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HomeMy WebLinkAboutES12-085 - Original - 2012 Dental Services Records Ma - emeff } KENT _ WA5H1NGTON = Document __tom CONTRACT COVER SHEET This is to be completed by the Contract Manager prior to submission to City Clerks Office. All portions are to be completed. If you have questions, please contact City Clerk's Office. Vendor Name: Washington Dental Service Vendor Number: JD Edwards Number qq Contract Number: This is assigned by City Clerk's Office Project Name: Dental Service Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment ® Contract ❑ Other: Contract Effective Date: 1/1/2012 Termination Date: 12/31/2012 Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager: B Fowler Department: Employee Services Detail: (i.e. address, location, parcel number, tax id, etc.): CM121311 S,Pub llc\RecordsManagement\Forms\ContractCover\ad cc7832 1 11/08 Washington Dental Service City of Kent Plan#00611 Effective January 1, 2012 Summary of changes in Contract Language The contract has been consolidated with the removal of information previously duplicated between the contract and the Certificate of Coverage The Certificate of Coverage has been incorporated into the contract as defined in Article I Article I Definitions Definition for"Certificate of Coverage" has been added The following definitions have been removed and can be referenced in the certificate of Coverage, "Emergency Dental Condition", "Emergency Examination", "Exclusions", "Limitations", "Not a Paid Covered Benefit" and "Specialist" The definition of a Full Time Employee has been deleted and minimum hours requirement is now referenced in Appendix A Section A °Licensed Professional"definition has been incorporated into the"Dentist"definition Definition of"Plan" has been reworded for clarification Article III Monthly Payment Legislative surcharge clause has been added to this section Article IV Benefits Provided, Limitations and Exclusions' Timely Filing and additional procedures language have been deleted This language is in the Certificate of Coverage Article VI Coordination of Benefits (COB) Article VI—has been deleted The full text is now in the Certificate of Coverage Article VI WDS's Obligations This Article has been renumbered from Article VII to Article VI with the deletion of Coordination of Benefits Article VI Grow's Obligations This Article has been renumbered from Article VIII to Article VII with the deletion of Coordination of Benefits Article VIII General Provisions Article 8.01 —This paragraph has been modified to include the group signature requirement This Article has been renumbered from Article IX to Article VIII with the deletion of Coordination of Benefits Article IX Notice and Termination This Article has been renumbered from Article X to Article IX with the deletion of Coordination of Benefits Article X List of Appendices This Article has been renumbered from Article XII to Article X with the deletion of Coordination of Benefits and Subrogation List has been revised Appendix Employee Eligibility Requirements This section of the contract has been consolidated with the removal of information previously duplicated between the contract and the Certificate of Coverage 2012-01-00611-RC-01 i Section A—Employee Eligibility has been rewritten to include the minimum hours requirement for a full-time employee Section C—Paragraphs 2, 3 and 4 relating to FMLA and COBRA have been removed from this document and now reside in the Certificate of Coverage Section D—Paragraph 2 relating to Extension of Benefits has been removed from this document and now resides in the Certificate of Coverage Appendix B Dependent Eligibility Requirements This section of the contract has been consolidated with the removal of information previously duplicated between the contract and the Certificate of Coverage Section A—Dependent Eligibility has been rewritten to mirror Employee Eligibility Language for the contract Dependent Eligibility language now resides in the Certificate of Coverage Section C—Reference to the Certificate of Coverage for COBRA has been removed Section D—Paragraph 2 relating to Extension of Benefits has been removed from this document and now resides in the Certificate of Coverage Section E—Paragraphs relating to Dependent Enrollment rules and Special Enrollments have been removed from this document and now reside in the Certificate of Coverage Appendix C Covered Dental Benefits, Limitations and Exclusions This Appendix has been deleted as duplicated between the Contract and the Certificate of Coverage All subsequent Appendices have been renumbered Please refer to the Certificate of Coverage for this information Appendix C Method of Payment This Article has been renumbered from Appendix D to Appendix C with the deletion of Covered Dental Benefits, Limitations and Exclusions Appendix D Groups Financial Obligations This Article has been renumbered from Appendix E to Appendix D with the deletion of Covered Dental Benefits, Limitations and Exclusions Plan information has been updated for this renewal Legislative surcharge clause has been deleted from this section Appendix F Continuation of Coverage—"COBRA" COBRA language has been removed from the contract and rests solely in the Certificate of Coverage Summary of changes in the Certificate