HomeMy WebLinkAboutContract 46248 CITY SECRETARY
CONTRACT NO.
R Delta Dental Insurance Company
Contract Delivery Receipt
Contract # 17182
For
CITY OF FORT WORTH
I acknowledge receipt of the above contract on
at Fort Worth, TX
(month, day, year) (city, state)
Susan Alanis
(print name)
(signature)
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b LEGALITY:
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DELTA DENTAL INSURANCE COMPANY
1130 Sanctuary Parkway
Suite 600
Alpharetta,Georgia 30009
(770)641-5100
(888) 858-5252
Dental Provider Organization Program
City of Fort Worth ,("Contractholder")has applied for a group
dental insurance contract with Delta Dental Insurance Company,("Delta Dental").The following terms will apply:
I. Contractholder will pay Delta Dental the monthly Premium stated in this Contract.
II. Delta Dental has accepted the Application submitted by the Contractholder and when the Contractholder pays the first
month's Premium,the term of this Contract will begin at 12:01 a.m.Central Time,on the Effective Date listed in
Appendix A.The term of this Contract will end as stated in this Contract at the end of the Contract Term at 12:00
midnight Standard Time.
III. Contractholder will give each Primary Enrollee electronic access to a certificate of coverage furnished by Delta Dental.
Contractholder will also distribute to its Enrollees any notice from Delta Dental which affects their rights under this
Contract.
Notice: the premium under this Contract is payable to
Delta Dental Insurance Company
P.O.Box 7564
San Francisco,CA 94120-7564
The premium under this Contract may be increased upon renewal, with 180 days written notice,prior to the end
of the initial or any subsequent contract terms.
Delta Dental accepts the Application of"Contractholder."A copy is attached and made a part of this Contract.
So long as Contractholder pays the Premiums stated in Article 3, Delta Dental agrees to provide the Benefits described in
Article 4.Benefits will start at 12:01 a.m. Standard Time on the Effective Date.This Contract will continue from year to year
until terminated,as stated in Article 8.
This Contract is issued and delivered in the State of Texas and is governed by its laws.
WXb=M=nS1
Anthony S. Barth
President
THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES NOT
A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS POLICY,
EMPLOYER IS A NON-SUBSCRIBER,THE EMPLOYER LOSES THOSE BENEFITS WHICH
WOULD RWISE ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST
COMPLY W1 �I THE WORKERS' COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND
r" THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
TX-DPO-C(2006) OFFICII L RECORD 17182
CITY SECRETARY
FT. WORTH,TX
TEXAS NOTICE OF COMPLAINT
IMPORTANT NOTICE AVISO IMPORTANTE
To obtain information or make a complaint: Para obtener information o para someter una queja:
You may call Delta Dental Insurance Company's toll free Usted puede Ilamar al numero de telefon gratis de Delta
number for information or to make a complaint at Dental Insurance Company's para informacion o para
someter una queja al
1-800-521-2651
1-800-521-2651
You may also write to Delta Dental Insurance Company at
Usted tambien puede escribir a Delta Dental Insurance
Delta Dental Insurance Company Company
1 130 Sanctuary Parkway
Suite 600 Delta Dental Insurance Company
Alpharetta,Georgia 30009 1130 Sanctuary Parkway
Suite 600
You may contact the Texas Department of Insurance to Alpharetta,Georgia 30009
obtain information on companies,coverages,rights,or
complaints at Puede comunicarse con el Departamento de Seguros de
Texas para obtener informacion acerca de companias,
1-800-252-3439 coberturas, derechos o quejas al
You may write the Texas Department of Insurance at 1-800-252-3439
P.O.Box 149104 Puede escribir al Departamento de Seguros de Texas
Austin TX 78714-9104
FAX#(512)475-1771 P.O.Box 149104
Austin TX 78714-9104
Web: http://www.tdi.state.tx.us FAX#(512)475-1771
E-mail: ConsumerProtection@tdi.state.tx.us Web: http://www.tdi.state.tx.us
E-mail: Con sumerProtection@tdi.state.tx.us
PREMIUM OR CLAIM DISPUTES:
Should you have a dispute concerning your premium or
about a claim,you should contact your agent or Delta DISPUTAS SOBRE PRIMAS O RECLAMOS:
Dental Insurance Company first. If the dispute is not Si tiene una disputa concerniente a su prima o a un
resolved,you may contact the Texas Department of reclamo, debe comunicarse con el agente o Delta Dental
Insurance. Insurance Company primero. Si no se resuelve la
disputa, puede entonces comunicarse con el
ATTACH THIS NOTICE TO YOUR POLICY: departamento(TDI).
This notice is for information only and does not become a
part or condition of the attached document. UNA ESTE AVISO A SU POLIZA:
Este aviso es solo para proposito de informacion y no se
convierte en parte o condicion del documento adjunto.
TX-DPO-C(2006) 2 17182
TABLE OF CONTENTS
ARTICLE 1
DEFINITIONS
ARTICLE 2
ELIGIBILITY AND ENROLLMENT
ARTICLE 3
MONTHLY PREMIUMS
ARTICLE 4
BENEFITS,LIMITATIONS AND EXCLUSIONS
ARTICLE 5
DEDUCTIBLE,MAXIMUM&COORDINATION OF BENEFITS
ARTICLE 6
CONDITIONS UNDER WHICH BENEFITS WILL BE PROVIDED
ARTICLE 7
GENERAL PROVISIONS
ARTICLE 8
TERMINATION&RENEWAL
ARTICLE 9
ATTACHMENTS
TX-DPO-C(2006) 3 17182
ARTICLE 1
DEFINITIONS
Terms when capitalized in this document have defined meanings,given either in the section below or within the contract
sections.
1.01 Approved Amount--the maximum amount a dentist may charge for a Single Procedure.
1.02 Benefits(In-Network or Out-of-Network)--the amounts that Delta Dental will pay for dental services under this
Contract. In-Network Benefits are those covered by this Contract and performed by a Delta Dental DPO Dentist. Out-
of-Network Benefits are those covered by this Contract but performed by a Delta Dental Premier®Dentist or Non-Delta
Dental Dentist.
1.03 Claim Form--the standard form used to file a claim or request Pre-Treatment Estimate for treatment.
1.04 Contract--this agreement between Delta Dental and Contractholder, including the Application and the attachments
listed in Article 9.
1.05 Contract Allowance--the maximum amount Delta Dental will use for calculating Benefits for a Single Procedure.The
Contract Allowance for services provided:
Low Plan
• by DPO Dentists and Delta Dental Premier®Dentists is the lesser of the Dentist's submitted fee,the DPO Dentist's
Fee;the approved amount as outlined in the terms of the Contracting Dentist Agreement with Delta Dental or
Maximum Plan Allowance;or
• by Non-Delta Dental Dentists is the lesser of the Dentist's submitted fee or the DPO Dentist's Fee.
High Plan
• by DPO Dentists is the lesser of the Dentist's submitted fee,the DPO Dentist's Fee or the approved amount as
outlined in the terms of the Contracting Dentist Agreement with Delta Dental.
• by Delta Dental Premier®Dentists(who are not DPO Dentists) is the lesser of the Dentist's submitted fee,the
approved amount as outlined in the terms of the Contracting Dentist Agreement with Delta Dental or Maximum
Plan Allowance.
• by Non-Delta Dental Dentists is the lesser of the Dentist's submitted fee or the Maximum Plan Allowance.
1.06 Contract Term --the period during which this Contract is in effect,as shown in Appendix A.
1.07 Contract Year--the 12 months starting on the Effective Date and each subsequent 12 month period thereafter.
1.08 Contractholder--the employer,union or other organization or group contracting to obtain Benefits.
1.09 Contracting DPO Dentist Agreement(DPO Dentist Agreement)--an agreement between Delta Dental and a Dentist
which establishes the terms and conditions under which covered services are provided under a DPO program.
1.10 Contracting Dentist Agreement--an agreement between Delta Dental and a Dentist that establishes the terms and
conditions under which services are provided.
1.11 DPO Dentist--a contracting Delta Dental Dentist who agrees to accept DPO Dentist's Fees as payment in full and
complies with Delta Dental's administrative guidelines.All DPO Dentists are also Premier Dentists. All DPO dentists
must be contracted in the Premier network.
1.12 DPO Dentist's Fee--the fee outlined in the Contracting DPO Dentist Agreement. DPO Dentists agree to charge no
more than this fee for treating DPO Enrollees.
1.13 Delta Dental Premier®Dentist(Premier Dentist)--a Dentist who contracts with Delta Dental or any other member
company of the Delta Dental Plans Association and who agrees to abide by certain administrative guidelines.Not all
Premier Dentists are DPO Dentists;however,all Premier Dentists agree to accept Delta Dental's Maximum Plan
Allowance for each Single Procedure as payment in full.
TX-DPO-C(2006) 4 17182
1.14 DPO--a Dental Provider Organization.
1.15 Dentist-- a person licensed to practice dentistry when and where services are performed.
1.16 Dependent Enrollee--an Eligible Dependent enrolled in the plan to receive Benefits.
1.17 Effective Date--the date the program starts,as shown in Appendix A.
1.18 Eligible Dependent--a dependent of an Eligible Employee or domestic partner eligible for Benefits under Article 2.
1.19 Eligible Employee--any employee or retiree eligible for Benefits under Article 2.
1.20 Enrollee--an Eligible Employee("Primary Enrollee")or an Eligible Dependent("Dependent Enrollee")enrolled to
receive Benefits.
1.21 Maximum Plan Allowance(MPA)--the maximum amount Delta Dental will reimburse for a covered procedure.Delta
Dental establishes the MPA for each procedure through a review of proprietary filed fee data and actual submitted
claims. MTAs are set annually to reflect charges based on actual submitted claims from providers in the same
geographical area with similar professional standing.The MPA may vary by the type of network Dentist,
1.22 Non-Delta Dental Dentist--a Dentist who is neither a Premier nor DPO Dentist and who is not contractually bound to
abide by Delta Dental's administrative guidelines.
1.23 Open Enrollment Period-- the month of the year during which employees may change coverage for the next Contract
Year.
1.24 Pre-Treatment Estimate--an estimation of the allowable Benefits under this Contract for the services proposed,
assuming the patient is eligible.
1.25 Premium --the amounts payable monthly by the Contractholder as required in this Contract.
1.26 Primary Enrollee-- an Eligible Employee enrolled in the plan to receive Benefits.
1.27 Procedure Code--the Current Dental Terminology(CDT)number assigned to a Single Procedure by the American
Dental Association.
1.28 Qualifying Status Change--a change in:
• legal marital status(marriage,divorce, legal separation,annulment or death);
• number of dependents(a child's birth,adoption of a child,Eligible Person becomes party in a suit to adopt a child,
addition of a step or foster child or eligible grandchild or death of a child);
• employment status(change in employment status of Enrollee,spouse or dependent child);
• dependent child ceases to satisfy eligibility requirements(limiting age,student status or marital status);
• residence(Enrollee,dependent spouse or child moves);
• a court order requiring dependent coverage;or
• any other current or future election changes permitted by IRC Section 125.
1.29 Single Procedure--a dental procedure that is assigned a separate CDT number.
ARTICLE 2
ELIGIBILITY AND ENROLLMENT
2.01 Reporting
On or before the Effective Date,Contractholder will furnish to Delta Dental, in writing or in electronic media format
agreed by Delta Dental and the Contractholder, a listing of eligible Primary Enrollees and Dependent Enrollees. The
listing must show the names, Enrollee ID numbers,dates of hire,dates of birth, dependent status and location codes, if
any. The eligibility list shall include all active employees unless the employee waives coverage in writing or the
TX-DPO-C(2006) 5 17182
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Eligible Employee enrolls in an alternate dental plan offered by Contractholder. The eligibility list may also include
retired employees.
Thereafter,before the 10'h of each month,Contractholder must furnish to Delta Dental in the format agreed to above,a
listing indicating specific additions,changes or terminations made during the prior month.
Contractholder will notify Delta Dental in writing of any requests for Premium adjustments for Enrollees who should
have been terminated in the event Delta Dental was not previously notified of the termination(s). Said termination date
will be adjusted retroactively to the immediately preceding 3 months plus the current month,provided:
a) no claims were submitted to be processed on said Enrollee subsequent to the date of retroactive termination;and
b) Premiums were actually paid for the Enrollee subsequent to the date of retroactive termination.
Delta Dental will notify the Contractholder in writing of the revised termination date and Premiums will be adjusted
accordingly.
