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Benefits Agreement Contract with Delta Dental for 2013 BenefitsL~ DELTA DENTAL Delta Dental of Idaho Contract prepared for: 0133 Czty of Meridian 0133 Delta Dental of Idaho Delta Dental Premier This contract originally effective the 1st day of October,1984 A.D,, by and between City of Meridian, hereinafter referred to as the contractor and DELTA DENTAL OF IDAHO, INC,, an Idaho nonprofit corporation, hereinai~er referred to as Oelta Dental Section ~ Declarations The benefits afforded are only with respect to such benefits as are indicated in this contract. Delta Den ' li ' th+~ benefits stated herein; subject to all the terms of this contract Navin referent tal s ab~l~ty ~s llm~ted to g e thereto, A,. Effective Date of Contract Term: l2;dl A.M, Standard Time, January Oi, Z013 A.D, B. lttnewal Date: January O1, 2D14 C, Contract Term; One year D, Croup Number: 4133 E. Eligibility (subscriber and dependents); All active employees and directors of the contractor working at least 44 hours per week are eligible to be subscri~rs. All elected offtcials of the cantractor working at least 19.5 haurs per week are eligible to be subscribers There two subscribers who are legally married to each other are eligible under the same group or any other dental group of the contractor and/or have dental coverage separately or jointly under any other contractor, they will be enrolled under separate enrollment cards, Subscribers may dually cover any or all dependents with internal dual coverage allowed up to one maximum benef t, Dependents of above~mentianed subscribers are also eligible. Dependent children are eligible to age 26. F, Eligibility Period; A11 new subscribers (and their dependents, if covered above), defined as eligible subscribers added to the covered graup who are hired after the effective starting date of the contract will be eligible for enrollment oa7 the first day of the month following date of hire. G. Late Enrollee: Any employee and/or their dependentts) who did not enroll on the dental plan following completion of the employee's eligibility period, as defined above, will be considered a late enrollee and will have a 24 month waiting period for Major gerviees (Class Ill), The late enrollee waiting period shall be in addition to any other service waiting periods on the plan. Page 1 QI33 Oe{ta dental of Idaho H. Covered Services: Delta Dental Pays PFO Premier C1a39 ~ Benefsts Diagnostic and Preventive Services 104°/a $Q% Radiographs 100°l0 8a% Class XY Benefits 80% 74% Oral Surgery Services Endodontic Services $O4/° 7a% Periodontic Services ~Oa/o ?0% Minor Restorative Services g0% 7a% Class II1 Benefits Major Restorative Services 5a% 4Q% Prosthodontic Services ga% 40°/a class Iv Benefits Orthodontic Services Child and Adult a°~a 0°~0 Deductible Per Verson $5a $50 Per Family $ISa ~15a Maximum Benefit $1,Z5a ~l,aaa 1, Deductible: The deductible is a per person total per calendar y ear limited to a maximum of three deductibles per family per calendar year on Class II and Class III Benefits, The deductible does not apply to Class I or Class 1V Benefits. J. MAxlmum Payment; The maximum payment is a per person total per calendar year an Class I, Class II, and Class Iii Benefits, K. Rate: COBRA Rates: (COBRA rates are provided and applicable to Groups with 20 or mare employees). Employee S40.b0 $41.41 Employee + Spouse 581,30 $8.93 Employee + One Child $64,35 565.64 Fanployee + Twa or more Children $82.80 5$4,46 Employee+Spouse+ One Child S10S.15 ~I07.2S Employee + Spouse + Two or more Children S 123.3a 5125,77 Renewal dues will be based upon the experience ofthe plan in which the Contractor is enrolled with consideration given to the Contractor's individual group experience. Gtoup experience reports will be provided quarterly based upon a calendar year, L. These rates are contingent upon: The employer MUST contribute laa% of the full cost of eligible employees and ALL eligible employees MUST be enrolled. 50% of ALL eligible dependents MUST be enrolled, Page z ~ R . DI+LTA DENTAL QF IDAHO ~~ De~n~tians A, Benefits means payment for dental services that have been selected under the Contract, B. Child means the Subscriber's natural children, stepchildren, adopted children, children by virtue of legal guardianship, C. Contract means this document, including, if applicable, any appendices, supplements, riders, successor agreements, or renewals now or herea$er issued or executed. D, ""Contract Fee" means the maximum dollar amount, determined in accordance with the terms of the Delta Dental service agreement and policies, rules or schedules as may from time to time be adopted by Delta Dental, that may be paid to Delta Dental Premier Participating Dentists for dental services provided to subscribers and Eligible Dependents, E. Capayment means the percentage of benefit payment that the Subscriber must pay for Covered Services. F. Covered Services means the unique dental services selected for benefits as described in the Declarations Section and subject to the terms and conditions of this Contract. G. Deductible means the amount an individual and/or a family must pay toward Covered Services before Delta Dental begins paying for services under this Contract, If the Contractor has selected a Deductible, it will be indicated in the Declarations Section. H, Delta Dental means Delta Dental Plan of Idaho, Inc., a nonprofit dental service corporation providing dental benefits programs, I. Delta Rental's 1WonparticipatingRentist Fee means the maximum amount allowed per procedure for services rendered by a Delta Dental Nonparticipating Dentist. J. Delta Rental's Participating Dentist Fee means the maximum amount allowed per procedure for services rendered by a Delta Dental Premier Participating Dentist. K, Delta Dental Premier means Delta Dentai's standard fee~for-service dental benefits program. I.,, Dentist means a person licensed to practice dentistry in the state or caunhy in which dental services are rendered. An Idaho Dentist is a Dentist who is licensed in Idaho. * Delta Dental Premier participating Dentist means an Idaho Dentist who has signed an agreement with Delta Dental to participate, The Delta Dental Premier Participating Dentist accepts Delta Rental's payment and the patient's ca payment, if any, as payment in full. • Delta Dental lonparticipating Dentist means a Dentist who has not signed an agreement with Delta Dental, or a Delta Dental Participating PIan in another state, to participate in Delta Dente! Premier, It is the Subscriber's responsibility to make full payment to the Delta Dental Nonparticipating Dentist. M, Denh,rist means a person licensedby the State of Idaho to engage in the practice of denturism. N, Dental Hygienist means a person licensed to practice dental hygiene who is acting under the supervision and direction of a Dentist, DDi Group Contra page~3-! 