Loading...
HomeMy WebLinkAboutContract 28490 (2); � � 4 � � C���IP Di�fVii4L S�RVIC� A��EENI�IVT NOTIC� Tlie licensed HMO Plan is uad�rwritt�n by United Dental Care of Texas, Inc.. Beneiifs provided under the HMO Plan are available to ezirollees bp using in-network providers only, except for emergency dental care. Costs for dental services are based on a�ixed cop�ayaat�ent sclledule. An Indemnity Dental Plan, alsa available, is underwritten by Protecii�e Life Insurance Company. Benefits provided under tl�e �demniiy Plan are a�ailable to enrollees who may� use any provider. Costs for dentaI services incuired are reiinbnrsed af#er t��e deductible and coins�uance amounts, as specif'ied in tl�e policy, are met. It is agreed between Citv of Fort Worth ("Group") �d United Dental Care of Tea�as, Inc. �"Plan") as fallows; ARTICLE I CQVERAGE II�TI'aRMATION 1.I Grot� Name: Address: City, State, Zip; 1.2 Group Covera�e Sasis: ❑ Contributory Citv of Fort Worth 1000 Throckmorton Ft. Worth, TX 76142 1.3 Class af Memhers to be Covered: � Active �.4 Form of Cover��e (choos� one): � Non-Con�ributory ❑ Re#irees � Group requests coverage under dte Summit plan with Specialty Bene�it Option. ❑ Grou� requests coverage uz�dar tlie plan wiflioufi Specialty Benefit Qptior� 1.5 Monthlv Preqavment Fte: The Prepayrnent Fee for t��e n�mber of Memb�rs i;n each total �nontt�Iy fee category belaw is due and payabl.e from Group as set out in this Ageement. � Moat�lv Administrative Fee: A mantk�ly service fee paid by tl�e Graup only. This fee is not part af tl�e Memher's Prepayme:nt �'ee. Prepayment Fee + Subscriber Only Subscriber + One Subscriber �+ Two Subscriber -� Farnily Monthly Adiiunistrafive Fee � �.�i $ l 5.07 $ 23.77 $ 23.77 $ 0,00 Specialty Be�efit $ i.�.o $ 1.50 $ 1.80 $ 1.80 $ 0.00 TotaI Monflily Fee $ 1o.ii $ I6.57 $ 25.57 $ 25.57 � 0.00 I.6 Eifeciive Date: This Agreement shall become effect�ve on the iirst day of 1/1/2003 ("Effecti�e Date"). It may be renew�d pursuant to the renewal provisions of Agreement unle�s %rst terminated hy Pian or Group. � .. � UNITED DENTAL CARE OF TEXAS, INC �6775 Addison Raad, Suite 500 Addison, TX 75001 ���� ��������� n {800) 395-0557 G`�N�A�;�" � . (.�U � PDGTX-0058 (R05/01) Z a�7 GDSA 5/01 Tlie initial P1an Year sl�all coimnence on ti�e Effective Date and si�al� tenninate on date by PSan or Gronp. ARTICL� II ENTIRE CONTRACT F 111/204A� unless tenninated before tlus The Group Dental Service Agt�eement, Evidence of Coverage, Copayment Schadule and any applzcable exhibits, ainendments, ar riders hereinafter called "Agreemeni," form flie entire agreement of the parties. Tl�is Agreement may be amend�d or modi�ied. Changes must be in writing executed by Group and an authorized officer of Plan. ARTICLE III DEFIIVITTQNS The foilowing terms shall be defined as fa3lows: 3.1 3.2 Ann�versary Date: ShaII mean the day after tl�e ini�ial Plan Year en.ds. Tbe Anniversary Date occurs on the same date in each subsequent calendar year. Cana�ment: 5hall mean an additional fee ciiarged to Member by Plan Provider as identified in the Copaymenf Schedule. 3.3 Denendent: _ SY�all mean the spouse of any Subscriber at�.d all newbarn infants from and afker tt►e moment of birtl�, naturai children, adopted chilciren, grandehildren, children of whom the Sul�seriber has tempot�ary or p�rinanent couz't order granting canservatorship, or guardianslup, and stepchildren and foster children. Adopted children are considered dependents from the date the member becames a party in a sezit ut whicl� tlze adaption of the cluld by the member is snugl�t, ar from the date the cluld is placed with the member. All sueh chiidren shall be under die age of t�iineteen (i9), unmarried and chieily dependent on Subscrib�r �or support and live in Plan Service Area, Children vvhose co�erage is required by a medical-suppork order issued under Texas Law-Section I�.061-Family Cade, are not required to reside in the P1an Se�rvice Area. DeQendents shall be eligible for coverage on the day Subscriber is eligible for coverage ar on flie day Subseriber acquires such Depende:a�, whicl�ever is later. Eligibility may be extended up to age �venty eight (2�) for uYunarried children who are financially depenctent on Subscrihar far maintenance and support and are registered studenfs in regular attendance at an accredited schoal, coIIege or university. Dependent shall also mean the child of Subscriher age nineteen (19} or over not capable of self- sustaiuit�g employment by reason of inental retardation or physical disability and chiefly dependeni an Subscriber for maintenance and support. 3.4 E'ft'ective Date: The date coverage hegins under Agreement. 3.5 Emear�encv Services: Shal1 mean bona fide emergency dental services, liznited to procedures administered in a dentist's office, dental clinic, ar other comparabie faeility, to evaluate and stabilize dental conditians of a recent onset and se�erity accompanied by excessi�e bleeding, severe pain ar acute infection that would lead a p�dent lay person possessing an avera�e knowledge of dentistry to believe that iuunediate care is needed. 