Delta Dental will not pay any Benefits for an Enrollee or Dependent Enrollee if proof of eligibility is not submitted.
Also,Delta Dental will not pay Benefits for an Enrollee if Premiums are not paid for the month in which dental services
are rendered.
2.02 Contractholder will permit Delta Dental to audit Contractholder's records to check whether the lists of Primary
Enrollees are correct and to confirm compliance with Article 3. Delta Dental will give Contractholder written notice
within a reasonable time before the audit date.
2.03 Eligible Employees
All present permanent employees of the Contractholder,working 20 hours or more per week are eligible on the
Effective Date.
All future permanent employees of the Contractholder,working 20 hours or more per week will become eligible 1
month following the date of hire.
Retired employees are eligible for coverage as defined by the ContracthoIder's policy.
2.04 Eligible Dependents
Eligible Dependents of an Eligible Person are:
• Lawful spouse or domestic partner named in Contractholder's guidelines for Domestic Partnership.
• Dependent children from birth to the end of the month of their 261 birthday. "Children"includes natural children,
step-children,adopted children,children of the domestic partner and foster children with no distinction made based
on the marital status or lack of marital status between the Eligible Person and the other parent.Newborn infants are
eligible from the moment of birth. An adopted child will be eligible from the moment the Eligible Person becomes a
party in a suit to adopt the child.A newborn child or adopted child will automatically be covered for 60 days. To
continue coverage after 60 days,notice of the birth or notice regarding the suit to adopt and additional Premium, if
any, must be received within the 60 day period.
• Grandchildren who are less than 26 years of age and are a dependent of the Eligible Person for federal income tax
purposes at the time application for coverage of the grandchild is made. Coverage for said grandchild may not be
terminated solely because the grandchild is no longer dependent upon the Eligible Person for federal income tax
purposes.
• Dependent children, including grandchildren,under 26 years of age for whom the Eligible Person is required to
insure under a medical support order issued under Chapter 154, Family Code,or enforceable by a court in Texas.
Said child may request to be covered under the Eligible Person's coverage.
• A child, including grandchild, 26 years of age or older who is not self-supporting because of mental retardation or
physical handicap and the child is chiefly dependent upon the Eligible Person for support and maintenance. Proof
of these facts must be given to Delta Dental within 31 days of the child's attainment of age 26. Proof will not be
required more than once a year after the child is 28.
Dependents in military service are not eligible.
TX-DPO-C(2006) 6 17182
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2.05 Enrollment of Eligible Employees and Eligible Dependents
• If the Primary Enrollee must contribute any portion of the cost of coverage,Eligible Employees must enroll to be
covered under this Contract. Enrollment must be within 31 days after first becoming eligible or during an Open
Enrollment Period. Coverage cannot be dropped or changed other than during an Open Enrollment Period or
because of a Qualifying Status Change.
• If the Primary Enrollee is paying all or a portion of the cost for coverage for Dependent Enrollees in the manner
elected by the Contractholder and approved by Delta Dental,Eligible Dependents must be enrolled within 60 days
after the date becoming eligible or during an Open Enrollment Period.Coverage may not be changed at any time
other than during an Open Enrollment Period or if there is a Qualifying Status Change.
• If both spouses are Eligible Employees,one may enroll as a Dependent Enrollee of the other. Dependent children
may enroll as Dependent Enrollees of only one Primary Enrollee.
• All Eligible Dependents must be enrolled as Dependent Enrollees if dependent coverage is elected.
• A child who is eligible as a Primary Enrollee and a dependent can be insured under this Contract as a Primary
Enrollee or a Dependent Enrollee but not both at the same time.
2.06 Except for an employee absent from work due to a leave of absence approved by the Contractholder or governed by the
"Family&Medical Leave Act of 1993"(P.L. 103.3)or addressed under Section 2.08,an Enrollee wil I not be covered
for any dental services received while a Primary Enrollee is on strike, lay-off or leave of absence. Contractholder must
inform Delta Dental of any change in eligibility as required under section 2.01.
Benefits for such Primary Enrollee and his/her Eligible Dependents will resume as follows:
• If coverage is reactivated in the same Calendar Year,deductibles and maximums will resume as if the Primary
Enrollee were never gone.
• If coverage is reactivated in a different Calendar Year,new deductibles and maximums will apply.
Coverage will resume the first day of the month after the Primary Enrollee returns to work provided the Primary
Enrollee submits to Delta Dental an enrollment card requesting that coverage be reactivated.
If an employee is rehired within the same Calendar Year,deductibles and maximums will resume as if the Primary
Enrollee was never gone.
2.07 A Primary Enrollee loses coverage one month from the date of termination of employment or on the day this Contract is
terminated. Dependent Enrollees lose coverage along with the Primary Enrollee or on the date dependent status is lost.
Termination of Benefits on Loss of Eligibility
Delta Dental will not pay for Benefits for any services received by a patient who is not an Enrollee at the time of
treatment except for a Single Procedure incurred when the patient was covered if such procedure is completed within 31
days of the date coverage ends.A dental service is incurred as follows:
• for an appliance(or change to an appliance),at the time the impression is made;
• for a crown, bridge or cast restoration,at the time the tooth or teeth are prepared;
• for root canal therapy,at the time the pulp chamber is opened;and
• for all other dental services, at the time the service is performed or the supply famished.
Contractholder wit I reimburse Delta Dental for any payments made because of errors in Con tractholder's reports under
Section 2.0I.
2.08 Continued Coverage Under USERRA
As required under the Uniformed Services Employment and Reemployment Rights Act of 1994(USERRA), if a
Primary Enrollee is covered by this Contract on the date his or her USERRA leave of absence begins,the Primary
Enrollee may continue dental coverage for himself or herself and any covered dependents. Continuation of coverage
under USERRA may not extend beyond the earlier of:24 months beginning on the date the leave of absence begins or
the date the Primary Enrollee fails to return to work within the time required by USERRA. For USERRA leave that
extends beyond 31 days,the Premium for continuation of coverage will be the same as for COBRA coverage.
TX-DPO-C(2006) 7 17182
2.09 Continuation of Coverage under COBRA
When the Eligible Employees of Contractholder are covered under the Consolidated Omnibus Budget Reconciliation
Act of 1985,then in consideration of the payments specified in Article 3,Delta Dental agrees to provide the Benefits to
Enrollees who elect continued coverage pursuant to this section.
• Right to Continue.
(1) Coverage may continue in accordance with the following provisions when:
a) the Primary Enrollee or Dependent Enrollee becomes ineligible for coverage under this Contract due to a
Qualifying Event.
i) "Qualifying Event" means one of the following events, if it would otherwise result in a Qualified
COBRA Beneficiary's loss of coverage under this Contract:
• the Primary Enrollee's termination of employment;
• the Primary Enrollee's death;
• divorce or legal separation from the Primary Enrollee,or the Primary Enrollee terminates a
qualified domestic partnership;
• the Primary Enrollee becoming entitled to Medicare benefits;
• a dependent child ceasing to meet the description of a dependent child;or
• a bankruptcy proceeding under Title 11,United States Code with respect to Contractholder,which
results in a substantial elimination of coverage(within one year before or one year after the date
of commencement of the proceeding)of a retired Primary Enrollee(who retired on or before the
date of substantial elimination of coverage),or of a Dependent Enrollee of a retired Primary
Enrollee.
ii) "Qualified Beneficiary"means the Primary Enrollee and any Dependent Enrollee who is entitled to
continue coverage under this Contract from the date of the Primary Enrollee's first Qualifying Event.
It also includes the Primary Enrollee's natural child, legally adopted child or child placed for the
purpose of adoption when the new child:
• is acquired during the Primary Enrollee's 18 or 29 month continuation period;and
• is enrolled for coverage in accordance with the terms of this Contract.
But it does not include the Primary Enrollee's new spouse, stepchild or foster child acquired during
the continuation period,whether or not the new Dependent is enrolled for coverage.
b) this Contract remains in force.
• Continuation Periods. The maximum period of continued coverage for each Qualifying Event will be as follows:
(1) Termination of Employment. When eligibility ends due to the Primary Enrollee's termination of employment;
then coverage for the Primary Enrollee and any Dependent Enrollee may be continued for up to 18 months,
from the date employment ended.Termination of employment includes a reduction in hours or retirement.
However,exceptions apply as follows;
a) Misconduct. If the Primary Enrollee's termination of employment is for gross misconduct,coverage may
not be continued for the Primary Enrollee or any Dependent Enrollee.
b) Disability. "Disability"or"Disabled"as used in this section will be as defined by Title II or XVI of the
Social Security Act and determined by the Social Security Administration.
i) If the Primary Enrollee:
• becomes disabled by the 60th day after his or her employment ends;and
• is covered for Social Security Disability Income benefits;
then coverage for the Primary Enrollee and any Dependent Enrollees may be continued for up to 29
months from the date the Primary Enrollee's employment ended.
ii) If the Dependent Enrollee:
• becomes disabled by the 60th day after the Primary Enrollee's employment ends; and
• is covered for Social Security Disability Income benefits;
then coverage for that Dependent Enrollee,the Primary Enrollee and any other Dependent Enrollees
may be continued for up to 29 months from the date the Primary Enrollee's employment ended.
However, in the case of a newborn child or an adopted child,the 60 day period as stated above will
begin on the date of birth or on the date Eligible Person becomes party in a suit to adopt a child.
iii) If the Primary Enrollee or Dependent Enrollee becomes disabled as described above in i)or ii)
respectively,the Primary Enrollee must send the Contractholder a copy of the Social Security
Administration's letter:
• within 60 days after they find that the Primary Enrollee or Dependent Enrollee is disabled,and
before the 18 month continuation period expires;and again
TX-DPO-C(2006) 8 17182
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• within 31 days after they find that he or she is no longer disabled.
c) Subsequent Qualifying Event. If the Primary Enrollee's Dependent:
i) is a Qualified Beneficiary;and
ii) has a subsequent Qualifying Event during the 18 or 29 month continuation period;
then coverage for that Dependent Enrollee may be continued for up to 36 months from the date the
Primary Enrollee's employment ended.
(2) Loss of Dependent Eligibility. If a Dependent Enrollee's eligibility ends due to a Qualifying Event other than
the Primary Enrollee's termination of employment,then that Dependent Enrollee's coverage may be continued
for up to 36 months from the date of the event. Such events may include:
a) the Primary Enrollee's death,divorce or Medicare entitlement;and
b) a child reaching the age limit,getting married or ceasing to be a full-time student.
The Primary Enrollee must notify the Contractholder within 60 days of a divorce or child's ceasing to be an
Eligible Dependent(as defined by this Contract).One or more subsequent Qualifying Events may occur during
the Dependent Enrollee's 36 month period of continued coverage, but coverage may not be continued beyond
36 months from the date of the first event.
(3) Medicare Entitlement. If the Primary Enrollee's eligibility under this Contract ends when he or she becomes
entitled to Medicare benefits,then coverage may not be continued for the Primary Enrol lee, but coverage may
be continued for any Dependent Enrollees for up to 36 months from the Primary Enrollee's Medicare
entitlement date.
a) If the Primary Enrollee's eligibility under this Contract continues beyond Medicare entitlement but later
ends upon termination of employment or retirement,then any Dependent Enrollee may continue coverage
for up to:
(i) 36 months from the Primary Enrollee's Medicare entitlement date;or
(ii) 18 months from the date the Primary Enrollee's employment ended(whichever is later).
• Election.
(1) To continue coverage,the Primary Enrollee or Dependent Enrollees must notify the Contractholder of such
election within 60 days from the later of:
a) the date of the Qualifying Event;
b) the date of loss of coverage;or
c) the date the Contractholder sends notice of the right to continue.
(2) Continued coverage elected under this section will be effective on the date after the person's coverage under
this Contract would otherwise terminate due to the occurrence of a Qualifying Event, provided:
a) the person has notified the Contractholder within the applicable time period stated above,and
b) initial Premium for continued coverage has been received within 45 days after the person's notification.
• Termination. Continued coverage will end at the earliest of the following dates:
(1) the end of the maximum period for continued coverage shown above;
(2) the date this Contract terminates;
(3) the last day of the period for which Premium has been paid, if any Premium is not paid when due;
(4) the date after the date of the initial election to continue coverage on which the Primary Enrollee or Dependent
Enrollee:
a) first becomes covered under any other group dental plan; or
b) first becomes eligible for benefits for Medicare.
Once coverage ends, it cannot be reinstated.
