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CITY OF SANTA ANA <br />BENEFITS & RATES <br />DELTA CLIENT #599 <br />CURRENT RATES jffective 01/01/2016 to 12/31/2016) <br />Delta Dental PPO <br />One Party <br />$51.58 <br />Billed <br />PPO <br />T Non -PPD <br />____ <br />Subsidized <br />Diagnostic and Preventive <br />100% <br />100% <br />Copoyments <br />Basic <br />Crowns and Cast Restorations <br />80/20 <br />50/50 <br />75125 <br />50/50 <br />_ <br />$55.49 i <br />Prosthodontics <br />50/50 <br />I 50/50 <br />_ <br />Per patient per calendar year <br />$25 <br />$50 <br />Deductibles <br />Perfamlly per calendar year <br />$50 <br />$100 <br />&Pfro <br />exempt m deductible? <br />Yes <br />Yes <br />Maximums <br />__D - <br />Per patient per calendar rear <br />_ <br />—2) <br />$11000 _ <br />ggelimitations <br />Children (years o)a a <br />26 <br />26 <br />CURRENT RATES jffective 01/01/2016 to 12/31/2016) <br />Billed <br />One Party <br />$51.58 <br />Billed <br />7WO Party+ <br />$127.04 <br />____ <br />Subsidized <br />One Party <br />- - -- $3.91 <br />Subsidised <br />Two Party+ <br />$9.62 <br />Total <br />One Party <br />_ <br />$55.49 i <br />One Party <br />Two Part+ <br />Two Part y+ <br />$136.66 <br />RENEWAL RATES Effective 02 /01/2017 to 12/33/2017) <br />Billed Rate Action <br />1.90% <br />Billed <br />_ <br />One Party <br />Two Parry+ <br />— -- $52.56 -�- <br />$129.44 <br />Subsidized Rate Aedon <br />5.28% <br />Subsidised <br />One Part y <br />Two Party+ <br />$7.22 <br />Total <br />Total Rate Action <br />8100% <br />$55A9 <br />$136.66 <br />One Party <br />Two Part+ <br />SUGGESTED COBRA RATES jffective 01/01/2017 to 12131/2017) <br />One Party <br />$55.49 <br />Two Party <br />$105.58 <br />Three Party* <br />$158.37 <br />A Note About COBRA Rates <br />As part of Delta's commitment to assist employers In complying with the Consolidated Omnibus <br />Budget Reconciliation Act (COBRA), we are providing a suggested three -step rate structure for those <br />groups having a Super - Composite rate, a Two Party+ rate structure or for a self - funded contract. The <br />following recommended rates are the rates which the group may charge a COBRA eligible on a three - <br />step rate structure. The rates do not Include the 2% allowable employer charge for the administration <br />of COBRA. Please note that Delta Is not responsible for the billing for the individual COBRA eligibles. <br />Self-funded groups will continue to be charged by Delta for claims plus administration for ALL eligibles <br />including COBRA eligibles, Likewise, risk groups will continue to be charged the rate for ALL eligibles <br />under their plan, including COBRA eligibles. <br />EXHIBIT 1 <br />25D -9 <br />5/20/2016 <br />