3.6 3.7 3.8 Enraliment Form: Shall mean the Group Enrollment Forn�. Mamber: 51ia11 mean a Subscriber or Dependent who is enrblled in Plan, Plan Dentist: Sha11 mean a General Dentist who is under camxact with Plan and responsible for proviciing dental services to Members of Plan, 3,9 Plan �rovider: ShaIl mean a Plan Dentist or Specialty Dentist under co:ntract with Plan. The t�z�rm. shall include any hygienists and technicians recognized by the dental profession who act witlz and assis[ Plan Dentist or Specialty Dentist, Establishment and location of aIl PIan 1'roviders are witivn the saie discretion and deiermination of Flazi. A list of Plan Providers shall be published in Plar► Dentist Directory. 3.10 3.11 Sueei�tltv Dentist: Sha3j �nean a dentist practicing in a den.tal specialty under confract with Plan to provide specialty services ta Members �ix�cluding, but not linnited to, Endodontics, Orthodontics, Pedodontics, Periodontics and Oral Stu'gery. �lan Benefits: Shall inean services provided under Agreement, subject ta any lixnitations and exclusions. 3.12 Plan Year: The initial Plan Year shall begin on the Effective Date and last for a period of 12 calendar months. Each subsequent Plan Year shall begi�a on the Anniversary Date a�d last for a period of twel�e (12) calendar months. The Anniversary Date for tlus plan is January. 3.13 1'reuavmen�t Fee: Slzall mean tb.e monthly fee p�id bq Group to Pla� for each Meinber necess�y iar provision of co�erage. PDC-TX-�058 (RO51�1) 2 of 7 GDSA 5/01 3.14 Service Area: �hail mean all caunties in flte State of Texas except Srawster, Culberson., Jeff Davis, Presidio, Terrell, and Val � Verde. 3.15 Subscriber: Shall nnean an emplayee, member, or beneficiary of Group who is elzgible to particip�te in Plan under flie eligi�biliiy requirements determined by Graap. ARTICLE N PREPAYM�NT F�E AND EL�GIBlLITY 4.1 Prepa�ment F�e: Group sl�all pay Plan t�e rnonthly Prepayment Fee for each cavered Memberr, Tlus starts on the Effecti�+e Date and on the first day of each month thereafter wltile Agreement is in force. Ai}er the initial Plan Year, Plan reserves the right to change the Prepayment Fee upon sixty (60) days writien notice. Group's payment af any amended Prepayrnent Fee indicaies its acceptance of the amended Prepayment Fee. 4.2 Pravision of Plan BenefitslPlan Praviders: Group aclfriowledges tliat unless there is a need for Emergency Services or +Graup purchases the optional5peci�ty Benefit Rider, A�reement provides exclusively far services performed by a Plan Prov'tder. P1an s1�all npt have any liability due to treatment by airy non-Plan dentist, pl�ysician, hospital, otl�er persan, institution or group. Each Memher sl�all select a P1an Denfiist from Plan Dentist Directory furnished by Plan to Group. Agreemeni provides for services only. It is not an insurance golicy. It does nat reimburse Member pr Group, excepi for Emergency Services (as explained in the Evidence of Co�erage} or Specialry Benefit Rider services. 4.3 El��ibilitv List: Group shali �e responsible for providing Plan, t3y ihe 20�` day of tha month, tlre names and otl�er identifying data far each Member to be covered in arder for eligibility to be e�ective on flie 1a` day of tl�� �ucceeding montli. Group shall identi�y those Members who are newSy eligihle ta receive Plan Ber�e.�its. Tt shall name the Plan Dentist selected by each Member who is newly eligible. It shall identify Chose Members whase coverage wiil t�x�ninate, Group shall be xes�onsible far payment qf Prepay�nent �'ees due P1an for Membars. Payment s1��11 continue until notice of a change in eligibility is pravided to Plan. 4.4 Eli�ibilit�: Group shall deterttuine efigibiiity far p�'ticipation in Plan. Plan zna� rely upon such decision until Group provides notice of a change in eligibility. Any disputes or inquiries fram Members regarding eligibility, including renewal or cantinuation of coverage, shall be refened by Plan to Groug. Group shall advise Plan of its decision. Each Member �nust work or live in Plan 5ervice Area in arder to participate in Plan. Subscriber and his Dependent{s) are eligible to become Mambers of Plan during the apen enrollment period sei by Group. A nevvly acquired Dependent of Subscriber shall be eligible for coverage on tlte day Subscriber acquires Dependent or on the day Subscriber is eligible far coverage, �vvlriche�er is later. All newborn infants� shall be eligible for caverage from and after the moment of birth. If an additional Prepayment Fee is required for �overage of a nevvborn infan�, Group must natify Plan and must be paid w'sthin t1�i.Fty one (3 ]) days after the date of birth. Prepayment Fees for other Subscribers and Dependents are addressed in Section 4.5 Covera�e of Me�ubers, 4.5 Covera�e oi Members: The Effect�ve Date of co�erage for Subseriber or Depencient shall be the first day of the month after rvrztten notice and payment af the Pr�payment �'ee is accepted bq Plan. Each Subscriber or Dependent enroIled in Pian and whose proper Frepayment Fee has been accepted by 1'lan prior to tha 2Qt11 will be covered beginning the first day of the following znonth. Each Subscriber or Dependent �nrolled in Plan and whase proper Prepayment Fee has been accepted by Plan between. the 2bth and the last day of the monfl� will be cavered beginning tlie �rst day of the second following month. 