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HomeMy WebLinkAbout25C - AGMT GROUP INSURANCEREQUEST FOR COUNCIL ACTION CITY COUNCIL MEETING DATE: FEBRUARY 6, 2018 TITLE: APPROVE EMPLOYEE GROUP INSURANCE RENEWALS WITH METLIFE DENTAL, DELTA DENTAL, AND APPROVE AMENDED AGREEMENT WITH KEENAN AND ASSOCIATES TO INCLUDE DENTAL SERVICES. (STRATEGIC PLAN NO. 7,6) CITY MANAGER '/i RECOMMENDED ACTION CLERK OF COUNCIL USE ONLY: APPROVED ❑ As Recommended ❑ As Amended ❑ Ordinance on 161 Reading ❑ Ordinance on 2nd Reading ❑ Implementing Resolution ❑ Set Public Hearing For CONTINUED TO FILE NUMBER 1. Authorize the City Manager and Clerk of the Council to execute a new agreement with MetLife Dental, subject to non -substantive changes approved by the City Manager and City Attorney, to provide employee HMO dental plan services from January 1, 2018 to December 31, 2018 at a monthly cost of $28.53 Single and $48.76 Family. 2. Authorize the City Manager and Clerk of the Council to execute a new agreement with Delta Dental, subject to non -substantive changes approved by the City Manager and City Attorney, to provide employee PPO dental plan services from January 1, 2018 to December 31, 2019 at a monthly cost of $52.56 Single and $129.44 Family. 3. Authorize the City Manager and Clerk of the Council to execute an amended agreement with Keenan and Associates, subject to non -substantive changes approved by the City Manager and City Attorney, to expand the scope of the current agreement to include employee dental plan services, and execute the first contract extension for Keenan to provide services through June 30, 2021 as allowed by the agreement terms. DISCUSSION The City purchases its HMO dental insurance through MetLife and its PPO dental Insurance through Delta Dental. Rates and fiscal impact was previously approved on the September 5, 2017 council agenda for the period of January 1, 2018 through December 31, 2019. Staff is recommending new modern agreements with MetLife Dental on a year-to-year basis until terminated and Delta Dental for two years. Moving forward, services for employee dental benefits will go out for bid by the current broker, Keenan and Associates in July of 2018 and will be brought 25C-1 Employee Group Insurance Agreements February 6, 2018 Page 2 forward for council approval in September of 2018 for the following plan year. The City utilizes the services of Keenan & Associates. Keenan is the broker of record for life, accidental death & dismemberment (AD&D) coverage, long-term disability (LTD) insurance through the carrier Aetna, vision insurance through EyeMed, Flexible Spending accounts through TASC and EAP Program through REACH for all employees. It is recommended to include Keenan as the broker of record for dental coverage through the carrier Delta Dental effective January 1, 2018 and MetLife Dental effective July 1, 2018. City staff is recommending authorization to amend the agreement with Keenan and Associates, to expand the scope of services to provide broker services for dental plans for City employees. The City has previously contracted with Keenan and Associates to provide the majority of our health broker services and has been pleased with the services provided. Keenan and Associates won the bid issued on March 2, 2016 to be the City's insurance broker effective June 21, 2016 A-2016-162. City staff is also requesting to extend this contract for one (1) additional three-year period as indicated in the original agreement. This extension will be from July 1, 2018 through June 30, 2021. The City does not pay any compensation to Keenan and Associates under the agreement. All compensation to Keenan and Associates shall be directly paid by the insurance carriers to the broker according to the commission arrangements. FISCAL IMPACT There is no additional fiscal impact associated with this brokerage/consulting agreement. Budgeted funds are available in the Personnel Services Employee Benefits account (account no. 08109053-64010) to pay for group insurance premiums in which commissions are included. Acting Executive Di Personnel Services Exhibits: 1. MetLife Agreement 2. Delta Dental Agreement 3. Keenan and Associates Amended Agreement 25C-2 MetLife Benefits Provided by SafeGuard Health Plans, Inc., a MetLife company 200 Park Avenue, New York, New York 10166 SafeGuard Health Plans, Inc. ("SafeGuard"), a California corporation, will pay the benefits specified in the Exhibits of this contract subject to the terms and provisions of this contract. The Schedule of Exhibits lists each Exhibit to this contract, to whom it applies and Its effective date. Organization: City of Santa Ana Group Contract No.: 142337 EFFECTIVE DATE This contract will take effect on January 1, 2018. CONTRACT ANNIVERSARIES Contract anniversaries will be January 1, 2019 and each subsequent January 1. PREPAYMENT FEES This contract is issued in return for the payment of required Prepayment Fees. Prepayment Fees are payable at the home office of SafeGuard or to its authorized agent. The first Prepayment Fee is due on and must be paid by this contract's effective date. Any later Prepayment Fees are due monthly in advance on the first day of each Contract Month. These dates are the Prepayment Fee Due Dates. SafeGuard and the Organization may agree that payment be made in advance every 3, 6 or 12 months. CONTRACT SITUS This contract is issued for delivery in and governed by the laws of California. Signed as of this contract's effective date at SafeGuard's home office in Irvine, California. Signature SafeGuard Representative GROUP SPECIALIZED HEALTH CARE SERVICE PLAN GPNP10-DHMO EXHIBIT 1 25C-3 Page 1 TABLE OF CONTENTS Section POLICY FACE PAGE Effective Date ...................................................... Contract Anniversaries ........................................ Prepayment Fees Page ......................................................................1 .....................................................................1 .......................................................................................................................................1 ContractSitus.............................................................................................................................................1 DEFINITIONS................................................................................................................................................3 SCHEDULEOF BENEFITS...........................................................................................................................3 ELIGIBILITY AND EFFECTIVE DATES OF BENEFITS................................................................................4 CONTRIBUTIONS............................................................................................................................................... 4 PREPAYMENTFEES....................................................................................................................................4 InitialPrepayment Fee...............................................................................................................................4 Frequencyof Prepayment Fee Payment....................................................................................................4 Computation of the Prepayment Fee.........................................................................................................4 Prepayment Fee for Changes in Benefits..................................................................................................4 Right to Change the Prepayment Fee........................................................................................................4 GRACEPERIOD................................................................................................. END OF BENEFITS PROVIDED BY THIS CONTRACT ..................................... REINSTATEMENT ............... ............................. 5 ................................. 7 GENERALPROVISIONS..............................................................................................................................7 EntireContract...........................................................................................................................................7 ContractChanges or Waivers....................................................................................................................7 Incontestability: Statements Made by the Organization............................................................................7 Incontestability: Statements Made by Covered Persons...........................................................................7 Evidenceof Coverage................................................................................................................................8 ParticipatingProviders...............................................................................................................................8 Assignment................................................................................................................................................8 DataNeeded..............................................................................................................................................8 Misstatementof Age...................................................................................................................................8 Non -Dividend Paying............................................................................................................................ Conformitywith Law...................................................................................................................................8 SCHEDULE OF EXHIBITS SCH/EXHIBITS EXHIBIT 1: Prepayment Fee Schedule ................................................ .......................EXHIBIT 1 EXHIBIT 2: Evidence of Coverage Form......................................................................EXHIBIT 2 EXHIBIT 3: Schedule of Benefits................................................................................EXHIBIT 3 GPNP10-DHMO 25C-4 Page 2 DEFINITIONS As used in this contract, the terms listed below will have the meanings defined below. When defined terms are used in this contract, they will appear with initial capitalization. The plural use of a term defined In the singular will share the same meaning. Contract Anniversary is defined on page 1. Contribution means the amount the Organization may require the Member to pay toward the total Prepayment Fee that MetLife charges for the benefits provided by this contract. Contributory Benefits means benefits for which the Organization may require the Member to pay at least part of the Prepayment Fee. Covered Person means a Member and/or a Dependent as set forth in the Exhibit which applies to the Member. Contract Month. The first Contract Month will begin on the effective date shown on page 1. Subsequent Contract Months will begin on the same day of each subsequent calendar month. Dependent is defined in the Exhibit which applies to the Member. Member means the person, usually the employee, who represents the family unit in relation to the dental benefits. Noncontributory Benefits means benefits for which the Organization may not require the Member to pay any part of the Prepayment Fee. Policyholder means the Organization shown on page 1. Prepayment Fee means the amount the Organization must pay to SafeGuard for all the benefits provided under this contract. Prepayment Fee Due Date is defined on page 1. Selected General Dentist means a SafeGuard contracted dentist who agrees in Writing to provide dental services under special terms, conditions and financial reimbursement arrangements with SafeGuard. Selected General Dental Office means a dental office contracted with SafeGuard consisting of dentists who agree in Writing to provide dental services under special terms, conditions and financial reimbursement arrangements with SafeGuard. Signed means any symbol or method executed or adopted by a person with the present Intention to authenticate a record, and which is on or transmitted by paper or electronic media, and which is consistent with applicable law. Written or Writing means a record which is on or transmitted by paper or electronic media, and which is consistent with applicable law. SCHEDULE OF BENEFITS The schedules of benefits which apply under this contract are set forth in the Exhibits. GPNP10•DHM0 25C-5 Page 3 ELIGIBILITY AND EFFECTIVE DATES OF BENEFITS The Eligibility and Effective Dates of Benefits provisions that apply under this contract are set forth in the Exhibits. CONTRIBUTIONS The Organization will not require a Member to contribute to the cost of Noncontributory Benefits. The maximum amount that a Member may be required to contribute to the cost of Contributory Benefits will not exceed the Prepayment Fee charged for the amounts of such benefits. PREPAYMENTFEES Initial Prepayment Fee The initial Prepayment Fee is shown in the Exhibits. Frequency of Prepayment Fee Payment Prepayment Fees for this contract will be paid as shown on page 1. SafeGuard and the Organization may agree that payment be made in advance every 3, 6, or 12 months. Computation of the Prepayment Fee The Prepayment Fee due on any Prepayment Fee Due Date is determined by the total amount of benefits provided by this contract on such Prepayment Fee Due Date, multiplied by the appropriate Prepayment Fee which is then in effect subject to any Prepayment Fee adjustments, if applicable. SafeGuard may use any reasonable method to compute Prepayment Fees due under this contract. Prepayment Fee for Changes in Benefits For benefits that take effect after the first day of a Contract Month, the Prepayment Fee will be charged from the first day of the next Contract Month. However, if a contract amendment is required for such benefits, The Prepayment Fee will be charged as of the date such benefits take effect. If this contract ends, or if benefits end for a class of persons, the Prepayment Fee will be charged to the date benefits end. If benefits end for other reasons, the Prepayment Fee will be charged to the end of the Contract Month in which benefits end. Right to Change the Prepayment Fee SafeGuard may change Prepayment Fees for changes which materially affect the risk assumed for the benefits provided by this contract, as follows: 1. when this contract is amended or endorsed; 2. when a class of eligible persons is added to or deleted from this contract for any reason including corporate restructuring, acquisition, spin-off or similar situations; GPNP10-DHMO 25C-6 Page 4 Right to Change the Prepayment Fee (continued) 3. when the Organization's subsidiary, affiliate, division, branch or other similar entity is added to or deleted from this contract for any reason Including corporate restructuring, acquisition, spin-off or similar situations; 4. when there is a significant change in the geographic distribution of Covered Persons; 5. when applicable law requires a change in: a. the benefits provided by this contract; and/or b. the class of persons eligible for benefits under this contract; or 6. when a Prepayment Fee Due Date coincides with or next follows: a. a change greater than 10% in the number of Covered Persons since the later of the contract Effective Date and the last date that the Prepayment Fee was changed; or b. a change greater than 5% in the amount of benefits provided by this contract since the later of the contract Effective Date and the last date that the Prepayment Fee was changed. In addition, SafeGuard may change the Prepayment Fee: 1. except as may be stated in the Exhibits, on any date on or after the first Contract Anniversary; this will be done no more frequently than every 12 months and only If SafeGuard notifies the Organization, in Writing, at least 30 days before such change; and 2. on any other date agreed to by SafeGuard and the Organization. The new Prepayment Fee will apply only to a Prepayment Fee due on or after the date the rate change takes effect. GRACE PERIOD Each Prepayment Fee due after the Effective Date of this contract may be paid up to 15 days after its Prepayment Fee Due Date. This period is the grace period. The benefits provided by this contract will stay in effect during this period. SafeGuard will notify the Organization in Writing that, if the Prepayment Fee is not paid by the end of the grace period, this contract will end at the end of the last day of the grace period. If SafeGuard fails to give Written notice to the Organization, this contract will continue in effect until the date such notice is given. Organization's intent to end this contract during the grace period. The Organization may notify SafeGuard in Writing prior to the end of the grace period of its intent to end this contract before the end of the grace period. In this case, this contract will end on the later of: 1. the date stated in the notice; or 2. the date SafeGuard receives the notice. If the Organization replaces this contract with another group contract but does not give SafeGuard notice of Intent to end this contract, the grace period provisions will apply. GPNP10-DHMO 25C-7 Page 5 END OF BENEFITS PROVIDED BY THIS CONTRACT The Organization can end this contract by giving 60 days advance Written notice to SafeGuard. The contract will end on the later of: 1. the date stated in the notice; or 2. the date SafeGuard receives the notice. SafeGuard can end this contract as follows: 1. on the date the Prepayment Fee Is not paid when due, subject to the Grace Period provisions; or 2. on any Prepayment Fee Due Date, by giving the Organization 31 days advance Written notice, if less than: a. for benefits for Members, 65% of persons eligible under this contract are insured for Contributory Benefits; b. for benefits for Dependents, 75% of persons eligible under this contract who are not waiving coverage due to coverage elsewhere, are Insured for Contributory Benefits; c. 100% of persons eligible under this contract are Insured for Noncontributory Benefits; or d. 10 Members are insured by this contract. 3. on any Prepayment Fee Due Date, by giving the Organization 60 days advance Written notice, if the Organization fails to provide information on a timely basis or perform any obligations required by this contract or any applicable law; or 4. on any Contract Anniversary, except during a Rate Guarantee Period as may be provided in the Exhibits, by giving the Organization 31 days advance Written notice. This contract will end on the date on which the last evidence of coverage in effect under this contract ends. If this contract ends, all Prepayment Fees due must be paid. If SafeGuard accepts a Prepayment Fee after the date this contract ends, such acceptance will not act to reinstate the contract. SafeGuard will refund any unearned Prepayment Fee. Within 30 days of the end of this contract, SafeGuard will refund to Organization the pro rata portion of the Prepayment Fee which corresponds to any unexpired term for which a Prepayment Fee has been received, together with any amounts due on claims, if any, less amounts due SafeGuard. SafeGuard shall be paid the Prepayment Fee to the date this contract ends. Notice of end of contract. If SafeGuard ends this contract, it will notify Organization in Writing and Organization shall, within 5 calendar days, mail promptly to each Member a legible, true copy of the notice of cancellation and shall provide SafeGuard proof of such mailing and the date thereof within 2 calendar days of such mailing. Organization shall also have the obligation to provide notice to the Member when this contract has actually been terminated within five (5) calendar days of such termination. Notice of cancellation of Covered Person's benefits. If, without ending the contract, SafeGuard cancels a Covered Person's benefits under this contract because the Covered Person makes an intentional misrepresentation or participates in fraud in the use of services or facilities, it will notify Organization in Writing and Organization shall, within 5 calendar days, mail promptly to the Member a legible, true copy of the notice of cancellation and shall provide SafeGuard proof of such mailing and the date thereof within 2 calendar days of such mailing. If Organization fails to provide such notices as required under this contract, SafeGuard will provide such notices to the Members and will retain the right of recourse against Organization for failure to perform under this contract. GPNP10-DHMO 25C-8 Page 6/CA REINSTATEMENT Receipt by SafeGuard of a Prepayment Fee after cancellation of this contract for non-payment shall reinstate this contract as though it had never been cancelled if a Prepayment Fee is received on or before the due date of the succeeding Prepayment Fee. The Organization may request to reinstate this contract within one year from the date it ended. The request must be in Writing and it must provide SafeGuard with information that SafeGuard requires to consider such request. If SafeGuard approves the request, the contract will be reinstated on the date stated in Writing by SafeGuard. GENERAL PROVISIONS Entire Contract. The entire contract is made up of the following: 1. this contract, including Its Exhibits; 2. the Organization's Application For Group Dental Benefits; and 3. the amendments and endorsements to this contract. Contract Changes or Waivers. The terms and provisions of this contract may be changed, at any time, without the consent of the Covered Persons or anyone else with a beneficial interest in It. SafeGuard will issue amendments and endorsements to effect such changes. SafeGuard will only make changes that are consistent with applicable law. An amendment or endorsement will not affect the benefits provided under evidences of coverage issued before the effective date of the change, unless retroactivity is consistent with applicable law. An officer of SafeGuard must approve in Writing any change or waiver of the terms and provisions of this contract. A sales representative, or other SafeGuard employee, who is not an officer of SafeGuard, does not have SafeGuard's authority to approve such changes or waivers. A change or waiver will be evidenced by an amendment Signed by an officer of SafeGuard and the Organization or an endorsement Signed by an officer of SafeGuard. A copy of the amendment or endorsement will be provided to the Organization for attachment to this contract. Incontestability: Statements Made by the Organization. Any statement made by the Organization will be considered a representation and not a warranty. SafeGuard will not use such statement to avoid or reduce benefits or defend a claim unless it is contained in a Written application. Incontestability: Statements Made by Covered Persons. Any statement made by a Covered Person will be considered a representation and not a warranty. SafeGuard will not use such statement to avoid or reduce benefits or defend a claim unless the following requirements are met: 1. the statement is in a Written application or enrollment form; 2. the Covered Person has Signed the application or enrollment form; and 3. a copy of the application or enrollment form has been given to the Covered Person or his beneficiary. SafeGuard will not use such statements to contest an Increase or benefit addition after the Increase or benefit has been in force for 2 years during his life, unless the statement is fraudulent. GPNP10-DHMO 25C-9 Page 7/CA GENERAL PROVISIONS (continued) Evidence of Coverage. SafeGuard will issue an evidence of coverage to the Organization for delivery to each Covered Person, as appropriate. The evidence of coverage will describe the Covered Person's benefits and rights under this contract. "Evidence of coverage" includes any of SafeGuard's schedules of benefits, notices or other attachments to the evidence of coverage. Participating Providers. The Directory of Participating Providers contains a complete listing of Selected General Dental Offices. Selected General Dental Offices may also be located by accessing www.metlfe.com/mybenefiits to view Selected General Dental Offices by zip code. SafeGuard will maintain a contractual relationship with dental facilities at appropriate locations to provide services to Covered Persons. The Organization recognizes that the establishment maintenance and location of all dental facilities are within the sole discretion of SafeGuard; and SafeGuard shall make the sole determination of the location and establishment of a contractual relationship with all such dental facilities. SafeGuard agrees to promptly notify Covered Persons and the Organization in writing of the termination, breach of contract by, inability to perform of, or closure of any participating dental facility and to transfer Covered Persons to existing or alternate dental facilities. Assignment. The rights and benefits under this contract are not assignable prior to a claim for benefits, except as required by law or as permitted by SafeGuard. Data Needed. The Organization will provide SafeGuard with all the data needed to compute the Prepayment Fee and cant' out the terms of this contract. SafeGuard may examine such data at any reasonable time. If SafeGuard or the Organization make a clerical error in keeping the data, the Prepayment Fee and/or benefits will be adjusted according to the correct data. An error will not end benefits validly In effect, nor will it continue benefits validly ended. Misstatement of Age. If a Covered Person's age is misstated, the correct age will be used to determine if benefits are in effect and, as appropriate, adjust the Prepayment Fee and/or benefits. Non -Dividend Paying. This contract does not pay dividends. Conformity with Law. If the terms and provisions of this contract do not conform to any applicable law, this contract shall be interpreted to so conform. GPN P10-DHMO 25C-10 Page 8 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: MARIA HUIZAR Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney Laura A. Rossini Senior Assistant City Attorney RECOMMENDED FOR APPROVAL: CITY OF SANTA ANA Raul Godinez, II City Manager SAFEGUARD HEALTH PLANS, INC. (Name) (Title) Ellen Smiley Assistant Executive Director of Personnel Services 25C-11 SCHEDULE OF EXHIBITS Exhibit Effective Number Exhibit Type Applies To Date 1 Prepayment Fee Schedule All Covered Persons January 1, 2017 2 Evidence of Coverage All Covered Persons January 1, 2017 3 Schedule of Benefit All Covered Persons January 1, 2017 GPNP10-DHMO SCHIEXHIBITS 25C-12 EXHIBIT 1 PREPAYMENT FEE SCHEDULE The initial monthly Prepayment Fee for the benefits provided by this contract are determined as follows: Rate Guarantee Period Subject to the Right to Change the Prepayment Fee provision on page 4, the Prepayment Fee for Specialized Health Care Service Plan Benefits will be in effect from January 1, 2017 through December 31, 2017. Specialized Health Care Service Plan Benefits: Amount per unit for Specialized Health Care Service Plan Benefits in force hereunder Member Only $27,70 Member and Family $47.34 GPNP10-DHMO DATE: January 1, 2017 EXHIBIT 1 25C-13 EXHIBIT 2 EVIDENCE OF COVERAGE FORMS EOC Number GPNP10-DHMO EDC Form GCERT2011-DHMO-EOC Applies To All Covered Persons - DATE: January 1, 2017 25C-14 Effective Date January 1, 2017 EXHIBIT 2 Meftife Benefits Provided by SafeGuard Health Plans, Inc., a MetLife company 200 Park Avenue, New York, New York 10166-D188 COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE STATEMENT SafeGuard Health Plans, Inc. ("SafeGuard"), a MetLife company, certifies that You and Your dependents are covered for the benefits described in this evidence of coverage and disclosure statement , subject to the provisions of this evidence of coverage. This evidence of coverage is issued to You under the group contract and it includes the terms and provisions of the group contract that describe Your benefits. PLEASE READ THIS EVIDENCE OF COVERAGE CAREFULLY. This evidence of coverage is part of the group contract. The group contract is a contract between SafeGuard and Your Organization and may be changed or ended without Your consent or notice to You. THIS EVIDENCE OF COVERAGE ONLY DESCRIBES DENTAL BENEFITS. REVIEW THIS CERTIFICATE CAREFULLY. IF YOU ARE 65 OR OLDER ON YOUR EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY RETURN IT TO US WITHIN 30 DAYS FROM THE DATE YOU RECEIVE IT AND WE WILL REFUND ANY PREMIUM YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL BE CONSIDERED TO NEVER HAVE BEEN ISSUED. WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICES) CAREFULLY. GCERT2011-DHMO-EOC 25C-15 TABLE OF CONTENTS Section Paae NOTICE FOR RESIDENTS OF CALIFORNIA.................................................................................................... 4 Confidentiality of Dental Records.................................................................................................................... 4 OrganDonation............................................................................................................................................... 4 LanguageAssistance...................................................................................................................................... 4 NOTICE FOR RESIDENTS OF ALL STATES.................................................................................................... 5 Notice Regarding Your Rights and Responsibilities........................................................................................ 5 Rights........................................................................................................................................................... 5 Responsibilities............................................................................................................................................ 5 DENTALBENEFITS............................................................................................................................................6 Dentist -Patient Relationship............................................................................................................................ 6 WhoMay Enroll............................................................................................................................................... 6 SERVICEAREA.................................................................................................................................................. 