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HomeMy WebLinkAboutHR14-320 - Original - Delta Dental of Washington - 2015-2017 Contract Renewal - 12/13/2014 S 3 �{�s2M• ?3i. Records any ; . KEN7 Document V�ASIi INGTON `� Sy.= d ° 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 y (--A _ _ I Vendor Number: . 7D Edwards Number Contract Number: This is assigned by City Clerk's Office Project Name: O,C) �,A T-P�A '_-;1" Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment faContract ❑ Other: Contract Effective Date: - C)1 - { Termination Date: j 1 i Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager: ��,i�Lr(2 Department: Contract Amount: Approval Authority: ❑ Department Director ❑Mayor VCity Council Detail: (i.e. address, location, parcel number, tax id, etc.): adccW10877 8 14 Summary of Changes For Contracts issued between January 1, 2015 and December 31, 2015 We are pleased to inform you that there have been no changes to your covered benefits or plan administration for your 2015 Plan. The information contained in this summary represents a brief overview of the substantive changes made from your previous plan documents to your 2015 plan documents. The changes outlined below do NOT represent a change in benefits, but have been made to provide additional information, for clarity or to ensure accuracy with how your Plan is administered. Benefit Changes None Plan Administration Changes None Text Revisions for Clarity and Accuracy — Benefits in Booklet I Class I Preventive,Covered Dental Benefits: The term"Fissure Sealants" has been replaced with "Sealants"to be consistent with industry standard. Class II Restorative, Covered Dental Benefits and Limitations: Language has been revised to indicate whether or not Posterior Composites are a covered benefit. Class II or III Restorative, Covered Dental Benefits and Limitations: Language has been revised to provide information regarding Implant-Supported Crowns, if they are a covered benefit under the Plan. Class II Periodontics, Covered Dental Benefits: Gingivectomy has been added to Covered Dental Benefits, to accurately reflect the benefit. Global Revisions: In instances where"certain conditions of oral health" is referenced, language has been revised or added to define qualifying circumstances. Outdated and duplicative information in the benefit limitations and/or exclusions sections have been removed. Text Revisions for Clarity and Accuracy— Plan Administration Contract 5.05: Language has been revised to clarify that any DDWA required examinations are conducted by an independent dentist appointed by DDWA. 7.02: Language requesting Group generated Summary Plan Descriptions (SPDs) be provided to DDWA has been removed. DDWA does not require or assume any risk for Group SPDs. 9.03*: The termination article in the Contract has been re-drafted to provide additional information regarding the qualifying events that may lead to termination. 9.04: Language has been revised to provide clarity regarding parameters for the refund of premium following termination of the Contract. Appendix B, Section B: Definition of Eligibility Dependent has been revised to allow for more flexibility. Booklet Out-of-State Dentists/FAQ, How do I get Claim Forms: Information has been added regarding how to obtain and submit a claim form. 2015-01-00611-RC-02 i SOO-=rev 20150101 I Dependent Eligibility and Termination: Additional language has been added regarding newborn and adopted child enrollment. Predetermination of Benefits/Claim Review and Appeal, Predetermination of Benefits": Language in these sections has been re-drafted to ensure consistency with how these processes are administered. Glossary: Terms have been revised for clarity. Additionally, the Glossary has been relocated to the end of the booklet. Additional Global General Text Revisions How to Contact DDWA: Guidance regarding how to obtain Delta Dental Participating Provider Directories has been updated to include a telephone number(1-888-889-3734). Local telephone numbers have been removed throughout the Plan documents. Non-substantive Language Revisions: Revisions have been made to correct typos, grammar and punctuation throughout the Plan documents. Wording changes have been made to add clarity or to provide additional information throughout the Plan documents. *Detailed information regarding the changes represented above is available on our 2015 Side by Side comparison document, which will be provided upon request. 2015-01-00611-RC-02 ii SOC-LOG rev 20150101 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. i The effective date of this Contract shall be 12:01 a.m. Pacific Time on the first day of January, 2015 at Seattle, Washington, and shall run for a period of 36 months, through December 31, 2017. 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 4`"Avenue South Post Office Box 75983 Kent,Washington 98032 Seattle,Washington 98175-0983 f r 4+Signed: C�.'Ftc`_ L v� -'.- Signed: a Title: i t1r' { Title: Vice President Underwriting and Actuarial _ r Date: !r} l Date: November 5, 2014 i 2015-01-00611-RC-02 1 PPOL rev 20150101 Article 1—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. 1.03 "Certificate of Coverage"means the benefit 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 DDWA and Group. This Contract constitutes the entire Contract between the parties and supersedes any prior agreement, understanding or negotiation between the parties. 1.05 "Covered Dental Benefit"means those dental services that are covered under this Contract, subject to the Limitations set forth in the Certificate of Coverage. 1.06 "DDWA" means Delta Dental of Washington, a nonprofit corporation incorporated in Washington State. DDWA is a member of the Delta Dental Plans Association. 1.07 "Delta Dental" means Delta Dental Plans Association, a nationwide non-profit organization of dental benefit carriers offering a range of group dental benefit plans. 1.08 "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, which includes looking solely to Delta Dental for payment for covered services. 1 M "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. 1.10 "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 Licensed Professional. A 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 becomes eligible to enroll in the Plan as detailed in Appendix A or B. 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 "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. 1.16 "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. 1.17 "Group" means the employer or entity that is contracting for dental benefits for its employees in this Contract. 1.18 "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. 2015-01-00611-RC-02 2 PPOL rev 20150101 1.19 "Maximum Allowable Fee" means the maximum dollar amount that will be allowed toward the reimbursement for any service provided for a Covered Dental Benefit. 1.20 "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. 1.21 "Open Enrollment Period" means the annual period in which Eligible Employees can select benefits Plans and add or delete Eligible Dependents. 1.22 '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. 