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HomeMy WebLinkAboutHR14-022 - Original - Delta Dental of Washington - 2014 PPO Contract - 01/17/2014 Records M erne, KENT Document WA5H1 70H 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: L pfz: Vendor Number: 88 3 ID Edwards Number Contract Number: R 14 - 022 This is assigned by City Clerk's Office c� Project Name: ©ly CoNTRR T Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment Igl Contract ❑ Other: Contract Effective Date: S- - Do 14 Termination Date: 1 -?S�- Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager:�Btcc�-( i7vjy-P-,Department: ►1'. Detail: (i.e. address, location, parcel number, tax id, etc.): S Public\RecordsManagement\Forms\ContractCover\adcc7832 1 11/08 Delta Dental of Washington City of Kent Plan#00611 Effective January 1,2014 Summary of Plan Changes The information contained in this summary represents a brief overview of the substantive changes made to your plan documents.A comprehensive listing of all changes is available upon request. Global Changes Name Change ® To reflect the name change of the carrier all references to"Washington Dental Service"and"WDS" have been replaced by"Delta Dental of Washington" and"DDWA", respectively General • To distinguish an eligible person from an enrolled member,the terms"Enrolled Employee," "Enrolled Dependent," and "Enrolled Person" have been added where applicable. Contract Changes Article I: Definitions • The following definitions have been added: "DDWA", "Enrolled Dependent, Enrolled Employee, Enrolled Person", "Licensed Professional", and"Retiree'. • The following definitions have been deleted: "Contract Term", "Nonparticipating Dentist". • The following definitions have been updated: "Delta Dental "Delta Dental PPO Dentist", "Delta Dental Participating Dentist""Dentist","Eligibility Date". Article IV: Benefits Provided. Limitations and Exclusions • Paragraph regarding paying the lowest fee of two or more professionally accepted plans has been deleted. Article VII: Group's Obligations • Language regarding group-prepared benefit booklets has been added. Article Vill: General Provisions • Amendment language has been updated. Appendix A: Employee Eligibility Requirements • Language has been updated. Appendix B Dependent Eligibility Requirements • Language has been updated and revised. Appendix C Method of Payment • Language has been updated and reorganized for clarity. • Adding unlimited annual maximum for children and unlimited medically necessary maximum. Appendix D Group's Financial Obligations • Language has been updated. 2014-01-00611-RC-02 i PPOL rev20131115 Certificate of Coverage Changes The following sections have been updated for reading clarity: • How to Use Your Plan • Claim Forms • Reimbursement Levels • Employee Eligibility, Enrollment and Termination • Dependent Eligibility and Termination • Special Enrollment Periods ® Extension of Benefits Plan Deductible • Statement added for clarity Annual Maximum • Language has been updated to include unlimited annual maximum for children and unlimited medically necessary maximum Additional Procedures • Section removed to reflect change in internal practices Glossary Terms updated Appeals of Denied Claims • Additional language added to inform subscriber of rights Coordination of Benefits • State-required language changes have been incorporated to clarify the term"Allowable Expense". This change was effective January 1, 2012 and all claims have been paid accordingly. Benefits Changed or Updated Class I Diagnostic • Limitation language has been clarified to be consistent with industry standards Class I Preventative • Space maintainer age limitation has been added for clarification— no change in benefit Class II Restorative • Inlay coverage has been moved to Class III Restorative to correct a discrepancy—no change in benefit Class II Endodontics • Retreatment language added for clarity—no change in benefit Class III Prosthodontics • Post and core limitation has been added • Language regarding amalgam allowances has been clarified • Implant-support crown and inlays have been added to crown frequency limitations Class III Prosthodontics • Implant maintenance procedures language has been removed from covered benefit and exclusion section to correct a discrepancy—no change in benefit • Denture reline and adjustment limitation has been added for clarity—no change in benefit 201401-00611-RC-02 ii PPDL rev20131115 Delta Dental of Washington Dental Care Service Contract DDWA Plan #00611 Name of Group: City of Kent Herein called Group, agrees to a Dental Care Service Contract with Delta Dental of Washington, herein called DDWA. The effective date of this Contract shall be 12:01 a.m. Pacific Time on the first day of January, 2014 at Seattle, Washington, and shall run for a period of 12 months, through December 31, 2014. 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 Delta Dental of Washington 220 4th Avenue South Post Office Box 75983 Kent,Washington 98032 Seattle,Washington 98175-0983 T f Signed: , '� . >'' a>-, Signed: Title: f g ` Title: Vice riVWU nr / l Underwriting and Actuarial Date: I1 Date: November 18, 2013 I 2014-01-00611-RC-02 1 PPOL rev20131115 Article I— Definitions For the purpose of this Contract,the following definitions shall apply: 1.01 "Administrative Fee" means the monthly amount payable by Group to cover claims paid by DDWA and as designated in Appendix D. 1.02 "Benefit Period" means the period beginning January 1 and ending December 31. 1.02 "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. 1.03 "Contract" means this agreement between DDWA and Group.This Contract constitutes the entire Contract between the parties and supersedes any prior agreement, understanding or negotiation between the parties. 1.04 "Covered Dental Benefit"means those dental services that are covered under this Contract, subject to the Limitations set forth in the Certificate of Coverage. 1.05 "DDWA" means Delta Dental of Washington, a nonprofit corporation incorporated in Washington State. DDWA is a member of the Delta Dental Plans Association. 1.06 "Delta Dental" means Delta Dental Plans Association, a nationwide non-profit organization of dental benefit carriers offering a range of group dental benefit plans. 1.07 "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, which includes looking solely to Delta Dental for payment for covered services. 1.08 "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, which includes looking solely to Delta Dental for payment for covered services. 