ARTICLE 3
MONTHLY PREMIUMS
3.01 Contractholder will remit the monthly Premium in the amount and manner shown in Appendix A for all Primary
Enrollees and Dependent Enrollees to:
Delta Dental Insurance Company
Post Office Box 7564
San Francisco,CA 94120
Delta Dental will receive a full month's Premium for Enrollees whose coverage is effective on the first(1')through the
151h calendar day of a month. Premiums are not due to Delta Dental for Enrollees who are enrolled on the 16'"through
the last day of a month.
TX-DPO-C(2006) 9 17182
Delta Dental will receive a full month's Premium for Enrollees whose coverage is terminated on the 16"through the last
calendar day of a respective month. Premiums are not due to Delta Dental for Enrollees whose enrollment is terminated
on the first(I")through the 15'h day of a month.
3.02 This Contract will not be in effect until Delta Dental receives the first month's Premiums. Subsequent Premiums will be
paid by the first day of each month.For each Premium after the first,a grace period of 31 days from the due date will be
allowed for the payment of the Premium.This Contract will continue in force during this period; if the Premium
remains unpaid at the end of the grace period,this Contract may be terminated by Delta Dental in accordance with the
notice requirements of Section 8.01.
3.03 If this Contract is terminated before the end of a Contract Term, Contractholder will pay additional charges in
accordance with Article 8.
3.04 Delta Dental will not be responsible or liable for any incorrect, obsolete or unreadable data or information supplied to
Delta Dental including,but not limited to,eligibility and enrollment information.
3.05 Delta Dental may change the rate of monthly Premium whenever the Contract is amended as stated in Article 3.06 by
giving the Contractholder 60 days written notice or whenever the Contractholder requests a change in benefits. Any
change in Premium shall not be effective during a Contract Term unless Contractholder and Delta Dental agree in
writing,except as provided in Articles 3.06 and 3.07.
3.06 Premiums are based on the number of covered employees at the beginning of each Contract Term. If the Contractholder
reports a 15 percent addition or reduction in the number of covered Primary Enrollees for three(3)months in a row,
Delta Dental may propose a choice of changes in Premiums or Benefits to remedy the increase in cost per person which
may result from the difference in the number of enrolled employees. Within 31 days, Contractholder will select one of
the choices by written notice to Delta Dental.If Contractholder fails to do so,Delta Dental may select one of the choices
by written notice to Contractholder.This Contract will be modified for all dental services predetermined and paid after
notice.
3.07 If during the Contract Term any new or increased tax is imposed on the amounts payable to Delta Dental under this
Contract,the amount stated in Appendix A will be increased by the amount of any such new or increased tax.
ARTICLE 4
BENEFITS,LIMITATIONS AND EXCLUSIONS
4.01 Subject to the limitations and exclusions in this Contract,Delta Dental will pay the Benefits stated for each type of
dental service described below when provided by a Dentist and when necessary and customary under generally accepted
dental practice standards. Delta Dental may use dental consultants to review treatment plans,diagnostic materials and/or
prescribed treatments or to determine generally accepted dental practices. Additional eligibility periods, if any,for
specific services are shown in Appendix A. If an Enrollee receives dental services from a Dentist outside the state of
Texas,the Dentists will be reimbursed according to Delta Dental's network payment provisions for said state according
to the terms of this Contract.
If a primary dental procedure includes component procedures that are performed at the same time as the primary
procedure,the component procedures are considered to be part of the primary procedure for purposes of determining the
benefit payable under this Contract. Even if the Dentist bills separately for the primary procedure and each of its
component parts,the total benefit payable for all related charges will be limited to the maximum benefit payable for the
primary procedure.
4.02 No change in Benefits will become effective during a Contract Term unless Contractholder and Delta Dental agree in
writing.
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f
4.03 Enrollee Coinsurance
Delta Dental's provision of Benefits is limited to the applicable percentage of Dentist's fees or allowances specified in
Appendix A.The Enrollee is responsible for paying the balance of any such fee or allowance,known as the"Enrollee
Coinsurance".Contractholder has chosen to require patient Coinsurances under this program as a method of sharing the
costs of providing dental Benefits between Contractholder and Enrollees.If the Dentist discounts,waives or rebates any
portion of the Enrollee Coinsurance to the Enrollee,Delta Dental will be obligated to provide as Benefits only the
applicable percentages of the Dentist's fees or allowances reduced by the amount of such fees or allowances that is
discounted,waived or rebated.
4.04 Benefits
Delta Dental will pay or otherwise discharge the percentage shown in Appendix A of the Contract Allowance for the
following services:
LOW PLAN
• Diagnostic and Preventive Benefits
(1) Diagnostic: procedures to aid the Dentist in choosing required dental treatment.
(2) Preventive: cleaning(periodontal cleaning in the presence of inflamed gums is considered
to be a Maior Benefit for payment purposes),topical application of fluoride
solutions,space maintainers,bitewing x-rays and cephalometric x-rays.
(3) Sealants: topically applied acrylic,plastic or composite materials used to seal
developmental grooves and pits in permanent molars for the purpose of
preventing decay.
• Basic Benefits
(1) Simple Extractions: extractions of erupted tooth or exposed root.
(2) Palliative: treatment to relieve pain,
(3) Restorative: amalgam,synthetic porcelain and plastic restorations(fillings).
(4) Other Basic Services: full-mouth or panoramic x-rays,all other x-rays(except bitewings&
cephalometric x-rays).
• Major Benefits
(1) Oral Surgery: extractions(excluding simple extractions)and other surgical procedures
(including pre-and post-operative care).
(2) General Anesthesia or when administered by a Dentist for covered oral surgery or selected endodontic
IV Sedation: and periodontal surgical procedures.
(3) Endodontics: treatment of the tooth pulp.
(4) Periodontics: treatment of gums and bones supporting teeth.
(5) Crowns,Inlays/Onlays treatment of carious lesions(visible decay of the hard tooth structure)when
and Cast Restorations: teeth cannot be restored with amalgam,synthetic porcelain or plastic
restorations,prefabricated stainless steel restorations for treatment of carious
lesions(visible destruction of hard tooth structure resulting from the process of
decay).
(6) Prosthodontics: procedures for construction of fixed bridges,partial or completed dentures and
the repair of fixed bridges; implant surgical placement and removal;and for
implant supported prosthetics, including implant repair and recementation.
(7) Denture Repairs: repair to partial or complete dentures, including rebase procedures and relining.
TX-DPO-C(2006) 11 17182
1 =
Additional benefits for specific medical conditions-When an Enrollee has any of the following medical conditions,
Delta Dental will pay for additional services to help improve the oral health of the Enrollee.The additional services
each Calendar Year while the Enrollee is covered under this Contract include:one(1)additional oral exam and either
one(1)additional routine cleaning or one(1)additional periodontal scaling and root planing per quadrant.Written
confirmation must be provided by the Enrollee or his/her dentist when the claim is submitted.
(1) cardiovascular disease;
(2) cerebrovascular disease;
(3) diabetes;
(4) chronic kidney disease;
(5) organ transplant;
(6) head&neck cancer radiation;
(7) pregnancy.
LIMITATIONS
• Limitations on Diagnostic and Preventive Benefits:
(1) Delta Dental will pay for routine oral examinations and cleanings(including periodontal cleanings)no more
than four(4)times in a Calendar Year while the person is an Enrollee under any Delta Dental program or
dental care program provided by the Contractholder, Note that periodontal cleanings are covered as a Major
Benefit and routine cleanings are covered as a Diagnostic and Preventive Benefit. See"Additional benefitsfor
specific medical conditions".
(2) Bitewing x-rays are provided twice in a Calendar Year for each Enrollee.
(3) Topical application of fluoride solutions is limited to once in a Calendar Year for Enrollees under age 14.
(4) Space maintainers are limited to the initial appliance only for an Enrollee under age 14.
(5) Sealants are limited to once in a lifetime for permanent bicuspids or molar teeth through age 15 if they are
without cavities or restorations on the occlusal surface. Sealants do not include repair or replacement of a
sealant on any tooth.
• Limitations on Basic Benefits:
(1) Full-mouth x-rays or panoramic x-rays are limited to once every five(5)years while the person is an Enrollee
under any Delta Dental program.
(2) Delta Dental will not pay to replace an amalgam,synthetic porcelain or plastic restorations(fillings)within 12
months of treatment if the service is provided by the same Dentist.
• Limitations on Major Benefits:
(1) Benefits for periodontal scaling and root planing in the same quadrant are limited to once in every 36-month
period. See"Additional benefits for specific medical conditions".
(2) Delta Dental will not pay to replace prefabricated stainless steel restorations within 36 months of treatment if
the service is provided by the same Dentist.
(3) Delta Dental will not pay to replace any crowns,inlays/onlays,or cast restorations which the Enrollee received
in the previous five(5)years under any Delta Dental program or any program of the Contractholder.
(4) Prosthodontic appliances and/or implants that were provided under any Delta Dental program will be replaced
only after five(5)years have passed,except when Delta Dental determines that there is such extensive loss of
remaining teeth or change in supporting tissue that the existing fixed bridge or denture cannot be made
satisfactory. Replacement of a prosthodontic appliance and/or implant supported prosthesis not provided under
a Delta Dental program will be made if Delta Dental determines it is unsatisfactory and cannot be made
satisfactory. Delta Dental will pay for the removal of an implant once for each tooth during the Enrollee's
lifetime.
(5) Delta Dental limits payment for dentures to a standard partial or denture(coinsurances apply).A standard
denture means a removable appliance to replace missing natural, permanent teeth that is made from acceptable
materials by conventional means.
TX-DPO-C(2006) 12 17182
HIGH PLAN
• Diagnostic and Preventive Benefits
(1) Diagnostic: procedures to aid the Dentist in choosing required dental treatment.
(2) Preventive: cleaning(periodontal cleaning in the presence of inflamed gums is considered
to be a Basic Benefit for payment purposes),topical application of fluoride
solutions,space maintainers,bitewing x-rays and cephalometric x-rays.
(3) Sealants: topically applied acrylic,plastic or composite materials used to seal
developmental grooves and pits in permanent molars for the purpose of
preventing decay.
• Basic Benefits
(1) Oral Surgery: extractions and other surgical procedures(including pre-and post-operative
care).
(2) General Anesthesia or when administered by a Dentist for covered oral surgery or selected endodontic
IV Sedation: and periodontal surgical procedures.
(3) Endodontics: treatment of the tooth pulp.
(4) Periodontics: treatment of gums and bones supporting teeth.
(5) Palliative: treatment to relieve pain.
(6) Restorative: amalgam,synthetic porcelain and plastic restorations(fillings).
(7) Other Basic Services: full-mouth or panoramic x-rays,all other x-rays(except bitewings&
cephalometric x-rays).
• Major Benefits
(1) Crowns,Inlays/Onlays treatment of carious lesions(visible decay of the hard tooth structure)when
and Cast Restorations: teeth cannot be restored with amalgam,synthetic porcelain or plastic
restorations,prefabricated stainless steel restorations for treatment of carious
lesions(visible destruction of hard tooth structure resulting from the process of
decay).
(2) Prosthodontics: procedures for construction of fixed bridges,partial or completed dentures and
the repair of fixed bridges; implant surgical placement and removal; and for
implant supported prosthetics, including implant repair and recementation.
(3) Denture Repairs: repair to partial or complete dentures,including rebase procedures and relining.
• Orthodontic Benefits
Procedures performed by a Dentist using appliances to treat malocclusion of teeth and/or jaws which significantly
interferes with their function.
Additional benefits forspecific medical conditions-When an Enrollee has any of the following medical conditions,
Delta Dental will pay for additional services to help improve the oral health of the Enrollee.The additional services
each Calendar Year while the Enrollee is covered under this Contract include:one(1)additional oral exam and either
one(1)additional routine cleaning or one(1)additional periodontal scaling and root planing per quadrant.Written
confirmation must be provided by the Enrollee or his/her dentist when the claim is submitted.
(1) cardiovascular disease;
(2) cerebrovascular disease;
(3) diabetes;
(4) chronic kidney disease;
(5) organ transplant;
(6) head&neck cancer radiation;
(7) pregnancy.
TX-DPO-C(2006) 13 17182
LIMITATIONS
• Limitations on Diagnostic and Preventive Benefits:
(1) Delta Dental will pay for routine oral examinations and cleanings(including periodontal cleanings)no more
than four(4)times in a Calendar Year while the person is an Enrollee under any Delta Dental program or
dental care program provided by the Contractholder. Note that periodontal cleanings are covered as a Basic
Benefit and routine cleanings are covered as a Diagnostic and Preventive Benefit. See"Additional benefusfor
specific medical conditions".