7 DEPENDENTCOVERAGE................................................................................................................................. 7 WHEN COVERAGE BEGINS............................................................................................................................. 7 Choiceof Dentists............................................................................................................................................7 Facilities........................................................................................................................................................... 7 Changing Your Selected General Dental Office .............................................................................................. 6 ProviderReimbursement................................................................................................................................. 8 Liability of Subscriber or Enrollee for Payment................................................................................................8 PrepaymentFee...........................................................................................................................................8 Co-Payments............................................................................................................................................... 8 Orthodontic Covered Services..................................................................................................................... 9 YearlyMaximums.........................................................................................................................................9 Covered Services After Dental Coverage Ends........................................................................................... 9 Non -Covered Services................................................................................................................................. 9 OtherCharges..............................................................................................................................................9 Reimbursement Provisions.............................................................................................................................. 9 SpecialtyCare Referrals.................................................................................................................................. 9 SecondOpinion............................................................................................................................................. 10 EmergencyDental Care................................................................................................................................ 10 TERMINATION OF BENEFITS......................................................................................................................... 11 Cancellationof Benefits................................................................................................................................. 11 RenewalProvisions....................................................................................................................................... 12 Reinstatement................................................................................................................................................12 Disen rollment................................................................................................................................................. 12 CONTINUITYOF CARE................................................................................................................................... 12 CurrentMembers........................................................................................................................................... 12 NewMembers................................................................................................................................................12 DENTAL BENEFITS: INQUIRIES AND GRIEVANCE PROCEDURES............................................................13 Routine Questions About Dental Benefits..................................................................................................... 13 GrievanceProcedures................................................................................................................................... 13 Arbitration ......... :.................................... ............... ............ ......... ................. ......... .................... .... ............ ...... 14 Coordinationof Benefits................................................................................................................................ 14 ThirdParty Liability .....................................................................................................:.................................. 14 Assignmentof Benefits.................................................................................................................................. 14 INDIVIDUAL CONTINUATION OF DENTAL BENEFITS WITH PAYMENT OF THE PREPAYMENT FEE..... 14 For Mentally Or Physically Handicapped Children........................................................................................ 14 ForFamily And Medical Leave...................................................................................................................... 15 AtThe Organization's Option.........................................................................................................................15 COBRA CONTINUATION FOR DENTAL BENEFITS....................................................................................... 15 Cal -Cobra Continuation For Dental Benefits................................................................................................. 15 Events that Allow Continuation, and Length of Continuation..................................................................... 15 NewDependents........................................................................................................................................16 Termination of Coverage............................................................................................................................16 Notice and Election of Coverage................................................................................................................16 Costof Continued Coverage...................................................................................................................... 17 Payment of the Prepayment Fees..............................................................................................................17 Exceptions..................................................................................................................................................17 GCERT2011-DHMO-EOC 25^-16 Continuationunder a New Plan................................................................................................................. 18 GENERALPROVISIONS.................................................................................................................................. 18 EntireContract............................................................................................................................................... 18 Incontestability: Statements Made by You.....................................................................................................18 Misstatementof Age...................................................................................................................................... 18 Conformitywith Law...................................................................................................................................... 18 PublicPolicy Committee................................................................................................................................ 18 DEFINITIONS.................................................................................................................................................... 19 GCERT2011-DHMO-EOC 25^-17 3 NOTICE FOR RESIDENTS OF CALIFORNIA This evidence of coverage provides contract operates, Your entitlements, combined evidence of coverage i detailed summary of how your SafeGuard dental and the contract's restrictions and limitations. This and disclosure statement constitutes only a summary of the contract. The contract must be terms and conditions of coverage. If You have sl read carefully those sections that apply to You. You requesting it from the Organization, or by writing to Legal Department, 5 Park Plaza, Suite 1850, Irvine, 880-1800. consulted to determine the exact recial health care needs, You should may obtain a copy of the contract by SafeGuard Health Plans, Inc., Attn: CA, 92614-2533, or by calling (800) This evidence of coverage and disclosure statement is subject to Chapter 2.2 of Division 2 of the California Health and Safety Code (commonly referred to as the Knox -Keene Act) and the regulations Issued thereto by the Department of Managed Health Care, Should either the law or the regulations be amended, such amendments shall automatically be deemed to be a part of this document and shall take precedence over any inconsistent provision of this contract. Any provision required to be in this evidence of coverage and disclosure statement by either law or the regulation shall automatically bind SafeGuard. Pursuant to Section 1365(b) of the Knox -Keene Health Care Service Plan Act of 1975, as amended, an enrollee or subscriber who alleges that his or her enrollment has been canceled or not renewed because of his or her health status or requirements for health care services may request a review by the Director of California Department of Managed Health Care. If the Director determines that a proper complaint exists, the Director shall notify SafeGuard. Within 15 days after receipt of such notice, SafeGuard shall either request a hearing or reinstate the enrollee or subscriber. If, after hearing, the Director determines that the cancellation or failure to renew is improper, the Director shall order SafeGuard to reinstate the enrollee or subscriber. A reinstatement pursuant to this provision shall be retroactive to the time of cancellation or failure to renew and SafeGuard shall be liable for the expenses incurred by the subscriber or enrollee for covered health care services from the date of cancellation or non -renewal to and including the date or reinstatement. Confidentiality of Dental Records A STATEMENT DESCRIBING SAFEGUARD'S POLICIES AND PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF DENTAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST. Organ Donation Donating organs and tissues provides many societal benefits. Organ and tissue donation allows recipients of transplants to go on to lead fuller and more meaningful lives. Currently, the need for organ transplants far exceeds availability. If You are interested in organ donation, please speak with Your physician. Organ donation begins at the hospital when a person is pronounced brain dead and is identified as a potential organ donor. An organ procurement group will become involved to coordinate the activities. Language Assistance As a SafeGuard Member You have a right to free language assistance services, including interpretation and translation services. SafeGuard collects and maintains Your language preferences, race, and ethnicity so that we can communicate more effectively with our Members. If You require spoken or Written language assistance or would like to inform SafeGuard of Your preferred language, please contact us at (BOD) 880- 1800. x(800) 880.2800. GCERT2011-DHMO-EOC 25C-1 8 Como miembro de SafeGuard usted tiene derecho a recibir servicios gratuitos de asistencia an Idiomas. Esto incluye servicios de interpretaci6n y traducci6n, SafeGuard recaba la informac16n sobre sus preferencias de idloma, raze, y etnia de manera qua nos podamos comunicar eficazmente con nuestros afiliados. Si necesita asistencia verbal o escrita an su idloma o quiere Informarle a SafeGuard sobre su idiom@ de preferencia, comunlquese con nosotros at (800) 880-1800. NOTICE FOR RESIDENTS OF ALL STATES Notice Regarding Your Rights and Responsibilities Rights: • During the term of the group contract between SafeGuard and Your Organization, SafeGuard will not decrease any benefits, increase any Co -Payment, or the Prepayment Fee, or change any exclusion or limitation, except after at least 30 days Written notice to Your Organization. • We will provide Written notice within a reasonable time to Your Organization of any termination or breach of contract by, or inability to perform of, any contracting provider if Your Organization may be materially and adversely affected. • We will not cancel or fail to renew Your enrollment in this group contract because of your health condition or your requirements for dental rare. • We will treat communications, financial records and records pertaining to Your care in accordance with all applicable laws relating to privacy. • Decisions with respect to dental treatment are the responsibility of You and Your Selected General Dentist. We neither require nor prohibit any specified treatment. However. • Only certain specified services are Covered Services. Please see the Schedule of Benefits. Please also review the DENTAL BENEFITS section of this evidence of coverage for more details. • Your Selected General Dentist must follow the rules and limitations set up by SafeGuard and conduct his or her professional relationship with You within the guidelines established by SafeGuard. If SafeGuard's relationship with Your Selected General Dentist ends, Your Selected General Dentist must complete any and all treatment in progress. SafeGuard will arrange a transfer for You to another Selected General Dentist to provide for continued coverage under the group contract. As indicated on Your enrollment form, Your signature authorizes SafeGuard to obtain copies of your dental records, if necessary. • You may request a response from SafeGuard to any Written concern or complaint. Responsibilities: • You should identify Yourself to Your Selected General Dentist as a covered person under the group contract. If You fail to do so, You may be charged the Selected General Dentist's usual and customary fees instead of the applicable Co -Payment, if any. • You should treat the Selected General Dentist and his or her office staff with respect and courtesy and cooperate with the prescribed course of treatment. If You continually refuse a prescribed course of treatment, Your Selected General Dentist or Specialty Care Dentist has the right to refuse to treat You. SafeGuard will facilitate second opinions and will permit You to change Your Selected General Dental Office; however, SafeGuard will not interfere with the dentist -patient relationship and cannot require a particular dentist to perform particular services. • You should contact the Selected General Dental Office twenty-four (24) hours in advance to cancel an appointment. If You do not, You may be charged a missed appointment fee. • You are responsible for the prompt payment of any charges for services performed by the Selected General Dentist. If the Selected General Dentist agrees to accept part of the payment directly from SafeGuard, You are responsible for prompt payment of the remaining part of the Selected General Dentist's charge. GCERT2011-DHMO-EOC 25C-1 9 • You should notify SafeGuard of changes In family status. If You do not, SafeGuard will be unable to authorize dental care for You and/or Your dependents. • You should consult with Your Selected General Dentist about treatment options, proposed and potential procedures, anticipated outcomes, potential risks, anticipated benefits and alternatives. You should share with Your Selected General Dentist the most current, complete and accurate information about Your medical and dental history and current conditions and medications. • You should follow the treatment plans and health care recommendations agreed upon by Your Selected General Dentist. DENTAL BENEFITS The group contract provides access to You and Your dependents to dental benefits through the use of Selected General Dentists. When You or a dependent receive dental services; You and not Us or Your Organization are solely responsible for payment of all Co -Payments and other charges listed In the Schedule of Benefits and for any excluded procedure, and must make payment directly to the Selected General Dentist rendering such services. Dentist -Patient Relationship We do not provide dental services. Whether or not benefits are available for a particular service does not mean You or Your dependents should or should not receive the service. You and Your dependents, along with the Selected General Dentist have the right and are responsible at all times for choosing the course of treatment and services to be performed, The relationship between You and Your dependents and the Selected General Dentist rendering services or treatment shall be subject to the rules, limitations and privileges incident to the professional relationship, and SafeGuard's Peer Review Committee and Public Policy Committees. The Selected General Dentist shall be solely responsible to You or Your dependent, without interference from SafeGuard or Your Organization, for all services or treatment within the professional relationship. The Selected General Dentist shall have the right to refuse treatment if You or Your dependents continually fail to follow a prescribed course of treatment, use the relationship for illegal purposes, or make the professional relationship onerous. While SafeGuard desires and will actively seek to contract with the most modem dental facilities available in the profession, it is understood and agreed that the operation and maintenance of the Selected General Dentist's facility, equipment and the rendition of all professional services shall be solely and exclusively under the control and supervision of the Selected General Dentist, including all authority and control over the selection of staff, supervision of personnel, and operation of the professional practice and/or the rendition of any particular professional service or treatment. SafeGuard will undertake to see that the services provided to You or Your dependents by Selected General Dentists shall be performed in accordance with professional standards of reasonable competence and skill of dental practitioners, as applicable, prevailing in the community in which each Selected General Dentist practices. Upon termination of a provider contract with a Selected General Dentist, SafeGuard is liable for Covered Services rendered by such provider (other than for Co -Payments) to You or Your dependents who remain under the care of such provider at the time of such termination until the services being rendered are completed, unless We make reasonable and medically appropriate provision for the assumption of such services by another Selected General Dentist. In the event of termination of this group contract, each Selected General Dentist shall complete all dental procedures which have been started prior to the date of termination, pursuant to the terms and conditions of this group contract. Who May Enroll Your Organization is responsible for determining eligibility. You may enroll Yourself and Your dependents, provided each meets Your Organization's eligibility requirements and/or the Service Area and dependent coverage requirements listed below. GCERT2011-DHMO-EOC 25C_20 SERVICE AREA SafeGuard's service area is the geographic region in the state of California where SafeGuard is authorized by the California Department of Managed Health Care to provide Covered Services to Members and in which SafeGuard has a panel of Selected General Dentists and Specialty Care Dentists who have agreed to provide care to SafeGuard members, To enroll in the SafeGuard plan, You and Your dependents must reside, live, or work in the Service Area. DEPENDENT COVERAGE Your Organization is responsible for determining dependent eligibility. In the absence of such a determination, SafeGuard defines eligible dependents as: • Your lawful Spouse or domestic partner; • Your children or grandchildren up to age 28 for whom You provide care, including adopted children, step -children, or other children for whom You are required to provide dental care pursuant to a court or administrative order; • Your children who are incapable of self-sustaining employment and support due to a developmental disability or physical handicap; and • Other dependents if Your Organization provides benefits for these dependents. Please checkwith Your Organization if you have questions regarding your eligibility requirements. WHEN COVERAGE BEGINS Coverage for You and Your enrolled dependents will begin on the date determined by Your Organization. Newborn children are covered the day of birth as long as You are enrolled; legally adopted children, foster children and stepchildren are covered the first day of the month following placement as long as SafeGuard is notified within ninety (90) days. Your coverage will begin on the date determined by Your Organization. Waiting periods for eligibility, if applicable, are determined by Your Organization. Adopted child are covered from the earlier of the moment the child is placed in Your residence, and the child's birth, if You have entered into a written agreement to adopt the child prior to its birth. Newborn children are covered the first day of the month following the date of birth, and foster children and stepchildren are covered the first day of the month following placement as long as Your Organization is notified within 90 days and any Prepayment Fee is paid within that period. Check with Your Organization if You have any questions about when Your coverage begins Choice of Dentists PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS DENTAL CARE MAY BE OBTAINED. When enrolling for dental benefits, You and Your dependents must choose a Selected General Dental Office from Our network. You and Your dependents each may select a different Selected General Dental Office. If You do not select a Selected General Dental Office or the one you chose is not available, SafeGuard may do so for You. Please refer to the Directory of Participating Providers for a complete listing of Selected General Dental Offices. You may obtain a Directory of Participating Providers from Our website www.metlife.com\ mybenefits or by calling (800) 880-1800. Facilities You may obtain a list of SafeGuard's Selected General Dental Offices and their hours of availability by calling SafeGuard at (800) 880-1800. A list of SafeGuard's participating General Dental Offices can be found it is Directory of Participating Providers or online at www.metlife.com\mybenefits. GCERT2011-DHMO-EOC 25C-21 Changing Your Selected General Dental Office You or Your dependent may change Selected General Dental Offices at any time. To do so, please contact Us at (800) 880-1800. We will help You locate a convenient Selected General Dental Office. The transfer will be effective on the first day of the month following the transfer request. There is no limit to how often You or Your dependent may change Selected General Dental Offices. You must pay all outstanding charges owed to Your or Your dependent's Selected General Dental Office before transferring to a new Selected General Dental Office. You may also have to pay a fee for the cost of duplicating x-rays and dental records. Provider Reimbursement By statute, every contract between SafeGuard and its providers state that, in the event SafeGuard fails to pay the provider, You shall not be liable to the provider for any sums owed by SafeGuard. Selected General Dental Offices will collect all applicable co -payments from you directly at the time of service and then bill SafeGuard for reimbursement according to the contracted plan provisions. Selected General Dental Offices are paid on a per member, per month, or "capitated" basis for members that have selected the Selected General Dental Office and may receive an additional or supplemental fee for certain procedures performed. Specialty Care Dentists are compensated according to a negotiated fee schedule. No bonuses or incentives are paid to Selected General Dental Offices or Specialty Care Dentists. For additional information, you may contact SafeGuard at (800) 880-1800 or speak directly with Your provider. Liability of Subscriber or Enrollee for Payment Covered Services must be performed by Your Selected General Dental Office or a Specialty Care Dentist to whom You are referred in accordance with the terms of Your evidence of coverage and Schedule of Benefits. Services performed by any Out -of -Network Dentist are not Covered Services, without prior approval by SafeGuard or Your Selected General Dentist, in accordance with the terms of Your evidence of coverage and Schedule of Benefits (except for out -of -area emergency services). If You or Your dependent self -refer to a Selected General Dentist (other than Your or Your dependent's Selected General Dentist) or an Out -of - Network Dentist, You are responsible for the cost of those services. Prepayment Fee Your Organization prepays Us for Your and Your dependent's coverage. If You are responsible for any portion of this Prepayment Fee, Your Organization will advise You of the amount and how it is to be paid. Please refer to the Co -Payment section, below, for Information relating to Your Co -Payments under this group contract. The Prepayment Fee is not the same as a Co -Payment. The exact Prepayment Fee is contained in the group contract between Us and Your Organization. You may obtain a copy of the group contract from Your Organization, or by writing to SafeGuard Health Plans, Inc., Attn: Legal Department, 5 Park Plaza, Suite 1850, Irvine, CA 92614-2533, or by calling (800) 880-1800. Co -Payments When You or Your dependent receive care from either a Selected General Dentist or a Specialty Care Dentist, You must pay the Co -Payment. The Co -Payment is a fixed dollar amount or a fixed percentage of the Maximum Allowed Charge of the Covered Services performed by Your Selected General Dentist for which We are not responsible, as shown in the Schedule of Benefits. When You or Your dependent are referred to a Specialty Care Dentist, the Co -Payment may be either a fixed dollar amount, or a percentage of the Maximum Allowed Charge. Please refer to the Schedule of Benefits for specific details. When You have paid the required Co -Payment, if any, You have paid in full. If We fail to pay the Selected General Dentist, You will not be liable to the Selected General Dentist for any sums owed by Us. If You or Your dependent choose to receive services from an Out -of -Network Dentist, You will be liable to the Out -of -Network Dentist for the cost of services unless specifically authorized by Us or in accordance with Emergency Dental Condition provisions of this evidence of coverage. We do not require claim forms. GCERT2011-DHMO-EOC 2 5C_2 2 Orthodontic Covered Services Orthodontic treatment is governed by the Schedule of Benefits. If Dental Benefits terminate after the start of Orthodontic treatment, You will be responsible for any additional incurred charges for any remaining Orthodontic treatment. Yearly Maximums The Schedule of Benefits lists the Yearly maximums for Covered Services, if applicable Covered Services After Dental Coverage Ends Dental services received after You or Your dependent's coverage terminates are not covered. Your Selected General Dentist must complete any dental procedure started on you before your termination, abiding by the terms and conditions of the plan. Orthodontic treatment is governed by the Orthodontic limitations listed in the Schedule of Benefits. If coverage from the plan ends after the start of Orthodontic treatment, You or Your dependent will be responsible for any costs Orthodontic treatment after coverage ends. Non -Covered Services IMPORTANT: If you opt to receive dental services that are not covered services under this plan, a participating dental provider may charge you his or her usual and customary rate for those services. Prior to providing a patient with dental services that are not a covered benefit, the dentist should provide to the patient a treatment plan that Includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about dental coverage options, you may call member services at (800) 880- 1800 or your insurance broker. To fully understand your coverage, you may wish to carefully review this evidence of coverage. Other Charges All other charges You may be required to pay under this evidence of coverage are listed in the Schedule of Benefits. You must pay all Co -Payments, or the percentage of the Maximum Allowed Charge that We are not responsible for under the group contract. Reimbursement Provisions You are financially responsible for the cost of any services received from Out -of --Network Dentist unless those services were arranged by Your or Your dependent's Selected General Dentist or were required to treat an Emergency Dental Condition. When You or Your dependent receive a Covered Service from an Out -0f -Network Dentist for an Emergency Dental Condition, You should request that the Out -of -Network Dentist bill Us. If the Dentist refuses to bill Us but agrees to bill You, You should immediately submit the bill to Us In accordance with the sub -section titled Emergency Dental Care. If you receive a bill or have paid for a Covered Service and seek reimbursement, please contact SafeGuard at (800) 880-1800. Once you have paid your Co -Payments for Covered Services at Your Selected General Dentist Office, you are no responsible for any other payments for Covered Services. Specialty Care Referrals During the course of treatment, Your Selected General Dentist may encounter situations that require the services of a Specialty Care Dentist. Your Selected General Dentist is responsible for determining when the services of a Specialty Care Dentist are necessary. How Specialty Care is accessed is determined by Your plan. Some plans allow self -referral while others require that Your Selected General Dentist refer You directly to a provider whose practice is limited to Specialty Care. Please consult the Schedule of Benefits for full information. GCERT2011-DHMO-EOC 25C-23 9 Second Opinion You or Your dependent may request a second opinion if there are unanswered questions about diagnosis, treatment