6 4710 Page ~ l;Wndelv~rili~glConiradslDcUs Dental Group Cotgracl pages 3.16 8-I O,doac DELTA DENTAL 0~ IDAHO D. );ligible Dependent means to}the Subscriber's legal spouse and ~b}any other dependents who meet the criteria for eligibility set forth in the Declarations Section. If dependent coverage has been selected, it will be included in the Declarations Section, P, Maximum Payment means the maximum dollar amount Delta Dental will pay in any benefit year or lifetime for covered dental services. The Maximum Payment is specified in the Declarations Section, Q, Processing Policies means Delta Rental's policies and guidelines used for predetermination and payment of claims, The Processing Policies maybe amended from time to time. R, Rate means the amount, per Subscriber and Subscriber classification, the Contractor agrees to pay Delta Dental each month. This amount, or the information necessary to compute it, is specified in the Declarations Section. S, Sabrnitted Amount means the fee a Dentist bills to Delta Dental for a specific treahnent. T. Subscriber means nit eligible persons who; 1. are certified as being elig~~le by the Contractor; and 2. receive compensation from the Contractor; $ad 3, are members of the group specified in the Declarations Section. S'ec~ion ~'rr. Sri ibiriuy A. Effective Date of Eligibility 1. Initial effective date; All persons enrolled as Subscribers or listed ar acknowledged as an Eligible Dependent on the effective date of this Conduct are immediately eligible for dental benefits. 2. Alter the initial effective date; For all Subscribers (and their Eligible Dependents, if specified in this Contract} not associated with the Contractor on the initial effective date of this Contract, eligibility for dental benefits wilt begin on the first day of the month following whichever of the following dates is applicable; a. Newly hired or rehired employees: The date for which employment compensation. begins plus the number of days specified as the eligibility period in the Declarations Section, b. Spouse; Date of marriage. c, Newborn; Date of birth, d. Legal adoptions or guardianships: Date of placement when the legal petition for adoption or guardianship becomes legally final, Placement means physical placement in the care of the adopting health plan Subscriber. An adopted newborn child placed with the adoptive subscriber mare than sixty (60}days after the birth of the adopted child shall be from and after the date the child is so placed. An adopte{1 newborn child placed with the adopting Subscriber within sixty {64) days of birth may be added to the adopting Subscriber's planar a newborn dependent. e, Stepchild; Date that the child's natural parent becomes a dependent. eligible far dental benefits, DD1CroupComnctpeges3-160?10 Pag84 l;lUnderwriti,-~IContr~etelDelleDantelGroupComnctptgg3.16 8•l0,daa C~ DELTA DENTAL DELTA DEN~'AL 0~ IDAHO ~. General Eligibility Mules t. No person v~ill be eligible for dental benefits under this Contract unless the Contractor has either currentl enrolled that person as a Subscriber or currently listed or acknowledged that person as an Eli ible De endent. y g p ~. Unless the eligibility requirements stated in the Declarations Section are different, an Eligible Dependent is; a. The Iegal spouse of the Subscriber; ar b. A child of the Subscriber who has nat yet reached the end of the calendar month of his or her Zbth birthday; and c, A child who is not eligible for other dental coverage if age ~S; or d. A child of the Subscriber or the Subscriber's legal spouse if, pursuant to a court decree, the Subscriber or the Subscriber's legal spouse is financially responsible for the medical, health, or dental care of the child; or e. A child of the Subscriber who is totally and permanently disabled by either a physical or mental condition prior to age 2d and is not eligible for other dental coverage, If requested by Delta Dental, the Subscriber shall submit medical reports confirming the child's initial or continuing total disability, 3. No person will be eligible for orthodontic benefits under this Contract unless Class I~ benefits are selected in the Declarations Section, Na person will be eligible for orthodontic benefits on or after that person's 19th birthday, unless specifically allowed in the Declarations Section. C. Termiaativn of Eligibility Eligibility for dental benefits will terminate for all Subscribers and dependents under this Contract at the oarlier of: 1. The termination of this Contract; or Z, The last day of the month for whici~ payment has been made if the Contractor fails to make the payments required by this Contract. Eligibility of an individual Subscriber, and of the Eligible Dependents of that Subscriber, will also terminate if that Subscriber ceases to be a Subscriber as defined by this Contract, An Eligible Dependent also terminates upon failure to meet the eligibility requirements of this Contract. In no event will eligibility for any person covered under this Contract continue beyflnd the date Delta Dental is advised by the Contractor to terminate that person's eligibility. A person whose eligibility is terminated may not transfer to an individual direct payment contract with Delta Dental or may not continue group coverage under this Contract, unless required bylaw, D. Sass of Eligibility During Treatment 1, Yf a Subscriber andtar Eligible Dependent lose eligibility while receiving dental treatment, only Covered Services received while that individual was eligible under the plan will be payable, ~. Procedures begun before the loss ofeligibility may, at Delta Dental's sale option, be covered if the services were completed within a bU-day penod measurod fiom the date of the loss of eligibility. In those cases, Delta Dental evaluates those services in progress to determine what portion will be paid by Delta Dental. The balance of the total fee is the Subscriber's responsibility, E. Continuation Coverage - C~D1ZA 1. The other provisions of this section notwithstanding,eligibility for dental benefits will continuo for an individual who is required to be provided with, and elects continuation coverage pursuant to the Consolidated Omnibus Budget Reconciliation Act tCQBRA~ provided: Contiauation coverage is required to be provided under CDB1tA. The Contractor notifies Delta