's coverage under the Contract ended and then the Person later becomes covered again, that Person's Effective Date is the most recent Effective Date unless stated otherwise in the Contract. If Waiting Periods are applicable to coverage, they are noted on the Declaration Page. ARTICLE II. MONTHLY PREMIUM 2.01 PREMIUM DUE DATE. The Group agrees to remit to Delta Dental during the Contract Term, a monthly Premium that will become due and payable on the first day of the month, for each Employee. 2.02 MONTHLY PREMIUM. The Monthly Premiums for each Employee are as noted on the Declaration Page. 2.03 INITIAL PREMIUM. This Contract will not be in effect until the initial Premium is received by Delta Dental. Subsequent Premiums will become due and payable on the first day of each month. 2.04 PREMIUMS AT TERMINATION. In the event this Contract terminates for any . reason, the Applicant will be liable for all Premiums due but unpaid. Contract Page 5 DDPCO— C06