1.09 "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 Licensed Professional.A Dentist does not mean a dental mechanic or any other type of dental technician. 1.10 "Eligibility Date" means the date on which an Eligible Person becomes eligible to enroll in the Plan as detailed in Appendix A or B. 1.11 "Eligible Dependent' means any dependent of an Eligible Employee who meets the conditions of eligibility set forth in Appendix B. 1.12 "Eligible Employee" means any employee who meets the conditions of eligibility set forth in Appendix A. 1.13 "Eligible Person" means an Eligible Employee or an Eligible Dependent. 1.14 "Enrolled Dependent", "Enrolled Employee", or"Enrolled Person" means any Eligible Dependent, Eligible Employee or Eligible Person, as applicable,who has completed the enrollment process and for whom Group has submitted the monthly Administrative Fee to DDWA. 1.15 "Filed Fee" means the approved fee accepted by DDWA for a specific dental procedure performed by a 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 "Licensed Professional" means an individual legally authorized to perform services as defined in their license. Licensed Professional includes, but is not limited to, denturists, hygienists, and radiology technicians. 1.18 "Maximum Allowable Fee" means the maximum dollar amount that will be allowed toward the reimbursement for any service provided for a Covered Dental Benefit. 2014-01-00611-RC-02 -2- PPOL rev20131115 1.19 "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 a member of the Delta Dental Plans Association and such Dentist. 1.20 "Open Enrollment Period" means the annual period in which Eligible Employees can select benefits Plans and add or delete Eligible Dependents. 1.21 "Participating Plan" means Delta Dental of Washington and any other member of the Delta Dental Plans Association with which Delta Dental contracts to assist in administering the Benefits described in this Contract. 1.22 "Payment Level' means the applicable percentage of Maximum Allowable Fees for Covered Dental Benefits that shall be paid by DDWA as set forth in Appendix C. 1.23 "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. 1.24 "Retiree", for purposes of Group 00611 —Plan 03,the term Retiree may be inferred in place of the term Employee, where applicable. Article 11—Eligibility 2.01 Every person who meets the conditions of eligibility as set forth in Appendix A or Appendix B is eligible for enrollment in this Plan. 2.02 Group shall submit a list of Enrolled Persons to DDWA prior to the beginning of each monthly eligibility period. Article III—Monthly Payment 3.01 The monthly Administrative Fee and claims payment, to be remitted fully by Group, is determined as set forth in Appendix D. 3.02 Administrative fees are due with the Eligibility listing on or before the first day of the month. No person shall be entitled to benefits under this Contract during any month for which Administrative Fee payment has not been received by DDWA. 3.03 Claim Reimbursement is due as described in Appendix D.The total amount of claims payment shall be transferred,via wire transfer,to the appropriate DDWA bank account on or about the first of the month, within two business days of DDWA notification of amount paid. 3.04 If payment is not received within 30 days DDWA 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." 3.05 DDWA shall accept retroactive additions to eligibility(payments) that are received by DDWA within 60 days of the requested effective date. 3.06 DDWA shall accept retroactive terminations of eligibility(credits) that are received by DDWA within 60 days of the requested termination date, or to the end of the month of the last paid claim of termed Enrolled Person, whichever is later. 3.07 DDWA 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. 3.08 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 DDWA by Group, then DDWA is authorized to increase the monthly Administrative Fee by the amount of such new tax, assessment or increase, or pass through the exact tax amount to the Group separately. 2014-01-00611-RC-02 -3- PPOL rev20131115 Article IV—Benefits Provided, Limitations and Exclusions 4.01 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. 4.02 The percentages of the Maximum Allowable Fee, Filed Fee, or the Dentists'actual charges payable by DDWA for Covered Dental Benefits provided to an Enrolled Person are described in Appendix C. 4.03 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 fails to pay the dentist, the Enrolled Person shall not be liable to the dentist for any sums owed by Delta Dental. Article V—Conditions for Benefits—Dispute Determination Procedures 5.01 Covered Dental Benefits are available for an Enrolled Person from the enrollment date until such enrollment terminates. 5.02 An Enrolled Person may elect the services of any licensed Dentist. DDWA is not responsible for availability of any particular licensed Dentist. 5.03 DDWA 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 Enrolled Person as may be required in the administration of claims. 5.04 Provider dispute resolution process is available as outlined in individual provider contracts. 5.05 To determine Covered Dental Benefits for certain treatments, DDWA may require an Enrolled Person to obtain an examination from a DDWA-appointed consultant Dentist. DDWA will pay 100 percent of the charges incurred for this examination. Article VI—DDWA's Obligations 6.01 DDWA will issue to Group an electronic version of the Certificate of Coverage for this Plan in the form of a standard DDWA benefit booklet, which summarizes 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, electronic versions of corrected booklets or booklet inserts showing the change will be issued to Group. A new booklet shall be created upon initial inception of the Contract and every other year thereafter. An insert will be created and sent in the year in which a booklet is not produced to inform Enrolled Person of any Plan changes. 6.02 If requested, DDWA will provide to Group one printed booklet for each employee enrolled in the Plan, plus an additional 10 percent for a reserve supply. Group will reimburse DDWA for any additional costs due to variation in booklet size or paper requested by Group. DDWA will have booklets delivered to Group within 15 business days after reciept of a signed booklet approval form from Group. If a signed booklet approval form is not returned to DDWA by Group, printed booklets will not be provided. 