Dental that the individual is eligible for benefits. Coverage shall only be in effect up to the first day of the month after the individual notifies the Contractor that he or she no longer wants coverage from Delta nDi Group Conttad p~gea3.16 onto Page 5 ~,1Undenniti~glContrecaslne~la Denld Qronp Coatnet pages ]-l b B-l0.dopE ~~~~ ~~rrr~ a~ In~xo Dental or until the end of the individual's condnuation coverage period, whichever occurs first. Further, coverage shall only remain in effect to the Last day of the month for which payment has been made to Delta Dental by the Contractor, However, an individual's coverage may be retroactively reinstated forthe d0-day COBRA "election" period if the Contractor pays the applicable rate for the period. Delta Dental may, at its soie option and without notice, continue coverage, if legally required. Coverage gill not continue beyond the termination of this Contract. The individual is responsible for the costs o#'any service provided after an individual is no longer eligible far continuation coverage under this subsection, Proper and timely notification should be given to Delta Dental by the Contractor t8 delete the individual's coverage. The monthly rate that the Contractor must pay on behalf of any individual who is provided coverage under this subsection will be based an the COBRA continuation coverage rates then in effect during that month, An individual who continues coverage will be considered tp be either a Subscriber or an Eligible Dependent under this Contract and the dental care certificate as long as coverage is provided under this section. Delta Dental does not assume any of the obligations assigned by COBRA to the Contractor or any employer (including the obligation to notify potential beneficiaries of their rights or options under COBRA, and the Contractor agrees that it will perform those obligations in full, Section ~'Y. ~ene~lx Types of Dental Benefits Delta Dental agrees to provide Benefits to Subscribers and Eligible Dependents under the policies and procedures of Delta Dental, including the Processing Policies, and under the terms and conditions of this Contract, including, but not limited to, the follawing classifications, exclusions, and limitations. Benefits will be divided into the follawing classes unless otherwise specified in the Declarations Section: i, Class X Benefits a, Diagnostic and preventive Service Services and procedures to evaluate existing conditions andlor to prevent dental abnormalities or disease, These services include examinations, prophylaxis, and fluoride treatments. b. Radiographs X-rays as required for routine care or as necessary for the diagnosis of a specific condition. Z, class X~ Benefits a. Dral Surgery Services Extractions and dental surgery, including pre+ and postoperative care. b, Endodontic Services The trEatment of teeth with diseased ar damaged nerves (far example, root canals}, c. Perlodontic Services The treatment of diseases of the gums and supporting structures of the teeth, This includes periodvntai maintenance following active therapy (periodontai prophylaxis), d. Minor Restorative Services Services to rebuild and repair natural tooth stractore when damaged by disease or injury. Minor Restorative services include amalgam (silver) and resin (white) fillings. e. Emergency Palliative Treatment Emergency treatment to temporarily relieve pain. ___ DATGraup Contras pages3~lb 0714 ° page 6 I:IUndeswritioglCaN~ectslD~lt~ Aentd Gaup iromr~d psi 3-16 8-IO.docx l~ DELTA DENTAL DELTA DENTAL OF IDAHO 3, Class III Bene#3ts a, lViajor ~estoratiYe Services Services to rebuild and repair natural tooth structure when damaged by disease or injury, Major Restorative services include crowns when teeth cannot be restored with another filling. b. Prosthodontic Services Services and appliances that replace missing natural teeth tsuch as bridges, partial dentures and complete dentures). 4. Class N Benefits a. Orthodontic Services Services, treatment, and procedures to correct malpositioned teeth, S'ectian V. ' Excir~srgns and Lirnitat~ons A. No payment will be made by Delta Dental and all charges for the following services will be the responsibility of the Subscriber; i, Services for in~uries,or conditions payable under Workers' Compensation or Employer's Liability Iaws. Benefits ar services that are available from any government agency, political subdivision, community agency, foundation, or similar entity, NO'[~: This provision does not apply to any programs provided under Title XIX Social Security Act, i.e,, Medicaid. ~. Services for cosmetic surgery, or dentistry far aesthetic reasons. . 3. Services or appliances started before an individual became eligible under this Contract, 4. Prescription drugs, pre-medications and/or relative analgesia. General anesthesia and/or intravenous sedation ether than for covered oral surgery, Charges far hospitalization, laboratory tests, and examinations and any additional fees charged by the dentist for hospital treatment, 5. Preventive control programs, including home care items, b, Charges for failure to keep a scheduled visit with the Dentist. 7. Repair, relines, or adjustments of occlusal guards, 8, Charges for completion of forms, A Participating Dentist may not make these charges to a Subscriber or Eligible Dependent. 9, 1?rosthodontic services (Class ~ Benefits), unless specified as a Covered Service in the Declarations Section. 10. Orthodontic services (Class IV Benef ts), unless specified as a Covered service in the Declarations Section, 11. Lost, missing, or stolen appliances of any type and replacement or repair of orthodontic appliances, 12. Services for which no valid dental need can be demonstrated, that are specialized techniques, or that are experimental in nature as determined by the standards of generally accepted dental practice. 13. Appliances, surgical procedures, and restorations for increasing vertical dimension; for restoring occlusion; for replacing tooth structure lass resulting dam attrition, abrasion, or erosion, Yf orthodontic benefits have been selected under this Contract, this exclusion will not apply to the orthodontic services, 14, Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or denfiuist within the scope of his or her license. 15, Those Benefits excluded by the policies and procedures of Delta Dental, including the Processing Policies, pD~ Croup Canl~aa p~ea3.16 4710 Page ~ l:tund«wrpinglcoalr~dclDelta 1Jon1~ C~Mract pia 3•IG B•ladocx D~I.TA DENTAL OF IDAHO 16, Services or supplies for which no charge is made, far which the patient is not legally obligated to pay or for which no ' charge would be made in the absence of Delta Dental coverage, 17. Services or supplies received as a result of defect, or injury due to an oat of war, declared ar undeclared. 