plans, and/or the results achieved by such dental treatment. In addition, We or You or Your dependent's Selected General Dentist may also request a second opinion. There is no second opinion consultation charge. You or Your dependent will be responsible for the office visit Co -Payment as listed in the Schedule of Benefits. Reasons for a second opinion to be provided or authorized shall include, but are not limited to, the following: (1) If You or Your dependent question the reasonableness or necessity of recommended surgical procedures. (2) If You or Your dependent question a diagnosis or plan of care for a condition that threatens loss of life, loss of limb, loss of bodily function, or substantial impairment, including, but not limited to, a serious chronic condition. (3) If the clinical indications are not clear or are complex and confusing, a diagnosis is in doubt due to conflicting test results, or the treating Selected General Dentist is unable to diagnose the condition, and the enrollee requests an additional diagnosis. (4) If the treatment plan in progress is not improving Your or Your dependent's dental condition within an appropriate period of time given the diagnosis and plan of care, and You or Your dependent request a second opinion regarding the diagnosis or continuance of the treatment. Requests for second opinions are processed within five (5) business days of Our receipt of such request, except when an expedited second opinion is warranted; in which case a decision will be made and conveyed to You within twenty-four (24) hours. Upon approval, We will contact the consulting Selected General Dentist and make arrangements to enable You or Your dependent to schedule an appointment. All second opinion consultations will be completed by a Selected General Dentist with qualifications in the same area of expertise as the referring Selected General Dentist or Selected General Dentist who provided the initial examination or dental care services. You or Your dependent may request a second opinion or obtain a copy of the second dental opinion policy by contacting Us either by calling (800) 880-1800 or sending a written request to the following address: SafeGuard Go Customer Service PO Box 3594 Laguna Hills, CA 92654-3594 Emergency Dental Care Emergency Dental Care means dental screening, examination, and evaluation by a Dentist, or, to the extent permitted by applicable law, by appropriate personnel under the supervision of a Dentist to determine if an Emergency Dental Condition exists, and, if it does, the care and treatment necessary to relieve or eliminate the Emergency Dental Condition. All Selected General Dental Offices provide treatment for Emergency Dental Conditions twenty-four (24) hours a day, seven (7) days a week and We encourage You or Your dependent to seek care from Your Selected General Dental Office. If treatment for an Emergency Dental Condition is required, You or Your dependent may go to any dental provider, go to the closest emergency room, or call 911 for assistance, as necessary. Prior authorization is not required. Your reimbursement from Us for treatment for an Emergency Dental Condition, if any, is limited to the extent the treatment You or Your dependent received directly relates to the evaluation and stabilization of the Emergency Dental Condition. All reimbursements will be allocated in accordance with the group contract, subject to any exclusions and limitations. Hospital charges and/or other charges for care received at any hospital or outpatient care facility are not Covered Services. If You or Your dependent receive treatment for an Emergency Dental Condition, You will be required to pay the charges to the Dentist and submit a claim to Us for a benefits determination. If You or Your dependent seek treatment for an Emergency Dental Condition from a provider located more than fifty (50) miles away GCERT2011-DHMO-EOC 2 5^-2 4 10 from Your or Your dependent's Selected General Dentist, You or Your dependent will receive coverage for the treatment of the Emergency Dental Condition up to a maximum of fifty dollars ($50). To be reimbursed for treatment of an Emergency Dental Condition, You must notify Us after receiving such treatment. If You or Your dependent's physical condition does not permit such notification, You must make the notification as soon as it is reasonably possible to do so. Please include your name, ID number of the person who received treatment, address and telephone number on all requests for reimbursement. If You or Your dependent do not have an Emergency Dental Condition and a delay in receiving treatment would not be detrimental to Your or Your dependent's health, please contact Your or Your dependent's Selected General Dental Office or Our Customer Service Department at (800) 880-1800 to make reasonable arrangements for Your or Your dependent's care. TERMINATION OF BENEFITS Cancellation of Benefits Your coverage may be cancelled for any reason, after not less than sixty (60) days Written notice by either SafeGuard or Your Organization. Your coverage may be cancelled after not less than thirty (30) days Written notice for: • Non-payment of amounts due under the contract, except no Written notice will be required for failure to pay premium. • Failure to establish a satisfactory Dentist -patient relationship and if it is shown that SafeGuard has, in good faith, provided You with the opportunity to select an alternative Dentist, • Failure to reside, live or work in the Service Area. Your coverage may be cancelled for not less than fifteen (15) days Written notice for: • An intentional misrepresentation, except as limited by statute. • Fraud in the use of services or facilities, or on the part of Your Organization. • Such other good cause as agreed upon in the group contract. Your coverage may be cancelled Immediately: • Subject to any continuation of coverage and conversion privilege provisions, if applicable, if You do not meet eligibility requirements other than the requirements that You live, work or reside in the Service Area. • Upon termination of the group contract between SafeGuard and Your Organization, if expired and not renewed. If Your Organization fails to pay the Prepayment Fees through and including the final month of the group contract, all coverage may be terminated at the end of the group contract's grace period, and You may be responsible for the usual and customary fees for any services received from Your Selected General Dentist or Specialty Care Dentist during the period the Prepayment Fees went unpaid, Including the group contract's grace period. If You terminate from the plan while the contract between SafeGuard and Your Organization is in effect, Your coverage will extend to the end of the month following notice of termination. Your Selected General Dentist must complete any dental procedures started on You before Your termination, abiding by the terms and conditions of the plan. Your and Your dependents' enrollment will be cancelled as of the last day for which Prepayment Fees have been received, subject to compliance with notice requirements. In the event Your and Your dependents' enrollment is cancelled, SafeGuard will send such notification to Your Organization, which will, in turn, notify You. Your Organization will also send You notice when Your actual coverage is terminated. GCERT2011-DHMO-EOC 25C-25 11 Orthodontic treatment is governed by the Orthodontic limitations listed on Your Schedule of Benefits. If You terminate coverage from the plan after the start of Orthodontic treatment, You will be responsible for any additional incurred charges for any remaining Orthodontic treatment. Renewal Provisions Your Organization has contracted with SafeGuard to provide services for the time period specified in the group contract. Your coverage under the plan is guaranteed for that time period so long as You meet the eligibility requirements under the plan. When the group contract expires, it may be renewed. If renewed, it Is possible that the terms of the plan may have been changed. If changes to Covered Services, Co -payments or Your contribution to the Prepayment Fees have been made to a renewed contract, Your Organization will notify You not less than thirty (30) days before the effective date, Reinstatement Receipt by SafeGuard of the proper prepaid or periodic payment after cancellation of the contract for non- payment shall reinstate the contract as though It had never been cancelled if such payment is received on or before the due date of the succeeding payment. A Member who alleges that his or her enrollment has been cancelled or not renewed because of his or her health status or requirements for health care services may request a review by the Director of the California Department of Managed Health Care. If the Director determines that a proper complaint exists, the Director shall notify SafeGuard. Within fifteen (15) days after receipt of such notice, SafeGuard shall either request a hearing or reinstate the person as a Member. If, after the hearing, the Director determines that the cancellation or failure to renew is improper, the Director shall order SafeGuard to reinstate the person as a Member. A reinstatement pursuant to this provision shall be retroactive to the time of cancellation or failure to renew and SafeGuard shall be liable for the expenses incurred by the subscriber or enrollee for covered health care services from the date of cancellation or non -renewal to and including the date of reinstatement. Disenrollment You may disenroll from the plan at the end of the term of the group contract, Please contact Your Organization for more information. CONTINUITY OF CARE Current Members If You are a current Member of SafeGuard, You may be eligible to temporarily continue receiving Covered Services for You and/or Your dependents from a former Selected General Dentist Office or Specialty Care Dentist whose contract with SafeGuard is terminated (a "Terminated Provider") for treatment of certain specified dental conditions. Please call SafeGuard at (800) 880-1800 to see if You are eligible for this benefit. You may request a copy of SafeGuard's Continuity of Care Policy from SafeGuard. You must make a specific request to continue under the care of a Terminated Provider. SafeGuard is not required to continue Your care with Your Terminated Provider if You are not eligible under SafeGuard's Continuity of Care Policy or if SafeGuard cannot reach agreement with the Terminated Provider on the terms regarding Your and/or Your dependents' care in accordance with California law. New Members If You are a new Member of SafeGuard, You may be eligible to temporarily continue receiving Covered Services for You and Your dependents from an Out -of -Network Dentist for treatment of certain specified conditions if the services were being provided by an Out -of -Network Dentist at the time the Your coverage becomes effective. Please call SafeGuard at (800) 880-1800 to see If You may be eligible for this benefit. You may request a copy of SafeGuard's Continuity of Care Policy from SafeGuard. You must make a specific request to continue under the rare of the Out -of -Network Dentist. SafeGuard is not required to continue care with the Out -of -Network Dentist if You are not eligible under SafeGuard's Continuity of Care Policy or if SafeGuard cannot reach an agreement with the Out -of -Network Dentist on the terms regarding Your for You and Your dependents care in accordance with California law. GCERT2011-DHMO-EOC 25C-26 12 DENTAL BENEFITS: INQUIRIES AND GRIEVANCE PROCEDURES Routine Questions About Dental Benefits If You have any questions about dental benefits provided by the group contract, please call Us at (800) 880- 1800. Grievance Procedures If You or Your dependents have a grievance with Us or Your Selected General Dentist, You may submit such grievance by calling Our customer service department at (800) 880-1800. When You call, You may: • submit the grievance orally, or • request a grievance form to submit the grievance in Writing. To submit the grievance in Writing, complete the grievance form, or provide a detailed summary of Your grievance to: SafeGuard c/o Quality Management Department PO Box 3532 Laguna Hills, CA 92654-3532 You may also file a Written grievance via our website at www.metlife.com/mybenefits. Please click on Members, then °Forms to Print," and then "Grievance Forms". In all Written correspondence, please be sure to include at least the following information: • Your name, • Name of the Plan, • Identification Number of the person You are Writing about: and • Facility (or Selected General Dental Office) name and number. We agree to investigate and try to resolve complaints received. We will confirm receipt of Your complaint in writing within five (5) calendar days of receipt. We will resolve the complaint and communicate the resolution in writing within thirty (30) calendar days. A grievance must be filed within one hundred and eighty (180) days of the occurrence or incident that is the subject of the grievance. If Your grievance involves an imminent and serious threat to Your health, including but not limited to severe pain, potential loss of life, limb or major bodily function, You or Your provider may request an expedited review, and if Your grievance qualifies as an urgent grievance, We will process Your grievance within three (3) calendar days from receipt of Your request. You are not required to file a grievance with SafeGuard before asking the California Department of Managed Health Care ("Department") to review Your case on an expedited basis. The Department may be contacted at (1 -888 -HMO -2219), TDD line (1-877-688-9891) for the hearing and speech impaired, or http://www.hmohelp.ca.gov. The California Department of Managed Health Care ("Department") is responsible for regulating health care service plans. If You have a grievance against Your health plan, You should first telephone Your health plan at (800) 880-1800 and use Your health plan's grievance process before contacting the Department. Using this grievance procedure does not prohibit any potential legal rights or remedies that may be available to You. If You need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by Your health plan, or a grievance that has remained unresolved for more than sixty (60) days, You may call the Department for assistance. You may also be eligible for an Independent Medical Review ("IMR"). If You are eligible for ]MR. the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1 -888 -HMO -2219) and a TDD line (1- GCERT2011-DHMO-EOC 250-27 13 877-688-9891) for the hearing and speech impaired. The Department's Internet Web Site http://www.hmohelp.ca.gov has complaint forms, [MR application forms and instructions online. Arbitration Each and every disagreement, dispute or controversy which remains unresolved concerning the construction, interpretation, performance or breach of this contract, or the provision of dental services under this contract after exhausting SafeGuard's complaint procedures, arising between the Organization, a Member or the heir- at-law or personal representative of such person, as the case may be, and SafeGuard, its employees, officers or directors, or Selected General Dentist or their dental groups, partners, agents, or employees, may be voluntarily submitted to arbitration in accordance with the American Arbitration Association rules and regulations, whether such dispute involves a claim in tort, contract or otherwise. This includes, without limitation, all disputes as to professional liability or malpractice, that is as to whether any dental services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered. It also includes, without limitation, any act or omission which occurs during the term of this contract but which gives rise to a claim after the termination of this contract. Arbitration shall be initiated by Written notice to SafeGuard at 5 Park Plaza, Suite 1850, Irvine, CA, 92614-2533. Coordination of Benefits We do not coordinate benefits with any other carrier. If You have coverage with another carrier, please contact that carrier to determine whether coordination of benefits is available. Third Party Liability If benefits covered by the group contract or evidence of coverage are provided to treat an injury or illness caused by the wrongful act or omission of another person or third party, provided that You are made whole for all other damages resulting from the wrongful act or omission before SafeGuard is entitled to reimbursement. You shall: • Reimburse SafeGuard for the reasonable cost of services paid by SafeGuard to the extent permitted under California Civil Code section 3040 immediately upon collection of damages by You, whether by action or law, settlement or otherwise; and • Fully cooperate with SafeGuard's effectuation of its lien rights for the reasonable value of services provided by SafeGuard to the extent permitted under California Civil Code section 3040. SafeGuard's lien may be filed with the person whose act caused the injuries, his or her agent, or the court. SafeGuard shall be entitled to payment, reimbursement, and subrogation in third parry recoveries and You shall cooperate to fully and completely effectuate and protect the rights of SafeGuard, including prompt notification of a case involving possible recovery from a third party, Assignment of Benefits By accepting coverage under the group contract, You agree to cooperate in protecting the interest of SafeGuard under this provision and to execute and deliver to SafeGuard or its nominee any and all assignments or other documents which may be necessary.or proper to fully and completely effectuate and protect the rights of SafeGuard or its nominee. You also agree to fully cooperate with SafeGuard and not take any action that would prejudice the rights of SafeGuard under this provision. INDIVIDUAL CONTINUATION OF DENTAL BENEFITS WITH PAYMENT OF THE PREPAYMENT FEE For Mentally Or Physically Handicapped Children Benefits for a dependent child may be continued past the age limit if the child is incapable of self-sustaining employment because of a mental or physical handicap as defined by applicable law. Proof of such handicap GCERT2011-DHMO-EOC 2 5C-2 8 14 must be sent to Us within thirty-one (31) days after the date the child attains the age limit and at reasonable intervals after such date. Subject to the TERMINATION OF BENEFITS section, benefits will continue while such child: • remains incapable of self-sustaining employment because of a mental or physical handicap; and • continues to qualify as a child, except for the age limit. For Family And Medical Leave Certain leaves of absence may qualify under the Family and Medical Leave Act of 1993 (FMLA) for continuation of benefits. Please contact the Organization for information regarding the FMLA. At The Organization's Option Your Organization may elect to continue benefits by paying the Prepayment Fee for any of the reasons specified below. Please check with Your Organization if You have questions regarding continuation. If Your benefits are continued, benefits for Your dependents may also be continued. You will be notified by Your Organization how much You will be required to contribute. 1. For the period You are laid off, up to two (2) months. 2. For the period You are not at work due to injury or sickness, up to nine (9) months. 3. For the period You are not at work due to any other Organization approved leave of absence; up to two (2) months. At the end of any of the continuation periods listed above, Your benefits will be affected as follows: • if You return to work within these time periods, Your coverage will continue under the group contract; • if You do not return to work within these time periods, Your employment will be considered to end and Your benefits will end. If Your benefits end, Your dependents' benefits will also end. COBRA CONTINUATION FOR DENTAL BENEFITS The following applies to employers with 20 or more employees that are not church or government plans: If Dental Benefits for You or a dependent end, You or Your dependent may qualify for continuation of such benefits under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA). Please contact Your Organization for information regarding continuation of insurance under COBRA. Cal -Cobra Continuation For Dental Benefits If dental benefits for You or a dependent ends, You or Your dependent may qualify for continuation of such benefits under Cal -Cobra, section 1366.20 of the California Health and Safety Code. Events that Allow Continuation, and Length of Continuation You and Your dependent may continue dental benefits under this plan for a period of up to thirty-six (36) months, if Your dental benefits would otherwise end because: 1. Your employment ends for any reason other than Your gross misconduct, or 2. Your hours worked are reduced. Your Organization must notify us of Your termination or reduction of hours within thirty-one (31) days after Your termination or reduction of hours. GCERT2011-DHMO-EOC 25C-29 15 Your dependent may continue coverage under this plan for up to thirty-six (36) months if Your dependent's dental benefits would otherwise end because of: 1. Your divorce, 2. Your legal separation, 3. Your death or 4. Your becoming eligible for Medicare. Also, Your dependent child may continue coverage under this plan for up to thirty-six (36) months if such child's benefits would otherwise end because that child no longer qualifies as a dependent under the terms of this plan. New Dependents During the continuation period, a child of Yours that is: 1. born; 2. adopted by You; or 3. placed with You for adoption; will be treated as if the child were a dependent at the time benefits were lost due to an event described above. To obtain benefits for the child, You must enroll the child for coverage within thirty (30) days of birth, adoption or placement for adoption. Termination of Coverage With respect to each person who continues benefits, the continued benefits will end on the earliest of: 1. the end of the thirty-six (36) month continuation period; 2. the date of expiration of the last period for which the required payment was made; 3. the date this plan or coverage for Your class is cancelled; 4. the date the person becomes entitled to Medicare; 5. the date the person becomes covered by another group benefit plan that does not have an exclusion or limitation for preexisting conditions that applies to the person; 6. the date the person becomes covered or could become covered by Federal Cobra (Section 4980B of the United States Internal Revenue Code); 7. the date the person becomes covered or could become covered under a plan governed by Chapter 6A of the Public Health Service Act, 42 U.S.C. Section 300bb-1 at seq., relating to Requirements for Certain Group Health Plans for Certain State and Local Employees; 8. The first day of the first month that begins more than thirty-one (31) days after the date of final determination under Title I or Title XVI of the Social Security Act that the person is no longer disabled. Notice and Election of Coverage When You or Your dependents become entitled to continue benefits under the plan because of. 1. Your termination or 2. Your reduction of hours worked, We will send You, at Your last known address, the necessary Prepayment Fee information and enrollment forms and disclosures within fourteen (14) days. You or Your dependents, will then have sixty (60) days to elect to continue benefits from the latest of: 1. the date of the event that gives a right to continue coverage; GCERT2011-DHMO-EOC 25C-30 16 2. the date You are given notice of a right to continue coverage; and 3. the date coverage under this plan ends. When You or Your dependents become entitled to continue benefits under the plan because of: 1, Your or Your dependent's receipt of determination of disability under the terms of the Social Security Act; 2. Your dependent child's ceasing to qualify as a dependent under this plan; 3. Your divorce; 4. Your legal separation; 5. Your death; or 6. Your becoming eligible for Medicare; You or Your dependent must notify us within sixty (60) days. If We do not receive notice within sixty (60) days, the person or persons who would otherwise have been entitled to continued benefits will be disqualified from having dental benefits continued. You or Your dependent's notice and request for continued benefits must be in Writing and delivered to Us by first class mail or other reliable means of delivery including personal delivery, express mail, or private courier company. Cost of Continued Coverage Any person who elects to continue coverage under the plan must pay not more than one -hundred and ten percent (110%) of the full cost of that benefits (including both the share You now pay and the share Your Organization now pays), Payment of the Prepayment Fees The first Prepayment Fee must be paid within forty-five (45) days of Your election to continue benefits. Your first payment of the Prepayment Fee must be sufficient to pay all required Prepayment Fees and all Prepayment Fees due. The Prepayment Fee payment must be sent to Us by first class mail, certified mail or other reliable means of delivery, including personal delivery, express mail or private courier company. After the first Prepayment Fee payment, Your payments for continued coverage must be made on the first day of each month in advance. Failure to submit the correct Prepayment Fee amount within the forty-five (45) day period will disqualify the person(s) to whom the Prepayment Fee relates from receiving continuation coverage. Exceptions This right to continue coverage under this plan does not apply: 1. to a person who is not a resident of California; 2. to a person who is covered by or eligible to be covered by Medicare; 3. to a person who is covered or who becomes covered by another group benefit plan that does not have an exclusion or limitation for preexisting conditions that applies to the person; 4. to a person who is covered, becomes covered, or could become covered by Federal Cobra (Section 4980B of the United States Internal Revenue Code); 5. to a person who is covered, becomes covered, or could become covered under a plan governed by Chapter 6A of the Public Health Service Act, 42 U.S.C. Section 300bb-1 et seq., relating to Requirements for Certain Group Health Plans for Certain State and Local Employees; 6. to a person who fails to meet any one or more of the time limits set forth above for notice and election of coverage; 7, to a person who fails to submit the correct Prepayment Fee when or before it is due; 8. if at the time coverage under this plan ends Your Organization has twenty (20) or more employees; or 9. if Your Organization fails to notify Us of Your termination or reduction In hours within thirty-one (31) days. GCERT2011-DHMO-EOC 25C-31 17 Continuation under a New Plan Your Organization must notify each person who has continued benefits under this plan if this plan ends for any reason and is replaced by Your Organization with a new group plan. The notice must be given thirty (30) days before this plan ends. The notice will be sent to the last known address of the person who has continued coverage under this plan. If this plan ends, continued benefits under this plan will end. A person who has continued benefits under this plan may then elect similar coverage under Your Organization's new group plan, if any, for the balance of the period that the person would have remained covered under this plan. Continued benefits will end for that person if the person does not, within thirty (30) days of receiving notice that this plan has ended, enroll in the new plan and pay any required contribution to the cost of the new plan. Your Organization will provide benefit and contribution information, enrollment forms and instructions for enrolling in the new plan. This information will be sent to the last known address of the person who has a right to continue benefits. If Your Organization or any successor Organization or purchaser of Your Organization ceases to provide a similar group benefit plan to active employees, the right to continue benefits ends. GENERAL PROVISIONS Entire Contract Your dental benefits are provided under a group contract with Your Organization. The entire contract with Your Organization is made up of the following: 1. the group contract and its Exhibits, which include the evidence of coverage and Schedules of Benefits; 2. Your Organization's application; and 3, any amendments and/or endorsements to the group contract. Incontestability: Statements Made by You Any statement made by You will be considered a representation and not a warranty. We will not use such statement to avoid or reduce benefits or defend a claim unless the following requirements are met: 1, the statement is in a Written application or enrollment form; 2. You have Signed the application or enrollment form; and 3, a copy of the application or enrollment form has been given to You or Your Beneficiary. Misstatement of Age If Your or Your dependent's age is misstated, the correct age will be used to determine eligibility for dental benefits and, as appropriate, We will adjust the benefits and/or premiums. Conformity with Law If the terms and provisions of this evidence of coverage do not conform to any applicable law, this evidence of coverage shall be interpreted to so conform. Public Policy Committee The Public Policy Committee ("Committee") provides Our clients with the opportunity to participate in the review of quality improvement activities. Representatives of group contractholders, Selected General Dentists and Specialty Care Dentists, and Our employees, meet quarterly to discuss quality improvement activities and policies. If You are interested in being a representative to the Committee meeting, please contact Us at (800) 880-1800 and ask for the Director of Quality Management. GCERT2011-OHMO-EOC 25C-32 18 DEFINITIONS As used in this evidence of coverage, the terms listed below will have the meanings set forth below. When defined terms are used in this evidence of coverage, they will appear with initial capitalization. The plural use of a term defined in the singular will share the same meaning. Amalgam means a silver filling material usually used on posterior teeth. Anterior means teeth located in the front of the mouth — upper and lower six (6) teeth with three in each Quadrant of the mouth; twelve (12) teeth in total. Asymptomatic means without symptoms, the