6.03 DDWA shall provide descriptions of predetermination, claim review, and complaint and appeal procedures in the benefit booklets issued to Group. 6.04 If a Dentist or an Enrolled Person requests a predetermination of benefits, DDWA will provide a predetermination of benefits for the Enrolled Person. Such predetermination of benefits will be valid 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. 6.05 DDWA shall not be obligated to make payment for any services rendered to a person who is not an Enrolled Person at the time the services were performed. 6.06 DDWA may provide professional review of the adequacy and appropriateness of services rendered to Enrolled Persons through its Quality Management and Clinical Review processes. 2014-01-00611-RC-02 -4- PPOL rev20131115 6.07 DDWA shall provide Delta Dental Participating Dentist Directories to Group. This directory is available on- line at www.DeltaDentaIWA.com. It is understood that the composition of such directory is subject to change. DDWA reserves the right to change the directory without notice. Each Enrolled Person is free to select a Dentist of his or her choice. DDWA 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 DDWA 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. Article VII—Group's Obligations 7.01 Group shall provide information to all Enrolled Employees as to the existence and terms of this Contract. Group shall make available to each Enrolled Employee, booklets summarizing the Covered Dental Benefits and other essential features of the Plan. 7.02 If Group elects to prepare and print its own summary plan description, it does so at its own risk and expense. The Group-prepared summary plan description must be based on the most current Certificate of Coverage provided by DDWA, and will be for informational purposes only, not incorporated into this Contract. Group will provide DDWA with a copy of any summary plan description that is distributed to Enrolled Employees in lieu of the Certificate of Coverage provided by DDWA. Group is responsible for assuring the accuracy of any summary plan description that it elects to prepare and distribute. DDWA is not obligated to review or approve any summary plan description prepared by Group, and will not provide any warranty for the content of the Group-produced summary plan description. 7.03 Group shall permit DDWA, at DDWA's expense, on reasonable advance written notice, to inspect eligibility records in order to verify the accuracy of information submitted to DDWA.An equitable adjustment of Administrative Fee shall be made in the event of inadvertent clerical errors or delays in reporting eligibility. 7.04 Group shall sign and return any and all Contract documents within 30 days of the effective date or the date DDWA sends the Contract document to Group or its authorized representative or agent,whichever is later. 7.05 If a signed Contract or any changes affecting the Contract provisions are not received by DDWA from the Group or the Group's legal representative(s)within 30 days following the effective date or the date DDWA mails the contract to Group or its authorized representative or agent,whichever is later, but Group remits the first month's Administrative Fee,the group will be deemed by DDWA to have agreed to the terms of this Contract as stated, including acceptance of rates. Contract language and provisions. In such cases, DDWA will process claims on the effective date according to these Contract provisions. Article Vill—General Provisions 8.01 No change in this Contract shall be valid unless evidenced by written amendment signed by an authorized representative or agent of DDWA and an authorized representative or agent of Group. 8.02 Legal action to recover benefits provided for in this Contract may not be initiated prior to 60 days after receipt of claim by DDWA. In addition, such legal action must commence within six years from the date the claim was received by DDWA. 8.03 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. 8.04 Indemnification DDWA 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 DDWA'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 DDWA, 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. 2014-01-00611-RC-02 -5- PPOL rev20131115 8.05 Force Maieure In the event DDWA 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 DDWA, be suspended. During any period of suspension, DDWA shall not be required to perform any service hereunder, nor shall DDWA 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. 8.06 DDWA 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. 8.07 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. 8.08 Group and DDWA both acknowledge and agree that DDWA may contract with a third-party administrator to perform certain administrative functions under this Contract, including but not limited to collection of Administrative Fee payments due, and collection of enrollment and termination information. Any third- party administrator performing these functions is acting as an authorized representative of DDWA, and DDWA does not waive or disclaim any responsibility for our obligations under this Contract. Article IX—Notice and Termination 9.01 Any notice under this Contract shall be sufficient if given by either Group or DDWA 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. 9.02 This Contract may be terminated effective at the end of the term by either Group or DDWA, by either party giving written notice to the other at least 30 days prior to the end of the Contract term, except as otherwise provided in Article III or this Article IX. 9.03 Upon default by Group in any of its obligations hereunder, DDWA may elect to terminate this Contract, effective at the end of the month for which Administrative Fees have been received by DDWA prior to the time of such election, by giving written notice thereof to Group. If DDWA elects to so terminate because of default by Group, then Group shall be indebted to and agrees to pay DDWA the sum of all claims payments and expenses incurred for dental services rendered from the date of default until the date of termination, including costs of recovery. 