18. Services that are covered under a hospital, surgicaUmedical, or prescription drug program. l9. Appliances, restorations, or services far the diagnosis or treatment of disturbances of the temporornandibular joint (TMJ), 2Q. Myofitnctional Therapy. 21. Delta Dental is not obligated to pay claims received more than twelve {12) months aver the date of rendition of the service, B. Services that are not within the classes of benefits that have been selected and are not in this Contract. The Benefits for the following services are limited as follows unless specified in the Declarations Section. All time IimitaNons are measured from the last date of service in any dental plaa or paid individuals. I. Prophylaxis, including periodontal prophylaxis, and oral exams are payable once in a six (b) month period. ~. Bitewing X-rays are payable Qnce in any period of twelve (12} consecutive months. Full mouth X-rays {which include bitewing X-rays) are payable once in any five {5}-year period. A panographic X-ray (including bitewings} is considered a full mouth X-ray. 3. Amalgam and resin restorations are payable once within atwenty-four (24} month period regardless of the number or combination of restorations placed on a surface. 4. Cast restorations (including jackets, crowns, onlays} on the same tooth are payable once in any seven (7}year periad. 5. Porcelain, porcelain subsfrate, and cast restorations are not payable for children less than sixteen {1 bj years of age. 6. optional treatment; If the Subscriber or Eligible Dependent selects a more expensive dental service than is customarily provided or far which Delta Dental determines that a valid dental Head is not shown, Delta Dental may make an allowance based pn the fee for the customarily provided service or to provide service for tl~e necessary Covered Service. The Subscriber is responsible for the dif ference in cost.. 7. Benefits for root planing are payable once in any two (2) year period, Periodontal surgery is payable once in any three (3) year period. 8, 1?rosthodontic (Class IIl}benefit. limitations: a. One {1}complete upper and one (1) complete lower denture are benefits once in any seven {7) year period for any individual, b. A partial denture, fixed bridge, or for any individual can be covered once. in any seven (7) year periad. c. Fixed bridges and removable cast partials are not payable for children Less than sixteen (lb} years of age. d. A reline or the complete replacement of denture base material is limited to once in any two (2) year period per ' appliance. 9, Preventive fluoride treatments are payable for children less than nineteen {19) years of age, once in any twelvo {12) consecutive months, unless otherwise specified in the Aeclarations Section. IU. Qrthodoatic (Class I~ benefit limitations; if Orthodontic services are a covered benefit listed in the Declarations Section: a. ~Jrthodontic benefits are payable for children less than nineteen (19} years of age of a Subscriber or Eligible Dependent, unless otherwise specified in the Declarations Section. DDI Group Conlnct paget3~i6 0714 page ~ (;Wndawr'icinglContnaslDtlh Dental Group Coq p~ge~ 3• l6 $-I O,docx !~ DELTA DENTAL DELTA DENTAL. 4P IDAH4 b. Yf the treatment plan is terminated before completion of the case for any reason, Delta Dental's obli anon wil l cease with payment far services rendered up to the date of termination. g c. The Dentist may terminate treatment, with written notification to Delta Dental and to the patient, for lack of anent interest and cooperation. In those cases, Delta Denial's obligation for pa ent of benefits ends on the las p month in which the patient was last treated, ~' t day of the d. Any charge for the replacement or,repair of an orthodontic appliance furnished under any Delta Dental pro am will not be paid by Delta Dental and will be the responsibility of the patient. ~ e. Payment is based on the signed Financial Agreement and/or treatment length. Initial down payment is paid on E~anding date followed by quarterly payment for ongoing treatment, tl, Delta Denial's obligation for payment for covered services ends on the last day of the month in which coverage is terminated under ors Contract, unless otherwise specified in the Declarations Section. ~2, When services in progress are interrupted and completed later by another Dentist', D$Ita Dental will review the claim and determine the amount of payment, if any, to each nentist. 13. i~iaxintum Payment; a. The maximum benefit payable in any one (1) benefit year will be limited to the amount specified in the Declarations Section of this Contract, y b, Delta Denial's payment for orthodontic (Class 1'~}benefits will be limited to the lifetime maximum specified in the Declarations Section of this Contract. ~4. Ifa plan Deductible amount is specified in the Declarations Section, Delta Dental will not be obligated to pay for, in whole , or in part, any services until the Deductible amount is met. l~. Rollover Maximum Benefit Limitations; if Rollover Maximum Benefit is a covered benefit listed in the Declarations Section: . a. If total paid claims do not exceed the annual threshold amount, the rollover amount will automatically rollover each year until the maximum benefit amount is reached, b. To be eligible for the rollover benefit, enrollees must receive a preventive service such as a dental cleaning or a~enta! exom~ within the calendar year, G To receive the maximum rollover benefit on a Delta Dental Premier plan, enrollees must obtain ALL dental services from a Delta Dental Premier. network dentist, To receive the maximum rollover benefit on a Delta Dental PPa plan, enrollees must obtain ALL dental services from a FPp network dentist. d. If enrollees receive care from a non participating dentist at any time during the calendar year, they will not accrue the rollover benefit for that year. e, The maximum rollover amount is available to enrollees each calendar year. Annual maximum dollars are used first. If paid dental claims exceed the annual maximum, the remaining amount will be deducted from the accrued rollover amount. f, The maximum rollover amount does not apply to any services with a lifetime rnaximurn (such as orthodontics. g. There is no time limit for using the accrued maximum rollover amount as long as enrollees have continuous coverage and their employer continues to offer a Rollover Maximum Benefit dental plan, h, Enrollees will lose their rollover balance if they disenroll or have a break in coverage. 