of Coverage Choosing a Dentists,and descriptions of dentists have been rewritten for clarification. Finding a Dentist Language has been added Predetermination of Benefits: New language has been added for clarification of procedure around predeterminations Necessary vs. Not Covered Treatment: Language has been added to the Certificate of Coverage Benefits Covered By Your Plan: This section has been rewritten for clarification and new language recommending consulting the provider prior to treatment has been added 2012-01-00611-RC-01 ii Class I: The note advising consulting the provider has been moved to"Benefits Covered by Your Plan" The note after this section referring to General Limitations and General Exclusions has been deleted Diagnostic: This section has been rewritten for clarification of process with no change in benefits Preventive: This section has been rewritten for clarification of process with no change in benefits Preventive Resin Restoration language has been added Periodontics: This section has been rewritten for clarification of process with no change in benefits Class II: The note advising consulting the provider has been moved to"Benefits Covered by Your Piano The note after this section referring to General Limitations and General Exclusions has been deleted Sedation: General Anesthesia & Intravenous Sedation have been combined and rewritten for clarification of process with no change in benefits Restorative: This section has been rewritten for clarification of process with no change in benefits Periodontics: Reference to crown and bridgework in conjunction with penodontal splinting have been deleted with no change in benefits Gingival curettage has been deleted as an invalid reference with no change in benefits Class III: The note advising consulting the provider has been moved to"Benefits Covered by Your Plan" The note after this section referring to General Limitations and General Exclusions has been deleted Restorative: This section has been rewritten for clarification of process with no change in benefits Prosthodontics. This section has been rewritten for clarification of process with no change in benefits Orthodontic Benefits: The note after this section referring to General Limitations and General Exclusions has been deleted Well Baby Checkups: This language has been moved from the inside front cover to a new location after"Benefits Covered by Your plan" Additional Procedures: New Language has been added Coordination of Benefits: This section has been moved to a new location and complete revised to match the Washington State requirement language for COB 2012-01-00611-RC-01 iii Washington Dental Service Dental Care Service Contract WDS Plan#00611 Name of Group City of Kent Herein called Group, agrees to a Dental Care Service Contract with Washington Dental Service, herein called WDS The effective date of this Contract shall be 12 01 a m Pacific Time on the first day of January, 2012 at Seattle, Washington, and shall run for a period of two years This Contract is issued and delivered in the state of Washington and is governed by Washington state laws It is subject to the terms set forth on the subsequent pages, appendices and amendments, which are a part of this Contract Accepted by: Accepted by: City of Kent Washington Dental Service 220 4`"Avenue South Post Office Box 76983 Kent,Washington 98032 Seattle,Washington 98176-0983 By By JTie Title S for Vic resident Underwriting &Actuarial Date d'/ �/ 7-- Date October 29, 2011 2012-01-00611-RC-01 -1 - SMREV[2011-01-31] Y - Article I— Definitions For the purpose of this Contract,the following definitions shall apply: 101 "Administrative Fee" means the monthly amount payable by Group to cover claims paid by WDS and as designated in Appendix D 1.02 "Benefit Period" means the period beginning January 1 and ending December 31 103 "Certificate of Coverage" means the benefits booklet which describes in summary form the essential features of the contract coverage, and to or for whom the benefits hereunder are payable In the event that contracts are changed or amended, new certificates or a clearly understandable benefit booklet insert to existing certificates shall be furnished The Certificate of Coverage is incorporated into this contract by this reference as if the contents thereof were fully set out herein 1.04 "Contract" means this agreement between WDS and Group This Contract constitutes the entire Contract between the parties and supersedes any prior agreement, understanding or negotiation between the parties 105 "Contract Term"means the time period specified in Appendix D 106 "Covered Dental Benefits" means those dental services that are covered under this Contract, subject to the Limitations set forth in The Certificate of Coverage 107 "Delta Dental" means Delta Dental Plans Association, which is a nationwide non-profit organization of health care service plans, which offers a range of group dental benefit Plans 1 08 "Delta Dental PPO Dentist" means a Participating Dentist who has agreed to render services and receive payment in accordance with the terms and conditions of a written Delta Dental PPO Participating Dentist Agreement between the Participating Plan and such Dentist, which includes looking solely to Delta Dental for payment for covered services 109 "Delta Dental