4.6 Enrollmer►t k'orms: A Subscriber s11a11 complete an Enrolltnent Forn� or submik suitable proof of enrolIment for lum/�aarself and any Degendents. Al� state�nents made by� the Subscriber on the enrollrnent form or suitable evidence of coverage slu�ll be cansidered representations and not warranties. A stateznent may not be used in a contest to void, cancel pr non-ren�w a Member's caverage unless a copy oithe ent'oliment form has been furnislied to the Member. ARTICLE V BENEFITS 5.1 Plan Benefits: Flan sh�li provide services to Members as set forth irt tIie E�idence of Caverage and Cvpayiuent Scl�ednle. Services ar� subject to limitatiflns and exclusions. Servic�s are pro�ided for tlie term of Agreelnent. Pian reserves tiie right to change Plan Benefits after tlie initiall'lan Year. Noiice of such chang� is subject to sixty (60) c�ays written noizce prior to the renewal date. PDGTX-DQ58 (RO5/01) 3 of 7 GDSA 5101 5.2 Couavments: Mernher shall be responsible for payment nF all Copa�ments and charges for non-covered services. Meinber � shall malce payment to dental provider at tlie time service is renciered. Member may have an option to pay according to provider's billing proceduxes. ART�CLE VI MEIi+IBER/PLAN PROVID�+ A RELATIONSHIP 6, I MemberlPlan Provider Aelationshin: The reiatianslup between Member and Pl�n Provider sl�all be an inc�ependent professianal one. Plan Frovider siia�l be solely responsible, without infrusion by Plan or Group fot' all services wit3un fl�e professianal relafi�onship between Member and Flaxa Provider, l�lan has the right to tenminate a Mernber's coverage for failure of the Me�x�.ber and the Pian Pro�ider to establisl� a satisfactory patient-den�ist relationship. Refer to Article IX TERM AND TERNIINATION. 5.2 G.3 Plan Provider Faeilities: `Fhe operation and maintenance of Plan Provider's faci�ities and equipment shaII be completely under the control of Pla�n �ovider. Tlus includes tlie select�on o� staff, supervision of personnel and operatios� of the pxofessional practice. It also it�cludes rendition of any particular professional service or treatment. 6.�4 Providers not narticipating with Plan: �'Ian does not evaluate or review pracdce standards of non Plan Providez's. Members who obtair► se�vices from non Plara Pro�iders should separately evaluate the practice standards and skills of those providers. ARTICLE VII ADMINISTRATION 7.1 Dist�ribution of Plan Materials and Notices to Members: F1an may be abligated t�der state law to give any notice or Plan materials to Member. If so, it shall be suff'tcienf for 1'lan to give notice ar Pla;n materials to the Group's delegate. Ttris stzall apply unless state lary requires othenvise. Group shall then be resgansible for praviding natice or 1'lan materials to Subscribers. 7.2 Grievance Resolufion �rocedures: 1�ny inquiries, camplaints or grie�ances shall be made by contacting Y1an or Flan Pravider, Members should take anq question or concern directly to PFan �'ro�ider rendering service to resolve the issue immedzately, Grievance Resolut�on Procedtrres are outLined in the Evidence of Co�erage. A copy of the procedures may be abtained by contacting P1an. 7.3 Selection of Provider: A. Plan Dentist: Each Membex sha31 select a Plan Dentist from Plan Deniist Directory, To obtain Plan Bene�its, Mamber shall contact selected Plan Denrist. Either Memher or Plan Dentist z�aay request a change of Plan Provider selection by contacting Plan. H. Suecialiv Dentist: Witliout 5tiecialtv Benefit Rider: If Member requires specialty services cavered un.der Plan tIiat cannot be psovided by Member's selected Plan Denfist, Member may ohtai n services fram a Specialty Dentist, No referral from the selected Plan Dentist is needed. Plan cioes not cover services received from non-Plan Providers. With Stieci�ltv Benefit Rider: Under the S�ecialty Benefit Rider, Member nnay obtain services from a Speczalty Den�ist or a non-Specialty Dentist. No referral is needed from the selec#ed Plan Dentist in order for Member to obtain se�vices from the specialist of his cl�oice. Member's out-of-pocicet ainount for a particular seroice may vary depending on whether services are receiv�d from a Specialty Dentist or a no��-Speciarty Dentist, C. Licensed Dentists Not Under Contract with 1'lan: In ihe event necessary covered benefits aze not available tl�rough Plan Providers, Pian shaIl, upon the requ�st of a Provider, ailow referral ta a licensed dentist nat under contract with 1'lan and shall reitnbuxse such licensed dentist at the usua� and custoinary or an agreed rate. Plan shai! not deny any suclz referral withaut providing for a review by a specialist or si�nilar specialty as the Plan Prvvider. 7.4 �mer�encv Se�ices: Plan shall arrange for Emergency Services ttiventy fou:r (24) hours a day, seven (7) days a week. Procedures for obtai�ing Emergency Services ar� in the Evidence of Coverage. A copy of tlie procedures may also be obtained by contacting Plazi. 