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25C - AGMT GROUP INSURANCE
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25C - AGMT GROUP INSURANCE
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Last modified
2/1/2018 7:02:12 PM
Creation date
2/1/2018 7:10:52 PM
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City Clerk
Doc Type
Agenda Packet
Agency
Personnel Services
Item #
25C
Date
2/6/2018
Destruction Year
2023
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(m) Occlusal guards and complete occlusal adjustment. <br />(n) Orthodontic services (treatment of mal -alignment of teeth and/or jaws). <br />(o) Diagnostic casts. <br />4.8 An agreement between the Contractholder and Delta Dental Is required to change Benefits <br />during a Contract Term. <br />ARTICLE 5 - DEDUCTIBLES & MAXIMUM AMOUNT <br />5.1 Applicable to services provided by a Delta Dental PPO Dentist: Each Enrollee must pay <br />the first $25 ("deductible amount") of fees for services that are Benefits received by an <br />Enrollee during the term of this Contract and otherwise covered by this Contract. Such <br />deductible amount will not exceed $50 for all Enrollees in a single family, consisting of a <br />Primary Enrollee and his or her Dependents, as defined. Delta Dental will compute these fees <br />based on the Dentist's Usual, Customary and Reasonable fees. <br />Applicable to services provided by other dentists: Each Enrollee must pay the first $50 <br />("deductible amount") of fees for services that are Benefits received by an Enrollee during the <br />term of this Contract and otherwise covered by this Contract. Such deductible amount will not <br />exceed $100 for all Enrollees in a single family, consisting of a Primary Enrollee and his or her <br />Dependents, as defined. Delta Dental will compute these fees based on the Dentist's Usual, <br />Customary and Reasonable fees. <br />5.2 Such deductible amounts shall apply once each calendar year or portion thereof during which <br />the Enrollee Is continuously eligible under this Contract. The deductible does not apply to <br />Diagnostic and Preventive Benefits. <br />5.3 Applicable to services provided by a Delta Dental PPO Dentist: The maximum amount <br />Delta Dental will pay for Diagnostic and Preventive, Basic, Crowns, Inlays, Onlays and Cast <br />Restorations and Prosthodontic Benefits provided to any Enrollee in a calendar year Is 1,250. <br />Applicable to services provided by other dentists: The maximum amount Delta Dental <br />will pay for Diagnostic and Preventive, Basic, Crowns, Inlays, Onlays and Cast Restorations <br />and Prosthodontic Benefits provided to any Enrollee In a calendar year is 1,000, <br />ARTICLE 6 - COORDINATION OF BENEFITS <br />6.1 If a group insurance policy or any other group health Benefits plan, Including another Delta <br />Dental plan, entitles a person to receive or be reimbursed for the cost of dental services, <br />which are also Benefits under this plan, and If this plan is "primary" under the rules described <br />below, Delta Dental will provide Benefits as if the other plan did not exist. If the other plan is <br />"primary" under these rules, then Delta Dental will coordinate Benefits under this plan with <br />the primary plan in accordance with California law (California Health and Safety Code <br />1374.19 (2007). <br />6.2 If the other plan mainly covers services or expenses other than dental care, this plan is <br />"primary." Otherwise, Delta Dental will use the following rules to determine which plan is <br />"primary": <br />(a) The plan that covers the person as other than a Dependent is primary over the plan <br />that covers the person as a Dependent, with the following exception: <br />If the person is also a Medicare Beneficiary and Medicare is: <br />(1) secondary to the plan covering the person as a Dependent; and <br />io <br />25C-62 <br />
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