9.04 If on termination of this Contract, Group has paid Administrative Fee to DDWA applicable to a period of time after the termination date, DDWA shall, within 30 days after termination, return such portion of Administrative Fee to Group less any amounts due to DDWA. 9.05 Acceptance by DDWA of the proper amount of Administrative Fee, after termination of this Contract and without requiring a new application, shall reinstate the Contract as though it had never terminated, unless DDWA shall, within five business days of receipt of such payment, either: 1) Refund the payment so made, or 2) Issue to Group a new Contract accompanied by written notice stating clearly those respects in which the new Contract differs from the terminated Contract in benefits, coverage or otherwise. 9.06 Upon termination of this Plan, all expenses incurred prior to the termination of the Plan, but not submitted to DDWA within six months after the date of such treatment will be excluded from any benefit consideration. 2014-01-00611-RC-02 -6- PPOL rev20131115 Article X—List of Appendices 10.01 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 2014-01-00611-RC-02 -7- PPOL rev20131115 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 the employee becomes: • an active, full-time, non-uniformed employee who regularly works a minimum of 40 hours a week; • an active, part-time, non-uniformed 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 jab share employee working at least 20 hours per week; • an active uniformed employee; or Uniformed employees are defined as follows: o 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. priorto October 1, 1977.` o 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 1 st Ex. Sess. on or after October 1, 1977. • an elected Council Member for the City of Kent. o 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. Eligible Employees are Enrolled Employees after fully completing the enrollment process, including payment of Administrative Fee by Group to DDWA. Section B Effective Date of Coverage Eligible Employees are eligible to enroll in this Plan on the effective date of this Contract. An employee hired after the effective date of this Contract shall become eligible to enroll in this Plan on the date of hire. Section C Continuation of Coverage An employee shall continue to be eligible to enroll in this Plan during the time this Contract is in effect as long as the employee remains an Eligible Employee. An Enrolled Employee shall continue to be enrolled as long as the Group has made timely payment of the monthly Administrative Fees on behalf of the Enrolled Employee to DDWA. While satisfying the various requirements of the FMLA and COBRA laws rests primarily with the Group, DDWA 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 premium 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. 2014-01-00611-RC-02 -8- PPOL rev20131115 Section D Termination of Coverage An employee shall cease to be eligible to enroll or cease to be enrolled in the Plan at the end of the calendar month in which the employee ceases to be an Eligible Employee or upon termination of this Contract,whichever occurs first. An Enrolled Employee shall cease to be enrolled at the end of the calendar month in which the Enrolled Employee ceases to be an Eligible Employee, or at the end of the calendar month for which Group has made the last timely payment of the monthly Administrative Fees on behalf of the Enrolled Employee to DDWA, or upon termination of this Contract,whichever occurs first. Section E Enrollment Requirements All Eligible Employees enrolled in the Group-sponsored medical plan must be enrolled in this Plan 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 this I Plan. Each Eligible Employee must complete the enrollment process. DDWA must receive the completed enrollment information within 60 days of the employee's Eligibility Date. If the enrollment information is not received within 60 days, enrollment will not be accepted until the next Open Enrollment Period. 2014-01-00611-RC-02 -9- PPOL rev20131115 Appendix B. Dependent Eligibility Requirements Section A Definition of Eligible Dependent An Eligible Dependent is a dependent of an Eligible Employee that meets the requirements of this Appendix B. An Eligible Dependent becomes an Enrolled Depended upon completion of the enrollment process and submission of the Administrative Fee to DDWA. To be a dependent under this plan, the family member must be: ® The lawful spouse of the subscriber, unless legally separated; • The state-registered domestic partner of the subscriber; ® An eligible child under 26 years of age; or o Spouses and children of dependents are not eligible for coverage under this plan. o 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 • Foster children are not eligible for coverage C A legally placed ward of the subscriber, spouse, or domestic partner living permanently in the home of the subscriber. Section B Effective Date of Coverage An Eligible Dependent shall become eligible to enroll in this Plan on the date the Eligible Employee becomes eligible to enroll in this Plan, or on the first day of the calendar month following the month in which such person became an Eligible Dependent of the Eligible Employee. Section C Continuation of Coverage A dependent shall continue to be eligible to enroll in this Plan while this Contract is in effect as long as the dependent remains an Eligible Dependent of an Eligible Employee. An Enrolled Dependent shall continue to be enrolled as long as the Group has made timely payment of the monthly Administrative Fees on behalf of the Enrolled Employee to DDWA. While satisfying the various requirements of the FMLA and COBRA laws rests primarily with the Group, DDWA will fully cooperate with Group in complying with these laws. Section D Termination of Coverage An Eligible Dependent shall cease to be eligible to enroll or cease to be enrolled in this Plan at the end of the calendar month during which the employee ceases to be an Eligible Employee or the person no longer meets the definition of an Eligible Dependent,whichever occurs first. An Enrolled Dependent shall cease to be enrolled at the end of the calendar month in which the Enrolled Employee ceases to be enrolled, at the end of the calendar month for which Group has made timely payment of the monthly Administrative Fees on behalf of the Enrolled Employee to DDWA, or upon termination of this Contract, whichever occurs first. 