absence of any indication of disease, surrounding pathology or impaired function. Bicuspid means teeth located immediately in front of the molar teeth — upper and lower with two in each Quadrant of the mouth; eight (8) teeth in total. Bridge or Bridgework means a fixed replacement for one or more missing teeth that is permanently attached to the teeth adjacent to the empty space(s). Cast Restoration means an inlay, onlay, or crown. Co -Payment or Co -Pay means a fixed dollar amount or a fixed percentage of the Maximum Allowed Charge of the Covered Services performed by Your Selected General Dentist, for which We are not responsible, as shown in the Schedule of Benefits. You must pay Your Co -Payment at the time of delivery of supplies or services. Cosmetic means services performed solely for appearance. Treatment of decay, disease or injury to the teeth or supporting tissues of the teeth is not evident. Cosmetic means any procedure which is directed at improving the patient's appearance and does not meaningfully promote the proper function or prevent or treat illness or disease. Covered Service means a dental service used to treat Your or Your dependent's dental condition which is: • prescribed or performed by a Dentist while such person is covered for dental benefits; • Dentally Necessary to treat the condition; and • described in the Schedule of Benefits, or • Dental Benefits sections of this evidence of coverage. Crown means a restoration place over a tooth to strengthen and/or replace missing tooth structure. A crown can be made of different materials, for example, noble, high noble, and base metals, or porcelain or porcelain and metal. Dental Hygienist means a person trained to: • remove calcareous deposits and stains from the surfaces of teeth; and • provide information on the prevention of oral disease. The term does not include: • You; • Your Spouse; or • any member of Your immediate family including Your and/or Your Spouse's parents; children (natural, step or adopted); siblings; grandparents; or grandchildren. Dentally Necessary means that a dental service or treatment is performed in accordance with generally accepted dental standards and is: • necessary to treat decay, disease or injury of the teeth; or • essential for the care of the teeth and supporting tissues of the teeth. GCERT2011-DHMO-EOC 25C-33 19 Dentist means: • a person licensed to practice dentistry in the jurisdiction where such services are performed; or • any other person whose services, according to applicable law, must be treated as Dentist's services for purposes of the group contract. Each such person must be licensed in the jurisdiction where the services are performed and must act within the scope of that license. The person must also be certified and/or registered if required by such jurisdiction. • For purposes of dental benefits, the term will include a physician who performs a Covered Service. The term does not include: • You; • Your spouse; or • any member of Your immediate family including Your and/or Your spouse's parents; children (natural, step or adopted); siblings; grandparents; or grandchildren. Dentures means fixed partial dentures (bridgework), removable partial dentures and removable full dentures. Directory of Participating Providers means the list of Selected General Dentists from whom You must select to receive Covered Services. Domestic Partner means each of two people, of the same or opposite sex, one of whom is an employee of Your Organization, who represent themselves publicly as each other's domestic partner and have: • registered as domestic partners with a government agency or office where such registration is available; or • submitted a domestic partner declaration to Your Organization. The domestic partner declaration must establish that: • each person is 18 years of age or older; • neither person is married; • neither person has had another domestic partner within 6 months prior to the date they enrolled for insurance for the Domestic Partner under the Group Policy; • they have shared the same residence for at least 6 months prior to the date they enrolled for insurance for the Domestic Partner under the Group Policy; • they are not related by blood in a manner that would bar their marriage in the jurisdiction in which they reside; • they have an exclusive mutual commitment to share the responsibility for each other's welfare and financial obligations which commitment existed for at least 6 months prior to the date they enrolled for insurance for the Domestic Partner under the Group Policy, and such commitment is expected to last indefinitely; and • 2 or more of the following exist as evidence of joint responsibility for basic financial obligations: a joint mortgage or lease; designation of the Domestic Partner as beneficiary for life insurance or retirement benefits; joint wills or designation of the Domestic Partner as executor and/or primary beneficiary; designation of the Domestic Partner as durable power of attorney or health care proxy; ownership of a joint bank account, joint credit cards or other evidence of joint financial responsibility; or other evidence of economic interdependence. Your Organization will review the declaration and determine whether to accept the request to insure the Domestic Partner. Your Organization will inform the employee of its decision. GCERT2011-DHMO-EOC 2 5C-34 20 Emergency Dental Condition means a dental condition the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including, but not limited to, bleeding, swelling or severe pain, that a prudent layperson, possessing an average knowledge of dentistry and health, could reasonably expect the absence of Immediate dental attention to result in: • placing the health of the person afflicted with such condition in serious jeopardy; • serious impairment to such person's bodily functions; • serious impairment or dysfunction of any bodily organ or part of such person; or • serious disfigurement of such person. Endodontics means procedures that treat the nerve or the pulp of the tooth. These procedures are usually needed due to injury or infection of the tooth, Experimental means services that do not have endorsement from professional organizations whose role is to evaluate such Items. Services that are either unproven for the diagnosis or treatment of a condition or not generally recognized by the professional community as effective or appropriate for the diagnosis or treatment of a condition. Maximum Allowed Charge means the lesser of: • the amount charged by the Selected General Dentist or; the maximum amount which the Selected General Dentist has agreed with Us to accept as payment in full for the dental service. Member means an individual enrolled in the Safeguard dental plan. Oral Surgery means surgery performed in and around the mouth, to remove teeth, reshape portions of the bone or soft tissue, or biopsy suspect areas of the mouth. Organization means an employer or other entity that has contracted with Us to arrange for the provision of dental care benefits. Orthodontics means braces and other procedures or appliances to help align the upper and lower teeth. Out -of -Network Dentist means a Dentist who does not have a contractual agreement with Us to provide Covered Services to You or a dependent Periodontics means procedures related to treatment of the supporting structures of the teeth, such as gums and underlying bone. Posterior means teeth that have flat chewing surfaces, located in the back of the mouth - upper and lower twenty (20) teeth, including molars, bicuspids (premolars), and wisdom teeth. Prepayment Fee means the monthly fee paid to Us by Your Organization. The prepayment fee is not the same as a Co -Payment. Primary Teeth means the first set of teeth ("baby" teeth). Prophylaxis means a standard cleaning, the scaling and polishing of teeth to remove plaque and tarter above the gum line. Prosthodontics means the replacement of missing teeth with artificial substitutes. The appliances can be fixed (bridge or implant) or removable (dentures). Quadrant means one of the four equal sections into which Your mouth can be divided. GCERT2011-DHMO-EOC 25C-35 21 Reasonable and Customary Charge means the least of: • the amount charged by the Selected General Dentist for a Covered Service; • the usual amount charged by the Selected General Dentist for dental services which are the same as, or similar to, the Covered Service; or • the usual amount charged by other Selected General Dentist in the same geographic area for dental services which are the same as, or similar to, the Covered Service. Resin -based Composite means tooth -colored (white) fillings Selected General Dentist means a SafeGuard contracted dentist who agrees in Writing to provide dental services under special terms, conditions and financial reimbursement arrangements with SafeGuard. Selected General Dental Office means a dental office contracted with SafeGuard consisting of dentists who agree in Writing to provide dental services under special terms, conditions and financial reimbursement arrangements with SafeGuard. Service Area means the geographical area in which SafeGuard has a panel of Selected General Dentists and Specialty Care Dentists who have agreed to provide care to SafeGuard customers. To enroll in the SafeGuard plan, You and Your dependents (except dependent children) must, reside, live, or work in the Service Area. Signed means any symbol or method executed or adopted by a person with the present intention to authenticate a record, which is on or transmitted by paper or electronic media, which is acceptable to Us and consistent with applicable law. Specialty Care means services provided by an endodontist, periodontist, pediatric Dentist, oral surgeon, or orthodontist. These services may be covered at a Co -Payment, or at 75% of the Dentists Reasonable and Customary Charge. Specialty Care Dentist means a SafeGuard contracted dentist who agrees in Writing to provide Specialty Care services under special terms, conditions and financial reimbursement arrangements with SafeGuard. We, Us and Our mean SafeGuard Health Plans, Inc. Written or Writing means a record on or transmitted by paper or electronic media which is acceptable to Us and consistentwith applicable law. Year or Yearly means the 12 month period that begins January 1. You and Your mean a person, other than a dependent, who is covered under the group contract for the dental benefits described in this evidence of coverage. GCERT2011-DHMO-EOC 25^-36 22 MetLife Our Privacy Notice We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers, "Personal information" as used here means anything we know about you personally. This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, or group insurance or annuity contract. In this notice, "you" refers to these individuals. We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling It. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us. We typically collect your name, address, age, and other relevant Information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates Include life, car, and home insurers. They also include a bank, a legal plans company, and securities broker-dealers. In the future, we may also have affiliates in other businesses. We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don't control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources. We collect your personal information to help us decide if you're eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your Information to: • administer your products and services • process claims and other transactions • perform business research • confirm or correct your information • market new products to you • help us run our business • comply with applicable laws MWWIIIIICOSIMUM We may share your personal information without your consent if permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate orjoint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out. Other reasons we may share your information include: • doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas) • telling another company what we know about you if we are selling or merging any part of our business • giving information to a governmental agency so it can decide if you are eligible for public benefits CPN -Group -Ann -2015 25C-37 • giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on youraccount) • giving your information to your health care provider • having a peer review organization evaluate your information, if you have health coverage with us • those listed in our "Using Your Information" section above We will not share your health information with any other company — even one of our affiliates — for their own marketing purposes. The Health Insurance Portability and Accountability Act (" HIPAK) protects your information if you request or purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the information that we obtain as a result of your request or purchase of insurance. Information about your rights under HIPAA will be provided to you with any dental, vision, long-term care or medical coverage issued to you. You may obtain a copy of our HIPAA Privacy Notice by visiting our website at www.MetLife.com. Select "Privacy Policy" at the bottom of the home page. For additional information about your rights under HIPAA; or to have a HIPAA Privacy Notice mailed to you, contact us at HIPAAorivacyAmericasUS(@metlife.com, or callus at telephone number (212) 578-0299. You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is reasonably retrievable and within our control. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you anything we learned as part of a claim or lawsuit, unless required by law. If you tell us that what we know about you is incorrect, we will review it If we agree, we will update our records, Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife. We want you to understand how we protect your privacy. If you have any questions about this notice, please contact us. When you write, include your name, address, and policy or account number. Send privacy questions to: MetLife Privacy Office P. 0. Box 489 Warwick, RI 02887-9954 Privacy(),metlife.com We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies: Metropolitan Life Insurance Company MetLife Insurance Company USA SafeGuard Health Plans, Inc. CPN -Group -Ann -2015 MetLife Health Plans, Inc. General American Life Insurance Company SafeHeatth Life Insurance'Company 25C-38 EXHIBIT 3 SCHEDULE OF BENEFITS SOB Number GPNP10-DHMO SOB Form GCERT2010-DHMO-SOB Applies to All Covered Persons — 0041-D DATE: January 1, 2017 25C-39 Effective Date January 1, 2017 EXHIBIT 3 MetLeife SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* 0041-D This Schedule of Benefits lists the services available to you under your SafeGuard plan, as well as the co- payments associated with each service. There are other factors that impact how your plan works and those are Included here in the Exclusions & Limitations. We have also added some dental terminology definitions to help you better understand your plan - these can be found at the back of this Schedule. During the course of treatment, your SafeGuard selected general dentist may recommend the services of a dental specialist. 'Your SafeGuard selected general dentist is responsible for coordinating your dental care, and If necessary, referring you to a SafeGuard contracted specialist, and will submit all required documentation to SafeGuard for any necessary referral. Your and Your Dependent's Code Service uo-vayr Diagnostic Treatment D0120 Periodic oral evaluation - established patient $0 D0140 Limited oral evaluation - problem focused $0 D0145 Oral evaluation for a patient under three years of age and counseling with $0 primary caregiver D0150 Comprehensive oral evaluation - new or established patient $0 D0171 Re-evaluation — post-operative office visit $0 D0180 Comprehensive periodontal evaluation - new or established patient $0 Office visit — per visit (including all fees for sterilization and/or infection control $0 Radiographs / Diagnostic Imaging (X-rays) $0 D0210 Intraoral — complete series of radiographic Images $0 D0220 Intraoral — periapical first radiographic image $0 D0230 Intraoral — periapical each additional radiographic image $0 D0240 Intraoral — occlusal radiographic Image $0 D0250 Extraoral —first radiographic image $0 D0260 Extraoral — each additional radiographic image $0 D0270 Bitewing — single radiographic image $0 D0272 Bitewings — two radiographic images $0 D0273 Bitewings — three radiographic Images $0 D0274 Bitewings — four radiographic images $0 D0330 Panoramic radiographic image $0 D0350 2D oral/facial photographic image obtained intra -orally or extra -orally $0 Tests and Examinations D0460 Pulp vitality tests $0 D0470 Diagnostic casts $0 0041 -D -SOB 25C-40 1 01/15 SCHEDULE OF BENEFITS (Continued) 0041-D•SOB 25C-41 2 Your and Your Dependent's Code Service Co -Payment Preventive Services Procedures identified with an asterisk (`) are limited to twice a year, unless medically necessary. D1110 Prophylaxis — adult' $0 D1120 Prophylaxis — child' $0 D1206 Topical application of fluoride varnish' $0 D1208 Topical application of fluoride — excluding varnish $0 D1330 Oral hygiene instructions $0 D1351 Sealant — per tooth $0 D1510 Space maintainer — fixed — unilateral $0 D1515 Space maintainer — fixed — bilateral $0 D1520 Space maintainer— removable — unilateral $0 D1525 Space maintainer — removable — bilateral $0 D1550 Re -cement or re -bond space maintainer $0 D1555 Removal of fixed space maintainer $0 Restorative Treatment D2140 Amalgam — one surface, primary or permanent $0 D2150 Amalgam — two surfaces, primary or permanent $0 D2160 Amalgam — three surfaces, primary or permanent $0 D2161 Amalgam —four or more surfaces, primary or permanent $0 D2330 Resin -based composite — one surface, anterior $0 D2331 Resin -based composite — two surfaces, anterior $0 D2332 Resin -based composite — three surfaces, anterior $0 D2335 Resin -based composite — four or more surfaces or involving incisal angle $0 (anterior) D2390 Resin -based composite crown, anterior $0 Crowns The use of noble or high noble for any procedure will include additional lab fees. $75 fee per crown unit above co -pay for porcelain on molars. D2710 Crown — resin -based composite (indirect) $0 D2712 Crown —3/a resin -based composite (indirect) $0 D2740 Crown — porcelain/ceramic substrate $0 D2750 Crown — porcelain fused to high noble metal $0 D2751 Crown — porcelain fused to predominantly base metal $0 D2752 Crown — porcelain fused to noble metal $0 D2780 Crown - 3/4 cast high noble metal $0 D2781 Crown —3/ cast predominantly base metal $0 D2782 Crown — 3/a cast noble metal $0 D2790 Crown —full cast high noble metal $0 D2791 Crown —full cast predominantly base metal $0 D2792 Crown —full cast noble metal $0 0041-D•SOB 25C-41 2 SCHEDULE OF BENEFITS (Continued) Periodontics D4210 Gingivectomy or gingivoplasty — four or more contiguous teeth or tooth Your and Your bounded spaces per quadrant Dependent's Code Service Co -Payment D2794 Crown — titanium $0 D2910 Re -cement or re -bond inlay, onlay, veneer or partial coverage restoration $0 D2915 Re -cement or re -bond indirectly fabricated or prefabricated post and core $0 D2920 Re -cement or re -bond crown $0 D2930 Prefabricated stainless steel crown — primary tooth $0 D2931 Prefabricated stainless steel crown — permanent tooth $0 D2940 Protective restoration $0 D2950 Core buildup, including any pins when required $0 D2951 Pin retention — per tooth, in addition to restoration $0 D2952 Post and core in addition to crown, Indirectly fabricated $0 D2953 Each additional indirectly fabricated post — same tooth $0 D2954 Prefabricated post and core in addition to crown $0 D2970 Temporary crown (fractured tooth) $0 Endodontics All procedures exclude final restoration. $0 D3110 Pulp cap — direct (excluding final restoration) $0 D3120 Pulp cap — indirect (excluding final restoration) $0 D3220 Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to $0 the dentinocemental junction and application of medicament D3310 Endodontic therapy, anterior tooth (excluding final restoration) $0 D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) $0 D3330 Endodontic therapy, molar tooth (excluding final restoration) $0 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $0 D3346 Retreatment of previous root canal therapy — anterior $0 D3347 Retreatment of previous root canal therapy — bicuspid $0 D3348 Retreatment of previous root canal therapy — molar $0 D3351 Apexification/recalcification — initial visit (apical closure / calcific repair of $0 perforations, root resorption, etc.) D3410 Apicoectomy — anterior $0 D3421 Apicoectomy— bicuspid (first root) $0 D3425 Apiccectomy— molar (first root) $0 D3426 Apicoectomy (each additional root) $0 D3430 Retrograde filling — per root $0 Periodontics D4210 Gingivectomy or gingivoplasty — four or more contiguous teeth or tooth $0 bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty — one to three contiguous teeth or tooth bounded $0 spaces per quadrant D4240 Gingival flap procedure, including root planing — four or more contiguous teeth $0 or tooth bounded spaces per quadrant D4241 Gingival flap procedure, including root planing — one to three contiguous teeth $0 or tooth bounded spaces per quadrant D4260 Osseous surgery (including elevation of a full thickness flap and closure) — four $0 or more contiguous teeth or tooth bounded spaces per quadrant 0041 -D -SOB 25C-42 3 SCHEDULE OF BENEFITS (Continued) Removable Prosthodontics • Replacement limit I every 3 years. Your and Your • Denture relines: Twice in one year Dependent's Code Service Co -Payment D4261 Osseous surgery (including elevation of a full thickness flap and closure) — one $0 D5120 to three contiguous teeth or tooth bounded spaces per quadrant $0 D4341 Periodontal scaling and root planing —four or more teeth per quadrant $0 D4342 Periodontal scaling and root planing — one to three teeth per quadrant $0 D4356 Full mouth debridement to enable comprehensive evaluation and diagnosis $0 D4910 Periodontal maintenance $0 Removable Prosthodontics • Replacement limit I every 3 years. • Denture relines: Twice in one year • Includes up to 3 adjustments within 6 monthsof delivery. D5110 Complete denture — maxillary $0 D5120 Complete denture—mandibular $0 D5130 Immediate denture — maxillary $0 D5140 Immediate denture — mandibular $0 D5211 Maxillary partial denture — resin base (including any conventional clasps, rests $0 and teeth) D5212 Mandibular partial denture — resin base (including any conventional clasps, $0 rests and teeth) D5213 Maxillary partial denture— cast metal framework with resin denture bases $0 (including any conventional clasps, rests and teeth) D5214 Mandibular partial denture — cast metal framework with resin denture bases $0 (including any conventional clasps, rests and teeth D5410 Adjust complete denture — maxillary $0 D5411 Adjust complete denture — mandibular $0 D5421 Adjust partial denture — maxillary $0 D5422 Adjust partial denture — mandibular $0 D5510 Repair broken complete denture base $0 D5520 Replace missing or broken teeth — complete denture (each tooth) $0 D5610 Repair resin denture base $0 D5620 Repair cast framework $0 D5630 Repair or replace broken clasp $0 D5640 Replace broken teeth — per tooth $0 D565D Add tooth to existing partial denture $0 D6660 Add clasp to existing partial denture $0 05710 Rebase complete maxillary denture $0 D5711 Rebase complete mandibular denture $0 D5720 Rebase maxillary partial denture $0 D5721 Rebase mandibular partial denture $0 D5730 Reline complete maxillary denture (chairside) $0 D5731 Reline complete mandibular denture (chairside) $0 D5740 Reline maxillary partial denture (chairside) $0 D5741 Reline mandibular partial denture (chairside) $0 D5750 Reline complete maxillary denture (laboratory) $0 0041 -D -SOB 25C-43 4 SCHEDULE OF BENEFITS (Continued) Your and Your Dependent's Code Service Co -Paye D5751 Reline complete mandibular denture (laboratory) $0 D5760 Reline maxillary partial denture (laboratory) $0 D5761 Reline mandibular partial denture (laboratory) $0 D5820 Interim partial denture (maxillary) $0 D5821 Interim partial denture (mandibular) $0 D5850 Tissue conditioning, maxillary $0 D5851 Tissue conditioning, mandibular $0 Crowns/Fixed Bridges - Per Unit The use of noble or high noble for any procedure will include additional lab fees. $75 fee per crown/bridge unit above co -pay for porcelain on molars. D6206 Pontic— indirect resin based composite $0 D6210 Pontic—cast high noble metal $0 D6211 Pontic— cast predominantly base metal $0 D6212 Pontic — cast noble metal $0 D6214 Pontic—titanium $0 D6240 Pontic — porcelain fused to high noble metal $0 D6241 Pontic— porcelain fused to predominantly base metal $0 D6242 Pontic — porcelain fused to noble metal $0 D6250 Pontic — resin with high noble metal $0 D6251 Pontic — resin with predominantly base metal $0 D6252 Pontic — resin with noble metal $0 D6710 Crown — Indirect resin based composite $0 D6720 Crown — resin with high noble metal $0 D6721 Crown — resin with predominantly base metal $0 D6722 Crown — resin with noble metal $0 D6750 Crown — porcelain fused to high noble metal $0 D6751 Crown — porcelain fused to predominantly base metal $0 D6752 Crown — porcelain fused to noble metal $0 D6780 Crown — % cast high noble metal $0 D6781 Crown —3/<castpredominantly base metal $0 D6782 Crown — M cast noble metal $0 D6790 Crown —full cast high noble metal $0 D6791 Crown—full cast predominantly base metal $0 D6792 Crown —full cast noble metal $0 D6794 Crown—titanium $0 D6930 Re -cement or re -bond fixed partial denture $0 Oral Surgery • Includes routine post operative visits/treatment. • Surgical removal of impacted teeth - (not covered unless pathology (disease) exists). 0041 -D -SOB 25C-44 1; SCHEDULE OF BENEFITS (Continued) 0041 -D -SOB 25C-45 Your and Your Dependent's Code Service Co -Payment Surgical removal of wisdom tooth/third molar for orthodontic reasons only is not covered. D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $0 D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning $0 of tooth and including elevation of mucoperiosteal flap if indicated D7220 Removal of Impacted tooth — soft tissue $0 D7230 Removal of impacted tooth — partially bony $0 D7240 Removal of impacted tooth — completely bony $0 D7250 Surgical removal of residual tooth roots (cutting procedure) $0 D7285 Inclsional biopsy of oral tissue — hard (bone, tooth) $0 D7286 Incisional biopsy of oral tissue — soft $0 157310 Alveoloplasty In conjunction with extractions — four or more teeth or tooth $0 spaces, per quadrant D7311 Alveoloplasty in conjunction with extractions — one to three teeth or tooth $0 spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions — four or more teeth or tooth $0 spaces, per quadrant D7321 Alveoloplasty not in conjunction with extractions — one to three teeth or tooth $0 spaces, per quadrant D7960 Frenulectomy — aka frenectomy or frenotomy— separate procedure not Incidental to another procedure $0 D7903 Frenuloplasty $0 Orthodontics D8020 Limited orthodontic treatment of the transitional dentition (up to 24 months) $500 D8030 Limited orthodontic treatment of the adolescent dentition (up to 24 months) $500 D8040 Limited orthodontic treatment of the adult dentition (up to 24 months) $500 D8070 Comprehensive orthodontic treatment of the transitional dentition (full treatment case up to 24 months - including fixed/removable appliances) $1,000 D8080 Comprehensive orthodontic treatment of the adolescent dentition (full treatment case up to 24 months - including fixed/removable appliances) $1,000 D8090 Comprehensive orthodontic treatment of the adult dentition (full treatment case up to 24 months - including fixed/removable appliances) $1,000 D8660 Pre -orthodontic treatment examination to monitor growth and development $25 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $250 D8693 Re -cement or re -bond fixed retainers $0 Adjunctive General Services D9110 Palliative (emergency) treatment of dental pain — minor procedure $0 D9120 Fixed partial denture sectioning $0 D9215 Local anesthesia In conjunction with operative or surgical procedures $0 D9219 Evaluation for deep sedation or general anesthesia $0 D9310 Consultation — diagnostic service provided by dentist or physician other than requesting dentist or physician $0 0041 -D -SOB 25C-45 SCHEDULE OF BENEFITS (Continued) Your and Your Dependent's Code Service Co -Payment D9430 Office visit for observation (during regularly scheduled hours) — no other services performed $0 D9440 Office visit — after regularly scheduled hours $0 D9952 Occlusal adjustment—complete D9986 Missed appointment (less than 24 -hr notice) D9987 Cancelled appointment (if less than 24 -hr notice, see D9986) 0041 -D -SOB Current Dental Terminology © American Dental Association 25C-46 $0 Not to exceed $25 $0 Dental Terminology Definitions These definitions are designed to give you a "layman's understanding" of some dental terminology in order for you to better understand your plan; they are not full descriptions. Amalgam: A silver filling Anterior: Teeth that are in the front of the mouth Bicuspid: Most people have eight bicuspid teeth; they are located immediately preceding the molar teeth with two in each quadrant of the mouth. Bridge: A replacement for one or more missing teeth that is permanently attached to the teeth adjacent to the empty space(s), Crown: A covering created to place over a tooth to strengthen and/or replace tooth structure. A crown can be made of different materials (noble, high noble), base metal, porcelain or porcelain and metal. Endodontics: Procedures that treat the nerve or the pulp of the tooth due to injury or infection. Oral Surgery: Surgery to remove teeth, reshape portions of the bone in the mouth, or biopsy suspect areas of the mouth. Orthodontics: Braces and other procedures to straighten the teeth. Periodontics: Procedures related to treatment of the supporting structures of the teeth (gums, underlying bone). Posterior: Teeth that set towards the back of the mouth, including molars and bicuspids (premolars). Primary Teeth: The first set of teeth ("baby" teeth). Prophylaxis: Scaling and polishing of teeth by removal of the plaque above the gum line. Prosthodontics: The restoration of natural and/or the replacement of missing teeth with artificial substitutes. Quadrant: One of the four equal sections into which your mouth can be divided (some procedures like periodontics are done in quadrants). Resin -based Composite: Tooth -colored (white) fillings 0041 -D -SOB 25C-47 Exclusions and Limitations Exclusions 1. Services performed by a general dentist or dentist whose practice is limited to providing Specialty Care, not contracted with SafeGuard without prior approval by SafeGuard, (except for out of area emergency services). 