(2) Bitewing x-rays are provided once in a Calendar Year for each Enrollee.
(3) Topical application of fluoride solutions is limited to twice in a Calendar Year for Enrollees under age 14.
(4) Space maintainers are limited to the initial appliance only for an Enrollee under age 14.
(5) Sealants are limited to once in a lifetime for permanent bicuspids or molar teeth through age 15 if they are
without cavities or restorations on the occlusal surface. Sealants do not include repair or replacement of a
sealant on any tooth.
• Limitations on Basic Benefits:
(1) Full-mouth x-rays or panoramic x-rays are limited to once every five(5)years while the person is an Enrollee
under any Delta Dental program.
(2) Delta Dental will not pay to replace an amalgam,synthetic porcelain or plastic restorations(fillings)within 12
months of treatment if the service is provided by the same Dentist.
(3) Benefits for periodontal scaling and root planing in the same quadrant are limited to once in every 36-month
period. See"Additional benefits for specific medical conditions".
• Limitations on Major Benefits:
(l) Delta Dental will not pay to replace prefabricated stainless steel restorations within 36 months of treatment if
the service is provided by the same Dentist.
(2) Delta Dental will not pay to replace any crowns, inlays/onlays,or cast restorations which the Enrollee received
in the previous five(5)years)under any Delta Dental program or any program of the Contractholder.
(3) Prosthodontic appliances and/or implants that were provided under any Delta Dental program will be replaced
only after five(5)years have passed,except when Delta Dental determines that there is such extensive loss of
remaining teeth or change in supporting tissue that the existing fixed bridge or denture cannot be made
satisfactory. Replacement of a prosthodontic appliance and/or implant supported prosthesis not provided under
a Delta Dental program will be made if Delta Dental determines it is unsatisfactory and cannot be made
satisfactory. Delta Dental will pay for the removal of an implant once for each tooth during the Enrollee's
lifetime.
(4) Delta Dental limits payment for dentures to a standard partial or denture(coinsurances apply).A standard
denture means a removable appliance to replace missing natural, permanent teeth that is made from acceptable
materials by conventional means.
• Limitations on Orthodontic Benefits:
(1) The maximum amount payable for each Enrollee during the Enrollee's lifetime is specified in the Appendix A.
(2) Orthodontic Benefits will be provided in two(2) payments after the person becomes covered(the initial
payment at the banding date and the second in 12 months);however,for treatment plans of less than$500 or
when the treatment plan is 12 months or less,one(1)payment will be made.
(3) Benefits are not paid to repair or replace any orthodontic appliance received under this program.
(4) Benefits are not provided for orthodontic retreatment procedures.
(5) Non-orthodontic procedures performed for the purpose of orthodontic treatment are subject to the Orthodontic
coinsurance and lifetime maximum if covered as Benefits under Delta Dental's standard processing policies.
TX-DPO-C(2006) 14 17182
ALL PLANS
4.05 Limitations on All Benefits-Optional Services:
Services that are more expensive than the form of treatment customarily provided under accepted dental practice
standards are called"Optional Services".Optional Services also include the use of specialized techniques instead of
standard procedures. For example:
• a crown where a filling would restore the tooth;
• a precision denture/partial where a standard denture/partial could be used;
• an inlay/onlay instead of an amalgam restoration.
If an Enrollee receives Optional Services,Benefits will be based on the lower cost of the customary service or standard
practice instead of the higher cost of the Optional Service,The Enrollee will be responsible for the difference between
the higher cost of the Optional Service and the lower cost of the customary service or standard procedure.
4.06 Exclusions
Delta Dental does not pay Benefits for:
• treatment of injuries or illness covered by workers' compensation or employers' liability laws;services received
without cost from any federal,state or local agency,except for services covered by the Medical Assistance Act of
1967, as amended(Article 695j-1,Vernon's Texas Civil Statutes). Delta Dental will reimburse the Texas
Department of Human Services for the cost of services paid by the Department under the said Act to the extent such
costs are for services which are Benefits under this Contract.
If the Texas Department of Human Services is paying benefits pursuant to Chapters 31 and 32 of the Human
Services Code(financial and medical assistance programs administered pursuant to the Human Services code)and a
parent who is covered by the group policy has possession or access to a child pursuant to a court order,or is entitled
to access or possession of a child and is required by the court to pay child support,then all benefits paid on behalf
of the child or children must be paid to the Texas Department of Human Services.
• cosmetic surgery or procedures for purely cosmetic reasons.
• services for congenital (hereditary)or developmental(following birth)malformations, including but not limited to
cleft palate,upper and lower jaw malformations,enamel hypoplasia(lack of development),fluorosis(a type of
discoloration of the teeth)and anodontia(congenitally missing teeth), unless the service is provided to a newborn
or adopted dependent child for treatment of a medically diagnosed congenital defect.
• treatment to restore tooth structure lost from wear,erosion,or abrasion; treatment to rebuild or maintain chewing
surfaces due to teeth out of alignment or occlusion;or treatment to stabilize teeth.For example:equilibration,
periodontal splinting.
• any Single Procedure started prior to the date the patient became eligible for services under this program.
• prescribed drugs, medication, pain killers or experimental procedures.
• charges by any hospital or other surgical or treatment facility and any additional fees charged by the Dentist for
treatment in any such facility.
• charges for anesthesia,other than general anesthesia and 1V sedation administered by a licensed Dentist in
connection with covered oral surgery or selected endodontic and periodontal surgical procedures.
• extraoral grafts (grafting of tissues from outside the mouth to oral tissues).
• treatment by someone other than a Dentist or a person who by law may work under a Dentist's direct supervision,
• charges incurred for oral hygiene instruction,a plaque control program, dietary instruction,x-ray duplications,
cancer screening or broken appointments.
TX-DPO-C(2006) 15 17182
• services or supplies covered by any other health plan of the Contractholder.
• services for Orthodontic treatment(treatment of malocclusion of teeth and/or jaws)except as provided under the
Orthodontic Benefit section, if applicable.
• services for any disturbance of the temporomandibular(jaw)joints or associated musculature,nerves and other
tissues (MPD-TMJ).
ARTICLE 5
DEDUCTIBLE,MAXIMUM,&COORDINATION OF BENEFITS
5.01 Deductible
As shown on Appendix A, Delta Dental will not pay Benefits for the deductible amount of the Dentist's Contract
Allowance for services received each Calendar Year by an Enrollee.The annual maximum deductible per family, if any,
is shown in Appendix A. Only fees an Enrollee pays for services that are described under Article 4 will count toward the
deductible.
5.02 Maximum
Delta Dental will pay the maximum amount(s)shown in Appendix A per Enrollee for all Benefits under this Contract.
5.03 Coordination of Benefits
Delta Dental coordinates the Benefits under this Contract with an Enrollee's benefits under any other group pre-paid
plan or insurance policy designed to fully integrate with other policies. Benefits under one of the plans may be reduced
so that combined coverage does not exceed the Dentist's total fees for covered services. If this is the"primary" plan,
Delta Dental will not reduce Benefits, but if the other plan is the primary one,Delta Dental will reduce Benefits
otherwise payable under this Contract.The reduction will be the amount paid for or provided under the terms of the
primary plan for covered services under Article 4.
Order of Benefit Determination Rules:
The following rules determine which is the"primary"plan:
• If the other Plan is not primarily a dental plan,this Plan is primary.
• If the other Plan is a dental plan,the following rules are applied:
(1) The Plan covering the patient as an employee is primary over a Plan covering the patient as a dependent.
(2) The Plan covering the patient as an employee is primary over a Plan which covers the insured person as a
dependent;except that: if the insured person is also a Medicare beneficiary,and as a result of the rule
established by Title XVIII of the Social Security Act and implementing regulations,Medicare is:
a) Secondary to the Plan covering the insured person as a dependent and
b) Primary to the Plan covering the insured person as other than a dependent(e.g. a retired employee),
then the benefits of the Plan covering the insured person as a dependent are determined before those of the
Plan covering that insured person as other than a dependent.
(3) Except as stated in paragraph(4),when this Plan and another Plan cover the same child as a dependent of
different persons,called parents:
a) The benefits of the Plan of the parent whose birthday falls earlier in a year are determined before those of
the Plan of the parent whose birthday falls later in that year,but
b) If both parents have the same birthday,the benefits of the Plan which covered one parent longer are
determined before those of the Plan which covered the other parent for a shorter period of time.
(4) In the case of a dependent child of divorced parents,the Plan covering the patient as a dependent of the parent
with legal custody,or as a dependent of the custodial parent's spouse(i.e.step-parent)will be primary over the
Plan covering the patient as a dependent of the parent without legal custody.If there is a court decree which
would otherwise establish financial responsibility for the health care expenses with respect to the child,the
benefits of a plan which covers the child as a dependent of the parent with such financial responsibility will be
determined before the benefits of any other policy which covers the child as a dependent child.
(5) If the specific terms of a court decree state that the parents will share joint custody,without stating that one of
the parents is responsible for the health care expenses of the child,the Plans covering the child will follow the
order of benefit determination rules outlined in paragraph(3).
TX-DPO-C(2006) 16 17182
(6) The benefits of a Plan which covers an insured person as an employee who is neither laid off nor retired are
determined before those of a Plan which covers that insured person as a laid off or retired employee.The same
would hold true if an insured person is a dependent of a person covered as a retiree and an employee. If the
other Plan does not have this rule,and if, as a result,the Plans do not agree on the order of benefits, this Rule
(vi) is ignored.
(7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law
also is covered under another plan, the following will be the order of benefit determination:
a) First, the benefits of a Plan covering the insured person as an employee,member or subscriber(or as that
insured person's dependent);
b) Second,the benefits under the continuation coverage.
If the other Plan does not have the rule described above,and if, as a result, the Plans do not agree on the
order of benefits,this rule is ignored.
(8) If none of the above rules determine the order of benefits,the benefits of the Plan which covered an employee
longer are determined before those of the Plan which covered that insured person for the shorter term.
ARTICLE 6
CONDITIONS UNDER WHICH BENEFITS WILL BE PROVIDED
6.01 Choice of a Dentist
Enrollees may choose a Dentist from Delta Dental's panel of DPO Dentists and Premier Dentists,or Enrollees may
choose a Non-Delta Dental Dentist.A I ist of Delta Dental Dentists can be obtained by accessing the Delta Dental
National Dentist Directory at deltadentalins.com.Enrollees are responsible for verifying whether the selected Dentist is a
DPO Dentist or a Premier Dentist. Dentists are regularly added to the panel. Additionally,Enrollees should always
confirm with the dentist's office that a listed Dentist is still a contracted DPO Dentist or a Premier Dentist.
DPO Dentist
The DPO program potentially allows the greatest reduction in Enrollees'out-of-pocket expenses,since this select group
of Dentists will provide dental Benefits at a charge which has been contractually agreed upon between Delta Dental and
the DPO Dentist.
Premier Dentist
Low Plan
The Premier Dentist has not agreed to the features of the DPO program; however,Enrollees may still receive dental
care at a lower cost than if Enrollees use a Non-Delta Dental Dentist.A Premier Dentist can balance bill for the
difference between the DPO Dentist's Fee and the Premier Dentist's Approved Amount.This amount may be more
than the charge accepted by a DPO Dentist.
High Plan
The Premier Dentist has not agreed to the features of the DPO program;however, Enrollees may still receive dental
care at a lower cost than if Enrollees use a Non-Delta Dental Dentist.
Non-Delta Dental Dentist
If a Dentist is a Non-Delta Dental Dentist,the amount charged to Enrollees may be above that accepted by the DPO or
Premier Dentists.Non-Delta Dental Dentists can balance bill for the difference between the DPO Dentist's Fee(Low
Plan), MPA(High Plan) and the Non-Delta Dental Dentist's Approved Amount.For a Non-Delta Dental Dentist, the
Approved Amount is the Dentist's submitted charge.
Additional advantages of using a DPO Dentist or Premier Dentist
• The DPO Dentist and Premier Dentist must accept assignment of Benefits,meaning DPO Dentists and Premier
Dentists will be paid directly by Delta Dental after satisfaction of the deductible and coinsurance,and the Enrollee
does not have to pay all the dental charges while at the dental office and then submit the claim for reimbursement.