2014-01-00611-RC-02 -10- PPOL rev20131115 An Enrolled Employee may terminate coverage of an Enrolled Dependent only coincident with a subsequent renewal or extension of this Plan. Once an Enrolled Employee terminates such Enrolled Dependent's coverage,the coverage cannot be reinstated, unless there is a change in family status as defined in the Special Enrollment Period section of the Certificate of Coverage. Section E Enrollment Requirements Eligible Dependents enrolled in the Group-sponsored medical plan of the Enrolled Employee must also be enrolled in this Plan provided they satisfy the requirements of an Eligible Dependent. A family member not covered under the Group-sponsored medical plan cannot be covered under this Plan. When an Eligible Dependent is no longer enrolled in the medical plan, they no longer satisfy the requirements of an Eligible Dependent and must be disenrolled from this Plan. If a new Eligible Dependent is not enrolled in this Plan pursuant to the rules set forth in this Contract, such Eligible Dependents shall not be eligible for enrollment in this Plan during the then-current contract term. Such person may enroll during any Open Enrollment Period or during a Special Enrollment Period as defined in the Certificate of Coverage. 2014-01-00611-RC-02 -11 - PPOL rev20131115 Appendix C. Method of Payment Section A Constant Payment Plan Fees for Covered Dental Benefits provided to an Enrolled Person are based on the following: • Delta Dental PPO Participating Dentist based on their state's Maximum Allowable Fee for Delta Dental PPO Participating Dentists, or their actual fee, whichever is less • Delta Dental Participating Dentist based on their state's Maximum Allowable Fee for Delta Dental Participating Dentists, or their actual fee, whichever is less • Nonparticipating Dentist based on their DDWA's Maximum Allowable Fee for Nonparticipating Dentists, or their actual fee, whichever is less The percentages of the above-indicated fee payable by DDWA for Covered Dental Benefits are as follows: 100% and Group Health Coop. Medical - Plan 01 and 80% and HSA Medical-Plan 02 Delta Dental PPO Dentists Delta Dental Premier Dentists Covered Dental Benefits Dentists outside of Nonparticipating Dentists in Washington State Washington State Class 100 percent 100 percent Class II 80 percent 80 percent Class 111 80 percent 80 percent Orthodontic 50 percent 50 percent Accidental Injury 1 100 percent 100 percent Retirees—Plan 03 Delta Dental PPO Dentists Delta Dental Premier Dentists Covered Dental Benefits Dentists outside of Nonparticipating Dentists in Washington State Washington State Class 1 100 percent 100 percent Class II 80 percent 80 percent Class 111 50 percent 50 percent Orthodontic 1 50 percent 50 percent Accidentalln'u 100 percent 100 percent 2014-01-00611-RC-02 -.12- PPOL red20131115 Section B Plan Maximum (i) PLAN 01 -FOR ENROLLEES IN THE 100 PERCENT&(CROUP HEALTH MEDICAL PLAN The maximum amount payable by DDWA for Class I, II and III Covered Dental Benefits (including Accidental Injury Benefits) per Enrolled 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 DDWA for orthodontic benefits is $1,800 per Enrolled Person. Covered benefits for Medically Necessary Orthodontia provided to children up to the age of nineteen do not accrue towards the maximum benefit allowed under this plan. Covered benefits provided to children up to the age of nineteen do not accrue towards the maximum benefit allowable under this plan. (ii) PLAN 02-FOR ENROLLEES IN THE HSA AND 80 PERCENT MEDICAL PLAN The maximum amount payable by DDWA for Class I, II and III Covered Dental Benefits (including Accidental Injury Benefits) per Enrolled 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. The lifetime maximum amount payable by DDWA for orthodontic benefits is$1,800 per Enrolled Person. Covered benefits for Medically Necessary Orthodontia provided to children up to the age of nineteen do not accrue towards the maximum benefit allowed under this plan. Covered benefits provided to children up to the age of nineteen do not accrue towards the maximum benefit allowable under this plan. (III) PLAN 03-RETIREES The maximum amount payable by DDWA for Class I, II and III Covered Dental Benefits (including Accidental Injury Benefits) per Enrolled 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 DDWA for Orthodontic Benefits provided to an Enrolled Person shall be$1,000. Covered benefits for Medically Necessary Orthodontia provided to children up to the age of nineteen do not accrue towards the maximum benefit allowed under this plan. Covered benefits provided to children up to the age of nineteen do not accrue towards the maximum benefit allowable under this plan. Section C Plan Deductible (ALL PLANS) DDWA is not obligated to pay the deductible, defined as the first$50 of fees for Covered Dental Benefits received by an Enrolled Person during each Benefit Period. The total deductible amount for a family which includes an Enrolled Employee and one or more Enrolled Dependents will not exceed three times the individual deductible or $150 during each Benefit Period. Once the maximum deductible perfamily has been satisfied, no further deduction will apply to any Enrolled Person in that family until the next succeeding Benefit Period.The deductible does not apply to Class 1 Covered Dental Benefits, Orthodontic Benefits or Accidental Injury Benefits. 2014-01-00611-RC-02 -13- PPOL rev20131115 Appendix D. Group's Financial Obligations Claim Reimbursement DDWA shall notify Group, on the last DDWA payment day of each calendar month, the actual amount of claims paid by DDWA for that month. Notification will be via email which will constitute an invoice. Group will then have two business days to transfer funds electronically to the appropriate DDWA 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 DDWA with a subsequent payment notification. Administrative Fee The monthly Administrative Fee payable by Group under this Contract Term during the period January 1,2014 through December 31, 2014 shall be$6.35 per Enrolled Employee. Group's payment shall be in the form of a check or electronic transfer and shall accompany the eligibility listing. DDWA will then update the files and send a new billing to Group for the next month of coverage. 