2. Any dental services, or appliances which are determined to be not reasonable and/or necessary for maintaining or improving the member's dental health, as determined by the SafeGuard Selected General Dentist. 3. Any procedures not specifically listed as a covered benefit in the Schedule of Benefits. 4. Dental procedures or services performed solely for cosmetic purposes or solely for appearance. 5. Orthognathic surgery. 6. Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions or medications. 7. Replacement of dentures, crowns, appliances or bridgework that have been lost, stolen, or damaged due to abuse, misuse,or neglect. 8. Treatment of malignancies, cysts, or neoplasms. 9. Procedures, appliances, or restorations whose main purpose is to change the vertical dimension of occlusion, correct congenital, developmental, or medically induced dental disorders including, but not limited to treatment of myofunctional, myoskeletal, or temporomandibular joint disorders unless otherwise specified as an orthodontic benefit on the Schedule of Benefits. 10. Dental implants and services associated with the placement of implants, prosthodontics restoration of dental implants, and specialized implant maintenance services. 11. Precision attachments. 12. Dental procedures initiated prior to the member's eligibility under this Plan or started after the members termination from the Plan. 13. Dental services provided for or paid by a federal or state government agency or authority, political subdivision, or other public program other than Medicaid or Medicare. 14. Dental services required while serving in the Armed Forces of any country or international authority or relating to a declared or undeclared war or acts of war. 15. Services considered unnecessary or experimental in nature. 16. Dental procedures or appliances for minor tooth guidance or for the control of harmful habits such as thumb sucking and tongue thrusting. 17. Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the member including, but not limited to physical or emotional resistance, inability to visit the dental office, or allergy to commonly utilized local anesthetics. 0041 -D -SOB 25C-48 EL's 2.15 Exclusions and Limitations Limitations 1. Cleanings (prophylaxis) and fluoride treatments are limited to twice a year unless medically necessary. 2. An additional charge will be applied for any procedure using noble or high noble metal. 3. Full -mouth X-rays: Once initially and thereafter when diagnostically necessary, 4. Periodontal maintenance procedures are a covered benefit only when listed as a covered service on your plan's Schedule of Benefits. If covered, periodontal maintenance procedures must follow active periodontal therapy, and are limited to 2 in a 12 month period. 5. Dentures (full or partial): Replacement only after three (3) years have elapsed following any prior provision of such dentures under a SafeGuard Benefit Plan. Replacements will be a benefit only if the existing denture is unsatisfactory and can not be made satisfactory as determined by the SafeGuard Selected General dentist. 6. Denture relines: Twice in one year 7. Sealants are a covered benefit only when they are listed as a covered service on your plan's Schedule of Benefits. If covered, the plan benefit applies to primary and permanent molar teeth, within four (4) years of eruption. S. There is a $75 co -payment per crown/bridge unit in addition to regular co -payments for porcelain on molars. 9. Surgical removal of wisdom teeth/third molar for orthodontic reasons only is not a covered benefit. 10. Delivery of removable prosthodontics includes up to three (3) adjustments within six (6) months of delivery date of service. 11. Surgical removal of impacted teeth is not a covered benefit unless pathology [disease] exists. 12. The co -payments listed for endodontic procedures do not include the cost of final restoration. 13. General anesthesia Is a covered benefit only when it is listed as a covered service on your plan's Schedule of Benefits, and when it is administered by the treating dentist, In conjunction with oral and periodontal surgical procedures. Orthodontic Exclusions & Limitations 1. Orthodontic treatment must be provided by a SafeGuard Selected General Dentist or contracted dentist whose practice is limited to providing Specialty Care in order for the cc -payments listed in the Schedule of Benefits to apply. 2. Plan benefits shall cover twenty-four (24) months of usual and customary orthodontic treatment and an additional twenty-four (24) months of retention. Treatment extending beyond such time periods will be subject to a per -office -visit charge of $25 dollars. 3. The following are not included as orthodontic benefits: A. Repair or replacement of lost or broken appliances; B. Retreatment of orthodontic cases; C. Treatment in progress at inception of eligibility; 0041 -D-SOB 25C-49 EL's 2.15 Exclusions and Limitations D. Interceptive or phase I orthodontics; E. Changes in treatment necessitated by an accident; F. Treatment involving: 1) Maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia 2) Hormonal imbalances or other factors affecting growth or developmental abnormalities; 3) Treatment related to temporomandibular joint disorders; 4) Lingually placed direct bonded appliances and arch wires ("invisible braces"); and 5) Functional appliances that are used in conjunction with fixed appliances. G. Diagnostic records: 1) Cephalometric x-rays and other x-rays; 2) Diagnostic tracings of cephalometric x-rays; 3) Photographs; and 4) Study models. 4. The retention phase of treatment shall include the construction, placement, and adjustment of retainers, 5. Should a member or client terminate from the Plan for any reason and at that time be receiving orthodontic treatment, the Member and not SafeGuard shall be responsible for payment of the balance due for any orthodontic treatment performed after termination. The member's payment shall be increased by an additional $2,050 above the members co -payment and excluding any charges for diagnostic records, shall be prorated over the number of months to completion of active treatment, and be payable on such terms and conditions as are arranged between the Member and the orthodontist. 6. The retention phase of treatment, if required, shall Include the construction, placement and adjustment of retainers, the maximum cost of which shall not exceed $250.00. 7. If a member does not require treatment or chooses not to start treatment after the participating SafeGuard orthodontist has completed a diagnosis and consultation, the Member will be charged a consultation fee of $25.00 in addition to the fees for such diagnostic records. 0041 -D -SOB 25C-50 EUs 2.15 LANGUAGE ASSISTANCE As a SafeGuard member you have a right to free language assistance services, including interpretation and translation services. SafeGuard collects and maintains your language preferences, race, and ethnicity so that we can communicate more effectively with our members. If you require language assistance or would like to inform SafeGuard of your preferred language, please contact SafeGuard at (800) 880-1800. Como miembro de SafeGuard usted tiene derecho a recibir servicios gratuitos de asistencia en Idlomas. Esto incluye servicios de Interpretaclon y traduccidn. SafeGuard recaba la informaclbn sabre sus preferencias de idiom@, raza, y etnia de manera que nos podamos comunicar eficazmente con nuestros afiliados. Si necesita asistencia an su idioma o quiere informarle a SafeGuard sabre su idioma de preferencia, comuniquese con SafeGuard al (800) 880-1800. iV,*jSafeGaardt` ,&A, 3 { t#A fttjaf, Saf4UafdgM2. jW.V*r NZONSM91 AMfOWOtiWMC+. kAf MMMARtAMA. AIIAZIM&M ffilft4b. At*MW9:iR#W R*MSafeGuard, 7i�S� § $SaieGuardl , A(sao) swiss@, 25C-51 25C-52 DELTA DENTAL OF CALIFORNIA (A Not -for -Profit Corporation Incorporated in California and a Member of the Delta Dental Plans Association) Home Office: 100 First Street, San Francisco, California 94105 (Herein referred to as "Delta Dental") 415-972-8300 Group Number 00599 IN CONSIDERATION of the application made by CITY OF SANTA ANA, referred to In this Contract as "the Contractholder," and IN CONSIDERATION of payment by the Contractholder of the Premiums as stated in Article 3, Delta Dental agrees to provide the Benefits In Article 4 for a period of two years, beginning at 12:01 a.m., Standard Time, on the Effective Date, January 1, 2018, and continuing from year to year thereafter, unless this Contract is terminated in accordance with Article 9. Premiums are payable by the Contractholder before the Effective Date, and thereafter as stated in Article 3. The following document is attached to this Contract and made a part hereof: Appendix B Current Dental Terminology This Contract contains the following Articles: Article 1 Definitions Article 2 Eligibility Article 3 Premium Payments Article 4 Benefits Provided; Limitations and Exclusions Article 5 Deductibles & Maximum Amount Article 6 Coordination of Benefits Article 7 Conditions Under Which Delta Dental WIII Provide Benefits Article 8 Other Delta Dental Obligations Article 9 Termination and Renewal Article 10 Continued Coverage Option Article 11 General Provisions EXHIBIT 2 25d-53 ARTICLE 1 - DEFINITIONS These terms, when used in this Contract, mean the following: 1.1 Administrator - a third party entity designated by Delta Dental to perform administrative functions described throughout this Contract, including, but not limited to, the collection of premium and eligibility. 1.2 Benefits - those dental services that are available under the terms of this Contract as set out In Article 4. 1.3 Contract - this agreement between Delta Dental and the Contractholder Including the attached appendices. This Contract Is the entire Contract between the parties. 1.4 Contract Term - the period beginning on the Effective Date and ending on December 31, 2018, and each subsequent yearly period during which this Contract remains in effect. 1.5 Delta Dental PPO(5A) Dentist - a Dentist with whom Delta Dental has a written agreement to provide services at the in -network level for Enrollees in this Delta Dental PPO Plan. 1.6 Delta Dental PPO Dentist's Fee - the fee that a Delta Dental PPO Dentist has contractually agreed with Delta Dental to accept for treating Enrollees under this plan, or the Fee Actually Charged, whichever is less, for a Single Procedure. 1.7 Delta Dental PPO Dentist's Prevailing Fee - the fee for a Single Procedure that satisfies the majority of Delta Dental PPO Dentists, as determined by Delta Dental based upon confidential fee listing accepted by Delta Dental from Delta Dental PPO Dentists. 1.8 Delta Dental Dentist - a Dentist who has signed an agreement with Delta Dental or a. Participating Plan, agreeing to provide services under the terms and conditions established by Delta Dental or the Participating Plan. 1.9 Dentist - a duly licensed Dentist legally entitled to practice dentistry when and where services are provided. 1.10 Dependent - a Primary Enrollee's Dependent who is eligible for Benefits under Article 2 of this Contract. 1.11 Eligibility Date - the date an Enrollee's eligibility for Benefits becomes effective under the terms of this Contract. 1.12 Enrollee - a Primary Enrollee or Dependent who is eligible and enrolls for Benefits under Article 2 of this Contract, or a person ceasing to meet such conditions who chooses Continued Coverage as set out In Article 10, and for whom Delta Dental receives the appropriate monthly payment as set out In Article 3. 1.13 Enrollee Co -payment.- the portion of the Dentist's fees or allowances charged for Benefits that is the Enrollee's responsibility. 1.14 Fee Actually Charged - the fee for a particular dental service or procedure that a Dentist submits to Delta Dental on a claim form, less any portion of such fee that is discounted, waived or rebated, or which the Dentist does not use good faith efforts to collect. 1.15 Participating Plan - Delta Dental and any other member of the Delta Dental Plans Association with which Delta Dental contracts to assist It In administering the Benefits of this Contract. 2 25C-54 1.16 Premiums - the amounts payable by the Contractholder as provided in Article 3. 1.17 Prevailing Fee - an allowance determined by Delta Dental and/or a Participating Plan for services provided by a dentist who Is not a Delta Dental Dentist. 1.18 Primary Enrollee - an individual, who by their association with the Contractholder, is eligible for Benefits under Article 2 of this Contract. 1.19 Procedure Numbers - the Procedure Numbers shown on Appendix B. 1.20 Single Procedure - a dental procedure to which a separate Procedure Number has been assigned by the American Dental Association In the current version of Current Dental Terminology (CDT). Many CDT codes are listed In Appendix B of this Contract. 1.21 For a Dentist who has signed a Delta Dental Dentist Agreement with Delta Dental of California, his or her "Usual, Customary and Reasonable Fee" for any Single Procedure Is the fee that the Dentist has filed with Delta Dental and which Delta Dental has accepted. For these Dentists, the words "Usual, Customary and Reasonable" means the following: Usual - the amount which a Dentist regularly charges and receives for a given service. If the Dentist charges more than one fee for a given service, the "usual" fee for that service is the lowest fee which the Dentist regularly charges or offers. Customary - the fee is within the range of usual fees charged and received for a particular service by Dentists of similar training in the same geographic area which Delta Dental determines Is statistically relevant. Reasonable - a fee schedule is reasonable If It Is "usual" and `customary." Additionally, a specific fee to a specific Enrollee is reasonable If It Is justifiable considering special circumstances, or extraordinary difficulty, of the case In question. ARTICLE 2 - ELIGIBILITY 2.1 All regular employees may enroll in this plan and will become eligible to receive Benefits immediately following one month from their date of hire. 2.2 Dependents of Primary Enrollees are eligible to enroll under this Contract provided: (1) a minimum of 50% of employees with Dependents enroll all their Dependents who are not covered under any other group dental care plan; (2) said Dependents are enrolled at the time of enrollment of the employee or within 30 days of loss of any other coverage and proof of prior coverage is provided to the Contractholder; (3) contributions for the enrolled Dependent continue to be made through payroll deductions until the employee's coverage terminates, or the Dependent is no longer eligible as defined below, or the employee elects to discontinue dependent coverage; and (4) new Dependents who qualify for enrollment are enrolled on the first day of the month next following their eligibility as Dependents, except that dependent children up to four years of age may be enrolled at the beginning of any Contract Year Including the Contract Year immediately following their fourth birthday. 2.3 Once a Primary Enrollee elects to discontinue dependent coverage, Dependents may not be re -enrolled under this plan, unless the Dependent Is the subject of a Qualified Medical Child Support Order requiring the Primary Enrollee to provide the Dependent Benefits under this plan. 2.4 Dependents are the Primary Enrollee's legal spouse and dependent children from birth to age 26. Children Include natural children, stepchildren, adopted children, children placed for adoption and foster children. The Dependents of Primary Enrollees are eligible to enroll on the same date that the employee, of whom they are a Dependent, becomes a Primary Enrollee. Later -acquired Dependents become'eligible as soon as they acquire dependent status. 25d-55 2.5 A dependent child may continue eligibility If; a) He or she is Incapable of self-sustaining employment because of a physically or mentally disabling Injury, Illness or condition that began prior to reaching the limiting age; b) He or she is chiefly dependent on the eligible employee for support; and c) Proof of Dependent's disability is provided within 60 days of request. Such requests will not be made more than once a year following a two year period after this Dependent reaches the limiting age. Eligibility will continue as long as the Dependent relies on the eligible employee for support because of a physically or mentally disabling Injury, Illness or condition that began before he or she reached the limiting age. 2.6 Dependents in military service are not eligible. 2.7 Every enrolled employee and Dependent meeting the preceding conditions of eligibility Is an Enrollee. However, Delta Dental will not provide Benefits for any employee or his or her Dependents unless (1) the employee Is Included on the list of Primary Enrollees submitted as required by this Article (or any revision or correction of such a list), and (2) the appropriate payments are made as required by Article 3 of this Contract, for the months in which Delta Dental provides covered dental services. 2.8 The Contractholder agrees to enroll all of Its Primary Enrollees in this plan, All employees of the Contractholder meeting the eligibility requirements of this Article are "Primary Enrollees" under this plan unless the Contractholder offers one or more alternate plans of dental coverage. In that event, Primary Enrollees will continue to be eligible under this plan unless they rile a choice card with the Contractholder electing an alternate plan during an open enrollment period agreed upon between Delta Dental and the Contractholder. 2.9 The Contractholder will compile and furnish Delta Dental with an initial report of all Primary Enrollees, showing their Enrollee ID numbers, their dates of hire and division codes. The initial report shall be provided to Delta Dental or prior to the Effective Date of this Contract. The Contractholder also agrees to report all persons electing continued coverage under Article 10, showing their Enrollee ID numbers and date of election. 2.10 The Contractholder may continue to submit subsequent eligibility reports monthly or may report only additions or deletions to the initial report. If the report is not updated by the Contractholder or has not arrived or been processed for the current month, Delta Dental will extend the last report received to process claims. The extension of the eligibility report does not waive the requirement that the Contractholder provide an updated report to Delta Dental each month indicating additions or deletions from any previous report. The Contractholder shall pay, as set forth in Article 3, all Premiums applicable for Primary Enrollees reported in the updated report. 2.11 Enrollees are not eligible during a period the Primary Enrollee does not report to work on a regular basis and is not actively employed as determined by the Contractholder. Eligibility resumes on the first day of the month following the return to active employment If amounts due to Delta Dental for Enrollees have been paid. Eligibility can continue without Interruption If the Contractholder continues to report the employee as a Primary Enrollee and the amounts due to Delta Dental are paid on the employee's behalf. Coverage is reinstated on the day employment Is resumed for Enrollees that are members of the National Guard or a military reserve unit absent from work due to active military duty. Any waiting period applied as a result of an Enrollee's absence from active employment due to service in the National Guard or military reserve unit shall be waived. a 25C-56 2.12 A Primary Enrollee absent from work due to a leave of absence governed by the "Family and Medical Leave Act of 1993" (P.L. 103-3) will not be subject to Section 2,11. 2.13 A Primary Enrollee absent from work due to a leave of absence governed by the "Uniformed Services Employment and Re-employment Rights Act of 1994" (P.L. 103-353) will not be subject to Section 2.11. Such Primary Enrollee shall have the right to continue coverage for up to 24 months while he or she Is on military leave. If the Primary Enrollee elects this continued coverage, he or she must submit the Premiums necessary to the Contractholder. 2.14 A Primary Enrollee's eligibility ends on the last day of the month in which his or her full-time employment ends, unless he or she chooses to continue coverage under Article lo. A Dependent's eligibility ends along with the Primary Enrollee's, or sooner if the Dependent loses his or her Dependent status, unless continued coverage Is chosen in a timely fashion by or on behalf of the Dependent(s) under Article 10. Eligibility for such continued coverage will continue for the period required by the Option. In any event, eligibility ends immediately when this Contract ends. 2.15 The Contractholder agrees to permit Delta Dental, by its auditors or other authorized representatives, on reasonable advance written notice, to inspect the Contractholder's records in order to verify the accuracy of lists of Primary Enrollees prepared by the Contractholder and submitted to Delta Dental and to verify the Contractholder's compliance with Article 3 of this Contract. ARTICLE 3 — PREMIUM PAYMENTS 3.1 Within ten days after receipt of Delta Dental's Invoice, except for the month of January 2018, the Contractholder agrees to pay the following monthly, billed Premiums to Delta Dental, at the address shown on the first page of this Contract, for all of Contractholder's Primary Enrollees and their Dependents who are "Enrollees" as set forth in ArtIcIe2 of this Contract: $52.56 for each Primary Enrollee without enrolled Dependents; and $129.44 for each Primary Enrollee with one or more enrolled Dependents. Contractholder agrees to pay the invoiced amount. Eligibility adjustments reported to Delta Dental after the date the invoice is prepared will be reflected on the subsequent month's invoice. Such adjustments are limited to the three-month period prior to the most current month for which the Contractholder provides eligibility data. Contractholder agrees to bear the cost of such Premiums without withholding or otherwise charging Primary Enrollees for their coverage. Primary Enrollees agree to bear the cost of coverage for their enrolled Dependents. 3.2 The Premium for each person electing continued coverage under the Continued Coverage Option in Article 10 for himself or herself will be the same as that for a single Primary Enrollee. The Premium for a person who also elects continued coverage for his or her Dependents is the same as that for a Primary Enrollee with the same number of Dependents. The Contractholder may charge persons choosing coverage under Article 10 such amounts as are permitted by law. 3.3 This Contract is not in effect until Delta Dental receives the initial Premiums from the Contractholder. 3.4 If this Contract terminates for any reason, the Contractholder agrees to pay all Premiums earned by Delta Dental but unpaid by the Contractholder. 256-57 3.5 In addition to the amounts, If any, which Delta Dental withholds from payments to Dentists as provided In Delta Dental Dentists Rules, the Contractholder authorizes Delta Dental to deduct from each of Its monthly payments to Delta Dental 15.75% of such amount as compensation for Delta Dental's administration of this dental plan. 3.6 After the end of each Contract Term, the stabilization shall be calculated by Delta Dental from the Effective Date of the Contract. The following percentage of any positive amount ("plus stabilization") may be reflected In the calculation of the renewal rate for the succeeding Contract Term and/or may be used to offset the additional cost of Increased Benefits for the succeeding Contract Term. 25% for Contractholders with an average monthly enrollment of 100 to 199 Primary Enrollees 50% for Contractholders with an average monthly enrollment of 200 to 299 Primary Enrollees. 75% for Contractholder with an average monthly enrollment of 300 to 399 Primary Enrollees. 100% for Contractholders with an average monthly enrollment of 400 or more Primary Enrollees. Average monthly enrollment Is based on the 12 -month period preceding each renewal date of this Contract. Any negative or positive amount occurring during a Contract Term will be Included in the calculation of the stabilization during the succeeding Contract Term. Stabilization means the negative or positive amount of Premiums paid under this plan after deduction of claims paid, reserves for Incurred but unreported claims and Delta Dental's administrative charge. In no event, however, shall the plus stabilization or any part of it be returned to the Contractholder In a cash transaction and such amounts remaining upon termination of the Contract shall remain with Delta Dental. 3.7 In the event the Contractholder chooses to convert to a self-funded plan during or at the end of a Contract Term, the stabilization accumulated under this plan is combined with the reserves held for incurred but unreported claims, with the balance used to pay for claims and administration without regard to the date of service. 3.8 Except as provided in the next paragraph, an agreement between Delta Dental and the Contractholder Is required to change the Contractholder's Premium rates during a Contract Term. 3.9 During a Contract Term, if any government agency Imposes any new tax on Delta Dental based on the amount of Premiums payable or the number of persons covered under this Contract, or if the rate of any existing tax on the amount of Premiums or the number of persons covered under this Contract increases, the Premiums stated in this Article will increase by the amount of any such new or increased tax(es): 3.10 Premiums and eligibility may be adjusted retroactively by Delta Dental or the Contractholder, but such adjustments are limited to the three-month period prior to the most current month for which the Contractholder provides eligibility data. ARTICLE 4 - BENEFITS PROVIDED; LIMITATIONS AND EXCLUSIONS 4.1 Subject to the limitations and exclusions set forth below, the following services are Benefits when they are provided by a Dentist and when they are necessary and customary as determined by the standards of generally accepted dental practice. 6 25C-58 4.2 DIAGNOSTIC AND PREVENTIVE BENEFITS. Delta Dental agrees to pay 100°/% of the Dentist's Usual, Customary and Reasonable fees or the Fee Actually Charged, whichever is less, or 100% of the Delta Dental PPO Dentist's Fee for the following Diagnostic and Preventive Benefits: Diagnostic- oral examinations (including initial examinations, periodic examinations and emergency examinations) x-rays examination of blopsled tissue palliative (emergency) treatment of dental pain specialist consultation Preventive- prophylaxis (cleaning) topical application of fluoride solution space maintainers Note on additional Benefits during pregnancy - When an Enrollee is pregnant, Delta Dental will pay for additional services to help Improve the oral health of the Enrollee during the pregnancy. The additional services each calendar year while the Enrollee is covered under this Contract Include: one additional oral exam and either one additional routine cleaning or one additional periodontal scaling and root planing per quadrant. Written confirmation of the pregnancy must be provided by the Enrollee or her dentist when the claim Is submitted. 4.3 BASIC BENEFITS. Delta Dental agrees to pay 75% of the Dentist's Usual, Customary and Reasonable fees or the Fee Actually Charged, whichever is less, or 80% of the Delta Dental PPO Dentist's Fees for the following Basic Benefits: Oral Surgery- extractions and certain other surgical procedures, including pre- and post- operative care Restorative- amalgam, silicate or composite (resin) restorations (fillings) for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay) Endodontic- treatment of the tooth pulp Periodontic- treatment of gums and bones supporting teeth Sealants- topically -applied acrylic, plastic or composite material used to seal developmental grooves and pits in teeth for the purpose of preventing dental decay Adjunctive General Services- general anesthesia; I.V. sedation; office visit for observation; office visit after regularly scheduled hours; therapeutic drug injection; treatment of post- surgical complications (unusual circumstances); occlusal adjustment, limited 4.4 CROWNS, INLAYS, ONLAYS AND CAST RESTORATIONS BENEFITS. Delta Dental agrees to pay 50% of the Dentist's Usual, Customary and Reasonable fees or the Fee Actually Charged, whichever is less, or 50% of the Delta Dental PPO Dentist's Fee for the treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay) which cannot be restored with amalgam, silicate or direct composite (resin) restorations. 25C'-59 4.5 PROSTHODONTIC BENEFITS. Delta Dental agrees to pay 50% of the Dentist's Usual, Customary and Reasonable fees or the Fee Actually Charged, whichever Is less, or 50% of the Delta Dental PPO Dentist's Fee for the construction or repair of fixed bridges, partial or complete dentures to replace missing, natural teeth; for Implant surgical placement and removal; and for Implant supported prosthetics, including Implant repair and recementatlon. 