• The DPO Dentist and Premier Dentist will complete the dental claim form and submit it to Delta Dental for
reimbursement.
TX-DPO-C(2006) 17 17182
6.02 Clinical Examination
Before approving a claim,Delta Dental may obtain,to such extent as may be lawful,from any Dentist,or from hospitals
in which a Dentist's care is provided,such information and records relating to an Enrollee as Delta Dental may require
to administer the claim. Or Delta Dental may require that an Enrollee be examined by a dental consultant retained by
Delta Dental in or near his community or residence. Such information and records will be kept confidential.
6.03 Notice of Claim Forms
Delta Dental will furnish to any Dentist or Enrollee,on request,a standard Claim Form to make a claim for payment of
Benefits.To make a claim,the form must be completed and signed by the Dentist who performed the services and by the
Enrollee(or the parent or guardian of a minor)and submitted to Delta Dental at the address shown thereon. If Delta
Dental does not furnish the form within 15 days after requested by a Dentist or Enrollee,the requirements for proof of
loss set forth in section 6.05 of this Contract will be deemed to have been complied with upon the submission to Delta
Dental within the time established in said section for filing proof of loss,of written proof covering the occurrence,the
character and the extent of the loss for which claim is made.Enrollees may download a Claim Form from Delta Dental's
web site.
6.04 Pre-Treatment Estimate
A Dentist may file a Claim Form before treatment,showing the services to be provided to an Enrollee. Delta Dental will
predetermine the amount of Benefits payable under this Contract for the listed services. Benefits will be processed
according to the terms of this Contract when the treatment is performed. Pre-Treatment Estimates are valid for 365
days,or until an earlier occurrence of any one of the following events:
• the date this Contract terminates;
• the date the patient's coverage ends;or
• the date the Premier Dentist or DPO Dentist Agreement with Delta Dental ends.
6.05 Written Notice of Claim/Proof of Loss
Delta Dental must be given written proof of loss within 12 months after the date of the loss. If it is not reasonably
possible to give written proof in the time required,the claim will not be reduced or denied solely for this reason,
provided proof is filed as soon as reasonably possible. In any event,proof of loss must be given no later than one year
from such time(unless the claimant was legally incapacitated).
All written proof of loss must be given to Delta Dental within 12 months of the termination of this Contract.
6.06 Time of Payment
Claims payable under this Contract for any loss other than loss for which this Contract provides any periodic payment
will be paid no later than 60 days after written proof loss is received. Delta Dental will notify the Primary Enrollee and
his/her dentist of any additional information needed to process the claim within this 60 day period. Delta Dental will
process the claim within 15 days of receipt of the additional information. If the requested information is not received
within 45 days,the claim will be denied. Subject to due written proof of loss,all accrued indemnities for loss for
which this Contract provides periodic payment will be paid monthly.
6.07 Claims Appeal
Delta Dental will notify the Enrollee and his/her Dentist if Benefits are denied for services submitted on an Claim Form,
in whole or in part,stating the reason(s)for denial.The Enrollee or his/her Dentist has 180 days after receiving a notice
of denial to appeal it by writing to Delta Dental giving reasons why he/she believes the denial was wrong.The Enrollee
and his/her Dentist may ask for copies,at no cost,of any pertinent documents that are relevant to the claim.
The Enrollee or his/her Dentist may also ask Delta Dental to examine any additional information he/she includes that
may support his/her appeal.
Delta Dental will make a full and fair review within 60 days after Delta Dental receives the request for appeal.Delta
Dental may ask for more documents if needed. In no event will the decision take longer than 60 days.The review will
take into account all comments,documents, records or other information,regardless of whether such information was
submitted or considered initially. If the review is of a denial based in whole or in part on lack of dental necessity,
experimental treatment or clinical judgement in applying the terms of this Contract,Delta Dental shall consult with a
Dentist who has appropriate training and experience.The review will be conducted for Delta Dental by a person who is
TX-DPO-C(2006) 18 17182
neither the individual who made the claim denial that is subject to the review,nor the subordinate of such individual.
The identity of such dental consultant is available upon request whether or not the advice was relied upon.
If the Enrollee believes he/she needs further review of said claim,he/she may contact his/her state insurance regulatory
agency if applicable or bring a civil action under section 502(a)of the Employee Retirement Income Security Act of
1974(ERISA)if this Contract is subject to ERISA.
6.08 To Whom Benefits Are Paid
Payment for services provided by a DPO Dentist or Premier Dentist will be made directly to the Dentist.Any other
payments provided by this Contract will be made to the Primary Enrollee,unless the Primary Enrollee requests when
filing proof of loss that the payment be made directly to the Dentist providing the services.All Benefits not paid to the
Dentist will be payable to the Primary Enrollee,or to his estate,except that if the person is a minor or otherwise not
competent to give a valid release,Benefits may be payable to his parent,guardian or other person actually supporting
him.
ARTICLE 7
GENERAL PROVISIONS
7.01 Entire Contract; Changes
This Contract,including the Application and the attachments listed in Article 9,is the entire agreement between the
parties.
No agent has authority to change this Contract or waive any of its provisions.No change in this Contract will be valid
unless approved in writing signed by an authorized representative of Contractholder and by an executive officer of Delta
Dental.
7.02 Severability
If any part of this Contract or an amendment of it is found by a court or other authority to be illegal,void or not
enforceable,all other portions of this Contract will remain in full force and effect.
7.03 Conformity With State Laws
All legal questions about this Contract will be governed by the state of Texas where this Contract was entered into and is
to be performed.Any part of this Contract which,on its Effective Date,conflicts with the laws of Texas is hereby
amended to conform to the minimum requirements of such laws.
7.04 Misstatements on Application; Effect
In the absence of fraud,all statements made by the Contractholder or Enrollee will be deemed representations and not
warranties. No such statement will be used in defense to a claim under this Contract, unless it is contained in a written
instrument signed by the Contractholder or Enrollee,a copy of which has been furnished to such Contractholder or
Enrollee.
7.05 Misstatement of Age
If the age of the Enrollee has been misstated,all amounts payable under the contract shall be such as the premium paid
would have purchased at the correct age.
7.06 Legal Actions
No action at law or in equity will be brought to recover on this Contract before 60 days after proof of loss has been filed
in accordance with requirements of this Contract;nor will an action be brought at all unless brought within three years
of the expiration of time the written proof of loss was due under this Contract.
7.07 Not in Lieu of Workers'Compensation
This Contract is not in lieu of and does not affect any requirements for coverage by workers' compensation insurance.
TX-DPO-C(2006) 19 17182
7.08 Certificate of Insurance
Delta Dental will issue to the Contractholder an electronic copy containing a certificate summarizing the Benefits to
which he is entitled and to whom Benefits are payable. Each Primary Enrollee will have electronic access to the
certificate. The certificate is not assignable and the Benefits are not assignable prior to a claim. If any amendment to
this Contract will materially affect any Benefits described in the certificate,new certificates or riders showing the
change will be issued.
7.09 Publications About Program
Contractholder and Delta Dental agree to consult as is reasonably practical on all material published or distributed about
this Contract.No material will be published or distributed which conflicts with the terms of this Contract.
7.10 Professional Relationship
Contractholder and Delta Dental agree to permit and encourage the professional relationship between Dentist and patient
to be maintained without interference.
7.11 Notice; Where Directed
All formal notice under this Contract must be in writing and sent by first-class United States mail,overnight delivery
service,or personal delivery.Notice by United States mail will be effective 48 hours after mailing with fully prepaid
postage to:
DELTA DENTAL INSURANCE COMPANY
I I30 Sanctuary Parkway
Suite 600
Alpharetta,Georgia 30009
Notice directed to Contractholder shall be sent to:
CITY OF FORT WORTH
1000 Throckmorton Street
Fort Worth, TX 76102
7.12 Indemnification
Contractholder will,to the extent allowed under Texas Law, indemnify,defend and hold harmless Delta Dental, its
directors,officers,employees, agents and affiliated companies against any and all claims,demands, liabilities,costs,
damages and causes of action or administrative proceedings whatsoever, including reasonable attorney's fees,arising
from Contractholder's negligent performance or non-performance of its obligations under this Agreement.
Delta Dental will indemnify,defend and hold harmless Contractholder and its directors,officers,employees and agents,
against any and all claims,demands, liabilities,costs,damages and causes of action or administrative proceedings
whatsoever, including reasonable attorney's fees,arising from Delta Dental's negligent performance or non-
performance of its obligations under this Agreement.
7.13 Time Limit On Certain Defenses
After this Contract has been in force for two(2)years from the Effective Date, no statement made by the Contractholder
will be used to void this Contract. No statement by you,with respect to the an Enrollee's insurability,will be used to
reduce or deny a claim or contest the validity of insurance for such Enrollee after that person's coverage has been in
effect two(2)years.
7.14 Compliance with Administrative Simplification,Security and Privacy Regulations
Contractholder shall comply in all respects with applicable federal,state and local laws and regulations relating to
administrative simplification,security and privacy of individually identifiable Enrollee information.The Contractholder
agrees that this Contract may be amended as necessary to comply with federal regulations issued under the Health
Insurance Portability and Accountability Act of 1996 or to comply with any other enacted administrative simplifications,
security or privacy laws or regulations.
TX-DPO-C(2006) 20 17182
7.15 Impossibility of Performance
Neither party shall be liable to the other or be deemed to be in breach of this Contract for a delay in performance due to
a weather related catastrophe or major natural disaster,as defined by the Texas Insurance Commissioner, provided that
the party whose performance is affected promptly notifies the other party. Should Delta Dental's performance be
affected by a weather related catastrophe or major natural disaster as defined by the Texas Insurance Commissioner,
claims-handling deadlines will be extended by 15 days.
ARTICLE 8
TERMINATION & RENEWAL
8.01 This Contract maybe terminated only as follows:
• By Contractholder upon 30 days written notice.
• By Delta Dental,
(1) upon 60 days written notice if Contractholder fails to furnish Delta Dental a list of all Enrollees as required
under section 2.01;or
(2) upon 60 days written notice if Contractholder fails to permit Delta Dental to inspect Contractholder's records
as called for under section 2.02;or
(3) upon 31 days written notice if Contractholder fails to pay Premiums, in the amount and manner required by
Article 3.
• By Delta Dental, if Contractholder reports fewer than the Minimum Number of Primary Enrollees shown in
Appendix A for three(3)consecutive months. Delta Dental must give Contractholder notice within 15 days after
receiving the list of Primary Employees which shows that Delta Dental may terminate on this basis.
• By Delta Dental at the end of a contract term upon 60 days written notice.
8.02 In the event this Contract is terminated under the second bullet item in Section 8.0 1,Contractholder will become
immediately obligated upon termination to pay Delta Dental for that portion of the monthly Premium which constitutes
for the current Contract Term Delta Dental's direct costs of administering this Contract(calculated by subtracting the
pure premium from the total premium)multiplied by the remaining number of months from the date of termination to
the expiration of the current Contract Term, but the amount will not exceed 25 percent of the total premium for the
entire Contract Term.
8.03 If Contractholder notifies Delta Dental that it intends to terminate this Contract upon less than 30 days notice,Section
8.02 will apply as if Delta Dental terminated this Contract under Section 8.01 second bullet.
8.04 Delta Dental will not be required to predetermine services if this Contract is terminated for any cause nor will Delta
Dental be required to pay for services performed beyond the termination date except for completion of Single Procedures
commenced while this Contract was in effect.
8.05 Delta Dental will provide 180 days advance written renewal notice prior to the end of the initial or any subsequent
contract terms indicating if Premiums and/or Benefits will remain the same or change.The Contractholder's payment of
the Premium indicated in the renewal notice for the new Contract Term will signify the Contractholder's acceptance of
the renewal. If the Contractholder fails to provide written notification to Delta Dental of non-renewal by the date
indicated in the renewal letter and/or does not pay the Premiums indicated in the renewal notice with the new Contract
Term,Delta Dental will terminate this Contract under 8.01 second bullet, item (3).