Participating Dentist" means a licensed Dentist who has agreed to render services and receive payment in accordance with the terms and conditions of a written Delta Dental Participating Dentist Agreement between WDS/Delta Dental and such Dentist, which includes looking solely to Delta Dental for payment for covered services 1 10 "Dentist" means a licensed Dentist legally authorized to practice dentistry at the time and in the place services are performed This Contract provides for covered services only if those services are performed by or under direction of a licensed Dentist or other WDS-approved Licensed Professional(a Licensed Professional means an individual legally authorized to perform services as defined in their license Licensed Professional includes, but is not limited to a denturist, hygienist and radiology technician) A "Licensed Dentist" does not mean a dental mechanic or any other type of dental technician 1 11 "Eligibility Date' means the date on which an Eligible Person's benefits become effective under the terms of this Contract 1.12 "Eligible Dependent" means any dependent of an Eligible Employee who meets the conditions of eligibility set forth in Appendix B 1.13 "Eligible Employee" means any employee who meets the conditions of eligibility set forth in Appendix A 1 14 "Eligible Person' means an Eligible Employee or an Eligible Dependent 1 15 "Filed Fee" means the approved fee accepted by WDS for a specific dental procedure performed by a WDS/Delta Dental Participating Dentist submitting that fee and performing the dental service 1 16 "Group" means the employer or entity that is contracting for dental benefits for its employees in this contract 1 17 "Maximum Allowable Fees" means the maximum dollar amount that will be allowed toward the reimbursement for any service provided for a Covered Dental Benefit 2012-01-00611-RC-01 -2- ' N 1 18 "Nonparticipating Dentist' means a licensed Dentist who has not agreed to render services and receive payment in accordance with the terms and conditions of a written Participating Dentist Agreement between WDS and such Dentist 1 19 "Open Enrollment Period" means the annual period in which Eligible Employees can select benefits Plans and add or delete Eligible Dependents 1.20 "Payment Level" means the applicable percentage of Maximum Allowable Fees for Covered Dental Benefits that shall be paid by WDS as set forth in Appendix C 1.21 "Plan" means this contract that provides dental benefits Any other contract that provides dental benefits and meets the definition of a"Plan" in the"Coordination of Benefits" section of the Certificate of Coverage is a Plan for the purpose of coordination of benefits 122 "Premium" means the monthly amount payable by Group as designated in Appendix D 123 "WDS" means Washington Dental Service, a nonprofit corporation incorporated in Washington state Washington Dental Service is a member of the Delta Dental Plans Association Article II—Eligibility 201 Every person who meets the conditions of eligibility as set forth in Appendix A or Appendix B is eligible for dental benefits for the purposes of this Contract 202 Group shall submit a list of Eligible Persons to WDS prior to the beginning of each monthly eligibility period Article III— Monthly Payment 301 The monthly Administrative Fee and claims payment, to be remitted fully by Group, is determined as set forth in Appendix D 302 Subsequent Administrative Fee shall be paid to WDS as described in Appendix D for each calendar month for which benefits are to be provided No person shall be entitled to benefits under this Contract during any month for which Administrative Fee payment has not been received by WDS 303 Claim Reimbursement is due as described in Appendix D The total amount of claims payment shall be transferred, via wire transfer, to the appropriate WDS bank account If payment is not received within 30 days WDS may give written notice that payment is due and may, at its option, terminate all benefits and be released from all further obligations as set forth in Article IX entitled"Notice and Termination " 304 WDS shall accept retroactive additions to eligibility(payments)that are received by WDS within 60 days of the requested effective date 305 WDS shall accept retroactive terminations of eligibility(credits)that are received by WDS within 60 days of the requested termination date, or to the end of the month of the last paid claim of termed Eligible Person, whichever is later 306 WDS shall not be obligated to refund paid claims for treatment from providers when the treatment was performed in good faith that eligibility was current and accurate at the time of treatment 307 Legislative Surcharge Clause—if any governmental unit imposes any new tax or assessment or increases the rate of any current tax or assessment that is measured directly by the payments made to WDS by Group, then WDS is authorized to increase the monthly Premium by the amount of such new tax, assessment or increase Article IV—Benefits Provided, Limitations and Exclusions 401 Covered Dental Benefits, Limitations and Exclusions are as described in the Certificate of Coverage and are subject to the Plan maximum and deductible, as described in Appendix C 402 The percentages of the Maximum Allowable Fee, Filed Fee or the Dentists' actual charges payable by WDS for