1b. Processing Policies may limit treatment. Processing Policies are available upon request. DDl Group Ccntrxd pagn~9-16.0719 Page ~ i:lUnderwriGagiContrutziDclu Drn~l tiroup CgnUva pegat 3.16 8-IO.~locx DELTA D~NTAI, OF IDAHO ,Sect~On Yr. A~reentents A, Delta Dental Agrees: 1. To make no payments from the money received from the Contractor far any services rendered to a person who is not eligible for dental benefits as defined in this Contract. Z, To endeavor to enlist Dentists to become Participating Dentists in sufficient number to ensure an adequate choice of Dentists. Nothing shall require Delta Dental to provide a Dentist to a Subscriber or to an l ligible Dependent, 3. To contractually require each participating Dentist to render all dental treatment provided under this Contract according to the standards of the dental profession in the community in which the dental procedures are rendered. ~, To make payments in the following manner for dental services provided to Subscribers and Eligible Dependents: a. If the Dentist is a Participating Dentist, Delta Dental will base payment on the lesser of the Submitted Amount or the Contract Fee, Delta Dental will send payment to the Participating Dentist and the Subscriber will be responsible far any Co-payment andlor any non~covered services. b, If the Dentist is a Nonparticipating Delta Dental Dentist, Delta Dental will base payment on the Lesser of the Subrriitted Amount or Delta Dental's Nonparticipating Dentist Fee. It is the Subscriber's responsibility to make full payment to the Nonparticipating Dentist. For dental services rendered by an out-of-state Dentist, Delta Dental will base payment on the lesser of the Submitted Amount or the Contract Fee in that area, if the out-of-state Dentist is a participatiag Dentist with a Delta Dental Plan in the state in which the service isrendered, Iftheout-of state dentist is not a participating dentist, payment will be made as provided in subparagraph 4{b) of this Section, B, Contractor Agrees: ~, To pay Delta Dental the monthly rate specified in the Declarations Section of this Contract, in advance, unless otherwise specified in the Declarations Section, Delta Dental may, at its sole option, sand notification to the Contractor of an adjustment in rates, benefits, or co-payments to correct potential adverse group experience resulting from the following: a, Information provided upon enrollment proves to be in error; or b, Terms and provisions of the Contract are violated; or c, Initial size ar composition of the group changes to the extent it adversely affects the rates. If an adjustment is warranted, Delta Dental will provide the Contractor written notice 30 days prior to implementing any adjustment, If the Contractor refuses to accept this adjustmen#, Delta Dental may,. in its sole discretion, implement the adjustment or an alternative adjustment as stated in Section T~ ofthis contract, or cancel this Contract. 2. To enroll as Subscribes all eligible employees of the Contractor and to list, if covered, all Eligible Depeadents of those employees, to the extent required under the Contract. The Contractor will provide Delta Dental an accurate monthly statement of the total number and names of ail Subscribers and, if applicable, all Eligible Dependents. ~, To permit Delta Dental, by its auditors or o#her authorized representatives, on reasonable advance written notice, to inspect the Contractor's records to verify the accuracy of lists of Subscribers and Eligible Dependents submitted to Delta Dental. Clerical errors ar delays in keeping or relaying data will not invalidate eligibility that would otherwise be validly in force or continue eligibility that would otherwise be validly terminated, if, after discovery ofthe errors or delays, an equitable adjustment of the Contractor's payments can be made in a reasonable period of time. 4. To provide each Subscriber with a standard certf cafe of the Eenefits provided under this Contract. The certificate will be provided by Delta Dental. Customized benefit literature can be provided for an additional cost, To collect and pay to Delta Dental any amounts that the Contractor's employees are required to pay to Delta Dental under this Contractor any written e~ployment contracts. Any amounts not collected will be the responsibility of the Contractor. uaa ~-,p Contract p~ge~3.1 a oaro Page 10 itunaerwrlangtco~tr~uklta Denc~l Qroup Cantra~ pis 3-t6 a-~o,aocx L~ DELTA DENTAL DELTA DENTAL OF IDAHD Section VII, ~etrertrl Provisions A, Dentists providing services are independent contractors, and neither the Contractor nor Delta Dental will be liable far an act or omission of any Dentist, his or her employees or agents or any person ravidin dental or other rofessional se y this Contract. p g p rvtces under B. All Dentists, Subscribers, and Eligible Dependents, by performing or receiving services under this Contract, are bound by all its terms. C, Delta Dental will not honor and no payment will be made for services if a claim for those services has not been received by Delta Dental within twelve (12}months from the date the services for the procedure were completed. D. No materials will be published ar distributed by the Contractor concerning this Contract until the materials are first approved by Delta Dental, ~. No action an a claim arising out of or related to this Contract will be brought until thirty (3U) days after notice of the claim has been given to Delta Dental, nor will any action be brought more than three (3) years after the claim first arose, F. Delta Dental and Contractor agree to defend, indemnify ar~d bold harmless the other and its directors, officers and employees (who are acting in the course of their employment, but not as claimants} from any loss, cast, or expense (including reasonable atxorney fees and court costs} resulting from or arising out of or in connection with its breach of this Contract or any negligent act or omission of any of its directors, officers or employees, G, While the Subscriber and/or Eligible Dependent are covered by Delta Dental, the Subscriberand/or Eligible Dependent agree to provide Delta Dental with any information it needs to process the claims and administer the Benefits, This includes allowing Delta Dental to have access to his or her dental records. H. Delta Dental will establish a procedure for resolving all questions raised by a Dentist, a Contractor, a Subscriber, or an Eligible Dependent in regard to claims for dental benefits allowed or rejected under the terms of this Contract. This procedure will bs used both for the initial dettrminatian of those questions and for the resolution of appeals made on the basis of those initial determinations. All determinati4us made acs~rdir~g to this procedure will be final and binding on the Dentist, the Contractor, the Subscriber, aid the Eligtble Del dent. All of the Benefits under this Conhract, if applicable, will be subject to a coordination of benefits provision that is designed to provide maximum coverage, but not to exceed 1 Oo percent of the total fee for a given treatment. 