ARTICLE 4
ATTACHMENTS
These documents are attached to this Contract and made a part of it:
Appendix A Group Policy Schedule
Appendix B Performance Guarantees
Appendix C Texas Life,Accident,Health and Hospital Service Insurance Guaranty Association
Copy of Application
TX-DPO-C(2006) 21 17182
APPENDIX A
GROUP POLICY SCHEDULE
Contractholder Name: CITY OF FORT WORTH
Address: 1000 Throckmorton Street
Fort Worth,TX 76102
Group Number: 17182
Effective Date: January 1,2015
Contract Term:
The initial Contract Term shall be a 12-month period starting on January 1,2015 and ending on December 31,2015. The 211
Contract Term shall be the 12-month period thereafter starting on January 1,2016 and ending on December 31,2016. The
31 Contract Term shall be the 12-month period thereafter starting on January 1,2017 and ending on December 31,2017 with
2-one year renewal terms that include a not to exceed rate cap of 7.5%.
Contractholder's Billing Option(Self-Pay)
The Contractholder will submit their own prepared eligibility roster,and remit payment based on that roster. The
Contractholder will forward payment(accompanied by the eligibility roster)to Delta Dental,and will not receive an invoice.
Enrollee additions,deletions,and changes in status must be clearly and separately identified.
Benefits: Low Plan High Plan
In-Network Out-of-Network In-Network Out-of-Network
Diagnostic&Preventive Benefits: 100% 100% I00% 100%
Basic Benefits: 50% 50% 80% 80%
Major Benefits: 50% 50% 50% 50%
Orthodontic Benefits: Not Covered 50% 50%
Deductibles:
Per Enrollee per Calendar Year: $50 $50
Per Family per Calendar Year: $150 $150
Any deductible amount satisfied by the Enrollee during the last three(3)months of the year will be applied toward the
deductible for the following year.
Diagnostic&Preventive Benefits and Orthodontic Benefits,if applicable,are not subject to the deductible.
Maximum Amounts:
Per Enrollee per Calendar Year: $1,000 $1,500
Diagnostic and Preventive Benefits are not subject to the Calendar Year Maximum Amount.
Lifetime for Orthodontic Services Not Covered $1,000
per Enrollee:
Lifetime Maximum Takeover Credit:
Delta Dental will receive credit for any amounts paid under the Con tractholder's previous dental care contract,if applicable,
for Orthodontic Benefits. These amounts will be credited towards the maximum amounts payable for Orthodontic Benefits.
Termination:
Less than 10 Primary Enrollees.
Premiums: **
Monthly Amount: Low Plan High Plan
Per Primary Enrollee: $19.85 $29.47
Per Primary Enrollee and Spouse: $37.72 $60.41
Per Primary Enrollee and Child(ren): $43.68 $78.09
Per Primary Enrollee and Family: $61.55 $98.72
"This is a 3-year rate guarantee with 2-one year renewal terms that include a not to exceed rate cap of 7.5%
TX-DPO-C(2006) 22 17182
APPENDIX A
GROUP POLICY SCHEDULE-Continued
Payment Breakdown:
Primary Enrollee shall pay: 100%for personal coverage
100%for Dependent coverage
Contractholder may charge persons electing continued coverage pursuant to Title X of P.L. 99 as permitted by law.
(APPLICABLE TO ENROLLEES IN THE LOW PLAN)
MAXIMUM ENHANCEMENT:
Delta Dental agrees to annually provide each Enrollee with an increase (hereinafter referred to as "Enhancement") to their
Annual Maximum of up to $250 of the unused portion of his/her Annual Maximum from the preceding Calendar Year to a
cumulativetotal of$1,000 provided the Enrollee meets the qualifying Conditions listed below.
Qualifying Conditions To qualify for an Enhancement,the Enrollee must meet all of the following:
• All claims paid on behalf of the Enrollee during the preceding Calendar Year must
not exceed$500.
• At least one preventive claim for covered dental treatment must have been
submitted during the preceding Calendar Year.
Grant of the Enhancement • Delta Dental will determine if an Enrollee is entitled to an Enhancement of their
individual Annual Maximum based on claims received by March 315`for the preceding
Calendar Year.Delta Dental will issue Enhancements within 120 days after the end of
the preceding Calendar Year.
• If an Enrollee fails to submit a claim for covered dental treatment during a Calendar
Year,the Enrollee will not be entitled to receive an Enhancement for that Calendar Year
but the Enrollee will retain all Enhancements of their Annual Maximum previously
ranted.
Use of Enhancement • Claims will be applied first to the satisfaction of the plan's standard Annual Maximum
before being applied to any Enhancement(s)and then in the order of the oldest
Enhancement.
• Enrollees may use an Enhancement only after it has been granted.
• Enhancements must be used within 10 years from when it is earned.
TX-DPO-C(2006) 23 17182
APPENDIX A
GROUP POLICY SCHEDULE-Continued
(APPLICABLE TO ENROLLEES IN THE I11CII PLAN)
MAXIMUM ENHANCEMENT:
Delta Dental agrees to annually provide each Enrollee with an increase (hereinafter referred to as "Enhancement") to their
Annual Maximum of up to $250 of the unused portion of his/her Annual Maximum from the preceding Calendar Year to a
cumulative total of$1,500 provided the Enrollee meets the qualifying Conditions listed below.
Qualifying Conditions To qualify for an Enhancement,the Enrollee must meet all of the following:
• All claims paid on behalf of the Enrollee during the preceding Calendar Year must
not exceed $500.
• At least one preventive claim for covered dental treatment must have been
submitted during the preceding Calendar Year.
Grant of the Enhancement • Delta Dental will determine if an Enrollee is entitled to an Enhancement of their
individual Annual Maximum based on claims received by March 31"for the preceding
Calendar Year.Delta Dental will issue Enhancements within 120 days after the end of
the preceding Calendar Year.
• If an Enrollee fails to submit a claim for covered dental treatment during a Calendar
Year,the Enrollee will not be entitled to receive an Enhancement for that Calendar Year
but the Enrollee will retain all Enhancements of their Annual Maximum previously
ranted.
Use of Enhancement . Claims will be applied first to the satisfaction of the plan's standard Annual Maximum
before being applied to any Enhancement(s)and then in the order of the oldest
Enhancement.
• Enrollees may use an Enhancement only after it has been granted.
• Enhancements must be used within 10 years from when it is earned.
TX-DPO-C(2006) 24 17182
APPENDIX B
PERFORMANCE GUARANTEES
Effective:January 1,2015 thru December 31,2017
Delta Dental agrees to provide the following levels of service in the performance of its obligations under this
contract. Should any of the following service levels not be met, any payment due will be issued in the form of
a check, based on the total administration at the end of each contract year.
Percent of
Service Category Expected Standards/Results Administration
at Risk*
Implementation The client will monitor and evaluate Delta Dental's
Implementation performance and provide feedback via a
Delta Dental Client Implementation Satisfaction Survey.
Pertinent questions for this guarantee are in the
Implementation Team section of the survey. 5%
Client satisfaction for each of the criteria above will be
deemed as being met given a rating of Good, Very Good or
Excellent.
Account The assigned Account Manager will partner with the client to
Management meet the dental benefit objectives and work on the client's
behalf to optimize service levels. Standards of service
include:
a) Account Manager will provide comprehensive assistance
for the client in support of top-tier customer service. 1%
(Client Satisfaction Survey item#7)
b) Account Manager will provide timely response and
follow-up on phone calls and e-mails from the client. 1%
(Client Satisfaction Survey item#8).
c) Account Manager will meet with the client's benefit staff
as needed to meet the client's objectives and oversee 1%
the annual open enrollment process, including
participation in employee information meetings, if
applicable. (Client Satisfaction Survey item#10).
d) Account Manager will provide ongoing assistance with 1%
any issues escalated by designated benefits contacts.
(Client Satisfaction Survey item#11).
The client will monitor and annually evaluate the Account
Management performance and provide feedback via a Delta
Dental Client Satisfaction Survey. Pertinent questions for this
guarantee are in the Account Management section of the
survey. Client satisfaction for each of the criteria above will
be deemed as being met given a rating of Good, Very Good
or Excellent.
Eligibility 95% of electronic eligibility will be loaded within three (3) 0.5%
business days from receipt of data.
Guarantee is contingent upon receipt of data in a mutually
agreed upon format.
Measurement will be on a global basis and reported annually.
TX-DPO-C(2006) 25 17182
Percent of
Service Category Expected Standards/Results Administration
at Risk*
Eligibility updates will be completed on average within five (5) 0.5%
business days from receipt of data.
Guarantee is contingent upon receipt of data in a mutually
agreed upon format
Measurement will be on a global basis and reported annually.
Eligibility updates will be guaranteed with 98% accuracy. 0.5%
Guarantee is contingent upon receipt of data in a mutually
agreed upon format
Measurement will be on a global basis and reported annually.
Claims 85% of claims received will be processed within 15 calendar 1%
Turnaround days.
Claims turnaround is measured from the date of the initial
receipt of the claim with complete information to the date the
claim is processed.
Measurement will be on a global basis and reported annually.
Overall Claims 99%financial (dollar) accuracy. 1%
Accuracy
Financial(dollar) accuracy is calculated from a random
sample and defined as the total dollar amount paid correctly
in the sample divided by the total dollar amount that should
have been paid in the sample.
Measurement will be on a global basis and reported annually.
97% payment accuracy. 1%
Payment accuracy is calculated from a random sample and
defined as the number of claims in the sample without
payment errors divided by the total number of claims in the
sample.
Measurement will be on a global basis and reported annually.
95% processing accuracy. 1%
Processing accuracy is calculated from a random sample
and defined as the number of claims in the sample without
payment or nonpayment errors divided by the total number of
claims in the sample.
Measurement will be on a global basis and reported annually.
Customer 85% of all customer calls to the Contact Center will be 1%
Service answered within 30 seconds.
Measurement will be on a global basis and reported annually.
90% of Customer Service phone inquiries will be resolved 1%
within one (1) business day.
Measurement will be on a global basis and reported annually.
TX-DPO-C(2006) 26 17182
Percent of
Service Category Expected Standards/Results Administration
at Risk*
Written inquiries will be responded to within an average of 1%
seven (7) calendar days of receipt.
Measurement will be on a global basis and reported annually.
Call abandonment rate will be 5% or less. 1%
Measurement will be on a global basis and reported annually.
Enrollee 85% of participants that respond to the Enrollee Satisfaction 0.5%
Satisfaction Survey will rate Delta Dental overall as Good,Very Good or
Excellent. Overall enrollee satisfaction is measured by a
survey distributed to a random sampling of enrollees.
Measurement will be on a global basis and reported annually.
Client Reporting Client-specific reporting package as agreed upon will be 1%
provided within 60 days from the close of the established
reporting period.
Measurement will be on a client-specific basis and reported
annually.
TOTAL ADMINISTRATION AT RISK 20%
City of Fort Worth Measurements of performance guarantees will not begin until the month after all
aspects of the implementation process have been completed including:
1) A completed and signed client application
2) All eligibility specifications for reformatting (if reformatting is necessary)
3) Full file history tape prior to processing of claims(if history load is required)
Unless specified above, the length of the Performance Guarantee period will follow the term of the
sold contract period.
* Performance Guarantees apply to Fee-for-Service Plans only;excludes assessments,taxes and commissions, if applicable.
Delta Dental will not incur penalties for its failure to meet the terms of these guarantees if this failure is caused by fires,acts
of public enemies, acts of God,civil disturbances, labor disputes or by any similar act or event beyond the reasonable control
of the client or Delta Dental.
TX-DPO-C(2006) 27 17182
APPENDIX C
TEXAS LIFE,ACCIDENT,HEALTH AND HOSPITAL SERVICE
INSURANCE GUARANTY ASSOCIATION
IMPORTANT INFORMATION ABOUT COVERAGE UNDER THE TEXAS LIFE, ACCIDENT, HEALTH AND
HOSPITAL SERVICE INSURANCE GUARANTY ASSOCIATION
Texas law establishes a system,administered by the Texas Life, Accident,Health and Hospital Service Insurance Guaranty
Association(the"Association"),to protect policyholders if their life or health insurance company fails to or cannot meet its
contractual obligations.Only the policyholders of insurance companies which are members of the Association are eligible for
this protection.However,even if a company is a member of the Association, protection is limited and policyholders must meet
certain guidelines to qualify.(The law is found in the Texas Insurance Code, Article 21.28-D.)
BECAUSE OF STATUTORY LIMITATIONS ON POLICYHOLDER PROTECTION, IT IS POSSIBLE THAT THE
ASSOCIATION MAY NOT COVER YOUR POLICY OR MAY NOT COVER YOUR POLICY IN FULL.