Covered Dental Benefits provided to an Eligible Person are described in Appendix C 2012-01-00611-RC-01 -3 - 403 If there are two or more professionally acceptable plans of dental treatment, the Plan will pay the appropriate percentage of the lowest fee as indicated in Appendix C The remaining amount will be the Eligible Person's responsibility 404 Payment for services provided by a Delta Dental Participating Dentist shall be made directly to the Dentist Contracts between Delta Dental and its Delta Dental Participating Dentists provide that, if Delta Dental fads to pay the dentist,the Eligible Person shall not be liable to the dentist for any sums owed by Delta Dental Article V—Conditions for Benefits—Dispute Determination Procedures 501 Covered Dental Benefits are available for an Eligible Person from the Eligibility Date until such eligibility terminates 502 An Eligible Person may elect the services of any licensed Dentist WDS is not responsible for availability of any particular licensed Dentist 503 WDS shall be entitled to receive from any attending Dentist, or from hospitals in which a Dentist's care is rendered, any records relating to treatment rendered to an Eligible Person as may be required in the administration of claims 504 Provider dispute resolution process is available as outlined in individual provider contracts 505 To determine Covered Dental Benefits for certain treatments,WDS may require an Eligible Person to obtain an examination from a WDS-appointed consultant Dentist WDS will pay 100 percent of the charges incurred for the examination Article VI—WDS's Obligations 6 01 WDS shall issue to Group—at no additional cost—standard WDS benefit booklets summarizing the Covered Dental Benefits and other essential features of the Plan If any amendment to this Contract materially affects any benefits described in such booklets, corrected booklets or booklet inserts showing the change shall be issued to Group A new booklet shall be created upon initial inception of Contract and every other year thereafter An insert will be created and sent in the year in which a booklet is not produced If Group requests a new or updated booklet for alternate years, Group shall reimburse WDS for the expense of producing the booklet Group shall also reimburse WDS for any charges for variation in booklet size or paper WDS shall provide to Group one printed booklet for each Eligible Employee enrolled in the plan with an additional 10 percent reserve supply Upon approval WDS shall have booklets delivered to Group within 15 business days 602 WDS shall provide descriptions of predetermination, claim review, complaint and appeal procedures and grievance procedures in the benefit booklets issued to Group 603 If a Dentist or an Eligible Person requests a predetermination of benefits, WDS shall predetermine benefits when satisfied that the person for whom the predetermination is requested is an Eligible Person. Such predetermination of benefits shall be for a reasonable period of time, but no longer than such person's period of eligibility Predeterminations are not an authorization for services but a notification of Covered Dental Benefits available and are not a guarantee of payment 6 04 WDS shall not be obligated to make payment for any services rendered to a person who is not an Eligible Person at the time the services were performed 605 WDS may provide professional review of the adequacy and appropriateness of services rendered to Eligible Persons through its Quality Management and Clinical Review processes 606 WDS shall provide WDS/Delta Dental Participating Dentist Directories to Group This directory is also available on-line at www DeltaDentalWA com It is understood that the composition of such directory is subject to change WDS reserves the right to change the directory without notice Each Eligible Person is free to select a Dentist of his or her choice WDS shall not be held liable for any act or omission on the part of the selected Dentist Nothing contained in this Contract shall be construed as obligating WDS to render dental services, its sole obligation being to pay the agreed-upon portion of Dentist's charges for Covered Dental Benefits in accordance with the terms of this Contract 2012-01-00611-RC-01 -4- r Article VII—Group's Obligations 701 Group shall provide information to all Eligible Employees as to the existence and terms of this Contract Group shall make available to each Eligible Employee, booklets summarizing the Covered Dental Benefits and other essential features of the Plan 702 Group shall permit WDS, at WDS's expense, on reasonable advance written notice, to inspect eligibility records in order to verify the accuracy of information submitted to WDS An equitable adjustment of Administrative Fee shall be made in the event of inadvertent clerical errors or delays in reporting eligibility 703 Group shall sign and return any and all Contract documents within 30 days of the effective date or the date WDS mails the Contract document to Group or its authorized representative or agent, whichever is later 704 If a signed Contract or any changes affecting the Contract provisions are not received by WDS from the Group or the Group's legal representative(s)within 30 days following the effective date or the date WDS mails the contract to Group or its