1, General a, This coordination of bene€tts ("C(}B"}provision applies to This plan when an employee or the employee's covered dependent has health care coverage under more than one plan, ")?lan" and "This Plan" are defined below. (1) If this COB provision applies, you should look first at the order of benefit determination rules. Those rules determine whether the benefits of This plan are determined before or after those of another plan, The benefits of This Plan; shall not be reduced when, under the order of l~nefit determination rules, This Plan determines its benefits before another plan; but (~) May be reduced when, under the order of benefits determination rules, another plan determines its benefits first, The above reduction is described in "effect on the Benefits of This Plan," 2. Definitions; ~. A plan is any of the following that provides benefits nr services for medical or dental care or treatment, If separate contracts are used to provide coordinated coverage far members of a group, the separate contracts are considered parts of the same plan and there is na COB among those separate contracts. DDt Croup CoMr~ct p~~-1b a~ ~ o Page I l 1,ulaaerw~tinglC4ntncsslD~l~e Dent~1 Group Coetna pages 3.1 b B-I o.docx DELTA n~NTAL OF IDAHO (1) Plan includes: group and non-group insurance contracts, health maintenance organization (HMO) contracts, closed anal plans or other forms of group or group type coverage (whether insured or uninsured); medical care P com onents of long-term care contracts, such as skilled nursing care; medical benefits under group or individual p automobile contracts; and Medicare or any other federal governmental plan, as permitted by law, (Z) PIan does not include: hospital indemnity coverage or other fixed indemnity coverage; accident only coverage; specified disease or specifies accident coverage; limited benefit health coverage, as defined by state law; school accident type coverage; beneft#s far non-medical components of lang~term care policies; Medicare supplement policies; Medicare or any other federal governmental plans, unless permitted by law, leach contract for coverage under tl) or 42) is a separate plan. Yf a plan has two parts and COB rules apply only to one of the two, each of tt-e parts is treated as a separate Plan. Each contract or other arrangement for coverage under 2(a) and (b) is a separate plan. If an arrangement has two parts and COB rules apply only to one of the two, each part is a separate plan. b, "This Plan" is the part of this group contract that provides benefits for health care expenses. e. "Primary P1an~Secondary Plan" the order of benefit determination rules state whether This Plan is a Primary Plan or Secondary Plan as to another plan covering the person. when This Flan is a Primary Plan, its benefits are determined before those afthe oftier plan and wout considering the other plan's benefits. when This Plan is a Secondary Plan, its benefits are deternriincd after those of the other plan and may be reduced because of the other plan's benefits, when there are mare than two plans covering the person, This Plan may be a Primary Plan as to one or more other plans and may be a Secondary Plan as to a different plan or plans, d. "Allowable Expense'' means a necessary, reasonable, and customary item of expanse for health care when the item of expense is covered by this plan. I~awever, This Plan is not required to pay for an item, service, or benefit .which is not a part of This Plan's contract. when a plan provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an allowable expense and benefit paid. 3. Urder of Benefit Determination Rules e, when there is a basis for a claim under This Plan and another plan, This Plan is a Secondary Plan whose benefits are determined after those of the other plan, unless: (1} The other plan has rules coordinating its benef is with those of This Plan; and ~Z) Both those rules and this plan's rules, in subsection (b) below, require that this plan's benefits be determined before those of the other plan. b. 'his Flan determines iks order afbenefits using the first of the following rules which applies: ~i} The benefits of the plan which covers the person as an employee, member, insured, or subscriber (that is, other than as a dependent) are determined before those ofthe plan which covers the person as a dependent; except that; if the person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is a. Secondary to the plan covering the person as a dependent and b, Primary to the plan covering the person as other than a dependent (for example, a retired employee). (2} Benefits for a dependent child whose parents are not separated or divorced shall be determined as follows: a. The benefits of the lan afthe anent whose birthday falls earlier in a year are determined before those of p ~ li later in that ear' but the plan of the parent whose birthday fa s y b. rf both parents have the same birthday, the benefits of the plan which r~avered one parent longer are determined before those of the plan which has covered the other parent for a shorter period of time. Pa a 12 1:IUadavvritinglCaMr~cts~Deltn Dental Group eontred pages 3.16 s-14,docx DD! {stoup Cankn~a paga3•Ib 0710 g [, DELTA DENTAL DEt.TA DENTAL Q~ IDAHO However, ifthe other plan does not have the rules described in (a~ above, but instead has a rule based u o the gender of the parent, and if, as a result, the laps do not p n plan will determine the order of benefi p agree on the order of benefits, the rule in the other ts. (3} Benefits far a dependent child whose parents are divorced or legally separated shall be determined as follows To the extent the plan has been notified by receiving a copy of the court decree; • a. If the specific terms of the court decree state that one of the parents is responsible for the health care expenses of the child, the benefits of the plan of that parent are determined first. The plan of the other parent shall be the Secondary PIan. b. If the specific terms of the court decree state that the parents shall share joint custody, without statin that one of the parents is responsible for the health care expenses of the child the fans roverin the chi g shall be subject to the order of benefit determination can 'n ~ ~ • p g ld tai ed m subdiv>Is~an b (2) of this section. If neither subparagraph (a) nor (b}applies, the order of benefits shall be determined in the following order; (a} The plan of the parent with primary legal custody of the child; (b} The plan of the spouse of the parent with the primary legal custody of the child; (c} The plan of the parent riot having primary legal custody of the child; and (d} The plan of the spouse of the parent not having primary legal custody of the child, (4} The benefits of a plan which covers a person as an employee who is neither laid off nor retired (ar as that employee s dependent) are detenatned before the benefits of a plan which covers that person as a laid off or retired ernpIayee (or as that employee's dependent}. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this paragraph shall be ignored. (5} Continuation Coverage. If a person whose coverage is provided under a right of continuation pursuant to federal law (i,e., COBRA) or state law also is covered under another plan, the benefits of the plan covering the person as employee, member, or subscn'ber (or that person's dependent} shall be determined before the benefits under the coatiauation coverage. If the other plan does not have this rule and if, as a result, the plans do not agree on the order of benef its, this paragraph shall be ignored. (6} Longer~shorter length of coverage. If none of the above rules determines the order of benefits, the benefits of the plan which covered an employee, member, or subscriber longer are determined before those of the plan which covered that person for the shorter term. d. Effect on the $enet3ts of This Pian a, This section applies when, in accordance with section "Order of Benefit Determines Rules," This Plan is a Secondary Plan as to one or mare other plans. In that evont, the benefits of This Plan may be reduced under this section, Such other plan ar plans are referred to as "the other plans" in b below, b. Reduction in This Plan's benefits, The benefits of This Plan will be reduced to the extent that the sum of: (1} The benefits that would be payable for the allowable expense under This Plan in the absence ofthis COB provision; and The benefits that would be payable for the allowable expenses under the other plans,. in the absence of provisions with a purpose like that of this COB provision, whether or not claim is made, exceeds those allowable expenses. ~~ Right to Receive and Relea9e Needed Information Certain facts are needed to apply these COB rule, Delta Dental has the right to decide which facts it needs. It may get needed facts from or give them to any other organization or person, Delta Dental need not tell. or get the consent of, DDZ Croup CoMratl pagts3.16 070 1?age l ~ I;lUnden+KitinglContriclslDeit~ Dtmal Gra,p Conlrac! pegsa 3-16 8-I o,ao~ G~ DELTA DENTAL DELTA DENTAL OF IDAHO an erson to do this. Each person claiming benefits under'I~is Plan must give Delta Dental any facts it needs to pay Yp the claim, 6. Facility of Payment A a ent made under another plan may include an amount which sltauld have been paid under This Plan. If it does, p ~ That amount will then be treated as Delta Dental may pay that amount to the organization which made that payment. ~ The term " a ent though it were a benefit paid under This Plan. Delta Dental wilt not have to pay that amount again. p ~ lue made" includes providing benefits in the form of services, in which case "payment made" means reasonable cash va of the benefits provided in the form of services. 7, Might of Recovery If the amount of the payments made by Delta Dental is mare than it should have paid under this COB provision, it may recover the excess from one or more of: a, The persons it has paid or for whoin it has paid; b. Another plan; or c. The provider of service. The "amount afthe payments made" includes the reasonable cash value of any benefits provided in the form of services. Section VIII. ~eaith Insurance ~ortab~tx`ty and Accountabrl' ~~~ As re uired b the administrative simplification mandates of HIPAA, codified at the Social Security Act (SSA) §§ 1171-1179 this Q y Section provides the protection of protected health information tFHI) to subscn`bers. A. HIPAA Pinal Standard Transactions and Code Set Rule. The final standard transactions and code set rule promulgated under HIPAA requires health care providers and health plans t4 use new national standards for certain electYOnic transfers of administrative and financial health care transactions. Delta Dental and the Contractor agree that by the final standard transactions and code set rule compliance date, each, to the extent reqult~ed, will +e~mply with the final standard ~nsaons and code set rule. Notwithstandingany provision of this Contract or ar~y arrange~-en~ con~mpla aY ~~ A~~~t ~' ~° contra ,the failure of Delta Dental or the Contractor to comply w'~ the final s~ tsac~io~ set, rule by the ry ftnal standard transactions and code set rule compliance date shall ,diva the c~her p the right to ~~'~ ~ Agream~nt following thirty (30}days' prior written notice. Public Law Io7 and .105 pxovid for a +~+e-y"~' extenstan of the date far coin 1 in with the final standard transactions and code set rule ~tt~ C3ctaber 1d, ~00'3~ fox arty cave~r~ad entl~ ~~ subm~ ~ ~e pY g Secret of Health and Human Services a plan of how the entity will come into cc-mpliat~ce with the requirements by ~lcta-b~r ary 16, 2oQ3. Delta Dental and the Contractor each acknowledge. anal agree thi~teither phctY may take advege ofsuch ~xtensxrn. B, HIPAA Final Privacy Rule. The final privacy rule promulgated under 1~IPAA imposes certain privacy requirements on the use and disclosure of "protected health information" by "covered entities" (as defined in the final privacy rule}, including a requirement that certain provisions must be included in contracts with "business associates" (as defined in the final privacy rule}. Contractor and Delta Dental acknowledge and agree that they have, or will, execute the Business Associate Agreement to satisfy the final privacy rule's requirement that they enter into a business associate agreement. C. Assignment and Delegation. Contractor acknowledges and agrees that certain services which Delta Dental is obligated to erform ursuant to this Contract may be delegated by Delta Dental, in Delta Dental's sole discretion, and performed by an p p affiliate of Delta Dental; provided, however, that