Eligibility for Protection by the Association
When an insurance company,which is a member of the Association, is designated as impaired by the Texas Commissioner of
Insurance,the Association provides coverage to policyholders who are:
• Residents of Texas at the time that their insurance is impaired
• Residents of other states,ONLY if the following conditions are met:
1. The policyholder has a policy with a company based in Texas;
2. The company has never held a license in the policyholder's state of residence;
3. The policyholder's state of residence has a similar guaranty association; and
4. The policyholder is not eligible for coverage by the guaranty association of the policyholder's state of residence.
Limits of Protection by the Association
Accident,Accident and Health or Health Insurance:
• Up to a total of$200,000 for one or more policies for each individual covered.
Life Insurance:
• Net cash surrender value up to a total of$100,000 under one or more policies on any one life; or
• Death benefits up to a total of$300,000 under one or more policies on any one life.
Individual Annuities:
• Net cash surrender amount up to a total of$100,000 under one or more policies owned by one contractholder.
Group Annuities:
• Net cash surrender amount up to$100,000 in allocated benefits under one or more policies owned by one contractholder;
or
• Net cash surrender amount up to $5,000,000 in unallocated benefits under one contractholder regardless of the number of
contracts.
THE INSURANCE COMPANY AND ITS AGENTS ARE PROHIBITED BY LAW FROM USING THE EXISTENCE
OF THE ASSOCIATION FOR THE PURPOSE OF SALES,SOLICITATION OR INDUCEMENT TO PURCHASE
ANY FORM OF INSURANCE.
When you are selecting an insurance company,you should not rely on Association coverage.
Texas Life, Accident, Health and Hospital Texas Department of Insurance
Service Insurance Guaranty Association P.O.Box 149104
6504 Bridge Point Parkway, Suite 450 Austin,Texas 78714-9104
Austin,Texas 78730 800-252-3439
800-982-6362
www.txlifega.org
CITY sEcRETARV Z
copmAct w.
Delta Dental Insurance Company I'DeltaDental's Use ONLY
Group#: TX-17182
Alpharetta,GA 30022 Group Dental Insurance Application
(770)645-8700 AE: Norma V.Cardenas/KirkLayallee
AM. Nola Ray
Name of Applicant: City of Fort Worth Fed ID/TIN#: 75-600528
Type of Croup: Employer Type of Industry: Municipality SIC Code; 9190
(employer,association,trust:subrait association by-taws or W vt agreement)
Address: 1000 Throckmorton Street Fort Worth Texas 76102 Tarrant
- ($U-) Why) (sin+.) (Tv) (c_"r)
Name of Contact Person; Maria L.Gray-Benefits Manager Telephone (817)392-7787
Fax No.: (817)392-2624 E-mail Address: maria.gray@fortworthtexas.gov
i$filling .dares if.different {Same as above)-Joai=,H'utton@frntworthtexas.gov Contact: . Ioanne Iiinton
1 TPA 0 No ❑Yes Fax: Email- see above Telephone#: 817-392-6275
Contract Effective Date: January 1,2015 Length of Contract: 3 yrs with 2 one-year renewal terms that include a
not to exceed rate cap of 7.5%
Type of Contract: ®Non Retention ❑Self Funded("ASC') ❑Self Funded with Stop Loss a ❑ Other
Program(check one) ❑Delta Dental Premier®("Premier") ❑Other:
--------- ------------- Mon[hS`►vitchin ❑__
Fee Basis ❑DPO in/DPO out ®DPO in/MPA out ❑Table of Allowance #
------ -- --- -------------------------------- ------------------•--------- --------------------------------------------------------------------
7}peofDentist DPO Premier Non-Delta
- - - - --•---------- -------------- --------------------------------------------------------------------
Diagnostic&Preventive 100% 100% 100% Sealants
- -- --- - - -- - -- __7_----------- ------------ --------------------------------------------
8Q% 80% 80% ❑Sealants M Endo ®Pedo ®Oral Surgery
---- - ----------------- ----- -- -•-------- -------- -- _:___.... .. - --- - -- - -- - - -- -- --- -- - - - - - -
Major 5001. 5Q% -----------------------------------------------50% Endo ❑Perio ❑Oral Surger------------------------------
Benefit
- -- -
------ --------------------------------------------------------------- --
Benefit Yearcheck one)) ®Calendar Year El Contract Year
Deductible $50_-_•per Enrollee; $I50 per Family or S_q&t Lifetime
Waived on D&P ®des ❑no
---- ------------------•--- ---------------------------- --------- ------------------------------------------------------
Annual Maximum $1.500
- - - - - ------------- - - - --- ,- - -- -- - -• - ----------a•--•--•......... --......y0............. ...---
Orthodontics•(check one) ❑not appliceb[e ®adults,children&students children and students onIchildren only
�0% I 50% I SQ% I Lifetime Ortho Max: $1,000 Annual Cap: $n/a
----------------------------
----------------------------------------- ---------------------------
----------- -------------- -- -
Waiting Period ❑Basic months ❑Major months ❑Orthodontic months
Waiting periods are calculated for each Enrollee from the e„feciNe date reported for the Primary Enrollee. ❑Yes❑No
Takeover ®yes*❑no If yes,previous carrier&takeover period: Orthodontics
*please check applicable boxes and provide history. ®Deductible Takeover ❑Maximum Takeover ®Orthodontic Takeover
----------•--------------------------------- ---------------------- ----------------------- ------------- -----------------------------------------
Dual Choice ®yes ❑no If yes,name of other carrier: DeltaCare Plan 15A and M74
-- - -- -- ----------------•-----------------•------------••-------------------------------- --- -------- - - --- - --- -------------------
❑ -yes ®no Missing Tooth Exclusion applies—only teeth extracted under the contract will be covered;-- F®yes ❑no Section 125
- - -----•-------- ------------ ------------------------------ -- ---- -- ----- ---------- ---- -------------- ------------------------ --- ----
® Special Requests(attach page if necessary):High/Low Plan w/Grp Specific Maximum Enhancement-see attached,41,Qrt Ded
Carryover,Non-Std Benefits;Benefits above are High plan and is PPO/MPA/90th;Low Plan is:l'PO/PPO/PPO-Ded$50/5150,AMax$1,000,
D&P@lQ0%,Basic@50%;Major @50%.Rates for low plan EO$19.65,ES$37.72,EC$43.68,EF$61.55;Rates below high plan;Elig 1"
of the month following DOH;Eligibilty-20 hours or more per week;Employee Eff Date- I month from Date of Hire
Employer Contribution: X percentage ❑dollar amount Employee: 0 Dependent: 0
Monthly Rates:
❑Two Tier: EE: $ BE&family: $
❑ Three Tien EE: $ Two Party: $ Three Party:
0 Four Tier: EE: $29.47 EE&Spouse: $60.41 EE&child(ren): $78.09 EE,Spouse&Child(ren): $98.72
❑Other(specify type and amount): If ASC:Per primary member$ per month or -%of claims per month
(Continued on next page)
GRP-DEN-AP-TX-2007 tev 09/07
REG�IVED pEC 15 P,M.
Group Dental Application(Continued) Applicant's Name: City of Fort Worth
Census 8;916 #of Eligible Employees
2,375 #ofEmployees Participating in Delta Denial's Fee-for-Service Program
------------------------------------------ - ------------ ---------•----------------------------------------------------------------------ea
Eligibility: #of Months: or #of Days: Hours/ S
----------------------------------------------------- ---------- --- - ---- ------------------------------------
Employee Effective Date: ❑ 1"day of the month following completion of eligibility ❑Date of hire
❑ la day of month following date of hire ❑Day following completion of eligibility
------------------------------------------------------------ ------- -----• ----------------- ----- -
Who is eligible: ®All ❑Class of employees:
Employees
®Retired Employees Children to age: 26 Students to age: 26
This program shall become effective only upon issuance of a written agreement executed by a duly authorized officer of Delta Dental. In the
absence of fraud or intentional misrepresentation of material fact,the statements in this application are deemed to be representations and not
warranties. Any misrepresentation,omission,concealment of fact or incorrect statement which is material to the acceptance of risk may
prevent recovery if,had the true facts been known to Delta Dental we would not in good faith have issued the contract at the same premium
rate.
Except as otherwise limited by the Health Insurance Portability and Accountability Act and its administrative simplification regulations
("HIPAA"),Applicant shall provide DehaDental with Protected Health information("PHI")for the proper implementation,administration
and management of the group dental services contract for which Applicant is applying. Delta Dental agrees that the PHI will be held
confidential and used or further disclosed only to administer the group dental program as described in the group dental contract or as
permitted or required by law.Applicant and Delta Dental shall comply with all the applicable federal and state laws and regulations relating
to administrative simplification,security and privacy of PHI,including the terms of any business associate addendum that maybe required
as part of the group dental contract to be executed between Applicant and Delta Dental.
® Applicant understands he/she will receive an electronic version of the evidence of coverage booklet for distribution to all employees/
members covered under the contract.
Executed this day of ,on '2014 for the Applicant at: Fort Worth,Texas
/� I �►A .O and State
By: ayi I'1 1�1w1i; �, S�. �-�� 1 Pl�r'Signature:
(p/ease prim-Atne and!!/te
Acceptedfor Delia Derlcallnsurance Company
This 24 day of &- A2 i2x' ,o.� f __
Authorization initials Anthony S.Barth,President,Delta Dental Insurance Company
Agent Inform4tion Are you appointed with Delta Dental Insurance Company? ®yes ❑no
Agent Name Galla her Benefit Services TIN or SS# ,?� - y � I ]I _ State license#
(dappItcable)
Signature Telephone# 512-499-8005
Address 221 'StSui
reet, te 1980 Austin Texas 78701 Travis
Street ( ry) (Sloro) sip (County)
—
A U
Con trct utih0V aatioa �'�J. �a g i C1f}�Se 0
� tZzJI �` y
Date �.r•�.. tr .
GRP-DEN-AP-TX-2007
N?&C Review CICVk-1 _61 j J `' z , KI Page 1 of 2
Official site of rrie City or rom'Nlc [i,"Ioxa�
CITY COUNCIL AGENDA F°RT_— VORT11
COUNCIL ACTION: Approved on 7/22/2014
DATE: 7/22/2014 REFERENCE NO.: C-26884 LOG NAME: 14DENTAL
CODE: C TYPE: NON-CONSENT PUBLIC HEARING: NO
SUBJECT: Authorize Execution of a Contract with Delta Dental for the Administration of Dental
Insurance with Participants Paying All Premiums and No Financial Impact to the City (ALL
COUNCIL DISTRICTS)
RECOMMENDATION:
It is recommended that the City Council authorize the execution of a contract with Delta Dental for the
administration of dental insurance with participating employees and retirees paying all premiums and
no financial impact to the City.
DISCUSSION:
The Human Resources Department (HRD) will use this Contract to provide City employees and
retirees with access to dental insurance plans.
The City of Fort Worth currently contracts with Cigna Insurance to provide employees access to this
type of insurance. Having worked with the same carrier for many years, HRD staff determined that it
would be in the best interest of City employees and retirees to go out to the market and give all
providers an opportunity to compete for the City's business to ensure that City employees are getting
the best overall policies and prices.
The City issued a Request for Proposals (RFP) on February 19, 2014. This RFP was advertised in
the Fort Worth Star-Telegram every Wednesday starting on February 19, 2014 through March 27,
2014. Fifty-nine vendors were solicited from the purchasing database; eight responses were
received. The proposals were thoroughly reviewed by an evaluation team consisting of Staff from the
following departments: Transportation and Public Works, Fire, Water, Parks and Communiy Services
and Human Resources. The evaluation team was provided with resources and assistance by the
City's benefits consultant, Arthur J. Gallagher, and by staff in the Human Resources Department and
Purchasing Division.
The evaluation team ranked the proposals based on the following factors: technical proposals,
qualifications, adherence to terms and conditions of the RFP, financial stability, value-added services
and pricing competitiveness. Two finalists were selected for presentations. Following the
presentations, the evaluation team determined that Delta Dental provides the best overall solution to
the City.
The proposed contract will offer enhanced dental benefits at reduced costs to City employees and
retirees. Delta Dental will provide a three-year rate guarantee through December 31, 2017 with a 7.5
percent rate cap in years four and five.
AGREEMENT TERMS - Upon City Council approval, the initial three-year term of this contract shall
begin on January 1, 2015 and expire on December 31, 2017.