7.5 Assi�nment of Beneft�s: Member's coverage is intended for sole use and benefit of Member. Coverage cannot be transferred to a third garty. �DGTX-0458 {RO5/01) 4 af7 GDSA 3101 ARTICLE VIII COORDINATION OF BENEk�TS �$.1 Coordination of Bene�ts: Is the process for determining payment responsibility in cases where Member has benefit caverage with more than ane carrier. The "priirnary" plan is the plan whose co�erage applies first. The "secondary" plan may pro�ide additional benefits after the primaxy benefits are applied. Plan is "primaxy" under the �ollo�ving conditions: 1. Tf Member has coverage under inare than one Iicensed HMO plan, the plan that covers th� individua! as Member or subscriber of Group is primary. 2. IfMember lias coverage under both a licensed HMO pla�� and an indeznnity plan, the HMO plan is pritnary. 3, In the case of cavered Dependa�ts who are not directly covered under a gxonp plan, the plan of the pax'ent wl�ose birthday occurs eariiest in the year (not ti�e one wiio is oldest} is primary. The above may not apply in the case of a divorce decree, court action or the iike in compliance with Texas Depart�nent of Insurance Regulations, which may mandate ttiat oflier coverage be primary. ARTICLE IX TERM AND TERMINAT�ON 91 Tern�: After the initial Plan Year, each Plan Year of Agreement shal! have a tr�velve month tenn. it s1�a31 be automatically renewed at the Anni�ersary Date unless otharwise terminated. 92 Tcrmination: Plan rr�ay be terminated as follows: (1) During flie initial Plan� Yaar by Plan: (a} for faiiure to pay proper rnanthly Prepaymeat Fees priar to kUe 10'� af flie month in wlucla Prepayment Fees are due, sub�ect to a thirty (30) day grace period; (b) for frauc� or misrepresenfarion of fact in obtaining coverage u�der PIan, upon fifteen {15} days prior written notice; (c) for matexial breacU af any provision of Agreetnent, upon sixty (60) days written notice to Group; (2) At Anniversary Date, upon s�ty (60) days grior written notice by Plan or Group. (3) After Ehe initia.! Plan Yea;r, without cause, upon sixty (60) days prior vvritten notice by P1an or Group. 9.3 Con#inUation af Cavera�e: If Agreement is terminated, each Plan Pxovider shall complete aIl dental procedures started prior to the date of terminatian. Tlus will be pursuant to the terms of Agreeinent and as required by state 1aw, except for orthodontia treatment. Should a Member in oarthadontia treatment terminat� fox any reason, Member sha11 be respansible far payn�ent of aIl services rendered after the terminaiion date. Anq enrollee whose caverage under tliis Agreement ttas heen terminated for any reasan except invaluntary termination for cause, and who has been continuously insured under tlzis Agreement o;r under any group contract groviding similar services and benefits wlueh it replaces for at Ieast three consecutive monflis itnmediately priar to termination s11a11 be entitied ta suc�i continua.tion privilege as outlined below. Ineolu:ntary tennina.tion far cause does not znclude termination for an� healfi�- related cause. A. Cantinuation of group coverage under this Agreement m�st be requested in writing witl�in tlzirtiy one (31) days following the later af: (a) the date fihe group coverage wauld other�vise terminate; or (b) t�ie date the enrollee is given notice of tl�e right of continuatian by the Group. B. An enrnllee elacting continuatian must pay to the Group on a manthly basis, in advance, the amount of contribution required by the Graup, plus two gercent of i��e group rate for the coverage being continued Un.der the AgreeFnent, on the due daie of each payment. C. The enrollee's written election of continuatian, togetl�er with the �'irst c�ntribution required to establish further contribuiians on a mantiily basis, in advance, must be given to the Graup within thirt5r one (31) days following the later of (a) the date the goup coverage would otherwise ten�ninate or, (b) the date t�e enrallee is given not�ce of the right of continuaiion by the Group. . D, Continuation �nay not terminate until the earliest of (a) six (6) monil�.s after the date the election is made, (b) tlie date on wlucl� failure to make �nely payments woul.d terminate coverage, (cj tkie date on wl�ich the covered person is cavered fnr sirnilar services azxd benefits by another hospital, surgical, medical, or xnajor medica! expense insutance policy or 1�ospital or medical selrvice subscrfber contract or medical pracfice or other prepayynent plan or any other program, ar {d} the date an whiclz the Agree�nent terminates in its entirely, PDC-TX-0058 (R05101) 5 of 7 GDSA 51Q 1 4.4 Member Termination: Member co�erage sl�ail terminate as follows; A. On the last day of the month for which Graup has placed Meix�ber on eligzbility list and has paid Yhe proper Prepayment Fee. B. if Member coFnrnits fraud or material misrepresentation in tlie use of services or facilities, coverage for Member will ternunate upon fi�een (15) days wriiten notice of terminatian. C. If Member evrrunits fraud or material misrepresentation an Enrollment Form submitted by Member, coverage will tertninate upon fifteen (15) days written notice of termination. This pro�ision