4.6 LIMITATIONS: (a) Only the first two oral examinations, including office visits for observation and specialist consultations, or combination thereof, provided to an Enrollee twice In a calendar year while he or she is enrolled under any Delta Dental plan are Benefits under this plan. See Note on additional Benefits during pregnancy. (b) Delta Dental pays for full -mouth x-rays only after five years have elapsed since any prior set of full -mouth x-rays was provided under any Delta Dental plan. Delta Dental pays for a panoramic x-ray provided as an Individual service only after five years have elapsed since any prior panoramic x-ray was provided under any Delta Dental plan. (c) Bitewing x-rays are provided on request by the Dentist, but not more than twice In a calendar year for children to age 18, or once In a calendar year for adults ages 18 and over, while the patient is an Enrollee under any Delta Dental plan. (d) A prophylaxis (cleaning) or Single Procedure that includes a prophylaxis is a Benefit twice each calendar year under any Delta Dental plan. See note on additional Benefits during pregnancy. Routine prophylaxes are covered as a Diagnostic and Preventive Benefit and periodontal prophylaxes are covered as a Basic Benefit. (e) Perlodontal scaling and root planing Is a Benefit once for each quadrant each 24 - month period. See note on additional Benefits during pregnancy. (f) Fluoride treatment Is a Benefit twice each calendar year under any Delta Dental plan. (g) Sealant Benefits include the application of sealants only to permanent first molars through age eight and second molars through age (15) if they are without caries (decay) or restorations on the occlusal surface. Sealant Benefits do not include the repair or replacement of a sealant on any tooth within two years of Its application. (h) Crowns, Inlays, Onlays or Cast Restoration are Benefits on the same tooth only once every five years while the patient Is an Enrollee under any Delta Dental plan, unless Delta Dental determines that replacement is required because the restoration is unsatisfactory as a result of poor quality of care, or because the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissues since the replacement of the restoration. (1) Prosthodontic appliances and implants that were provided under any Delta Dental plan will be replaced only after five years _ have passed, except when Delta Dental determines that there Is such extensive loss of remaining teeth or change in supporting tissues that the existing fixed bridge, partial denture or complete denture cannot be made satisfactory. Replacement of a prosthodontic appliance or Implant supported prosthesis not provided under a Delta Dental plan will be covered If It Is unsatisfactory and cannot be made satisfactory. Implant removal Is limited to one for each tooth during the Enrollee's lifetime whether provided under a Delta Dental or any other dental care plan. e 25C-60 (j) Delta Dental will pay the applicable percentage of the Dentist's Fee for a standard cast chrome or acrylic partial denture or a standard complete denture, (A "standard" complete or partial denture Is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials.) (k) If an Enrollee selects a more expensive plan of treatment than Is customarily provided, or specialized techniques, an allowance will be made for the least expensive, professionally acceptable alternative treatment plan. Delta Dental will pay the applicable percentage of the lesser fee and the Enrollee is responsible for the remainder of the Dentist's fee. For example: a crown, where an amalgam filling would restore the tooth, or a precision denture, where a standard denture would suffice. 4.7 EXCLUSIONS - The following services are not BeneFlts: (a) Services for Injuries or conditions that are covered under Workers' Compensation or Employer's Liability Laws. (b) Services which are provided to the Enrollee by any, Federal or State Government Agency or are provided without cost to the Enrollee by any municipality, county or other political subdivision, except as provided in California Health and Safety Code Section 1373(a). (c) Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, Including but not limited to: cleft palate, upper or lower jaw malformations, enamel hypoplasla (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth). (d) Services for restoring tooth structure lost from wear (abrasion, erosion, attrition, or abfractlon), for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. Such services Include but are not limited to equilibration and periodontal splinting. (e) Prosthodontic services or any Single Procedure started prior to the date the person became eligible for such services under this Contract. (f) Prescribed or applied therapeutic drugs, premedication or analgesia. (g) Experimental procedures. (h) All hospital costs and any additional fees charged by the Dentist for hospital treatment. (1) Charges for anesthesia, other than general anesthesia or I.V. sedation administered by a licensed Dentist In connection with covered Oral Surgery services and select Endodontic and Periodontic procedures. (j) Extra -oral grafts (grafting of tissues from outside the mouth to oral tissue). (k) Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joint or associated musculature, nerves and other tissues. (1) Replacements of existing restorations for any purpose other than active tooth decay. 25G-61 (m) Occlusal guards and complete occlusal adjustment. (n) Orthodontic services (treatment of mal -alignment of teeth and/or jaws). (o) Diagnostic casts. 4.8 An agreement between the Contractholder and Delta Dental Is required to change Benefits during a Contract Term. ARTICLE 5 - DEDUCTIBLES & MAXIMUM AMOUNT 5.1 Applicable to services provided by a Delta Dental PPO Dentist: Each Enrollee must pay the first $25 ("deductible amount") of fees for services that are Benefits received by an Enrollee during the term of this Contract and otherwise covered by this Contract. Such deductible amount will not exceed $50 for all Enrollees in a single family, consisting of a Primary Enrollee and his or her Dependents, as defined. Delta Dental will compute these fees based on the Dentist's Usual, Customary and Reasonable fees. Applicable to services provided by other dentists: Each Enrollee must pay the first $50 ("deductible amount") of fees for services that are Benefits received by an Enrollee during the term of this Contract and otherwise covered by this Contract. Such deductible amount will not exceed $100 for all Enrollees in a single family, consisting of a Primary Enrollee and his or her Dependents, as defined. Delta Dental will compute these fees based on the Dentist's Usual, Customary and Reasonable fees. 5.2 Such deductible amounts shall apply once each calendar year or portion thereof during which the Enrollee Is continuously eligible under this Contract. The deductible does not apply to Diagnostic and Preventive Benefits. 5.3 Applicable to services provided by a Delta Dental PPO Dentist: The maximum amount Delta Dental will pay for Diagnostic and Preventive, Basic, Crowns, Inlays, Onlays and Cast Restorations and Prosthodontic Benefits provided to any Enrollee in a calendar year Is 1,250. Applicable to services provided by other dentists: The maximum amount Delta Dental will pay for Diagnostic and Preventive, Basic, Crowns, Inlays, Onlays and Cast Restorations and Prosthodontic Benefits provided to any Enrollee In a calendar year is 1,000, ARTICLE 6 - COORDINATION OF BENEFITS 6.1 If a group insurance policy or any other group health Benefits plan, Including another Delta Dental plan, entitles a person to receive or be reimbursed for the cost of dental services, which are also Benefits under this plan, and If this plan is "primary" under the rules described below, Delta Dental will provide Benefits as if the other plan did not exist. If the other plan is "primary" under these rules, then Delta Dental will coordinate Benefits under this plan with the primary plan in accordance with California law (California Health and Safety Code 1374.19 (2007). 6.2 If the other plan mainly covers services or expenses other than dental care, this plan is "primary." Otherwise, Delta Dental will use the following rules to determine which plan is "primary": (a) The plan that covers the person as other than a Dependent is primary over the plan that covers the person as a Dependent, with the following exception: If the person is also a Medicare Beneficiary and Medicare is: (1) secondary to the plan covering the person as a Dependent; and io 25C-62 (II) primary to the plan covering the person as other than a Dependent (for example, a retired employee), then the Benefits of the plan covering the person as a Dependent are determined before the Benefits of the plan covering the person as other than a Dependent. (b) The plan which covers a child as a Dependent of a parent whose birthday occurs earlier In a calendar year Is primary over the plan which covers a child as a Dependent of a parent whose birthday occurs later in a calendar year (except for a dependent child whose parents are separated or divorced as described in (c) below). (c) In the case of a dependent child whose parents are legally separated or divorced: (I) If the parent with custody has not remarried, the plan that covers the child as a Dependent of the parent with custody is primary over the plan which covers the child as a Dependent of the parent without custody. (II) If the parent with custody has remarried, the plan which covers the child as a Dependent of the parent with custody Is primary over the plan which covers the child as a Dependent of the step-parent, and the plan which covers the child as a Dependent of the step-parent Is primary over the policy or plan which covers the child as a Dependent of the parent without custody. (iii) If there is a court decree that establishes financial responsibility for dental services which are Benefits under this plan, then notwithstanding (1) and (ii), the plan which covers the child as a Dependent of the parent with such financial responsibility is primary over any other plan which covers the child. 6.3 The Benefits of a plan covering a lald-off or retired employee (or Dependent of such person) shall be determined after the Benefits of any other plan covering such person as an employee. 6.4 If a person whose coverage is provided under federal or state law requiring continuation is covered under more than one plan, Benefits order shall be determined as follows: (a) The Benefits of the plan covering the person as an employee or Dependent shall be primary. (b) The Benefits under continuation coverage shall be secondary. 6.5 If the primary plan cannot be determined by the rules described in this Article 6, the plan that has covered the person longer shall be primary. 6.6 An Enrollee will provide Delta Dental with any information about the person that Is needed to administer this Article, and Delta Dental may release any information to or obtain any information from any Insurance company or other organization in order to coordinate the Benefits of an Enrollee. Delta Dental In Its sole discretion will determine whether any reimbursement is warranted to an Insurance company or other organization under this provision, and it is agreed that any such reimbursement paid by.Delta Dental will be Benefits under this Contract. Delta Dental has the right to recover the value of any Benefits provided by Delta Dental which exceed Its obligations under the terms of this provision from a Delta Dental Dentist, Enrollee, Insurance company or other organization, as Delta Dental chooses. 25C-63 ARTICLE 7 - CONDITIONS UNDER WHICH DELTA DENTAL WILL PROVIDE BENEFITS 7.1 Benefits, unless otherwise provided in Article 4, are available from the Eligibility Date of an Enrollee. 7.2 An Enrollee may choose the services of any licensed Dentist, but neither Delta Dental nor the Contractholder guarantees the availability of any particular Dentist. 7.3 Before Delta Dental Is obligated to approve and/or satisfy any claims under this Contract, Delta Dental is entitled to receive, to such extent as Is lawful, such Information and records relating to attendance to or examination of or treatment provided to an Enrollee from any attending or examining Dentist, or from hospitals In which a Dentist's care is provided, as may be required in the administration of such claims, or to require that an Enrollee be examined by a dental consultant retained by Delta Dental in or near his or her community or residence. Delta Dental agrees in every case to hold such information and records as confidential. 7.4 The process Delta Dental uses to determine or deny payment for services are distributed to all Delta Dental Dentists. They describe In detallthe dental procedures covered as Beneflts, the conditions under which coverage is provided and the limitations and exclusions applicable to the plan. Claims are reviewed for eligibility and are paid according to these processing policies. Those claims that require additional review are evaluated by Delta Dental's Dentist consultants. If any claims are not covered or if limitations or exclusions apply to services the Enrollee has received by a Delta Dental Dentist, the Enrollee will be notified by an adjustment notice on the Notice of Payment or Action. The Enrollee may contact Delta Dental's Customer Service department for more Information regarding Delta Dental's processing policies. 7.5 Second Opinions. Delta Dental reserves the right to obtain second opinions through regional consultant members of its quality review committee. This committee conducts clinical examinations, prepares objective reports of dental conditions, and evaluates treatment that is proposed or has been proposed. Delta Dental will authorize such an examination prior to treatment when necessary to make a Benefit determination in response to a request for a predetermination of treatment cost by a Dentist. Delta Dental will also authorize a second opinion after treatment If an Enrollee has a complaint regarding the quality of care provided. Delta Dental will notify the Enrollee and the treating Dentist when a second opinion is necessary and appropriate, and direct the Enrollee to the regional consultant selected by Delta Dental to perform the clinical examination. When Delta Dental authorizes a second opinion through a regional consultant Delta Dental will pay for all charges. The Enrollee may otherwise obtain second opinions about treatment from any Dentist they choose, and claims for the examinaflon may be submitted to Delta Dental for payment. Delta Dental will pay such claims In accordance with the Benefits of the plan. 7.6 For services provided by a dentist who is not a Delta Dental PPO Dentist or a Delta Dental Dentist, Delta Dental will not pay more than the lesser of the fees entered on the claim form reporting such services to Delta Dental or the Prevailing Fee, multiplied by the applicable percentage specified in Article 4 for such services. However, If the Dentist discounts, waives, rebates or does not use good faith efforts to collect some portion of the fees entered on the claim form from the Enrollee, Delta Dental will not pay more than the applicable percentage specified in Article 4 of the lesser of (1) the fees entered on the claim form, reduced by the portion discounted, waived, rebated or not collected, or (2) the Prevailing Fee, reduced by the portion discounted, waived, rebated or not collected. 25b-64 7.7 Delta Dental will pay a Delta Dental Dentist directly for services provided by that Dentist. Contracts between Delta Dental of California and Its Delta Dental Dentists provide that, In the event Delta Dental fails to pay the Dentist, the Enrollee will not owe the Dentist for any sums owed by Delta Dental. 7.8 Delta Dental will pay an Enrollee directly for services provided by a Dentist who Is not a Delta Dental Dentist, and those payments are not assignable. The Enrollee is liable to the Dentist for payment to the Dentist for the cost of the service. In addition, Delta Dental will pay for services from dental school clinics by students of dentistry or Instructors who are not licensed by the State of California. In the event Delta Dental falls to pay the Dentist who has not contracted with Delta Dental as a Delta Dental Dentist, the Enrollee may be liable to the Dentist for the cost of the service. 7.9 Delta Dental is not obligated to pay claims submitted more than 12 months after the date the service was provided. If a claim is denied because a Delta Dental Dentist failed to make a timely submission, the Enrollee does not owe the Dentist the amount which would have been payable by Delta Dental, provided that the Enrollee advised the Dentist of his or her eligibility for Benefits at the time of treatment. 7.10 Delta Dental, with the assistance of Participating Plans, will give each Delta Dental Dentist, and any other Dentist or Enrollee on request, a standard form to make a claim for payment for services covered by this Contract. In order to make a claim for payment, such form, completed by the Dentist who provided the service and by the Enrollee (or the Enrollee's parent or guardian if such Enrollee Is a minor) must be submitted to Delta Dental. 7.11 If an Enrollee has any questions about the services received from a Delta Dental Dentist, Delta Dental recommends that he or she first discuss the matter with the Dentist. If he or she continues to have concerns, the Enrollee may call or write Delta Dental. Delta Dental will provide notifications If any dental services or claims are denied, In whole or part, stating the specific reason or reasons for denial. Any questions of ineligibility should first be handled directly between the Enrollee and the group. If an Enrollee has any question or complaint regarding the denial of dental services or claims, the policies, procedures and operations of Delta Dental, or the quality of dental services performed by a Delta Dental Dentist, he or she may call Delta Dental toll-free at 800-765-6003, contact Delta Dental on the Internet through the website: deltadentalins.com or write Delta Dental at P. O. Box 997330, Sacramento, CA 95899 Attention: Customer Service Department. If an Enrollee's claim has been denied or modified, the Enrollee may file a request for review (a grievance) with Delta Dental within 180 days after receipt of the denial or modification. If a request for review Is not made within this 180 -day period, the right to further review of the claim determination will be lost. If in writing, the correspondence must include the group name and number, the Primary Enrollee's name and Enrollee ID number, the inquirer's telephone number and any additional Information that would support the claim for benefits. The correspondence should also include a copy of the treatment form, Notice of Payment and any other relevant information. Upon request and free of charge, Delta Dental will provide the Enrollee with copies of any pertinent documents that are relevant to the claim, a copy of any Internal rule, guideline, protocol, and/or explanation of the scientific or clinical judgment If relied upon in denying or modifying the claim. Delta Dental's review will take into account all information, regardless of whether such information was submitted or considered initially. Certain cases may be referred to one of Delta Dental's regional consultants, to a review committee of the dental society or to the state dental association for evaluatlon. Delta Dental's review shall be conducted by a person who Is neither the Individual who made the original claim denial, nor the subordinate of such Individual, and Delta Dental will not give deference to the initial decision. 25G-65 If the review of a claim denial is based in whole or in part on a lack of medical necessity, experimental treatment, or a clinical judgment In applying the terms of the contract terms, Delta Dental shall consult with a dentist who has appropriate training and experience. The identity of such dental consultant is available upon request. Delta Dental will provide the Enrollee a written acknowledgement within five calendar days of receipt of the request for review. Delta Dental will make a written decision within 30 calendar days of receipt of the request for review. Delta Dental will respond, within three calendar days of receipt, to complaints involving severe pain and Imminent and serious threat to an Enrollee's health. An Enrollee may file a complaint with the Department of Managed Health Care after he or she has completed Delta Dental's grievance procedure or after he or she has been involved in Delta Dental's grievance procedure for 30 calendar days. An Enrollee may file a complaint with the Department Immediately in an emergency situation, which is one involving severe pain and/or Imminent and serious threat to the Enrollee's health. The California Department of Managed Health Care Is responsible for regulating health care service plans. If an Enrollee has a grievance against Delta Dental or the health plan, the Enrollee should first telephone Delta Dental at 800-765-6003 and use Delta Dental's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to an Enrollee. If help is needed with a grievance Involving an emergency, a grievance that has not been satisfactorily resolved by this health plan, or a grievance that has remained unresolved for more than thirty (30) calendar days, the Enrollee may call the department for assistance. An Enrollee may also be eligible for an Independent Medical Review (IMR). If eligible for an IMR, the IMR process will provide an Impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational In nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (888 -HMO -2219) and a TDD line (877-688-9891) for the hearing and speech Impaired. The department's Internet Website (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions online. If the group health plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), the Enrollee may contact the U.S. Department of Employee Benefits Security Administration (EBSA) for further review of the claim or if the Enrollee has questions about the rights under ERISA. The Enrollee may also bring a civil action under section 502(a) of ERISA. The address of the U.S. Department of Labor is: U.S. Department of Labor, Employee Benefits Security Administration (EBSA), 200 Constitution Avenue, N.W. Washington, D.C. 20210. 7.12 The Benefits that Delta Dental provides are limited to the applicable percentages of the Dentist's fees or allowances specified In Article 4. The Contractholder requires the Enrollee to pay the balance of any such fee or allowance, known as the "Enrollee Co -payment," as a method of sharing the costs of providing dental Beneflts between the Contractholder and Enrollees. If the Dentist discounts, waives or rebates any portion of the Enrollee Co -payment to the Enrollee, Delta Dental only provides as Benefits the Dentist's fees or allowances reduced by the amount that such fees or allowances are discounted, waived or rebated. 14 25C-66 ARTICLE 8 - OTHER DELTA DENTAL OBLIGATIONS 8.1 Delta Dental shall encourage Delta Dental Dentists to submit a standardized claim form before providing service, showing the Enrollee's dental needs and the treatment necessary In the professional judgment of the Dentist. Delta Dental shall predetermine, from the claim and other data, what would be payable by Delta Dental and an Enrollee for the proposed service under the terms of this plan as of the date of predetermination. Such predetermination shall not constitute a guaranty or authorization of Benefits under this Contract, and any actual payment by Delta Dental will depend upon the Enrollee's eligibility and remaining annual maximum when completed services are reported to Delta Dental. Delta Dental shall advise Delta Dental Dentists to notify the Enrollee of all Information provided by Delta Dental In the predetermination. 8.2 A Dentist may file a statement before treatment, showing the services to be provided to an Enrollee. Delta Dental will predetermine the amount of Benefits payable under this Contract for the listed services. A predetermination will become Invalid at the end of the Contract Term or the date the Enrollee's eligibility ends. 8.3 Delta Dental will not make any payment for services provided to an Enrollee who Is not reported to Delta Dental as an Enrollee under this Contract when the service Is provided. Delta Dental shall not be obligated to recover claims paid to a Dentist as a result of Cc ntracthol der's retroactive eligibility adjustments to eligibility reports. The Contractholder agrees to reimburse Delta Dental for any erroneous claim payments made by Delta Dental as a result of Incorrect eligibility reporting by the Contractholder. 8.4 Delta Dental will provide professional review of the adequacy of service provided by Delta Dental Dentists. 8.5 Delta Dental, with the assistance of Participating Plans, agrees to furnish to the Contractholder on the effective date, and at reasonable times thereafter, a directory of Delta Dental Dentists and Delta Dental PPO Dentists who have agreed to provide the services described in this Contract. It Is understood that the Dentists listed in that directory may change from time to time and Delta Dental reserves the right to update the directory without prior notice to the Contractholder. However, Delta Dental agrees to give notice to the Contractholder within a reasonable time of any Delta Dental Dentist's termination or breach of Contract, or inability to perform, which will materially and adversely affect the Contractholder. Current Information concerning the Delta Dental Dentist status of any Dentist may be obtained by telephoning the Delta Dental Customer Service department at 800-765-6003. The Dentists providing or contracting to provide dental services under this Contract are solely responsible for those dental services, and in no case will Delta Dental or the Contractholder be liable for any act or omission by such Dentists, their agents or employees. 8.6 Delta Dental agrees to give to the Contractholder, and the Contractholder agrees to make available to each Primary Enrollee, an Evidence of Coverage summarizing Benefits to which the Enrollee Is entitled and other provisions of this Contract. If an amendment to this Contract materially affects any Benefits described in such Evidence of Coverage, Delta Dental will Issue a corrected Evidence of Coverage, rider or inserts. 25d-67 ARTICLE 9 - TERMINATION AND RENEWAL 9.1 This Contract may be terminated for the following causes; (a) By Delta Dental, if the Contractholder fails (1) to give Delta Dental a list of all Primary Enrollees, as required under Article 2, or (2) to permit the inspection of the Contractholder's records as called for under Article 2, or (3) to pay Premiums, In the amounts and manner required in Article 3, provided the Contractholder has been duly notified of such failure (and billed for Premiums, If applicable) and at least 15 days have elapsed since the date of notification. (b) By either the Contractholder or Delta Dental, upon expiration of a Contract Term. 9.2 If Delta Dental terminates this Contract under paragraph 9.1 (a), all Benefits end and Delta Dental is released from all further obligations of this Contract, effective the last day of the month in which written notice of termination Is given. The Contractholder will remain liable to Delta Dental for the greater of: (1) the unpaid Premiums applicable for the period this Contract was In effect before termination; or (2) the full amount of all Dentist's statements paid or otherwise discharged by Delta Dental during the full term of this Contract, plus 25% of such amount (to compensate Delta Dental for Its administration of the dental plan), less amounts actually paid by the Contractholder to Delta Dental during the term of such Contract. 9.3 A party choosing to terminate this Contract at the end of a Contract Term must give at least 60 days written notice of termination to the other party. If Delta Dental wants to change the Premiums or Benefits effective at the beginning of the next Contract Term, Delta Dental will give at least 60 days advance written notice of such changes to the Contractholder. Such an advance notice will have the effect of a notice of termination as of the end of the Contract Term, unless the Contractholder agrees to the new Contract provisions. 9.4 If the Contractholder notifies Delta Dental in writing of its Intention to terminate this Contract as of any date other than the end of the Contract Term, such notice will be treated as a failure to pay Premiums, and such notice will constitute a waiver of notification and billing required of Delta Dental by paragraph 9.1(a)(3). 9.5 If an Enrollee believes that this Contract, or coverage hereunder, has been terminated or not renewed due to their health status or requirements for health care services, they may request a review by the California Director of Managed Health Care under California Health and Safety Code Section 1365(b). 9.6 If this Contract Is terminated for any cause, Delta Dental is not required to predetermine services beyond the termination date or to pay for services provided after such termination date, except for the completion of Single Procedures begun while this Contract was In effect which are otherwise Benefits under this Contract. 9.7 Within 30 days after the end of this Contract, Delta Dental will return to the Contractholder any Premiums paid which are applicable to a time period after the termination date, together with amounts due on claims, if any, less any amounts due to Delta Dental. 9.8 If Delta Dental accepts the proper amount of Premiums after termination of this Contract and without requiring a new application, that acceptance will reinstate the Contract as though never terminated, unless Delta Dental within 20 business days after it receives such payment, either (1) refunds the payment so made or (2) issues to the Contractholder a new Contract accompanied by written notice stating clearly those respects in which the new Contract differs from the terminated Contract in Benefits, coverage or otherwise. 16 25C-68 9.9 All Benefits end for all Enrollees, when this Contract ends, and Delta Dental will not provide any right to continuation, renewal or reinstatement of Benefits to such persons In that event. 9.10 Delta Dental must notify the Contractholder in writing of any termination by Delta Dental under paragraph 9.1, and the Contractholder shall promptly mall a copy of such notice to each Primary Enrollee and provide Delta Dental with proof of mailing and the date thereof. ARTICLE 10 - OPTIONAL CONTINUATION OF COVERAGE (COBRA) 10.1 The federal Consolidated Omnibus Budget Reconciliation Act (or COBRA, pertaining to certain employers having 20 or more employees) and the California Continuation Benefits Replacement Act (or Cal -COBRA, pertaining to employers with two to 19 employees), both require that continued health care coverage be made available to "Qualified Beneficiaries" who lose health care coverage under the group plan as a result of a "Qualifying Event." Enrollees may be entitled to continue coverage under this plan, at the Quallfied eeneficlary's expense, If certain conditions are met. The period of continued coverage depends on the Qualifying Event and whether the Enrollee is covered under federal COBRA or Cal -COBRA. 