authorized representative or agent, whichever is later, but Group remits Administrative Fee as stipulated in Appendix D for the first month of this Contract term, the group will be deemed by WDS to have agreed to the terms of this Contract as stated, including acceptance of rates, Contract language and provisions WDS will process claims on the effective date according to these Contract provisions Article VIII—General Provisions 801 No change in this Contract shall be valid unless evidenced by written amendment signed by both the President of WDS and by the President of Group, or their respective designee 802 Legal action to recover benefits provided for in this Contract may not be initiated prior to 60 days after receipt of claim by WDS In addition, such legal action must commence within six years from the date the claim was received by WDS 803 Any provision of this Contract that is in conflict with any governing law or regulation of the state of Washington is hereby amended to comply with the minimum requirements of such law or regulation 804 Indemnification WDS shall indemnify and hold harmless Group, its affiliates and their respective directors, officers, employees and agents, for that portion of any liability, settlement and related expense (including reasonable attorneys'fees) resulting solely and directly from WDS's breach of this Agreement, negligence, willful misconduct, criminal conduct, fraud or its breach of a fiduciary responsibility related to or arising out of this Agreement Group shall indemnify and hold harmless WDS, its affiliates and their respective directors, officers, employees and agents, for that portion of any liability, settlement and related expense (including reasonable attorneys'fees) resulting solely and directly from Group's breach of this Agreement, negligence, willful misconduct, criminal conduct, fraud or its breach of a fiduciary responsibility related to or arising out of this Agreement 805 Force Majeure In the event WDS is unable to perform its obligations hereunder by reason of fire, casualty, lockout, strike, labor condition, riot, war, act of God or by ordinance, law, order or decree of any legally constituted authority, then this Contract may, at the option of WDS, be suspended During any period of suspension, WDS shall not be required to perform any service hereunder, nor shall WDS be liable for any damages arising from any event that precipitated the suspension If this Contract is suspended pursuant to this provision, Group's obligation to make Administrative Fee payments shall also be suspended for the same period of time 806 WDS and Group will act in accordance with applicable state and federal privacy requirements and disclosure requirements, such as the Gramm-Leach-Bliley Act (GLBA) and the Health Insurance Portability and Accountability Act (HIPAA), including any applicable regulations 2012-01-00611-RC-01 -5- d 807 For the purposes of this contract,the terms spouse, marriage, marital, husband, wife, widow, widower, next of kin, and family shall be interpreted as applying equally to domestic partnerships or individuals in domestic partnerships as well as to marital relationships and married persons, and references to dissolution of marriage shall apply equally to domestic partnerships that have been terminated, dissolved, or invalidated, to the extent that such interpretation does not conflict with federal law Where necessary, gender-specific terms such as husband and wife used in any part of this contract shall be construed to be gender neutral, and applicable to individuals in domestic partnerships Article IX— Notice and Termination 901 Any notice under this Contract shall be sufficient if given by either Group or WDS by regular mail to the other addressed to the office stated on the front page of this Contract or to such other address as may be designated by written notice to the other 902 This Contract may be terminated at the end of the Contract Term by either Group or WDS giving written notice to the other at least 30 days prior to the end of the Contract Term 903 In the event of termination for failure to pay Administrative Fee and claims payment, all benefits shall terminate and WDS shall be released from all further obligations of this Contract Group shall remain liable to WDS for the full amount of all Dentists' statements paid or otherwise discharged by WDS during the full term of this Contract, plus the appropriate percentage of such amount(to compensate WDS for its administration of the dental program), less amounts actually paid by Group to WDS during the term of such Contract(see Appendix D) 904 Termination at the end of the Contract Term shall be by at least 30 days written notice of termination given by the party desiring to terminate to the other party In the event that WDS shall desire to change the administrative percentage or benefits effective at the end of the Contract Term, advice of such changes may be given to Group in writing within such 30 day period, and shall have the effect of a notice of termination, as of the end of the Contract Term, unless an amendment of this Contract is mutually agreed upon between Group and WDS 905 If Group notifies WDS in writing of its intention to terminate this Contract as of any date other than the end of the Contract Term, such termination shall be