wil! nqt br. enforced after twa (2) years from tiie time 11,+Iember's caverage be�ins. D. If Graup and/or Flan terrninates Agreement, coverage �or Member shall cease on the ter�tunation date. This shall be subject to any notice required by state law. E. If Member fails ta make req�ired payinents, including Copayznents, �nissed appointment fees, Platt reserves the right to termznate covsrage upon sixty (b0) days written notice. Prepay�nent Fe�es xeceived an account of terminated Member, which agply to period after termination d�ta shall be refunded to Group. The�reeafter, Plan sliali have no furtlt�r I�ability or respansibiliry to Member, F. If Member, af�er reasonable efforts, is unable to establi,sh and maintain a satisfactory d�ntist-pabient relationship with Plan Pro�ider, Plan reserves the right to terminate coverage upon sixty {60) days written nolice. �repayment Fees rec�ived for tenninated Member For tha period after termination date sZaall be refixndsd to Group. Thereafter, �'lan shall l�ave na furttier liabilily ar responsibiIity tn Member. G. Coverage for Subscriber' a De�encients will be terminated if the coverage fox Subscriber terminates for any r��son. This is subject ta continuation pri�ileges for certain Dependents as set forth l�erein. H. Once a Member is no lon.ger quali%ed as a dependent, coverage for that Member will terminate. Caverage shall not tertnitnat�. �uvhile a De�endent child of Subscriber is and condnues to be incapable of seIf-sustaining employFnent. This is by reason of a daisability or physical handicap. Dependent must be chiefly dependent upon Subscriber far maintenance and support. Suhscriber inust fiunish proof of �ncapacity and dependency to Plan wsthin thirty one (3 I) days of the child attaining limiting ag� and every year tliereafter, if requested by Plan. I, If Member no langer works or lives in Plan Service Area coverage will te�minate upon thiriy (30) days written notice af terxninatian. This does not apply to a Depende�t child u�der a anedical suppart ozder as deiined in the Dependent Section 3.3 of this Agreement. J. Upon misconduct detrimental to safe plan operation and the de�i�ery of serviced, Meinber's coverage nc�ay be cancelled immediately. 9.5 Conversion Privile�e: If Member esases to meet eligibility rec�uireuaents of Group, Mernber may convert to an individual dental plan. Tk�is occurs withont furnishing e�idence of insurability. Ta obtain an individual dental plan, Member must worl� ar live in Plan Service A.rea. However, a Dependent child covered by P1an pursuant to a court arder is not required to work or reside in the Plan Service Area, but within the United States, for pwpases of accessing dus conversian privilege. The Member musE subzn�t the campleted intiividual enrollment form and all Prepayment Fees to Plan within ttzirty-one (31) days after termination date. Plan �ill notify Member in w.riting of coverage effective date. Co�version pri�ileges slz�l :not be made availa�le to Member terminated as a result of fraud or material misrepresentatian, 9.6 Cant'rnuation of Covera�e under COBRA: If under the provisions of Title X of the Consolidated Omnibus Badget Recanciliation Act of 19$5 (COBRA), Public Law 99-272, Member is gxanl�d the riglif to continnatiort ai coverage beyand the daie Member's coverage wauld otlienvis� terminate, flie following a�plies. Agreetnent sha11 be deexned tn allaw continuation of coverage as necessary to comply with the pravisions of applicable statu�s. Member shauld contact Group concerning eligibility. ARTICLE X GENERAL PROVISIUNS 10.1 Amendments or R,iders: By n�utual conseni, F1an and Graup may modify, amend or alter Agreement. Suc�y change shall be in writing and duly execu�ed by both parties. Any change shall be attached to Agreement. Plan may amend Agreement unilaterally to coinply �v:ith germane law. PDC-'TX-0058 (RQS/01) 6 of 7 GDSA 5101 I0.2 Waiver: The tvai�er by elther pariy of one or more defaults shall no# be construed as � waiver of any other or future defauIt. This applies to any covenat�t or other conditian cantained in Agreemenf. Only an authorized officer of plan may rvaive any conditions ar restrictions of Agreement. On1y an authorized office of Plan can amend Agreement, e�end ti�ne far inaicing a payment ar bind Plan by makiz�g any promise or representation. Sucli proinise or representation shall be in writing. No change in Agreement �hall be �a1id unless endarsed by an authorized o�"icer of Plan. 10.3 10.4 14,5 Nat'rce: Natice ta eit�er parEq under this Agxeement shall be in writing. Notice sha11 be sent to flie address shown in Agreeznent. Terms: Thraugltout Ageement, the singular shall include the plural and the plural �he singuIar. The masculine shall include flie neuter and feminine. TI�e neuter siiall include the masculine and femirune. �anvaliditv: If any grovision of Agreement is datermined to be illegal or invalid, ail ottiez provisions remain valid. This is irue unless fl�e illegaliiy or invalidily prevents �e purposes of Agreement fronn being rea�ized. 10.6 Assignment of A�reement: No assignment of Agreernent is binding upon Plan unless Plan agrees to it in writing, Any such assignment shall nat waive Plafi's right to withhold i�s consent to atzy other assignnient. There may occur a merger or acquisition involving Group. If so, Agreement shall re�nain in force with flie survivin� entity for the balance of the term of Agreement, 10.7 Acl�nowled�ment: Each of the parties acknowledges that it has read Agreaztzent and undersCands its contents. Each party acknowledges it execntes Agreement voluntarily. 