2014-01-00611-RC-02 -14- PPOL rev20131115 ® Delta Dental of Washington Falling Invoice Procedures This explanation should help you understand the procedures related to your monthly Delta Dental of Washington billing invoice. Your billing statement lists currently enrolled employees, retroactive changes and dental coverage for the month shown in the coverage period summary area. Payment is due the first day of the month. For example, if the coverage period is October 1 to October 31, payment is due the first day of October. Your monthly billing will be generated on or about the 15th day of the preceding month. Please pay as billed. Any changes you provide will be reflected on a future billing invoice. If an emergency arises and you need your enrollment information updated prior to the next billing cycle, please contact your Group Administration representative or the Delta Dental of Washington Group Administration team at (800)408-9850 for assistance. You will find the name and telephone number of your Group Administration team representative on the top of your monthly billing invoice. ADDITIONS To add an employee and his/her family members to your plan, please complete a Delta Dental of Washington enrollment application. Be sure to include the effective date and/or qualifying event if outside of open enrollment. Please also complete the Addition section of the billing summary page that is sent monthly with your billing invoice. The employee and his/her family member(s) must be added within 60 days of the effective date to become eligible for coverage, unless your contract states otherwise. PLEASE NOTE:To ensure accuracy,we must have a completed application to add anyone to your group account. TERMINATIONS To terminate an employee, please list the name of the employee who is no longer eligible for your dental benefits, the employee's Social Security number and the effective date of the termination in the Termination section of the billing summary page that is sent monthly with your billing invoice. Once you have returned the billing summary page, Delta Dental of Washington will make the changes. Unless your contract states otherwise,termination requests must be received within 60 days of the termination date. PLEASE NOTE: The termination date is the last day the employee is no longer eligible for coverage. CHANGES To make any changes to an existing employee's coverage, list the changes in the Changes section of the billing summary page that is sent monthly with your billing invoice. Any changes to coverage that include adding an additional person must accompany a Delta Dental of Washington enrollment form. Unless your contract states otherwise, changes to enrollment status must be received within 60 days of the effective date of the change. To ensure timely processing of dental claims for your employees, please return the completed summary page and payment to Delta Dental of Washington at the address below: Delta Dental of Washington P.O. Box 84885, Seattle,WA 98124-6185 If you have any problems or questions regarding your invoice or current eligibility, please call your administrative representative or the Group Administration team at 1-800-408-9850. For inquiries on claims or benefit information, please contact Delta Dental of Washington Customer Service at 1-8 0 0554-1 9 07. Billing Procedure SGRenew Rev 20140101 s Delta Dental of Washington NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. PROTECTING YOUR HEALTH INFORMATION Delta Dental of Washington (DDWA) is committed to protecting the privacy and the confidentiality of your health information.We recognize that you depend on us to safeguard your personal information and uphold your privacy rights. This document, which is based on state and federal law, describes our commitment to preserve the privacy and confidentiality of your health information. This notice explains our privacy practices, our legal requirements and your rights regarding your protected health information (PHI). Our Privacy Practices This notice protects the rights of both current and former members of DDWA. It explains how we use your information and when we may share that information with others. It provides you with your rights with respect to your health and/or dental information and how you may exercise those rights. By law, we are required to send you this notice so that you are aware of how we maintain the privacy of your information. DDWA employees are required to comply with our company policies and procedures to protect the privacy and confidentiality of your health and/or dental information.Violations identified or reported to DDWA are reviewed, and disciplinary and/or corrective actions are taken when appropriate.Access to information by our employees is limited to a business "need-to-know'basis. For example, DDWA employees need specific information to make benefit determinations, process claims, perform internal assessments and provide certain customer service functions. DDWA has physical, electronic and process safeguards in place to restrict access to your information. These safeguards include secured office facilities, locked filing cabinets and controlled computer network systems. This notice applies to all applicable companies within the Washington Dental Service family, which includes Delta Dental of Washington. Should any of our privacy practices change,we reserve the right to change the terms of this notice and to make the new notice effective for all health and/or dental information that we maintain. We will post the revised notice on our website and will provide you a printed copy of the notice upon request. Information Maintained at DDWA The"information" or"health information" or"dental information' referred to in this notice includes demographic information that may identify you and that relates to your past, present or future physical or dental health and related health care services. How We May Use or Share Your Information The following describes how we may use or share your information: For Treatment Dental information may be shared with your dentist in order to help him or her provide you with the care you need. For Payment Your information may be used when paying your dental claims submitted to us by you or your dental care provider or to coordinate benefits with other benefit plans you may have DDWA CPS NPP 2013274001 Page i Health Care Operations Certain dental information may be used or shared for necessary health care operations. These may include, but are not limited to, performing quality assessment and improvement activities, evaluating provider performance, performing auditing functions, resolving complaints and appeals, and making benefit determinations. Please note that DDWA may not use or share your genetic information for underwriting purposes, to adjust premiums, or to make enrollment or eligibility determinations based on your predisposition to a genetic condition. DDWA is also prohibited from requesting, requiring, or purchasing genetic information about an individual prior to enrollment. Incidental collection of genetic information