treated as a termination for failure to pay Administrative Fees and claims payment, and the notice by Group of intention to terminate shall constitute a waiver of notification and billing by WDS 906 Upon termination of this Plan, all expenses incurred prior to the termination of the Plan, but not submitted to Washington Dental Service within six months of the effective date of termination of this Plan,will be excluded from any benefit consideration Article X—List of Appendices 1001 The attached appendices are a part of this Contract Appendices are identified as follows: Appendix A—Employee Eligibility Requirements Appendix B—Dependent Eligibility Requirements Appendix C—Method of Payment Appendix D—Group's Financial Obligations 2012-01-00611-RC-01 -6- Appendix A. Employee Eligibility Requirements Section A Definition of Eligible Employee An employee of the City of Kent is eligible to enroll on the date he or she satisfies the following • Becomes an active full-time nonuniformed employee who regularly works a minimum of 40 hours a week • Becomes an active part-time nonuniformed employee who regularly works a minimum of 21 hours a week but less than 40 hours a week on a continuous service basis • An approved job share employee working at least 20 hours per week • Becomes an active uniformed employee Uniformed employees are defined as follows LEOFF I Employees - Full-time active law enforcement officers or fire fighters who established membership in the LEOFF system as defined in Sections (3)and (4), CH131, Law of 1972 1st Ex Sess prior to October 1, 1977" LEOFF II Employees - Full-time active law enforcement officers or fire fighters who established membership in the LEOFF System as defined in Sections (3) and (4), CH131, Law of 1972 1st Ex Sess on or after October 1, 1977 Becomes an elected Council Member for the City of Kent • The benefit provisions of this policy are available to City of Kent Council members only as a secondary source of insurance benefit If the insured Council member does not have insurance from a primary source, benefits in this policy will be primary 'Retired LEOFF I employees and retired disabled LEOFF I employees who are eligible to receive a retirement benefit under the LEOFF I Retirement Plan may enroll in the City of Kent Retiree Plan Section B Effective Date of Coverage Eligible Employees(as defined in Section A)are eligible on the effective date of this Contract An employee hired after the effective date of this Contract shall become eligible on the date of hire Section C Continuation of Coverage An employee shall continue to be eligible during the time this Contract is in effect as long as the employee remains an Eligible Employee as defined above While satisfying the various requirements of the FMLA and COBRA laws rests primarily with the Group, WDS will fully cooperate with Group in complying with these laws Leave of Absence Coverage for a subscriber and enrolled dependents may be continued for up to 180 days when the employer grants the subscriber a leave of absence and subscription charges continue to be paid If a medical leave is granted, the City of Kent may pay the required monthly charge for the employee and enrolled dependents for up to 180 days The 180-day leave of absence period counts toward the maximum COBRA continuation period, except as prohibited by the Family and Medical Leave Act of 1993 Section D Termination of Coverage An employee shall cease to be eligible at the end of the calendar month in which the employee ceases to be an Eligible Employee as defined above or upon termination of this Contract, whichever occurs first 2012-01-00611-RC-01 -7- r Section E Enrollment Requirements All Eligible Employees enrolled in the Group-sponsored medical Plan must be enrolled in the dental Plan under this contract regardless of whether or not enrolled as a dependent in another dental Plan Employees who are not enrolled in the Group-sponsored medical Plan may not enroll in the dental Plan under this contract Each Eligible Employee must complete an enrollment form WDS must receive the completed form within 60 days of the employee's Eligibility Date as defined in Section B If the enrollment form is not received within 60 days, enrollment will not be accepted until the next open enrollment period 2012-01-00611-RC-01 -8- Y Appendix B. Dependent Eligibility Requirements Section A Definition of Eligible Dependent An Eligible Dependent is a dependent of an Eligible Employee, for whom monthly Premium has been submitted to WDS To be a dependent under this plan, the family member must be • The lawful spouse of the subscriber, unless legally separated • An eligible child under 26 years of age Spouses and children of married dependents are not eligible for coverage under this plan (Eligibility and enrollment requirements for children placed for adoption and children covered because of a court decree can be found later in this section) c An eligible child is one of the following ■ A natural offspring of either or both the subscriber or spouse ■ A legally adopted child of either or both the subscriber or spouse ■ A child placed with the subscriber for the purpose of legal adoption in accordance with state law "Placed" for adoption means assumption and retention by the subscriber of a legal obligation for total or partial support