10.2 DEFINITIONS The meaning of key terms used in this Article are shown below and apply to both federal and Cal -COBRA. Qualified Beneficiary means: Enrollees who are enrolled In the Delta Dental plan on the day before the Qualifying Event, or A child who is born to or placed for adoption with the Primary Enrollee during the period of continued coverage, provided such child is enrolled within 30 days of birth or placement for adoption. Qualifying Event means any of the following events which, except for the election of this continued coverage, would result In a loss of coverage under the dental plan: Event 1: The termination of employment (other than termination for gross misconduct), or the reduction In work hours, by the Primary Enrollee's employer; Event 2: The death of the Primary Enrollee; Event 3: Divorce or legal separation from the Primary Enrollee; Event 4: A dependent child ceasing to meet the description of dependent child; Event 5: As to dependents only, a Primary Enrollee becoming entitled to Medicare. 10.3 PERIODS OF CONTINUED COVERAGE UNDER FEDERAL COBRA Qualified Beneficiaries may continue coverage for 18 months following the occurrence Qualifying Event 1. 25&-69 This 18 -month period can be extended for a total of 29 months, provided: 1. A determination is made under Title II or Title XVI of the Social Security Act that an individual is disabled on the date of the Qualifying Event or became disabled at any time during the first 60 days of continued coverage; and 2. Notice of the determination Is given to the employer during the Initial 18 months of continued coverage and within 60 days of the date of the determination. This period of coverage will end on the first of the month that begins more than 30 days after the date of the final determination that the disabled individual is no longer disabled. The Primary Enrollee must notify the employer/administrator within 30 days of any such determination. If, during the 18 month continuation period resulting from Qualifying Event 1, the Primary Enrollee's dependents experience Qualifying Events 2, 3, 4 or 5, they may choose to extend coverage for up to a total of 36 months (inclusive of the period continued under Qualifying Event 1). The Primary Enrollee's dependents may continue coverage for.36 months following the month In which Qualifying Events 2, 3, 4 or 5 occur. Under federal COBRA law only, when an employer has filed for bankruptcy under Title II, United States Code, benefits may be substantially reduced or eliminated for retired employees and their dependents, or the surviving spouse of a deceased retired employee. If this benefit reduction or elimination occurs within one year before or one year after the filing, It is considered a Qualifying Event. If the Primary Enrollee Is a retiree, and has lost coverage because of this Qualifying Event, he or she may choose to continue coverage until his or her death. The Primary Enrollee's dependents who have lost coverage because of this Qualifying Event may choose to continue coverage for up to 36 months following the Primary Enrollee's death. 10.4 PERIODS OF CONTINUED COVERAGE UNDER CAL -COBRA (groups of 2 - 19) In the case of Cal -COBRA, Delta Dental will act as the administrator. Notification and Premium payments should be made directly to Delta Dental. Notifications and payments should be delivered by first-class mail, certif ed mail, or other reliable means of delivery. Individuals who are eligible for coverage under the federal COBRA law are not eligible for coverage under Cal -COBRA. The employer must notify Delta Dental In writing within 30 days of the date when the Enrollee becomes subject to COBRA. Qualified Beneficiaries may continue coverage for 36 months following the month In which Qualifying Events 1, 2, 3, 4 or 5 occur. If, during the 36 -month continuation period resulting from Qualifying Event 1, the Qualified Beneficiary Is determined under Title II or Title XVI of the Social Security Act to be disabled on the date of the Qualifying Event or became disabled at any time during the first 60 days of continuation coverage; and notice of the determination Is given to the employer during the initial period of continuation coverage and within 60 days of the date of the social security determination letter, the Qualified Beneficiary may continue coverage for a total of 36 months following the month in which Qualifying Event 1 occurs. Is 25C-70 This period of coverage will end on the first of the month that begins more than 30 days after the date of the final determination that the disabled individual Is no longer disabled. The Qualified Beneficiary must notify the employer or administrator within 30 days of any such determination. If, during the 36 -month continuation period resulting from Qualifying Event 1, the Qualified Beneficiary experiences Qualifying Events 2, 3, 4 or 5, he or she must notify the employer within 60 days of the second qualifying event and has a total of 36 months continuation coverage after the date of the date of the first Qualifying Event. Delta Dental shall notify the Primary Enrollee of the date his or her continued coverage will terminate. This termination notification will be sent during the 180 -day period prior to the end of coverage. 10.5 ELECTION OF CONTINUED COVERAGE The Primary Enrollee's employer shall notify Delta Dental in writing within 30 days of Qualifying Event 1, A Qualified Beneficiary must notify his or her employer or the administrator in writing within 60 days of Qualifying Events 2, 3, 4 or 5, or within 60 days of receiving the election notice from the employer. Otherwise, the option of continued coverage will be lost. Within 14 days of receiving notice of a Qualifying Event, the employer or the administrator will provide a Qualified Beneficiary with the necessary benefits information, monthly Premium charge, enrollment forms, and instructions to allow election of continued coverage. A Qualified Beneflclary will then have 60 days to give the employer or the administrator written notice of the election to continue coverage. Failure to provide this written notice of election to the employer or the administrator within 60 days will result in the loss of the right to continue coverage. A Qualified Beneficiary has 45 days from the written election of continued coverage to pay the Initial Premium to his or her employer or the administrator, which Includes the Premium for each month since the loss of coverage. Failure to pay the required Premium within the 45 days will result in loss of the right to continued coverage, and any Premiums received after that date will be returned to the Qualified Beneficiary. 10.6 CONTINUED COVERAGE BENEFITS The Benefits under the continued coverage will be the same as those provided to active employees and their dependents who are still enrolled in the dental plan. If the employer changes the coverage for active employees, the continued coverage will change as well. Premiums will be adjusted to reflect the changes made. 10.7 TERMINATION OF COVERAGE A Qualified Beneficiary's coverage will terminate at the end of the month In which any of the following events first occur: 1. The allowable number of consecutive months of continued coverage is reached; 2. Failure to pay the required Premium in a timely manner; 3. The employer ceases to provide any group dental plan to its employees; 4. The individual moves out of the plan's service area; 19 25C-71 5. The Individual first obtains coverage for dental benefits, after the date of the election of continued coverage, under another group health plan (as an employee. or dependent) which does not contain or apply any exclusion or limitation with respect to any pre-existing condition of such person, if that pre-existing condition is covered under this plan; Entitlement to Medicare. The employer or Primary Enrollee shall notify Delta Dental or the administrator within 30 days of the occurrence of any of the above events. Once continued coverage terminates, It cannot be reinstated. 10.8 TERMINATION OF THE EMPLOYER'S DENTAL CONTRACT If the dental contract between the employer and Delta Dental terminates prior to the time that the continuation coverage would otherwise terminate, the employer shall notify a Qualified Beneficiary (either 30 days prior to the termination or when all Enrollees are notified whichever Is later) of that person's ability to elect continuation coverage under the employer's subsequent dental plan, If any. The employer must notify the successor plan of the Qualified Beneficiaries receiving continuation coverage so they may be notified of how to continue coverage under that plan. The continuation coverage will be provided only for the balance of the period that a Qualified Beneficiary would have remained covered under the Delta Dental plan had such plan with the former employer not terminated. The continuation coverage will terminate if a Qualified Beneficiary falls to comply with the requirements pertaining to enrollment In, and payment of Premium to the new group benefit plan within 30 days of receiving notice of the termination of the Delta Dental plan. 10.9 OPEN ENROLLMENT CHANGE OF COVERAGE A Qualified Beneficiary may elect to change continuation coverage during any subsequent open enrollment period, if the employer has contracted withanother plan to provide coverage to Its active employees. The continuation coverage under the other plan will be provided only for the balance of the period that a Qualified Beneficiary would have remained covered under the Delta Dental plan. ARTICLE 11 - GENERAL PROVISIONS 11.1 No agent has authority to change this Contract or waive any of Its provisions. Delta Dental may not change Premium rates, copayments or deductibles, If any, during any of the following time periods: (a) after the Contractholder has delivered written acceptance of the Contract, (b) after the start of an annual open enrollment period, and; (c) after receipt of the Premium for the first month of the contract term. Premiums may be changed under the following exceptions: (a) when authorized or required In the Contract, (b) when Premiums are subject to execution of a definitive agreement, and; (c) when Delta Dental and the Contractholder mutually agree in writing. No change in this Contract is valid unless.approved by an executive officer of Delta Dental and Included In this Contract by written amendment. zo 25C-72 11.2 The provisions of this Contract are severable. If any portion of this Contract or any Amendment of It is determined to be illegal, void or unenforceable by any arbitrator, court or other competent authority, all other provisions of this Contract will remain In effect. 11.3 The parties agree that the laws of the State of California, where the Contract was entered Into and Is to be performed, govern all questions regarding the interpretation or enforcement of this Contract. Delta Dental Is subject to the requirements of Chapter 2.2 of Division 2 of the California Health and Safety Code and Chapter 1 of Division 1 of Title 28 of the California Code of Regulations. Any provisions required to be in the Contract by those laws bind Delta Dental whether or not stated in this Contract. 11.4 Delta Dental and the Contractholder agree to consult each other to the extent reasonably practical concerning all materials published or distributed relating to this Contract. Neither Delta Dental nor the Contractholder will publish or distribute materials that are contrary to the terms of this Contract. 11.5 Delta Dental and the Contractholder agree to permit and encourage the professional relationship between Dentist and Enrollee to be maintained without Interference. 11.6 The Contractholder shall designate in writing a representative for purposes of receiving notices from Delta Dental under this Contract. The Contractholder may change Its representative at any time on 30 days notice to Delta Dental. Any notice required from Delta Dental to any Enrollee may be given to the Contractholder's representative, who shall disseminate such notice to the Enrollee by the next regular communication but in no event later than 30 days after receipt thereof. 11.7 The Contractholder shall comply in all respects with all applicable federal, state and local laws and regulations relating to administrative simplification, security and privacy of individually Identifiable Enrollee Information. The Contractholder agrees that this Contract may be amended as necessary to comply with federal regulations issued under the Health Insurance Portability and Accountability Act of 1996 or to comply with any other enacted administrative simplification, security or privacy laws or regulations. 11.8 Any notice under this Contract will be sufficient if given by either the Contractholder or Delta Dental to the other or, in the case of employees of the Contractholder, to Its representative at the addresses below: For the Contractholder: City of Santa Ana 20 Civic Center Plaza Santa Ana, CA 92701-4058 For Delta Dental: 100 First Street San Francisco, CA 94105 Such notice will be effective 48 hours after deposit in the United States mail with postage fully prepaid thereon., 256173 CITY OF SANTA ANA DELTA DENTAL GROUP NUMBER 19209 Printed Name Tltl Date: FOR: Delta Dental of California BY: Belinda Martinez Executive Vice President Chief Sales and Marketing Officer and BY: Thomas J. Leibowitz, FSA, MAAA Group Vice President and Chief Actuary Date: January 8, 2018 7.2 25C-74 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: MARIA HUIZAR Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: � . l Laura A. Rossini Senior Assistant City Attorney RECOMMENDED FOR APPROVAL: ELLEN SMILEY Acting Executive Director of Personnel Services CITY OF SANTA ANA Raul Godincz, II. City Manager 25C-75 APPENDIX B CODE ON DENTAL PROCEDURES AND NOMENCLATURE NOTE: All the listed procedures may not be benefits under the terms of your contract. Refer to your contract for your specific benefits. D0300 - D0999 DIAGNOSTIC Clinical oral evaluations D0120 Periodic oral evaluation - established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation - new or established patient D0160 Detailed and extensive oral evaluation - problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0180 Comprehensive periodontal evaluation - new or established patient D0190 Screening of a patient D0191 Assessment of a patient Radiographs/diagnostic imaging (including interpretation) D0210 Intraoral - complete series of radiographic Images D0220 Intraoral - periapical first radiographic Image D0230 Intraoral - periapical each additional radiographic Image D0240 Intraoral - occlusal radiographic Image D0250 Extra -oral - 2D projection radiographic image created using a stationary radiation source, and detector D0251 Extra -oral posterior dental radiographic image D0270 Bitewing - single radiographic image .. D0272 Bitewings - two radiographic images D0273 Bitewings - three radiographic Images D0274 Bitewings - four radiographic Images D0277 Vertical bitewings - 7 to 8 radiographic Images D0310 Sialography D0320 Temporomandibular joint arthrogram, Including Injection D0321 Other temporomandibular joint radiographic Images, by report D0322 Tomographic survey D0330 Panoramic radiographic image D0340 2D cephalometric radiographic Image - acquisition, measurement and analysis D0350 Oral/facial photographic images obtained Intraorally or extraorally Tests and examinations D0411 HbAlc In -office point of service testing D0415 Collection of microorganisms for culture and sensitivity D0416 Viral culture D0422 Collection and preparation of genetic sample material for laboratory analysis and report D0423 Genetic test for susceptibility to diseases - specimen analysis D0425 Caries susceptibility tests D0431 Adjunctive pre -diagnostic test that aids in detection of mucosal abnormalities Including premalignant and malignant lesions, not to include cytology or biopsy procedures D0460 Pulp vitality tests D0470 Diagnostic casts CDT2018(Eff. 01-01-18) 25C-76 oral pathology laboratory D0472 Accession of tissue, gross examination, preparation and transmission of written report D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report D0475 Decalcification procedure D0476 Special stains for microorganisms D0477 Special stains, not for microorganisms D0478 Immunohistochemical stains D0479 Tissue In-sltu hybridization, Including Interpretation D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report D0481 Electron microscopy - diagnostic D0482 Direct immunofluorescence D0483 Indirect Immunofluorescence D0484 Consultation on slides prepared elsewhere D0485 Consultation, including preparation of slides from biopsy material supplied by referring source D0486 Accession of brush biopsy sample, microscopic examination, preparation and transmission of written report D0502 Other oral pathology procedures, by report D0601 Caries risk assessment and documentation, with a finding of low risk D0602 Caries risk assessment and documentation, with a finding of moderate risk D0603 Caries risk assessment and documentation, with a finding of high risk, D0999 Unspecified diagnostic procedure, by report D1000 - D1999 PREVENTIVE Dental prophylaxis D1110 Prophylaxis - adult D1120 Prophylaxis - child through age 13 Topical fluoride treatment (office procedure) D1206 Topical application of fluoride varnish D1208 Topical application of fluoride - excluding varnish Other preventive services D1310 Nutritional counseling for control of dental disease D1320 Tobacco counseling for the control and prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant - per tooth D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth D1354 Interim caries arresting medicament application - per tooth Space maintenance (passive appliances) D1510 Space maintainer - fixed - unilateral D1515 Space maintainer - fixed - bilateral D1520 Space maintainer - removable - unilateral D1525 Space maintainer - removable - bilateral D1550 Re -cement or re -bond space maintainer D1555 Removal of fixed space maintalner D1575 Distal shoe space maintainer - fixed - unilateral CDT2018 (Eff. 01-01-18) 25C-77 D2000 - D2999 RESTORATIVE Amalgam restorations (including polishing) D2140 Amalgam - one surface, primary or permanent D2150 Amalgam - two surfaces, primary or permanent D2160 Amalgam - three surfaces, primary or permanent D2161 Amalgam - four or more surfaces, primary or permanent Resin -based composite restorations -direct D2330 Resin -based composite - one surface, anterior D2331 Resin -based composite - two surfaces, anterior D2332 Resin -based composite - three surfaces, anterior D2335 Resin -based composite - four or more surfaces or involving incisal angle (anterior) D2390 Resln-based composite crown, anterior D2391 Resin -based composite - one surface, posterior D2392 Resin -based composite - two surfaces, posterior D2393 Resin -based composite - three surfaces, posterior D2394 Resin -based composite - four or more surfaces, posterior Gold foil restorations D2410 Gold foil - one surface D2420 Gold foil - two surfaces D2430 Gold foil - three surfaces Inlay/onlay restorations D2510 Inlay - metallic - one surface D2520 Inlay - metallic - two surfaces D2530 Inlay - metallic - three or more surfaces D2542 Onlay - metallic - two surfaces D2543 Onlay - metallic - three surfaces D2544 Onlay - metallic - four or more surfaces D2610 Inlay - porcelain/ceramic - one surface D2620 Inlay - porcelain/ceramic - two surfaces D2630 Inlay - porcelain/ceramic - three or more surfaces D2642 Onlay - porcelain/ceramic - two surfaces D2643 Onlay - porcelain/ceramic - three surfaces D2644 Onlay - porcelain/ceramic - four or more surfaces D2650 Inlay - resin -based composite - one surface D2651 Inlay - resin -based composite - two surfaces D2652 Inlay - resin -based composite - three or more surfaces D2662 Onlay - resin -based composite - two surfaces D2663 Onlay - resin -based composite - three surfaces D2664 Onlay - resin -based composite - four or more surfaces Crowns - single restorations only D2710 Crown - resin -based composite (indirect) D2712 Crown - 3/4 resin -based composite (Indirect) D2720 Crown - resin with high noble metal D2721 Crown - resin with predominantly base metal D2722 Crown - resin with noble metal D2740 Crown - porcelain/ceramic D2750 Crown - porcelain fused to high noble metal D2751 Crown - porcelain fused to predominantly base metal D2752 Crown - porcelain fused to noble metal D2780 Crown - 3/4 cast high noble metal D2781 Crown - 3/4 cast predominantly base metal D2782 Crown - 3/4 cast noble metal D2783 Crown - 3/4 porcelain/ceramic CDT2018 (Eff. 01-01-18) 25C-78 D2790 Crown - full cast high noble metal D2791 Crown - full cast predominantly base metal D2792 Crown - full cast noble metal D2794 Crown - titanium D2799 Provisional crown - further treatment or completion of a diagnosis necessary prior to final impression Other restorative services D2910 Re -cement or re -bond Inlay, onlay, veneer or partial coverage restorations D2915 Re -cement or re -bond Indirectly fabricated or prefabricated post and core D2920 Re -cement or re -bond crown D2921 Reattachment of tooth fragment, Incisal edge or cusp D2929 Prefabricated porcelain/ceramic crown - primary tooth 02930 Prefabricated stainless steel crown - primary tooth D2931 Prefabricated stainless steel crown - permanent tooth D2932 Prefabricated resin crown D2933 Prefabricated stainless steel crown with resin window D2934 Prefabricated esthetic coated stainless steel crown - primary tooth D2940 Sedative filling D2941 Interim therapeutic restoration - primary dentition D2950 Core buildup, Including any pins when required D2951 Pin retention - per tooth, In addition to restoration D2952 Post and core in addition to crown, Indirectly fabricated D2953 Each additional Indirectly fabricated post - same tooth D2954 Prefabricated post and core in addition to crown D2955 Post removal D2957 Each additional prefabricated post - same tooth D2960 Labial veneer (resin laminate) - chairslde D2961 Labial veneer (resin laminate) - laboratory D2962 Labial veneer (porcelain laminate) - laboratory D2971 Additional procedures to construct new crown under existing partial denture framework D2975 Coping D2980 Crown repair, necessitated by restorative material failure D2999 Unspecifled restorative procedure, by report D3000 - D3999 ENDODONTICS Pulp capping D3110 Pulp cap - direct (excluding final restoration) D3120 Pulp cap - indirect (excluding final restoration) Pulpotomy D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament D3221 Pulpal debridement, primary and permanent teeth D3222 Partial pulpotomy for apexogenesis-permanent tooth with Incomplete root development D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) D3240 Pulpal.therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Endodontic therapy on primary teeth (including treatment plan, clinical procedures and. follow-up care) D3310 Endodontic therapy, anterior tooth (excluding final restoration) D3320 Endodontic therapy, premolar tooth (excluding final restoration) D3330 Endodontic therapy, molar tooth (excluding final restoration) CDT2018 (Eff. 01-01-18) 25C-79 D3331 Treatment of root canal obstruction; non-surgical access D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth D3333 Internal root repair of perforation defects Endodontic retreatment D3346 Retreatment of previous root canal therapy - anterior D3347 Retreatment of previous root canal therapy - premolar D3348 Retreatment of previous root canal therapy - molar Apexification/recalcification procedures D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352 Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulpal space disinfection, etc.) D3353 Apex! ncat! on/recalcification - final visit (Includes completed root canal therapy - apicai closure/calcific repair of perforations, root resorption, etc.) Apicoectomy/periradicular services D3410 Apicoectomy - anterior D3421 Apicoectomy - premolar (first root) D3425 Apicoectomy - molar (first root) D3426 Apicoectomy (each additional root) D3427 Periadicular surgery without apicoectomy D3430 Retrograde filling - per root D3450 Root amputation - per root D3460 Endodontic endosseous Implant D3470 Intentional relmplantation (including necessary splinting) Other endodontic procedures, D3910 Surgical procedure for isolation of tooth with rubber dam D3920 Hemisection (Including any root removal), not Including root canal therapy D3950 Canal preparation and fitting of preformed dowel or post D3999 Unspecified endodontic procedure, by report D4000 - D4999 PERIODONTICS Surgical services (including usual post-operative care) D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant D4212 Gingivectomy or gingivoplasty - to allow access for restorative procedure, per tooth D4230 Anatomical crown exposure - four or more contiguous teeth or bounded tooth spaces per quadrant D4231 Anatomical crown exposure - one to three teeth or bounded tooth spaces per quadrant D4240 Gingival flap procedure, Including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant D4245 Apically positioned flap D4249 Clinical crown lengthening - hard tissue D4260 Osseous surgery (Including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant D4263 Bone replacement graft - retained natural tooth - first site In quadrant D4264 Bone replacement graft - retained natural tooth - each additional site in quadrant D4265 Biologic materials to aid in soft and osseous tissue regeneration CDT2018(Eff. 01-01-18) 25C-80 D4266 Guided tissue regeneration - resorbable barrier, per site D4267 Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) D4268 Surgical revision procedure, per tooth D4270 Pedicle soft tissue graft procedure D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position In graft D4274 Mesial/distal wedge procedure, single tooth (when not performed In conjunction with surgical procedures in the same anatomical area) D4275 Non -autogenous connective tissue graft (Including recipient site and donor material) first tooth, Implant, or edentulous tooth position in graft D4276 Combined connective tissue and double pedicle graft, per tooth D4277 Free soft tissue graft procedure (Including recipient and donor surgical sites), first tooth, Implant, or edentulous tooth position in graft D4278 Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, Implant, or edentulous tooth position In same graft site D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) - each additional contiguous tooth, implant or edentulous tooth position In same graft site D4285 Non -autogenous connective tissue graft procedure (including recipient surgical site and donor material) - each additional contiguous tooth, implant or edentulous tooth position In same graft site. Non-surgical periodontal service D4320 Provisional splinting - Intracoronal D4321 Provisional splinting - extracoronal D4341 Periodontal scaling and root planing - four or more teeth per quadrant D4342 Periodontal scaling and root planing, - one to three teeth, per quadrant D4346 Scaling In presence of generalized moderate or severe gingival inflammation full mouth, after oral evaluation D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis on subsequent visit D4381 Localized delivery of antimicrobial agents via controlled release vehicle Into diseased crevicular tissue, per tooth Other periodontal services D4910 Perlodontal maintenance D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) D4999 Unspecified perlodontal procedure, by report 1135000 - D5899 PROSTHODONTICS (REMOVABLE) Complete dentures (including routine post -delivery care) D5110 Complete denture - maxillary D5120 Complete denture - mandibular D5130 Immediate denture - maxillary D5140 Immediate denture - mandibular Partial dentures (including routine post -delivery care) D5211 Maxillary partial denture - resin base (Including any conventional clasps, rests and teeth) D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5214 Mandibular partial denture - cast metal framework with resin denture bases (Including any conventional clasps, rests and teeth) D5221 Immediate maxillary partial denture - resin base (Including any conventional clasps, rests and teeth) CDT2018 (Eff. 01-01-18) 25C-81 D5222 Immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth) D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (Including any conventional clasps, rests and teeth) D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5225 Maxillary partial denture - flexible base (Including any clasps, rests and teeth) D5226 Mandibular partial denture - flexible base (Including any clasps, rests and teeth) D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth) Adjustments to dentures D5410 Adjust complete denture - maxillary D5411 Adjust complete denture - mandibular D5421 Adjust partial denture - maxillary D5422 Adjust partial denture - mandibular Repairs to complete dentures D5511 Repair broken complete denture base, mandibular D5512 Repair broken complete denture base, maxillary D5520 Replace missing or broken teeth - complete denture (each tooth) Repairs to partial dentures D5611 Repair resin partial denture base, mandibular D5612 Repair resin partial denture base, maxillary D5621 Repair cast partial framework, mandibular D5622 Repair cast partial framework, maxillary D5630 Repair or replace broken clasp - per tooth D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture - per tooth D5670 Replace all teeth and acrylic on cast metal framework (maxillary) D5671 Replace all teeth and acrylic on cast metal framework (mandibular) Denture rebase procedures D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture Denture reline procedures D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5740 Reline maxillary partial denture (chairside) D5741 Reline mandibular partial denture (chairside) D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5760 Reline maxillary partial denture (laboratory) D5761 Reline mandibular partial denture (laboratory) Interim prosthesis D5810 Interim complete denture (maxlllary) D5811 Interim complete denture (mandibular) D5820 Interim partial denture (maxlllary) D5821 Interim partial denture (mandibular) CDT2018 (Eff. 01-01-18) 25C-82 Other removable prosthetic services D5850 Tissue conditioning - maxillary D5851 Tissue conditioning - mandibular D5862 Precision attachment, by report D5863 Overdenture - complete maxillary D5864 Overdenture - partial maxillary D5865 Overdenture - complete mandibular D5866 Overdenture - partial