Delta Dental ogees that such delegation will not relieve Delta Dental of any liabili for its obligations under this Contract, In the event that Delta Dental delegates any of its obligations hereunder to an tY affiliate, such affiliate shall be requured to execute a Business Associate Agreement so as to comply with the HIPAA final privacy rule. DDI Qroup Co~t~ad pega3•IG x710 page 14 1;1U~dervtritinglCaatsidstiDcita DGnte1 Groisp Conarict P~Bes 3•ib 8•Id,doac l~ DELTA DENTAL DELTA D~N?Ai, pE CDAF{0 S`ectiort IX. Terms artd Termination This Contract shall remain in full force and effect for the initial term and an accordance with this contract. Delta Dental shall have th y rc°e~'al term of this Contract as detorm~ned is e option of terminating this C©ntract if: A. The Contractor fails for more than 30 days to make ~ required payment; or B. Delta Dental elects to cancel pursuant to Section VI B 1 of this Contract; or C. The Contractor fails to furnish Delta Dental with accurate enrollment data pursuant to Section VI B ~• or D, The Contractor permits voluntary enrollment of Subscrjbers and/or their dependents when not ermined ursuant to this Contract; or p p E, If the grouF enrollment changes to less than three enrolled subscribers, Delta Dental may terminate the ou contract effective the first of the month following less than three enrolled subscribers, ~ p F. If Contractor elects to cancel this Contract dwing the original term or any renewal term thereof, Contractor shall; 1. pay to Delta Dental the dollar amount pf benefits paid by Delta Dental, or which benefits Delta Dental is obligated to a pursuant to this Contract, in excess of total rate payments p y a. made or required to be paid by Contractor to Delta Dental pursuant to the original contract term, through the effective date of cancellation, or, b. in the event the cancellation occurs during a renewal period of the original or subsequent renewals of a renewed contract, those amounts in excess of the total rate payments made or required to be made by Contractor during the past rolling twelve month period immediately prior to the effective date of cancellation. • a e. In addition thereto, Contractor shall pay an~amoant equal to twelve percent (1Z%) of the amounts required to be paid by Contractor pursuant to subparagraphs (1) ta) ar tb) hereof, as liquidated damages, to compensate Delta Dental for damages and costs resulting from the contract termination prior to the contract expiration date. ~. Contractor s111 be liable for all rate payment owing to. Delta Dental pursuant to this Contact, ar any renavval thereof, that remain uppeid .for eny portion of the contract period up to and including the date of ~ncellation, l+or the es of Section I7t p~ (~, ~- failure by the Contractor tv make a required rate payment pwsuant ~o this Contrapt for more than sixty X60) consecutive days past the due date as set forth ~n this Contract shall be deemed an election by the Contractor to cancel this Contract on the sixty-first (61st} day following the due date of such required rate payment, 3. Contractor shall also pay to Delta Dental its costs of collection of the amounts set forth hcrcin, including reasonable court costs and attorney fees. G, The Contractor refuses to allow Delta Dental (by Delta Dental auditors or other authorized representatives) to inspect rho Contractor's records t4 verify the accuracy of the eligible Subscriber and dependent list; or ~. The Contractor has otherwise breached this Contract. fn the event Contract is terminated for any of the preiag reasons, except for car~ellation by the Con~ctor as set forth in subp-ur~graph E herec-f, during the original term ordering arenew~lterm ofthe Contract- the Controt'shale be liab t le o I~e1ta Dental fc~r the rate payment through the date ofterrnnation The provisions ofsrib~a~ph ~ rll govern Contractor's obligations in the event of cancellation by the Contractor, d. Delta Dental may from time to tune provide additional services or benefits by rider or other notice, Those additional services or benefits may be withdrawn at any time afrer notice given by Delta Dental, uQi Group Ccntrut paga3-iG 8710 Page 15 I;1~nderwritinglContrauslDel~a Dental Group CaYtrott p~grs ]-l6 e•FO,doac DELTA DENTAL O~ IDAHO K. Any notice required or permitted to be given by Delta Dental will be considered given if in writing and personally delivered, emailed, or if in writing and deposited in the United States mail with postage prepaid, addressed to the Contractor, a Dentist, or Subscriber at the last address of record. This notice will be considered given when personally delivered, emailed or mailed. L. No agent has authority to change any part of this Contract. No changes to this Contract will be valid unless approved in writing by Delta Dental, M. If Delta Dental pays a claim for which another person or company is liable, Delta Dental has the right to recover its payment from the other person or company. N. The right of a Subscriber or Eligible Dependent to Covered Services pursuant to this agreement may not be transferred or assigned to other persons. Sectxan ~'..Renewat o,~Contract Delta Dental shall, not less than forty-five (45}days prior to any renewal date of this Contract, notify Contractor of any change in rates to be effective during the renewal term of this Contract. Contractor shall, not less than thirty {30}days prior to any renewal date, notify Delta Dental if Contractor elects not to renew said contract for a period of time equal to the Original Contract Term or equal to the term of the immediately preceding renewal term thereof, In the event that Contractor does not notify Delta Dental of its election not to renew this Contract, this Contract shall be deemed to have been renewed for a term equal to the immediately preceding Contract term and all terms and conditions of this Contract shall remain in full force and effect for the renewal term as specified in this paragraph, Provided however, the rates charged for the benefits provided hereunder shall be as set forth in Delta Rental's notice of chap a in rates, as provided herein, during the renewal term. All notices required pursuant to this paragraph shall g be in writing and delivered to the respective party not later than the times set forth herein for giving said notice. ACCEPTED: .. ACCEPTED: {CONTRACTOR} DEDTA DENTAL OP' IDAHO, INC. By• . President and Chief Executive Officer Date: July 3 I, 2012 ~y. ~~~~ Print Name• W ~r Date: C` 1'~1 ~ (q k ~~ ~ DDl Group Contras pages3-l6 4714 Page 16 1;lUnderwritinglCo~raaslDeiu Dente) Group Contract pages 3.16 8.14.docx