10.8 Authoritv: Group represents it has kh� autharity under applicable law and its charter instrument to execute Agreement. 10.9 Worker's Comnensation: Ageet�aent is not izz place of and c�oes not affect any requirement for coverage Y�y 'V4''arker's Compensatiori. 10.I0 Governin� Law: Agreement sl�ll be governed b� and constY'�ed according to laws of th� Stat� oi Texas. 10.I i Circumstances Bevond Plan's Control: Rendirion of dental services may be delayed or made i�npractical due to circunnstances not within Plan's cantrol. If this occurs, neifl�er Plan nor Plan Pravider shall laave any iiability or obligatinn to provide services on account of suc1� delay. This incluc3es, but is not limited to, camplete or partial destnactiort of facilities, w�r, riot and civil insurrection. It also includes labar disputes or disability of a signif'icant number o� Plau Providers. 10.12 Maior Disaster or E»idemic: If a major disaster Qr epidemic occur�, Plan Provider shaIl render dental services as practical aceording to his judgment. 5uch dis�5ter or epidemic may li�nit availabie facilities or personatel. In such a situation, neither Plan nar Plan Frnvider shall have any liability or obligation for deIay or failure to provide de�tal services. 10.13 Attorne�'s Fees and Costs: If Group defaults in any of its obligations, Group agrees it �viI� pay all of Plan's costs to enfarce its rights hareunder. This includes, but is not Iimited to, PIan's attorneys' fees and court costs. 1�.14 ERISA: If Group is regulated under the Employee's Retirement Income 5ecurity Act of 1974 (ERISA), PIan va+ill work with Group in supplying Group with any inforn�alion in its possession in meeting any reparting requirements, Plan is not and shall not be fhe chasen adminis�rator or fiduciary for reportin� requirements, IN 1�VI�NESS WHEREOF, the parfies have aff'ixed their signature lo t�us Ageement. PLAN: United Dental Care of Texas, Inc, GROUI' Citv of Ft. Wortla By: Signature By: � �� Signature Chris T. Calos, VF', Dentai And Cnnsumer Benefits Cluef Markefing Oi�icer Date PDC-TX-QpS8 (ROS/p�) 7 oF7 Print Name and Title Date �� GDSA 5101 Page 1 of 1 S�IIy Co�chran - �. �. Sweeney sxaw�•��'.sr�^ �� ��.sa���� .o�r.�:w�xarxaa� .�rdr.�r�p,��r,dsb;�ss�a���.�u,�.o-x�r,�r.���x�t From: "Sandy Coieman" �scoleman@millsfinancialgroup.com> �o: <sally.cochran@us.forkis.com> �ate: � 211212a02 4:07 PM Subjec�: R. E. Sweeney Hi Sally, The meetings at R. E,. Sweeny will stari at 9:bd AM on Tuesday, �ec. 17th. I believe you have been there before, I will rneet you at their office about 8:45 AM. Wi11 yau please bring about 4D directories. Th� office in Birrriingham has sant new hire enrollment packages and I have the summaries they sent also for the Pinnacle plan with the specialty rider. We wifl har►e another meeting at 9:45 and then 1 a:30 and they wip have someone to speak Spanish there. As far as I know we will be done then. Her� is my cell phone (897) 308-7802. 5andy Coleman, Account Manager Mills Financial Group 817 332-3656 817 332-8609 {FAX) �le:ll C:1Documents%20and%20SettingslSC4S 8021Local%20 SettingslTempldlGW } 04Q01... 12/13/2002 :����i���� ������� ���ri�r��nt - Benefits pravicfed by: ��� 1��3 ���Tl�� C�►R� 0� ����, ��C. �6�i� Rddison Road, Sui�� 50fl Addison, iX 75001 ��00) 395�D557 This Specialty Benefiit Rider expands dental services covered under Agreement. Additional services are available from dentists practicing in a dental specialty. Dental specialty includes, but is nat limited to Endodontics, Orthodontics, Pedodontics, Periodontics and Oral Surgery. These beneffts are a�ailable to all Group Members enrolfed in the Plan. Dental services available are described in the Evidence of Cov�rage and Copayment Schedule. This Rider is subject to all terms, condi�ions and pravisions of Agreement whic� are not inco�sistent with this Rider. The amended Agreement shall be effect[ve 111103 . The Prepayment Fee for the number of Members in each total monthly fee categary below is due and paya�le to P[a� from Group. This 5hall �egin on the effective date of this Rider. It sF�all continue on that same day for each month the Agreement continues in force. Prepayment Fee Subscriber Only �u�scriber + Qne Subscriber + Two Subscriber + Family Manthly Administrative Fee $ 8.91 �is.o� $ � 23.77 $ � 23.77 $ o.00 + Specialty Benefit � $ _1.20 � _Z.so $ 1.80 $ _�.sa � _o.00 IN WITNESS WHEREOF, the parties have �f'ixed their signaLuxe ta this Agreement. P�,AN: United DentalCare of Texas, Inc. 5ignature Chris T. Calos, VP, Dental and Consumer Bene�Zts Chief Ma.rketing Officer Date GROUP Citv of Fort Warth Signature Print Name and Tifle Date �(Cc���.