HomeMy WebLinkAboutCORRESPONDENCE - RFP - 7054 BENEFITS DENTALos �
CONFIRMATION OF COVERAGE: 2011 Renewal - Dental
CARRIER/POLICY #: Delta Dental
Client / Legal name: City of Fort Collins
ERISA Plan name: City of Fort Collins
Eligible employees: 1,400
Client / Insured Address: 215 North Mason Street, 2"d Floor
Fort Collins, CO 80522
This document will confirm placement of the following coverage(s):
Dental
Coverage will be effective on: 1/1/2011
For a period of: 24 months
Rates / fees (including any subsequent period caps or guarantees) for the above -referenced
Dental Fee:
Per employee
$4.05
MOVING TO ONE DENTAL PLAN OPTION
Description of Benefits:
For both in and out of network: deductible does NOT apply to Diagnostic, Preventive and
Orthodontics Services.
In Network
Deductible - $50 Individual/$100 Family
Preventive - 100% coinsurance
Basic - 80% coinsurance
Major - 50% coinsurance
Calendar Max - $1,500 (combined w/out-of-network)
Orthodontic Services — 50%
Ortho. Lifetime Maximum - $1,500
Out -of -Network
Deductible - $50 Individual/$100 Family
Preventive - 80% coinsurance
Basic - 80% coinsurance / 60% coinsurance
Major - 50% coinsurance
Calendar Max - $1,500 (combined w/in-network)
Orthodontic Services — 50%
Ortho. Lifetime Maximum - $1,500
1) Added coverage for implants, white composite fillings, and remove age limit for fluoride treatments
2) Added coverage for dependents to age 26
3) Added coverage for domestic partners
*All red fonts correspond to changes made to the plan for the 2011 plan year
MERCER
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Conditions of coverage(s): None
As an authorized representative, I accept this confirmation of coverage. By signing below, I
acknowledge agreement with the rates and benefits described above and that subsequent
contract(s) shall conform to this document unless otherwise agreed to in writing.
Authorized Representative:
Legal Name of Insurer/
Administrator
Signature:
Date: Id- - 2 a -jl�
This form must be signed and returned to Mercer H&B prior to the effective date of coverage.
MERCER
MARSH MERCER R..LL
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Page 1 of 1
David Carey
From: LeeAnna, Vargas
Sent: Monday, December 27, 2010 10:00 AM
To: David Carey
v� DaDl)Subject: FW: Requisition info. Attachments 2011 Delta:Dental'COC(SIGNED) 122210.pdf �N�F1� b,_,_-. �v J 1
Here's Delta Dental.
From: Amy Sharkey
Sent: Wednesday, December 22, 2010 2:38 PM
To: LeeAnna, Vargas
Subject: RE: Requisition info.
Attached is Delta Dental. Thanks, Amy
Amy Sharkey, CCP, CBP, GRP
City of Fort Collins
Comp, Benefits, and HRIS Manager
(970)416-2721
From: Amy Sharkey
Sent: Tuesday, December 21, 2010 4:32 PM
To: LeeAnna, Vargas
Subject: RE: Requisition info.
Here's what I have.....waiting for Mercer to get back to me regarding Delta Dental.
Let me know if I'm missing anything else besides Delta Dental.
thanks, Amy
Amy Sharkey, CCP, CBP, GRP
City of Fort Collins
Comp, Benefits, and HRIS Manager
(970) 416-2721
From: LeeAnna, Vargas
Sent: Monday, December 20, 2010 3:30 PM
To: Amy Sharkey
Subject: Requisition info.
Amy — I entered all 2011 Requisitions this morning, except for two Cigna Req's (need vendor info).
According to David Carey, he only has renewal documentation for Family Care Connection. Do you have
renewal info you can email him that he can refer to when converting the Req's to PO's?
Thanks
LeeAnna
12/27/2010