does not violate the law. Business Associates Your information may also be shared with other individuals or entities, known as business associates, which perform payment or health care operations on behalf of DDWA.We will not share your information with these business associates unless they agree in writing to protect the privacy of your information. Communications Your information may be shared with third-parties acting on behalf of DDWA in order to provide you with information about alternative treatments and programs or about dental-related products and services that may be of value to you.We may also inform you about enhancements, replacements or substitutions to your dental coverage. If we wish to contact you to inform you about a product or service for which we are paid by a third party, we will ask you for your written permission. Non-personally Identifiable Information Information that is "de-identified" may be used or shared. Information is considered de-identified when it does not personally identify you.We may also use a"limited data set"that does not contain any information that can directly identify you. The limited data set is used only for purposes of research, public health matters or health care operations. Employee Benefit Plan Under certain circumstances,we may share limited information about you with an employee benefit carrier through which you receive benefits in order to perform administrative functions. Examples of information we may share include summary health information so that the carrier may obtain bids from other plans or modify, amend or terminate coverage with DDWA.We may share information related to your enrollment, disenrollment and/or participation in a DDWA plan. Detailed information is not shared with your benefit carrier unless it agrees to maintain the privacy of your information. Enrolled Dependents and Family Members Generally, we will mail explanation of benefit(E013)forms and other mailings containing PHI to the address we have on record for the subscriber of the dental plan. If you are unable to consent to the disclosure of your PHI, such as in an emergency situation, we may disclose your PHI to a family member or a friend to the extent necessary to help with your dental care. We will do so only if we determine that the disclosure is in your best interest. For a minor, we may disclose PHI to parents or guardians, consistent with state law. Special Circumstances and State and Federal Laws In special situations and under certain state and federal laws,we are required to use or release your health information to you or to your authorized personal representative (with certain exceptions), when required by the U.S. Secretary of Health and Human Services to investigate or determine our compliance with law, and when otherwise required under certain state and federal laws. DDWA may disclose your PHI without your prior authorization in response to the following: • Court order or subpoena related to a civil action, investigation of a government board, commission or agency, or for an arbitration; • Law enforcement search warrant; • To report information to state and federal agencies that regulate our business including health oversight agencies and public health authorities; DDWA CPS NPP 2013274001 Page • To assist correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official; • To report information to a government authority regarding child abuse, neglect or domestic violence; • To share information with a coroner or medical examiner in conjunction with an investigation; • To report information regarding job-related injuries as required by workers'compensation laws; • To armed services personnel for military activities and to authorized federal officials for national security activities and intelligence purposes; ® Under certain circumstances where your privacy is ensured by certain protocols, we may disclose your information to assist researchers when the research has been approved by an institutional board; or • To a family member or friend under the following circumstances: o If you provide verbal agreement to allow such disclosure o If you are given an opportunity to object to such disclosure and you do not raise an objection;or o If it can be inferred from the circumstances, based on DDWA's professional judgment, that you would not object Written Permission to Use or Share Your Information and Right to Revocation For activities or purposes other than those noted above or as otherwise permitted by law,we must obtain your written permission, known as an authorization, prior to using or sharing your health information. If you sign an authorization, you may change your mind at any time and revoke your authorization in writing. Once the authorization is revoked,we will no longer use or share the information as outlined in the authorization. However, be aware that we may not be able to retract information that was previously made based on a valid authorization. Your Rights Regarding Your Protected Health Information The following are your rights with regard to your PHI: Right to Request Restriction on Use and Disclosure You have the right to restrict how we use and share your information for treatment, payment or health care operations. You have the right to restrict your information for services paid in full out-of-pocket without plan benefits. You also have the right to ask to restrict your information that we have been asked to give to family members or to others who are involved in your care or payment for your care. Please note that we will try to grant your request, but we are not required to do so by law. Right to Receive Confidential Communications You have the right to request that we use a certain method to communicate with you about your PHI or that we send your PHI to an alternate location. If you advise us that disclosure of all or any part of your PHI could endanger you, we will comply with any reasonable request, provided you specify an alternate means of communication. Right to Access Your PHI You have the right to inspect and obtain a copy of your PHI we maintain in a designated record set.A designated record set refers to a group of records that includes enrollment, payment, claims determination or dental management activities. It also includes records that we use to make enrollment, coverage or payment decisions about you. Your request to review and/or obtain a copy of your PHI records must be made in writing.We may charge a fee for the cost of producing, copying and