- c , Total Manthly Fee $ 10,1i $ � 16.57 $ 25.57 $ � 25.57 � o.ao PDC-TX-0�64 (RO5/O1) 5BA 05/01 Delete 4.4 Cavera�e of 1Vlembers. The effective date of coverage for Subscriber or D�pendent shall be �he first day of the rnonth after written notice and payment of the Prepayment Fee is accepted by plan. Each Subscriber or Dependent enrolled in Plan and whose praper Prepayment fee has heen accep�ed by Plan prior to the 20th will be covered beginning the first day of the following month, Each Subscriberr or Dependent enrolled in Plan and whose proper Prepayment Fee has been accepted hy Plan between 20tb and the la.st day of �he month will be covered beginning the �st day of the second foilowing month. Insert 4.5 Covera�e oilViembers: The effective date of coverage for Subseriber or Dependent shall be the first day af the policy month ai�er written natice and paymenk of the Prepayment Fee is accepted by plan. Each Subscriber or Dependent enrolled in Plan and whose prvper Prepayment fee has been accepted by the seeond pay period of the month wi.11 be covered beginning the first day of the following manth. Each SubScriber or Dependent enrolled in Plan and whose proper Prepayment Fee has not baen accepted by the second pay period af the month will be covered beginning the first day of the second follawing month, after one full montii oipremiums have been collected. � 1, ���'�r_ .��-�--� Forhs Benefits Insurance Co. o �� �. � `-�.� . � .���� � - �-- � . � _.��� rn�.� _ �.c� Co�atxact �4u��io�:�za�ion � --,��,�,r.._...s___�_.__.�-�-- ---- .. ���� It is agreed that the dental plan carrier for City of Fort Worth is Fortis Benefits Insurance Co. and the dental HMO plan i� underwritt�n by United Dental Care of Texa�, Tnc, The Group Dental Service Agreement is hereby amended pursuant to Article X, Section 10.1, Amendments as follow: ARTICLE IV PREPAYMENT FEE AND ELIGIBILITY Delete 4.3 Eli�rbility List: Group shall be responsible for providing Plan, by the 20t�' day of the month, the nam�s and other identifying data for each Member ta be covered in order for eligibility to be effective the 1 St day of the succeeding month. Group shall identify those Members wha are newly eligiible to receive Plan B�nefits. It shall name the Plan Dentist selected by Members who is newly eligible. It shall identify those Members whose coverage will terminate. Group shall be responsible for payment af Prepayment Feed due Plan for Members. Payment shall can�inue until notic� af a change in eligibility is provided to Plan. Insert 4.3 Eli�ibilit_y List: Group sha1l be responsible far providing Plan, by the second pay period af each rnonth, the names and other identifying data �or each Member ta be covered in order for eligibility io be effective the ls` day of the month following one full mon�h. Group shall identify those Members who are newly eligible to receive Plan Benefits. I� shall name the Plan Dentist selec#ed by Members who is newly eligible. It shall identify those Members whose caverage will ternunate. Group shall be responsible for payment of Pre�ayment Feed due Plan for Members. Payment shall con�inue until notice of a change in eligibility is provided to Plan. Pri�acy �lofiice . � ����.o �� � 11 � S � � � 5olid p�clners, 1lexihle salutions� Fortis Benefi#s Insuratzce Company'�, First Fortis Life Insurance Company*, and the Fortis Bene�its DentalCare campanies* seek ta provide eost effective bene�it solutions far our policyl�olders, contractholders, and insureds. These solutions help to create a sense of securiiy for our customers, not onlq from the protection our products afford but, ec�ually i�nportant, from the care we t�lce in protecting . our eustomers' perso�al information eaen if the formal customer-client re2at�onship ends. Your tiust in us in protecting this information is of utznost importance to us. Please read our Privacy Not�ce and, if applicable, share it ;uith those individuaIs receiving car�erage under your policy or glan. The term "custoaner" as it is used zn this notice refers to �ndividual claimants, insurads, members, bene�ici�►ries or applic�tnts. Tktis notice details the typ�s of inforcnatian we collect, who we might sl�are thlt iz�ormation with, and the security measures we have in place to respect the privacy and confic�entiality of th� inf'orrnation we collect. I. Pewsonal infqrimation �ve +�ollec#: + Az�y information that is pro�ided to us fhrough the �ompletian of the foiFowing �'c�_rmc: � Ciaim farms • Enrollznent forms • Bene�iciary designativn/Assignment forms p Any otl�er form neeessary ta efifectuate coverage, adz►tiiuster coverage, or administer �nd pay d claim, e tlny information from others that is nacessary for us to properly �rocess a claun, underwrite Eh� co�erage, or io qtherwise compl�te a transactian requ�sted by our customer, policyholder, or contractholder. B Any information that our customer authorizes us to caU.ect from otliers, The inforraation coIIected caan incliide name, 5ocia� Security number, address, dat� of birth, phane number, maritaI stalus, gender, dependent infaz7mation, banic accvunt information anc� employmezzt infarmation. Wliile tlus list is �ot exh�ustive it shontd give you an idea of the types of