of a child in anticipation of adoption of such child • A legally placed ward of the subscriber or spouse living permanently in the home of the subscriber Foster children aren't eligible for coverage Domestic Partner is defined as follows Effective January 1, 2009 the City of Kent will be expanding the eligibility under their health insurance programs to include coverage for same sex domestic partners who have registered with the State of Washington as Domestic Partners (opposite sex age 62 and over) Coverage will also be available to children of Registered Domestic Partners who meet the age and other requirements of the City's health care plans Upon termination of a domestic partner relationship, an employee must submit a Notice of Termination of State Registered Domestic Partnership acknowledging that the relationship has ended Coverage for domestic partners and their dependent children will cease on the last day of the month the domestic partner relationship has ended The rules for the State Registry are as follows, To enter into a state registered domestic partnership the two persons involved must meet the following requirements 1) Both persons share a common residence, 2) Both persons are at least eighteen years of age, 3) Neither person is married to someone other than the party to the domestic partnership and neither person is in a state registered domestic partnership with another person, 4) Both persons are capable of consenting to the domestic partnership, 5) Both of the following are true a) The persons are not nearer of kin to each other than second cousins, whether of the whole or half blood computing by the rules of the civil law, and b) Neither person is a sibling, child, grandchild, aunt, uncle, niece, or nephew to the other person, and 6) Either a) both persons are members of the same sex Dependent eligibility validation documentation and information shall be maintained and verified by Group 2012-01-00611-RC-01 -9- Section B Effective Date of Coverage Coverage for an Eligible Dependent shall become effective on the date the Eligible Employee's coverage becomes effective or the date of previous coverage termination Section C Continuation of Coverage A dependent shall continue to be eligible while this Contract is in effect as long as the dependent remains an Eligible Dependent as defined above and Group has made timely payment of the monthly Administrative Fees on behalf of the dependent to WDS While satisfying the various requirements of the FMLA and COBRA laws rests primarily with the Group, WDS will fully cooperate with Group in complying with these laws Section D Termination of Coverage An Eligible Dependent shall cease to be eligible at the end of the calendar month during which the Eligible Employee's eligibility terminates or the person no longer meets the definition of an Eligible Dependent, whichever occurs first In any event, eligibility for a dependent shall terminate at the end of the calendar month for which timely payment of the monthly Administrative Fees were last received by WDS from Group or upon termination of this Contract, whichever occurs first An Eligible Employee may terminate coverage of an Eligible Dependent only coincident with a subsequent renewal or extension of the dental Plan Once an Eligible Employee terminates such Eligible Dependents coverage, the coverage cannot be reinstated, unless there is a change in family status Section E Enrollment Requirements Eligible Dependents enrolled in the Group-sponsored medical Plan of the Eligible Employee must also be enrolled in the dental Plan under this Contract provided they satisfy the dental eligibility requirements as provided in Section A of this Appendix B A family member not covered under the Group-sponsored medical Plan cannot be covered under the dental Plan under this contract When a family member is dropped from either the medical Plan or the dental Plan, the family member must also be dropped from the other Plan If a new family member is not enrolled in this dental Plan pursuant to the rules set forth above, such person shall not be eligible for Covered Dental Benefits during the then-current Contract Term Such person may become eligible by proper enrollment coincident with the effective date of any renewal or extension of this Contract 2012-01-00611-RC-01 -10- Appendix C. Method of Payment Section A Constant Payment Plan Fees for Covered Dental Benefits provided to an Eligible Person are based on the following: • A WDS PPO Participating Dentist in the state of Washington, based on the lesser of the Dentists allowable PPO fees, or such Dentist's actual charges, • A Delta Dental PPO Participating Dentist outside of the state of Washington, based on the lesser of that states allowable PPO fees or the Dentist's actual charges, • A WDS Premier Participating Dentist in the state of Washington, based on the lesser of the Dentists approved Premier fees, or such Dentist's actual charges, • A Delta Dental Participating Dentist outside of the state of Washington, based on the lesser of that states allowable Premier fees, or such Dentist's actual charges, • A Nonparticipating Dentist in the state of Washington based on the lesser of WDS's Maximum Allowable Fees for Nonparticipating Dentists, or such Dentist's actual charges, • A Nonparticipating Dentist outside