mailing your requested information, but we will tell you the cost in advance. The right does not include a right to obtain copies of information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding. Furthermore, it does not include PHI that is subject to other state or federal laws that prohibit us from releasing such information. We may limit your access to PHI if we determine that providing the information could possibly harm you or another person. If we limit access based upon a belief that it could harm you or another person, you have the right to request a review of that decision. DMIA CPS NPP 2013274001 Page Right to Amend Your PHI You have the right to ask us to make changes to the information that we maintain about you in your designated record set. These changes are referred to as amendments. Amendment requests must be in writing and must include the reason for the request.We may deny your request for certain reasons, including if you ask us to change information that we did not create. If we deny your request to amend your records,we will provide you with a written explanation for the reason for denial. This written notification will explain your right to file a written statement of disagreement. In turn, we have a right to rebut your statement. You have the right to request that your initial written request, our written denial and your statement of disagreement be included with your PHI for any future disclosures. If we accept your request to amend the information,we will make reasonable efforts to inform others, including people you have authorized, of the amendment and to include the changes in future disclosures of that information. Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your health information made by us for up to six years prior to your request.Your request for an accounting must be made in writing and must state a time period for which you want an accounting. The time period may not be longer than three years.We will provide you with the date on which we made a disclosure, the name of the person or entity to which we disclosed your information, a description of the disclosure,the reason for the disclosure and other applicable information. If you request this list more than once in a 12-month period, we may charge you a reasonable fee for creating and sending those additional reports.We are not required to provide you with an accounting of disclosures of the following information: • Information shared for treatment, payment or health care operations; • Information already disclosed to you, • Information shared as part of an authorization request; • Information that is incidental to a use or disclosure that is otherwise permitted; • Information that was provided to persons involved in your care or for other notification purposes; • Information shared for national security or intelligence purposes; • Information that was shared or used as part of a limited data set for research, public health or health care operation purposes; or • Information disclosed to correctional institutions, law enforcement officials or health oversight agencies. Right to Paper Copy of This Notice If you receive this notice on our website or by electronic mail (email), you are also entitled to receive it in written form. Please contact DDWA using the information at the end of this notice to obtain a written copy of the notice. QUESTIONS REGARDING USE AND DISCLOSURE OF YOUR PRIVACY RIGHTS How to File a Privacy Complaint If you believe that your privacy rights have been violated, you may file a complaint with DDWA by calling 1-206-985-5963 or toll free 1-888-338-0172. You may file a written complaint with DDWA by sending your complaint to: Delta Dental of Washington Attn: Compliance Officer PO Box 75688 Seattle,WA 98125 You may also direct your complaints to the Secretary of the Department of Health and Human Services. Delta Dental of Washington will not penalize you or take any action against you for filing a complaint. DDWA_CPS_NPP_2013274Wl Page4 BENEFITS DIVISION Becky Fowler Manager 400 West Gowe �'^,,4.� KENT Kent, WA 98032 W,s....... Fax: 253-856-6270 December 3, 2013 TO: Operations Committee FROM: Becky Fowler, Benefits Manager THRU: Lorraine Patterson, Human Resources Dirjr SUBJECT: Delta Dental of Washington (DDW) Administrative Services Contract for 2014 Motion: I move to recommend the 2014 Administrative Services contract with Delta Dental of Washington for the city's self-insured dental program be placed on the City Council consent calendar for the January 7, 2014 meeting subject to final terms and conditions of the City Attorney. SUMMARY: The city contracts with Delta Dental of Washington as a third-party administrator (TPA) to process claims and provide access to DDW PPO network of dentists. The city is self-insured for this program and will wire the monthly claims cost to DDW for our dental expenses. The 2014 contract reflects no increase in administrative fees for 2014 and is budgeted in the health and wellness fund. BUDGET IMPACT: $55,000. (Administrative Services Contract) BACKGROUND: All of the city's employee and dependent population are covered under the self-insured Delta Dental of Washington program totaling 2,300 lives. Included in this coverage is our LEOFF I retirees and their dependents. The overall projected cost of our self-insured plan inclusive of administration fees is approximately $826,601 and is budgeted in the health and wellness fund. 0 d G 3 MAYOR SUZETTE COOKS City of Kent Human Resources Department Lorraine Patterson, Director REQUEST FOR MAYOR'S SIGNATURE KENT Please Fill in All Applicable Boxes WnIn G.Ox Reviewed by Director Originator's Name: tcR-f f--e)L3ttnp. Dept Div. Extension: 14 2 Sago Date Sent: - n - 14 Date Required: Return to: CONTRACT TERMINATION DATE: I a-3 I-ao 14 VENDOR: -1 Q DATE OF COUNCIL APPROVAL: i h - 53 ATTACH THE COUNCIL MOTION SHEET FOR THE MAYOR - if applicable Brief Explanation of Document: —rii-+t. a-t) 14 D' LTA �t� >✓ ©r-= 0Vtr=-1, -tNC,,TbN aD Iy CDNTQACT p(A t, To 4EP LT14 All Contracts Must Be Routed Through The Law Department (This area to be completed by the Law Department) p(�j Received: of -� �j Approval of Law Dept.: FT ' `" ' 0 Law Dept. Comments: JAN 16 2 RECEIVED KEtg LAW DEPT. i %;14 Date Forwarded to Mayor: tl I CITY CLERK Shaded Areas To Be Completed By Administration Staff Received: RECEIVED Recommendations and Comments: JAN 16 2014 �/�/ice�y�d �i� Disposition: � �ye���'�� City of Kent Office of the Mayor Date Returned: -�112 iq--Wa- S