informatian we ara referring to in this notice. . II. Person�i infor�nation rve may disclose nnd to whom: � We da not disctose any af the above-d�seribed personal infoxmation about our cuirent anc3 former eustomers to any third parties except as pe�txitted by law, s�ich as for completing a requested transaction., and/or if authorized by aur customer. � For various business xeasons, we may need to pro�ide our customer's personal infozmation to ovr �liates or others, inclndin.g a policyholder's or contracthoider's broker, third-party admiiust�ator, reinsurer, employer or plan sponsor. These disclos�res rnay be made to others for the purpose of performing adaninistrat�ive services on our behalf, heiping us administer or revzew a claim, where we feel it necessary to protect our interests, or as requested by a governmental agency. � We may disclose the above-described personal informatian to ath�r non-affiliated third parties in oxder for them ta help us provide sctperiar products and services. Slxould we determine that Wese disclosures are necessary, we will seek assurances that these third parties will not further share khe in%rmation beyond its stated purpose. III. Health information. • We will not share any of our custpmers' health information unless allowed by applicable law and/or the customer ha,s provided ns the appropriate authorization. IV. Confidentiality and Tntegrify. � We use physical, �Iectronic, and procedural controls, includ'urg physically secured areas and comp�ter access controls. • We assess tiie integrity of our systems through auditing, monitoring and data management processes. o We hav� policies to direct and procedures to Iiinit access of a customar's information. � Qur ernplayees are continua2ly trained on how to keep onr customers' information safe. Page 1 of 2 � Fortls 8saafits Insurartce Company, 2�02 KC43tl5 (5l2�a2) E V. Questions? We hope this no�ice has been h�lpful in explaining our privacy policy. Please note, we reserve the right ta change this notice. If we da, we will notify you of any changes made. If thare are any ques�ions conceming dus privacy notice, please cozztact us at 1-8�0-733-7879 ar �ortis Beneiits Znsurance Campaizy, Attention Privacy Offacer, P,O. Box 4 Z9052, Kansas Giiy, MO 6414I-60S2, * In this notice, "we", "us", and "our" refer to Fortis Benefits Insut'�ice Company; First Fortis Life Insuranc� Company, Iicensed only in the State of New York; and the following Fortis Benefits DentaICare companies: UDC Life and Health Insarance Company; United Dental Care of Missotiri, Inc.; DentiCare of Qkla�toma, Inc.; DentiCare of Alabama, Inc.; DentiCare af Arkan,sas, Inc.; Deti�iCare, Inc. (A Florida Cotporation) A Pregaid Limited Health Service Org�nizatian Licensed Under Chapter 636 of the �'lorida Statutes; DentiCare, Ine. (A Kentucky Corporation); Georgia Denta.l Plan, Ine.; Internationa! DentaI Plans, Inc.; F4rtis Benefits DentalCare of Wisconsin, Inc.; Fortis Benef�ts DentalCare of New Jersey, Itzc.; UDC Dental Califortzia, Inc. dba United Dental Care of California, Inc.; UDC Qhio, Inc, dba United Dental Care of Ot�io, inc.; United Dental Care of Ariznna, Inc.; Uzuted Dental Care of Colarado, Inc.; United Dental Care of Inciiar�a, Inc. ; United De�tal Care of Michigan, �nc.; United Dental Care af Nebraska, Inc.; United Dental Care of New Mexico, �c.; United Dental Care of PEnnsylvania, Jnc.; i]nited Dental Care of Te7cas, Tnc.; United Dental Care of Uiah, �nc.; and United Dental Care Insurance Company. With regard to Firsi Fortis Life Insurance Company, tius notice only applies to its group disability, fife, and dental groducts and its prepa�d dental product. Pe�e 2 ot z KC9305 {512002) � Standard Business Associate Response to Poiicyhalders P � e� � O�o�.�ib• o �����a,. o �s 9e. ���tT1��M You are receiving this communication because you harre requested that Fortis Benefits Insurance Company or one of the �repaid companies qwned by Fartis sign a business associate agreement req�ired under HIPAA. It is our position that, as your insurer, we are not cansidered a busir�ess associate under HIPAA and therefare, not required to sign the submitted business associate agreement. , ln suppori of this pasition, we direct your attention to Vofume 65 af the Federal Register, page 82476, wherein the regulators comrnent or� this specific topic. In expfaining what is a business assaciate, the regulators state the fnElowing: (W�here a group fiea�th plan �urchases insur�nce or covera�e from a health insurance issuer or HMO, fhe provision of insurance by the health insurance rssuer or HMO to the �roup healfh plan does nof make fhe issuer a busirress associafe .!n such case, fhe aati�ities af the heaith insurance issuer or HMO are on their own behalf and nat on tne behalt of the �roup i�eatfh plan. Sta�dards for Priva�; c�f Individually Identifiable Heafth fnforma#ion; Final Rufe, 65 Fecl. Re�. 82A�76 (2000). Consequently, v�re will not �� exe4uting �he business associate agreement. Please contact Melonie Jones, privacy officer, at 816.881.8835 or rneloni�.iones{d>us.farfis.com if you have any questions. Thank you for your consideration of this matter.