RENEWAL OPTIONS -This contract may be renewed up to two one-year terms at the City's sole
discretion. This action does not require specific City Council approval provided that sufficient funds
are appropriated for the City to meet its obligations during the renewal period.
http://apps.cfwnet.org/council_packet/mc_review.asp?1D=20034&councildate=7/22/2014 6/30/2015
.TJ.1&C Review Page 2 of 2
M/WBE OFFICE -A waiver of the goal for MBE/SBE sub-contracting was requested by the
Purchasing Division and approved by the M/WBE Office, in accordance with the BIDE Ordinance,
because the purchase of goods or services is from sources where sub-contracting or supplier
opportunities are negligible.
FISCAL INFORMATION/CERTIFICATION:
The Financial Management Services Director certifies that this action does not have material effect
on City funds.
TO Fund/Account/Centers FROM Fund/Account/Centers
Submitted for City Manager's Office by: Susan Alanis (8180)
Originating Department Head: Brian Dickerson (7783)
Additional Information Contact: Margaret Wise (8058)
ATTACHMENTS
http://apps.cfwnet.org/council_packet/mc_review.asp?ID=20034&councildate=7/22/2014 6/30/2015
ti. 1 t
CITY SECRETAW
CONTRACT N0.,,.1UL
Delta Dental Insurance Company Delta Dental's Use ONLY
iAlpharetta,GA 30022 Group Dental Insurance Application Group#: TX- 17182
(770)645-8700 AE: Norma V.Cardenas/Kirk Lavallee
AM: Nola Ray
Name of Applicant: City of Fort Worth Fed ID/TIN#: 75-600528
Type of Group: Employer Type of Industry: Municipality SIC Code: 9190
(employer,association,trust:submit association by-laws or trust agreement)
Address: 1000 Throckmorton Street Fort Worth Texas 76102 Tarrant
(Street) (City) (State) (Tap) (co-ty)
Name of Contact Person: Maria L.Gray-Benefits Manager Telephone (817)392-7787
Fax No.: (817)392-2624 E-mail Address: maria.gray@fortworthtexas.gov
Billing Address ifdifferent: (Same as above)-Joanne.Hmton@fortworthtexas.gov Contact: Joanne Hinton
TPA ®No ❑ Yes Fax: E-mail: see above Telephone#: 817-392-6275
-------------------------------------------_-------------------------------------------------------------------------------------------------------
Contract Effective Date: January 1,2015 Length of Contract: 3 yrs with 2 one-year renewal terms that include a
not to exceed rate cap of 7.5%
Type of Contract: ®Non Retention ❑ Self Funded("ASC") ❑ Self Funded with Stop Loss % ❑ Other
Program (check one) ❑Delta Dental Premier'("Premier") ❑Other:
---------------------------------
__ ]RDental Pro_v-ider Organization-("DPO")----------------------------------Monthly-Switching-0__-_-
Fee Basis ❑ DPO in/DPO out ®DPO in/MPA out ❑ Table of Allowance #
-------------------------------------- ---------- ----------------------------- --------------------------------------------------------------------
Type of Dentist DPO Premier Non-Delta
---------- ------------- --------------- --------------------------------------------------------------------
Diagnostic&Preventive 100% 100% 100% ® Sealants
------------------------------------------------- ------------- ---------------------------------------------------- ------------------------
Basic 80% 80% 80% ❑ Sealants ®Endo ®Perio ® Oral Surgery
- --------------------------------- ---- - --------- --- -----=-----------------------------------------------------------------
Major 50% 50% 50% ❑Endo ❑Perio ❑ Oral Surgery
- ------------------------------------------------ ---------
- -------------------- --------------------------------------------------------------------
Benefit Year(check one) ®Calendar Year ❑Contract Year
-------------------------------------- -------------------------------------------------------------------------------------------------------------
Deductible $50 per Enrollee; $150 per Family or $n/a Lifetime
Waived on D&P ®yes ❑no
---------------------------------------- - - -------------------------------------------------------------------------------------------------
Annual Maximum $1,500
Orthodontics (check one) ❑ not applicable ®adults,children&students ❑ children and students only ❑ children only
50% I 50% I 50% I Lifetime Ortho Max: $1,000 1 Annual Cap: $n/a
----------------------------------------------------------- - - -- --------------------------------------------------------------------------------
Waiting Period ❑Basic months I ❑Major months I ❑Orthodontic months
Waiting periods are calculated for each Enrollee from the effective date reported for the Primary Enrollee. ❑ Yes❑No
--------... _----------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Takeover ®yes* ❑no If yes,previous carrier&takeover period: Orthodontics
*please check applicable boxes and provide history. ®Deductible Takeover ❑Maximum Takeover ®Orthodontic Takeover
----------------------------------------------------------------------------------------------------------------------------------------------------
Dual Choice ®yes ❑no If yes,name of other carrier: DeltaCare Plan 15A and M74
------------------------------------------------------------------------------------------------------------------ -
----------------------------
----
❑yes ®no Missing Tooth Exclusion applies—only teeth-extracted-under the contract will-be covered; ®yes ❑ no Section 125
-------------------------- ooth- xclu-o --------------------- --------- the contract be co------- ----------------------
®Special Requests(attach page if necessary):High/Low Plan w/Grp Specific Maximum Enhancement-see attached,41 Qrt Ded
Carryover,Non-Std Benefits;Benefits above are High plan and is PPO/MPA/90th;Low Plan is:PPO/PPO/PPO-Ded$50/$150,AMax$1,000,
D&P@100%,Basic@50%;Major @50%.Rates for low plan EO$19.85,ES$37.72,EC$43.68,EF$61.55;Rates below high plan;Elig 11`
of the month following DOH;Eligibilty-20 hours or more per week;Employee Eff Date- I month from Date of Hire
Employer Contribution: ®percentage ❑dollar amount Employee: 0 Dependent: 0
Monthly Rates:
❑Two Tier: EE: $ EE&family: $
❑ Three Tier:EE: $ Two Party: $ Three Party: $
®Four Tier: EE: $29.47 EE&Spouse: $60.41 EE&child(ren): $78.09 EE,Spouse&Child(ren): $98.72
❑Other(specify type and amount): If ASC:Per primary m mber$ per month or %of claims per month
OFFICIAL RECORD (Continued on next page)
GRP-DEN-AP-Tx-2007 CITY SECRETARY rev 09/07
FT.WORTH,TX RF CF EC DEC 1 P.M,
Group Dental Application(Continued) Applicant's Name: City of Fort Worth
Census 8,916 #of Eligible Employees
2,375 #of Employees Participating in Delta Dental's Fee-for-Service Program
---------------------------------------------------------- -----------------------------------------------------------------------------------------
Eligibility: #of Months: or #of Days: Hours/ Sp Req
-----------------------------------------------------------------------------------------------------------------------------------------------------
Employee Effective Date: ❑ 11 day of the month following completion of eligibility ❑Date of hire
❑-I'-day-of month following-date-of-hire ❑Da followin com letion of eligibility
Who is eligible: ®All ❑Class of employees:
Employees
®Retired Employees Children to age: 26 Students to age: 26
This program shall become effective only upon issuance of a written agreement executed by a duly authorized officer of Delta Dental. In the
absence of fraud or intentional misrepresentation of material fact,the statements in this application are deemed to be representations and not
warranties. Any misrepresentation,omission,concealment of fact or incorrect statement which is material to the acceptance of risk may
prevent recovery if,had the true facts been known to Delta Dental we would not in good faith have issued the contract at the same premium
rate.
Except as otherwise limited by the Health Insurance Portability and Accountability Act and its administrative simplification regulations
("HIPAA"),Applicant shall provide Delta Dental with Protected Health Information("PHI")for the proper implementation,administration
and management of the group dental services contract for which Applicant is applying. Delta Dental agrees that the PHI will be held
confidential and used or further disclosed only to administer the group dental program as described in the group dental contract or as
permitted or required by law.Applicant and Delta Dental shall comply with all the applicable federal and state laws and regulations relating
to administrative simplification,security and privacy of PHI,including the terms of any business associate addendum that may be required
as part of the group dental contract to be executed between Applicant and Delta Dental.
® .Applicant understands he/she will receive an electronic version of the evidence of coverage booklet for distribution to all employees/
members covered under the contract.
Executed this day of wer ,2014 for the Applicant at: Fort Worth,Texas
]l Vkft#.%V-
(please
City and State
By 1.7'print—nalne and title) Gn F
Accepted for Delta Dental Insurance Company
This day of
IAuthorization initials I Anthony S.Barth,President,Delta Dental Insurance Company
Agent Information Are you appointed with Delta Dental Insurance Company? ®yes ❑no
Agent Name Gallagher Benefit Services TIN or SS# ya q 1 q 7 1 State license#
(if applicable)
Signature Telephone# 512-499-8005
Address 221 W.6t}'Street,Suite 1980 Austin Texas 78701 Travis
(City) (State) (zip) (County)
OFFICIAL RECORD
CZ���� CITY SECRETARY 00
_ RM TX .�C?�
- °°��'
Contract Authorize ioa
A by' $ 0
Date * 0°°,��1
GRP-DEN-AP-TX-2007 Maty J. Kay , S6Y �Fkq S°�*
M&C Review Page 1 of 2
Official site of the City of Fort Worth,Texas
CITY COUNCIL AGENDA Fou WoRTH
COUNCIL ACTION: Approved on 7/22/2014
DATE: 7/22/2014 REFERENCE NO.: C-26884 LOG NAME: 14DENTAL
CODE: C TYPE: NON-CONSENT PUBLIC HEARING: NO
SUBJECT: Authorize Execution of a Contract with Delta Dental for the Administration of Dental
Insurance with Participants Paying All Premiums and No Financial Impact to the City (ALL
COUNCIL DISTRICTS)
RECOMMENDATION:
It is recommended that the City Council authorize the execution of a contract with Delta Dental for the
administration of dental insurance with participating employees and retirees paying all premiums and
no financial impact to the City.
DISCUSSION:
The Human Resources Department(HRD)will use this Contract to provide City employees and
retirees with access to dental insurance plans.
The City of Fort Worth currently contracts with Cigna Insurance to provide employees access to this
type of insurance. Having worked with the same carrier for many years, HRD staff determined that it
would be in the best interest of City employees and retirees to go out to the market and give all
providers an opportunity to compete for the City's business to ensure that City employees are getting
the best overall policies and prices.
The City issued a Request for Proposals (RFP) on February 19, 2014. This RFP was advertised in
the Fort Worth Star-Telegram every Wednesday starting on February 19, 2014 through March 27,
2014. Fifty-nine vendors were solicited from the purchasing database; eight responses were
received. The proposals were thoroughly reviewed by an evaluation team consisting of Staff from the
following departments: Transportation and Public Works, Fire, Water, Parks and Communiy Services
and Human Resources. The evaluation team was provided with resources and assistance by the
City's benefits consultant, Arthur J. Gallagher, and by staff in the Human Resources Department and
Purchasing Division.
The evaluation team ranked the proposals based on the following factors: technical proposals,
qualifications, adherence to terms and conditions of the RFP, financial stability, value-added services
and pricing competitiveness. Two finalists were selected for presentations. Following the
presentations, the evaluation team determined that Delta Dental provides the best overall solution to
the City.
The proposed contract will offer enhanced dental benefits at reduced costs to City employees and
retirees. Delta Dental will provide a three-year rate guarantee through December 31, 2017 with a 7.5
percent rate cap in years four and five.
AGREEMENT TERMS - Upon City Council approval, the initial three-year term of this contract shall
begin on January 1, 2015 and expire on December 31, 2017.
RENEWAL OPTIONS -This contract may be renewed up to two one-year terms at the City's sole
discretion. This action does not require specific City Council approval provided that sufficient funds
are appropriated for the City to meet its obligations during the renewal period.
http://apps.cfwnet.org/council_packet/mc review.asp?ID=20034&councildate=7/22/2014 12/15/2014
M&C Review Page 2 of 2
M/WBE OFFICE - A waiver of the goal for MBE/SBE sub-contracting was requested by the
Purchasing Division and approved by the M/WBE Office, in accordance with the BDE Ordinance,
because the purchase of goods or services is from sources where sub-contracting or supplier
opportunities are negligible.
FISCAL INFORMATION/CERTIFICATION:
The Financial Management Services Director certifies that this action does not have material effect
on City funds.
TO Fund/Account/Centers FROM Fund/Account/Centers
Submitted for City Manager's Office by: Susan Alanis (8180)
Originating Department Head: Brian Dickerson (7783)
Additional Information Contact: Margaret Wise (8058)
ATTACHMENTS
http://apps.cfwnet.org/council_packet/mc_review.asp?ID=20034&councildate=7/22/2014 12/15/2014