mandibular D5867 Replacement of replaceable part of semi -precision or precision attachment (male or female component) D5875 Modification of removable prosthesis following Implant surgery D5899 Unspecified removable prosthodontic procedure, by report D5900 - D5999 MAXILLOFACIAL PROSTHETICS D5911 Facial moulage (sectional) D5912 Facial moulage (complete) D5913 Nasal prosthesis D5914 Auricular prosthesis D5915 Orbital prosthesis D5916 Ocular prosthesis D5919 Facial prosthesis D5922 Nasal septal prosthesis D5923 Ocular prosthesis, Interim D5924 Cranial prosthesis D5925 Facial augmentation Implant prosthesis D5926 Nasal prosthesis, replacement D5927 Auricular prosthesis, replacement D5928 Orbital prosthesis, replacement D5929 Facial prosthesis, replacement D5931 Obturator prosthesis, surgical D5932 Obturator prosthesis, definitive D5933 Obturator prosthesis, modification D5934 Mandibular resection prosthesis with guide Flange D5935 Mandibular resection prosthesis without guide Flange D5936 Obturator prosthesis, Interim D5937 Trismus appliance (not for TMD treatment) D5951 Feeding aid D5952 Speech aid prosthesis, pediatric D5953 Speech aid prosthesis, adult D5954 Palatal augmentation prosthesis D5955 Palatal lift prosthesis, definitive D5958 Palatal lift prosthesis, interim D5959 Palatal lift prosthesis, modification D5960 Speech aid prosthesis, modification D5982 Surgical stent D5983 Radiation carrier D5984 Radiation shield D5985 Radiation cone locator D5986 Fluoride gel carrier D5987 Commissure splint D5988 Surgical splint D5999 Unspecified maxillofacial prosthesis, by report D6000 - D6199 IMPLANT SERVICES D6010 Surgical placement of implant body: endosteal implant D6012 Surgical placement of interim Implant body for transitional prosthesis: endosteal implant D6013 Surgical placement of mini Implant CDT2018 (Eff. 01-01-18) 25C-83 D6040 Surgical placement: eposteal Implant D6050 Surgical placement: transosteal Implant Implant supported prosthetics D6055 Dental Implant supported connecting bar D6056 Prefabricated abutment - includes modification and placement D6057 Custom fabricated abutment - includes placement D6058 Abutment supported porcelain/ceramic crown D6059 Abutment supported porcelain fused to metal crown (high noble metal) D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) D6061 Abutment supported porcelain fused to metal crown (noble metal) D6062 Abutment supported cast metal crown (high noble metal) D6063 Abutment supported cast metal crown (predominantly base metal) D6064 Abutment supported cast metal crown (noble metal) D6065 Implant supported porcelain/ceramic crown D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) D6068 Abutment supported retainer for porcelaln/ceramic FPD D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) D6072 Abutment supported retainer for cast metal FPD (high noble metal) D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) D6074 Abutment supported retainer for cast metal FPD (noble metal) D6075 Implant supported retainer for ceramic FPD D6076 Implant supported retainer for porcelain fused, to metal FPD (titanium, titanium alloy, or high noble metal) D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) Other implant services D6080 Implant maintenance procedures, Including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis D6081 Scaling and debridement In the presence of Inflammation or mucositis of a single Implant, including cleaning of the Implant surfaces, without flap entry and closure D6085 Provisional Implant crown D6090 Repair implant supported prosthesis, by report D6091 Replacement of semi -precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment D6092 Re -cement or re -bond Implant/abutment supported crown D6094 Abutment supported crown - (titanium) D6095 Repair Implant abutment, by report D6096 Remove broken Implant retaining screw D6100 Implant removal, by report D6101 Debridement of a periimplant defect or defects surrounding a single Implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure D6102 Debridement and osseous contouring of a periimplant defect or defects surrounding a single implant, and surface cleaning includes surface cleaning of the exposed Implant surfaces, including flap entry and closure D6110 Implant/abutment supported removable denture for edentulous arch- maxillary D6111 Implant/abutment supported removable denture for edentulous arch- mandibular D6112 Implant/abutment supported removable. denture for partially edentulous arch - maxillary D6113 Implant/abutment supported removable denture for partially edentulous arch - mandlbular CDT2018 (Eff. 01-01-18) 25C-84 D6114 Implant/ abutment supported fixed denture for edentulous arch - maxlllary D6115 Implant / abutment supported fixed denture for edentulous arch - mandibular D6116 Implant / abutment supported fixed denture for partially edentulous arch - maxlllary D6117 Implant / abutment supported fixed denture for partially edentulous arch - mandibular D6118 Implant/abutment supported interim fixed denture for edentulous arch - mandibular D6119 Implant/abutment supported Interim fixed denture for edentulous arch - maxillary D6190 Radiographic/surgical Implant Index, by Report D6093 Re -cement or re -bond Implant/abutment supported fixed partial denture D6194 Abutment supported retainer crown for FPD - (titanium) D6199 Unspecified Implant procedure, by report D6200 - D6999 PROSTHODONTICS, FIXED (Each retainer and each pontic constitutes a unit in a fixed partial denture) Fixed partial denture pontics D6205 Pontic - Indirect resin based composite D6210 Pontic - cast high noble metal D6211 Pontic - cast predominantly base metal D6212 Pontic - cast noble metal D6214 Pontic - titanium D6240 Pontic - porcelain fused to high noble metal D6241 Pontic - porcelain fused to predominantly base metal D6242 Pontic - porcelain fused to noble metal D6245 Pontic - porcelain/ceramic D6250 Pontic - resin with high noble metal D6251 Pontic - resin with predominantly base metal D6252 Pontic - resin with noble metal D6253 Provisional pontic - further treatment or completion of a diagnosis necessary prior to Impression. Fixed partial denture retainers - inlays/ onlays D6545 Retainer - cast metal for resin bonded fixed prosthesis D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis D6549 Resin retainer - for resin bonded fixed prosthesis D6600 Retainer Inlay - porcelain/ceramic, two surfaces D6601 Retainer Inlay - porcelain/ceramic, three or more surfaces D6602 Retainer Inlay - cast high metal, two surfaces D6603 Retainer Inlay - cast high metal, three or more surfaces D6604 Retainer inlay - cast predominantly base metal, two surfaces D6605 Retainer inlay -. cast predominantly base metal, three or more surfaces D6606 Retainer inlay - cast noble metal, two surfaces D6607 Retainer Inlay - cast noble metal, three or more surfaces D6608 Retainer onlay - porcelaln/ceramic, two surfaces D6609 Retainer onlay - porcelain/ceramic, three or more surfaces D6610 Retainer onlay - cast high noble metal, two surfaces D6611 Retainer onlay - cast high noble metal, three or more surfaces D6612 Retainer onlay - cast predominantly base metal, two surfaces D6613 Retainer onlay - cast predominantly base metal, three or more surfaces D6614 Retainer onlay - cast noble metal, two surfaces D6615 Retainer onlay - cast noble metal, three or more surfaces D6624 Retainer Inlay - titanium D6634 Retainer onlay - titanium Fixed partial denture retainers - crowns D6710 Retainer crown - indirect resin based composite D6720 Retainer crown - resin with high noble metal D6721 Retainer crown - resin with predominantly base metal D6722 Retainer crown - resin with noble metal 10 CD72018 (Eff. 01-01-18) 25C-85 D6740 Retainer crown - porcelain/ceramic D6750 Retainer crown - porcelain fused to high noble metal D6751 Retainer crown - porcelain fused to predominantly base metal D6752 Retainer crown - porcelain fused to noble metal D6780 Retainer crown - 3/4 cast high noble metal D6781 Retainer crown - 3/4 cast predominantfy base metal D6782 Retainer crown - 3/4 cast noble metal D6783 Retainer crown - 3/4 porcelain/ceramic D6790 Retainer crown - full cast high noble metal D6791 Retainer crown - full cast predominantly base metal D6792 Retainer crown - full cast noble metal D6793 Provisional retainer crown - further treatment of completion or a diagnosis necessary prior to final impression D6794 Retainer crown - titanium Other fixed partial denture services D6920 Connector bar D6930 Re -cement or re -bond fixed partial denture D6940 Stress breaker D6950 Precision attachment D6980 Fixed partial denture repair necessitated by restorative material D6985 Pediatric partial denture, fixed D6999 Unspecified, fixed prosthodontic procedure, by report D7000 - D7999 ORAL AND MAXILLOFACIAL SURGERY Extractions (includes local anesthesia, suturing, if needed, and routine postoperative care) D7111 Extraction, coronal remnants - primary tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical extractions (Includes local anesthesia, suturing, if needed, and routine postoperative care) D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and Including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth - partially bony D7240 Removal of impacted tooth - completely bony D7241 Removal of impacted tooth - completely bony, with unusual surgical complications D7250 Removal of residual tooth roots (cutting procedure) Other surgical procedures D7260 Oroantral fistual closure D7261 Primary closure of a sinus perforation D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth D7272 Tooth transplantation (Includes reimplantation from one site to another and splinting and/or stabilization) D7280 Exposure of an unerupted tooth D7282 Mobilization of erupted or malpositioned tooth to aid eruption D7283 Placement of device to facilitate eruption of impacted tooth D7285 Inclslonal biopsy of oral tissue - hard (bone, tooth) D7286 Incisional biopsy of oral tissue - soft D7287 Exfoliative cytological sample collection D7288 Brush biopsy - transepithelial sample collection D7290 Surgical repositioning of teeth D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report D7292 Placement of temporary anchorage device [screw retained plate] requiring Flap; Includes device removal D7293 Placement of temporary anchorage device requiring flap; includes device removal 11 CDT2018 (Eff. 01-01-18) 25C-86 D7294 Placement of temporary anchorage device without flap; includes device removal D7296 Corticotomy - one to three teeth or tooth spaces, per quadrant D7297 Corticotomy - four or more teeth or tooth spaces, per quadrant Alveoloplasty - surgical preparation of ridge for dentures D7310 Alveoloplasty In conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant D7320 Alveoloplasty not In conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant Vestibuloplasty D7340 Vestibuloplasty - ridge extension (secondary epithelialization) D7350 Vestibuloplasty - ridge extension (Including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) Surgical excision of soft tissue lesions D7410 Excision of benign lesion up to 1.25 cm D7411 Excision of benign lesion greater than 1.25 cm D7412 Excision of benign lesion, complicated D7413 Excision of malignant lesion up to 1.25 cm D7414 Excision of malignant lesion greater than 1.25 cm D7415 Excision of malignant lesion complicated D7465 Destruction of lesions) by physical or chemical method, by report Surgical excision of intra-osseous lesions D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm Excision of bone tissue D7471 Removal of lateral exostosis (maxilla or mandible) D7472 Removal of torus palatinus D7473 Removal of torus manibularis D7485 Reduction of osseous tuberosity D7490 Radical resection of maxilla or mandible Surgical incision D7510 Incision and drainage of abscess - Intraoral soft tissue D7511 Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) D7520 Incision and drainage of abscess - extraoral soft tissue D7521 Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fasclal spaces) D7530 Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue D7540 Removal of reaction -producing foreign bodies, musculoskeletal system D7550 Partial ostectomy/sequestrectomy for removal of non -vital bone D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body 12 CDT2018 (Eff. 01-01-18) 25C-87 Treatment of fractures - simple D7610 Maxilla - open reduction (teeth Immobilized, If present) D7620 Maxilla - closed reduction (teeth Immobilized, If present) D7630 Mandible - open reduction (teeth Immobilized, If present) D7640 Mandible - closed reduction (teeth Immobilized, if present) D7650 Malar and/or zygomatic arch - open reduction D7660 Malar and/or zygomatic arch - closed reduction D7670 Alveolus - closed reduction, may Include stabilization of teeth D7671 Alveolus - open reduction, may include stabilization of teeth D7680 Facial bones - complicated reduction with fixation and multiple surgical approaches Treatment of fractures - compound D7710 Maxilla - open reduction D7720 Maxilla - closed reduction D7730 Mandible - open reduction D7740 Mandible - closed reduction D7750 Malar and/or zygomatic arch - open reduction D7760 Malar and/or zygomatic arch - closed reduction D7770 Alveolus - open reduction splinting stabilization of teeth D7771 Alveolus - closed reduction stabilization of teeth D7780 Facial bones - complicated reduction with fixation and multiple approaches Reduction of dislocation and management of other temporomandibular joint dysfunctions D7810 Open reduction of dislocation D7820 Closed reduction of dislocation D7830 Manipulation under anesthesia D7840 Condylectomy D7850 Surgical discectomy, with/without implant D7852 Disc repair D7854 Synovectomy D7856 Myotomy D7858 Joint reconstruction D7860 Arthrotomy D7865 Arthroplasty D7870 Arthrocentesis D7871 Non -arthroscopic lysis and lavage D7872 Arthroscopy - diagnosis, with or without biopsy D7873 Arthroscopy: lavage and lysis of adhesions D7874 Arthroscopy: disc repositioning and stabilization D7875 Arthroscopy: synovectomy D7876 Arthroscopy: discectomy D7877 Arthroscopy: debridement D7880 Occlusal orthotic device, by report D7881 Occlusal orthotic device adjustment D7899 Unspecified TMD therapy, by report Repair of traumatic wounds D7910- Suture of recent small wounds up to 5 cm Complicated suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure) D7911 Complicated suture - up to 5 cm D7912 Complicated suture - greater than 5 cm Other repair procedures D7920 Skin graft (Identify defect covered, location and type of graft) D7940 Osteoplasty - for orthognathic deformities D7941 Osteotomy - mandibular rami 13 CDT2018 (Eff. 01-01-18) 25C-88 D7943 Osteotomy - mandibular rami with bone graft; includes obtaining the graft D7944 Osteotomy - segmented or subapical D7945 Osteotomy - body of mandible D7946 LeFort I (maxilla - total) D7947 LeFort I (maxilla - segmented) D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasla or retrusion) - without bone graft D7949 LeFort II or LeFort III - with bone graft D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach D7952 Sinus augmentation via a vertical approach D7953 Bone replacement graft for ridge preservation - per site D7955 Repair of maxillofacial soft and/or hard tissue defect D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not Incidental to another procedure D7963 Frenuloplasty D7970 Excision of hyperplastic tissue - per arch D7971 Excision of pericoronal gingiva D7972 Surgical reduction of fibrous tuberosity D7979 Non-surgical sialolithotomy D7980 Surgical sialolithotomy D7981 Excision of salivary gland, by report D7962 Sialodochoplasty D7983 Closure of salivary fistula D7990 Emergency tracheotomy D7991 Coronoldectomy D7995 Synthetic graft - mandible or facial bones, by report D7996 Implant - mandible for augmentation purposes (excluding alveolar ridge), by report D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar D7998 Intraoral placement of a fixation device not in conjunction with a fracture D7999 Unspecified oral surgery procedure, by report D8000 - D8999 ORTHODONTICS Limited orthodontic treatment D8010 Limited orthodontic treatment of the primary dentition D8020 Limited orthodontic treatment of the transitional dentition D8030 Limited orthodontic treatment of the adolescent dentition D8040 Limited orthodontic treatment of the adult dentition Interceptive orthodontic treatment 138050 Interceptive orthodontic treatment of the primary dentition D8060 Interceptive orthodontic treatment of the transitional dentition Comprehensive orthodontic treatment D8070 Comprehensive orthodontic treatment of the transitional dentition D8080 Comprehensive orthodontic treatment of the adolescent dentition D8090 Comprehensive orthodontic treatment of the adult dentition Minor treatment to control harmful habits D8210 Removable appliance therapy D8220 Fixed appliance therapy Other orthodontic services D8660 Pre -orthodontic treatment examination to monitor growth and development D8670 Periodic orthodontic treatment visit D8680 Orthodontic retention (removal of appliances, construction and placement of retainer[s]) 14 CDT2018 (Eff. 01-01-18) 25C-89 D8681 Removable orthodontic retainer adjustment D8690 Orthodontic treatment (alternative billing to a contract fee) D8691 Repair of orthodontic appliance D8692 Replacement of lost or broken retainer D8693 Re -bond or re -cement fixed retainer D8694 Repair of fixed retainers, includes reattachment D8695 Removal of fixed orthodontic appliance(s) - other than at conclusion of treatment D8999 Unspecified orthodontic procedure, by report D9OOO - D9999 ADJUNCTIVE GENERAL SERVICES Unclassified treatment D9110 Palliative (emergency) treatment of dental pain - minor procedure D9120 Fixed partial denture sectioning Anesthesia D9210 Local anesthesia not in conjunction with operative or surgical procedures D9211 Regional block anesthesia D9212 Trigeminal division block anesthesia D9215 Local anesthesia D9222 Deep sedation/general anesthesia - first 15 minutes D9223 Deep sedation/general anesthesia - each subsequent 15 minute Increment D9230 Analgesia, anxiolysis, inhalation of nitrous oxide D9239 Intravenous moderate (conscious) sedation/analgesia - first 15 minutes D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment D9248 Non -Intravenous conscious sedation Professional consultation D9310 Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician Professional visits D9410 House/extended care facility call D9420 Hospital call D9430 Office visit for observation (during regularly scheduled hours) - no other services performed D9440 Office visit - after regularly scheduled hours D9450 Case presentation, detailed and extensive treatment planning Drugs D9610 Therapeutic parenteral drug, single administration D9612 Therapeutic parenteral drugs, two or more administrations, different medications D9630 Drugs or medicaments dispensed In the office for home use Miscellaneous services D9910 Application of desensitizing medicament D9911 Application of desensitizing resin for cervical and/or root surface, per tooth D9920 Behavior management, by report D9930 Treatment of complications (post-surgical) - unusual circumstances, by report D9932 Cleaning and Inspection of removable complete denture, maxillary D9933 Cleaning and inspection of removable complete denture, mandibular D9934 Cleaning and inspection of removable partial denture, maxillary D9935 Cleaning and inspection of removable partial denture, mandibular D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9942 Repair and/or reline of occlusal guard D9943 Occlusal guard adjustment is 25C-90 CDT2018 (Eff. 01-01-18) D9950 Occlusion analysis - mounted case D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9970 Enamel mlcroabrasion D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections D9972 External bleaching - per arch - performed in office D9973 External bleaching - per tooth D9974 Internal bleaching - per tooth D9995 Teledentlstry - synchronous; real-time encounter D9996 Teledentlstry - asynchronous; Information stored and forwarded to dentist for subsequent review D9999 Unspecified adjunctive procedure, by report Note: This Appendix represents codes and nomenclature excerpted from the version of Current Dental Terminology (CDT) in effect at the date of this printing. CDT coding and nomenclature are the copyright of the American Dental Association, and have been accepted as the standard for data transmission purposes under federal Administrative Simplification regulations. For the purposes of this Appendix, Delta Dental's administration of Benefits, Limitations and Exclusions under this Contract will at all times be based on the then -current version of CDT whether or not a revised Appendix B Is provided. CDT2018 (Eff. 01-01-18) 25C-91 25C-92 AMENDMENT No.1 This Amendment No. 1 hereby amends the Consultant Agreement ("Agreement") dated June 21, 2016 by and between Keenan & Associates and the City of Santa Ana as follows (hereafter referred to collectively as "Pardes'J: WHEREAS, the current term of the Agreement expired or will expire on June 20, 2018; and WHEREAS, the Parties desire to continue their relationship and to provide for additional services subject to the terms and conditions outlined in the Agreement; NOW, THEREFORE, the parties agree as follows: 1. Renewal. The Parties agree to extend the term of the Agreement for an additional three (3) year term beginning on July 1, 2018 and ending on June 30, 2021 ("Renewal Term") as provided for in Section 3 of the Agreement. 2. Dental Plan Services. In addition to the services described in the Agreement, Keenan shall perform the following services: a. Broker of Record. Effective January 1, 2018, Keenan shall become the Broker of Record for Client's Dental PPO plan, currently through Delta Dental and • Effective July 1, 2018 Keenan shall become the Broker of Record for Client's Dental DHMO plan, currently with MetLife. • As Broker of Record, Keenan shall market both Keenan's PPO and DHMO plans for the plan year beginning January 1, 2019. b. Ongoing Support Services: Effective as of the date that that Keenan becomes the Broker of Record for such plan, Keenan shall perform the following services for Client's each of the Client's dental plans: • Provide continued analysis of benefit plan design and performance noting available alternatives as appropriate; • Provide direction and support with claims resolution and other related issues; • Review of claims experience and trends; • Provide support with billing/eligibility concerns; • Act as a liaison between Client and carriers and vendors and serving as a proactive Client advocate; • Respond to day-to-day benefit questions from Client; • Assist Client with governmental reporting and filings (e.g., 5500's and Summary Annual Reports), as applicable; • Provide information concerning current developments and trends in employee benefits and new legislation that may affect Client's plans; Keenan & Associates—Gcenee #0451271 rld'..' Amcndmcnt to Con mldng Sendces Agm=mt EXHIBIT 3 ConfidentW Information Page 1 of 11/21/2017 25C-93 Assist in drafting, review and/or amendment of benefit plan and related documents. Any document drafted or reviewed by Keenan and approved by Client under this Agreement shall apply solely to the plan year for which the Service was provided. They are not intended for use beyond the plan year for which they were created, reviewed or revised. Keenan shall not be held liable for any direct, punitive, special, consequential or incidental damages, loss of profit or revenue, loss of business, loss or inaccuracy of data or'scope of insurance resulting from the continued use of such plan documents or SPD beyond the dates for which they were intended; Assist in the coordination and preparation of open enrollment, orientation, health fairs, and/or question and answer meetings for Client's employees. and c. In accordance with Section 2 of the Agreement, Keenan's compensation for the additional services described in this Amendment shall be the commissions earned for the placement of Client's dental coverages. The commissions are paid by the dental insurance companies. Delta dental currently pays a 5% commission for the Dental PPO plan. 3. All the remaining terms and conditions of the Agreement shall retrain unchanged and in full force and effect during, and shall govern the conduct of the Parties during the Renewal Term 4. The effective date of this amendment is December 5, 2017. 5. Each person signing this Amendment to the Agreement on behalf of a Party represents and warrants that he or she has the necessary authority to bind such Party and that this Amendment is binding on and enforceable against such Party. City of Santa Ana Signature: See attached signature page By - Title: Address: Attention: Email: Keenan & Associates Signature: Keenan & Associams—facense #11451271 Annendmcnt to Consulting Semites Atmr=nt Confidential Information Page 2 of 3 25C-94 11/21/2017 By: Steve Gedestad Title: Municipalities Practice Leader Address: 2355 Crenshaw Blvd.. #200 Torrance. CA 90501 Attention: Laurie LoFranco Email: Llofrancona keenan.com Keenan & Associams—facense #11451271 Annendmcnt to Consulting Semites Atmr=nt Confidential Information Page 2 of 3 25C-94 11/21/2017 ATTEST: NIARIA HUIZAR Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By. CJ WICK-, K . Laura A. Rossini Senior Assistant City Attorney RECOMMENDED FOR APPROVAL: ED RAYA Executive Director of Personnel Services Keenan el Asusurcs — Ikeno: #0431271 .\mend.,t m 4m.ulting Sen'ices .\lgeunent Confidential Inloamatinn Page S of} CITY OF SANTA ANA Raul Godinez City Manager 25C-95 m 11/21/21117 25C-96 AMENDMENT No.1 This Amendment No. I hereby amends the Consultant Agreement ("Agreement's dated June 21, 2016 by and between Keenan & Associates and the City of Santa Ana as follows (hereafter referred to collectively as "Parties'): WHEREAS, the current term of the Agreement expired or will expire on June 20, 2018; and WHEREAS, the Parties desire to continue their relationship and to provide for additional services subject to the terms and conditions outlined in the Agreement; NOW, THEREFORE, the parties agree as follows: 1. Renewal. The Parties agree to extend the term of the Agreement for an additional three (3) year term beginning on July 1, 2018 and ending on June 30, 2021 ("Renewal Term") as provided for in Section 3 of the Agreement. 2. Dental Plan Services. In addition to the services described in the Agreement, Keenan shall perform the following services: a. Broker of Record. • Effective January 1, 2018, Keenan shall become the Broker of Record for .Client's Dental PPO plan, currently through Delta Dental and Effective July 1, 2018 Keenan shall become the Broker of Record for Clienes Dental DHMO plan, currently with MetLife. As Broker of Record, Keenan shall market both Keenan's PPO and DHMO Plans for the plan year beginning January 1, 2019. b. Ongoing Support Services: Effective as of the date that that Keenan becomes the Broker of Record for such plan, Keenan shall perform the following services for Client's each of the Client's dental plans: • Provide continued analysis of benefit plan design and performance noting available alternatives as appropriate; • Provide direction and support with claims resolution and other related issues; • Review of claims experience and trends; • Provide support with billing/eligibility concerns; • Act as a liaison between Client and carriers and vendors and serving as a proactive Client advocate; • Respond to day-to-day benefit questions from Client; • Assist Client with governmental reporting and filings (e.g., 5500's and Summary Annual Reports), as applicable; • Provide information concerning current developments and trends in employee benefits and new legislation that may affect Client's plans; Keenan & Asaoeiatce— License #0451271 Amendment to Consulting Services Agreement EXHIBIT 3 Confulenhd InformationPabre 1 of 3 11/21/2017 25C-97 Assist in drafting, review and/or amendment of benefit plan and related documents. Any document drafted or reviewed by Keenan and approved by Client under this Agreement shall apply solely to the plan year for which the Service was provided. They are not intended for use beyond the plan year for which they were created, reviewed or revised. Keenan shall not be held liable for any direct, punitive, special, consequential or incidental damages, loss of profit or revenue, loss of business, loss or inaccuracy of data or scope of insurance resulting from the continued use of such plan documents or SPD beyond the dates for which they were intended; Assist in the coordination and preparation of open enrollment, orientation, health fairs, and/or question and answer meetings for Client's employees. and c. In accordance with Section 2 of the Agreement, Keenan's compensation for the additional services described in this Amendment shall be the commissions earned for the placement of Client's dental coverages. The commissions are paid by the dental insurance companies. Delta dental currently pays a 5% commission for the Dental PPO plan. 3. All the remaining terms and conditions of the Agreement shall remain unchanged and in full force and effect during, and shall govern the conduct of the Parties during the Renewal Term. 4. The effective date of this amendment is December 5, 2017. 5. Each person signing this Amendment to the Agreement on behalf of a Party represents and warrants that he or she has the necessary authority to bind such Party and that this Amendment is binding on and enforceable against such Party. City of Santa An Signature: See attached signature Title: Address Attention: Email: Keenan & Associates Signature Keenan&.3s lows—license #0451271 Amendment to Co.Mdngtiemiccs ,%h c rnent Confidential rnfoamation Page 2 of 3 25C-98 11/21/:017 v B teve Gedestad Title: Municipalities Practice Leader Address: 2355 Crenshaw Blvd.. #200 Torrance. CA 90501 Attention: Laurie LoFranco Email: Llofranco( keenan.com Keenan&.3s lows—license #0451271 Amendment to Co.Mdngtiemiccs ,%h c rnent Confidential rnfoamation Page 2 of 3 25C-98 11/21/:017 ATTEST: NfARLA HLIZAR Clerk of the Council APPROVED AS TO FORM: SONIA R. CARV ALHO Cite .Attorney Laura :A. Rossini Senior Assistant Cin - Attorney RECOMMENDED FOR APPROVAL: ELLEN SMILEY Acting Executive Director of Personnel Services Fc<n:m tl .\smnans —License # W i I'_] I .\mcnJmcm m Gnrsuhmg Sen'itts .\�Tccmcm CunliJcnlial Iniurm:vinn I'u;c int i CITY OF SANTA ANA Raul Godinez II City Manager 25C-99 11/2I/2nl7 25C-100