the state of Washington based on the lesser of WDS's Maximum Allowable Fees for Participating Dentists, or such Dentist's actual charges The percentages of the above-indicated fee payable by WDS for Covered Dental Benefits are as follows: 100 PERCENT, GROUP WDS PPO Participating WDS Participating Dentists HEALTH, HSA AND 80 Dentists PERCENT MEDICAL PLANS Dentists outside of Nonparticipating Dentists in Covered Dental Benefits Washington State Washington State Class 1 100 percent 100 percent Class II 80 percent 80 percent Class III 80 percent 80 percent Orthodontic 50 percent 50 percent Accidental Bodily Injury 100 percent 100 percent RETIREES Covered Dental Benefits WDS PPO Participating WDS Participating Dentists Dentists Dentists outside of Nonparticipating Dentists in Washington State Washington State Class 1 100 percent 100 percent Class II 80 percent 80 percent Class III 50 percent 50 percent Orthodontic 50 percent 50 percent Accidental Bodily Injury 100 percent 100 percent 2012-01-00611-RC-01 -11 - Section B Plan Maximum FOR ENROLLEES IN THE 100 PERCENT tip GROUP HEALTH MEDICAL PLAN The maximum amount payable by WDS for Class I, II and III Covered Dental Benefits (including Dental Accident Benefits) per Eligible Person during each Benefit Period shall be$1,500 Charges for dental procedures requiring multiple treatment dates shall be considered incurred on the date the service is completed Amounts for such procedures shall be applied to the Plan maximum based on such incurred date FOR ENROLLEES IN THE HSA AND 80 PERCENT MEDICAL PLAN The maximum amount payable by WDS for Class I, II and III Covered Dental Benefits (including Dental Accident Benefits) per Eligible Person during each Benefit Period shall be $1,800 Charges for dental procedures requiring multiple treatment dates shall be considered incurred on the date the service is completed Amounts for such procedures shall be applied to the Plan maximum based on such incurred date FOR BOTH PLANS The lifetime maximum amount payable by WDS for Orthodontic Benefits provided to an Eligible Person shall be $1,800 FOR RETIREES The maximum amount payable by WDS for Class I, II and III Covered Dental Benefits(including Dental Accident Benefits) per Eligible Person during each Benefit Period shall be $1,500 Charges for dental procedures requiring multiple treatment dates shall be considered incurred on the date the service is completed.Amounts for such procedures shall be applied to the Plan maximum based on such incurred date The lifetime maximum amount payable by WDS for Orthodontic Benefits provided to an Eligible Person shall be $1,000 Section C Plan Deductible WDS shall not be obligated to pay the first$50 of fees for Covered Dental Benefits received by an Eligible Person during each Benefit Period Such deductible amount shall not exceed three times the individual deductible or $150 during each Benefit Period for all Eligible Persons in a single family consisting of an Eligible Employee and Eligible Dependents Once the maximum deductible per family has been satisfied, no further deduction shall apply until the next succeeding Benefit Period The deductible does not apply to Class I Covered Dental Benefits, Orthodontic Benefits or Dental Accident Benefits 2012-01-00611-RC-01 -12- Appendix D. Group's Financial Obligations Section A Monthly Premium Claim Reimbursement WDS shall notify Group, on the last WDS payment day of each calendar month, the actual amount of claims paid by WDS for that month Notification will be via Fax letter which will constitute an invoice Group will then have two business days to transfer funds electronically to the appropriate WDS bank account an amount equal to total claims paid for the month Funds are due on the date notified If the funds are not transferred within five days of notification, a late fee of one percent of claims will be charged An additional late charge of one percent of claims will be charged for each subsequent 30 day period for which payment is not received The charges shall be submitted by WDS with a subsequent payment notification Administrative Fee The monthly Administrative Fee payable by Group under this Contract Term during the period January 1, 2012 through December 31, 2013 shall be$6 35 per Eligible Employee Group's payment shall be in the form of a check or electronic transfer and shall accompany the eligibility listing WDS will then update the files and send a new billing to Group for the next month of coverage 2012-01-00611-RC-01 -13- REQUEST FOR MAYOR'S SIGNATURE KENT Please Fill in All Applicable Boxes WASHINGTON Routing Information (ALL REQUESTS MUST FIRST BE ROUTED THROUGH THE LAW DEPARTMENT) Originator: OLp Phone (Originator)- y, 0 Date Sent: -IS_) Date Required a-aa- l2. Return Signed Document to: CONTRACT TERMINATION DATE: VENDOR NAME: Ai c, DATE OF COUNCIL APPROVAL: Brief Explanation of Document: C901 a, �l�i 1�f4GT LiD L,TW (Z� Pvb b -i A &jv rJ lj)�tp,7 A L- i All Contracts Must Be Routed Through the Law Department (This Area to be Completed By the Law Department) Received: MELZVED Approval of City Attorney: FEB 16 2012 City Attorney Comments: LAW DEP-r Date Forwarded to Mayor: u ) Shaded Areas to Be Completed by Administration Staff Received: r� Recommendations & Comments: = ' Disposition:- ?- - CtTY CiE"4 Date Returned: lage5870 • 2/04