1.23 "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. 1.24 '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. 1.25 'Retiree", for purposes of Group 00611 —Plan 03, the term Retiree may be inferred in place of the term Employee, where applicable. Article II—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 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. 2015-01-00611-RC-02 3 PPOL rev 20150101 !, 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 The provider dispute resolution process as outlined in individual provider contracts is available upon request. 5.05 To determine Covered Dental Benefits for certain treatments, DDWA may require an Enrolled Person to obtain an independent examination from a DDWA-appointed Dentist. DDWA will pay all 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 at every other renewal thereafter. A booklet insert will be sent at renewal when a full booklet is not produced. Generally, new Booklets and/or Inserts are not issued mid Contract Term unless as otherwise specified in this Contract. 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. 2015-01-00611-RC-02 4 PPOL rev 20150101 6.07 DDWA shall provide Delta Dental Participating Dentist Directories to Group. This directory is available on- line at www.DeltaDentalWA.com. The directory may also be requested by telephone at 800-554-1907. 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 benefit booklets available to each Enrolled Employee, which summarize 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 awn 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 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 beginning on the effective date according to these Contract provisions. Article Vlll—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. 2015-01-00611-RC-02 5 PPOL rev 20150101 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. 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 DDWA may elect to terminate this Contract, without prior approval of the Washington State Insurance Commissioner, if any of the events outlined in this Section 9.03 occur. Termination would be effective at the end of the month for which Administrative Fees have been received by DDWA prior to the time of such election. If termination occurs, DDWA will provide 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. Events that allow termination: (i) A failure to pay Administrative Fee or perform Group's other obligations when due. (ii) Any violation of published policies of DDWA. (III) Change or implementation of federal or state health care reform laws that no longer permit the continued offering of such coverage. Events that allow termination if the Group does not take corrective action consistent with their obligations under this Contract: 2015-01-00611-RC-02 6 PPOL rev 20150101 (i) Enrolled Persons who become entitled to Medicare benefits who fail to apply for a Medicare Supplement Plan, or Medicare Cost, Risk, or HCPP Plan offered by DDWA. (ii) Enrolled Persons committing fraudulent acts against DDWA. (iii) Enrolled Persons who materially breach the terms of this Contract. 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 notification of 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. 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 2015-01-00611-RC-02 7 PPOL rev 20150101 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 job 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 11 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. 2015-01-00611-RC-02 8 PPOL rev 20150101 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. 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 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. 2015-01-00611-RC-02 9 PPQL rev 20150101 Appendix B. Dependent Eligibility Requirements Section A Definition of Eligible Dependent An Eligible Dependent is a dependent of an Enrolled Employee who meets the requirements for eligibility established by Group. 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; or • An eligible child under 26 years of age as follows: • A natural offspring of either or both the subscriber or spouse; • A legally adopted child of either or both the subscriber or spouse; or • 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; or • A legally placed ward of the subscriber, spouse, or domestic partner living permanently in the home of the subscriber. Foster children are not eligible for coverage. Spouses and children of dependents are not eligible for coverage under this plan. Dependent eligibility validation documentation and information shall be maintained and verified by Group. Eligible Dependents are Enrolled Dependents after fully completing the enrollment process, including payment of Administrative Fee by Group to DDWA. 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 in 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. 2015-01-00611-RC-02 10 PPOL rev 20150101 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. I 2015-01-00611-RC-02 11 PPOL rev 20150101 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 Premier Participating Dentists, or their actual fee, whichever is less • Nonparticipating Dentist in Washington State based on DDWA's Maximum Allowable Fee for Nonparticipating Dentists, or their actual fee, whichever is less • Nonparticipating Dentist outside of Washington State based on DDWA's Maximum Allowable Fee for Participating 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 1 100 percent 100 percent Class li 80 percent 80 percent Glass III 80 percent 80 percent Orthodontic 50 percent 50 percent Accidentalln]ury 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 I 100 ercent 100 percent Class If 80 percent 80 percent Class 111 50 percent 50 percent Orthodontic 50 eercent 50 percent Accidental Injury 100 percent 100 ercent 2015-01-00611-RC-02 12 PPOL rev 20150101 Section B Plan Maximum (i) PLAN 01 -FOR ENROLLEES IN THE 100 PERCENT& GROUP 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. I (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 per family 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 I Covered Dental Benefits, Orthodontic Benefits or Accidental Injury Benefits. 2015-01-00611-RC-02 13 PPOL rev 20150101 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, 2015 through December 31, 2017 shall be$6.99 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. 2015-01-00611-RC-02 14 PPOL rev 20150101 REQUEST FOR MAYOR'S SIGNATURE T Please Fill in All Applicable Boxes Reviewed by Director Y, �- Oriqinator's Name: De t/Div. Extension: Date Sent: Date Required: Return to: f CONTRACT TERMINATION DATE: I a -,44 VENDOR: '' ti TIA1. DATE OF COUNCIL APPROVAL: ATTACH THE COUNCIL MOTION SHEET FOR THE MAYOR - if applicable Brief Explanation of Document: I< y. -z 1�7 L ,I, I t-4 Ali Contracts Must Be Routed Through The Law Department (This area to be completed by the Law Department) Received: Approval of Law Dept.: j Law Dept. Comments: Date Forwarded to Mayor: Shaded Areas To Be Completed By Administration Staff Received: Recommendations and Comments: Disposition: Date Returned: