Loading...
HomeMy WebLinkAbout1985-447 ,l . '~"'--' 1 2 3 4 5 6 7 8 9 10 11 12 13 RESOLUTION NO. 85-447 RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE EXECUTION OF AN AGREEMENT WITH MISSION DENTAL HEALTH PLAN FOR EMPLOYEES' GENERAL DENTISTRY PLAN WITH ORTHODONTIC BENEFITS, EFFECTIVE JANUARY 1, 1986. BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF SAN BERNARDINO AS FOLLOWS: SECTION 1. The Mayor is hereby authorized and directed to execute on behalf of said City an Agreement with Mission Dental Health Plan, relating to employees' general dentistry plan with orthodontic benefits, effective January 1, 1989, which agreement is attached hereto, marked Exhibit nAn, and incorporated herein by reference as fully as though set forth at length. I HEREBY CERTIFY that the foregoing resolution was duly adopted by the Mayor and Common Council of the City of San 14 Bernardino at a regular meeting thereof, held on 15 the 4th November day of , 1985, by the 16 following vote, to wit: 17 18 19 20 21 22 23 AYES: Council Members Estrada, Reilly, Hernandez, Marks, Frazier, Strickler NAYS: None ABSENT: Council Member Quiel ~&7-?~/.b / City Clerk The foregoing resolution is hereby approved this ].2th day 24 of 25 26 November Bernardino Approved as to form: :: Ci~C~~ . ~ GROUP SUBSCRIBER AGREEMENT (PLAN - 82-V ) GRP# 900476 - 81-0R This Agreementis made and executed this 21st day of OCTOBER .19 85 by and between CITY OF SAN BERNARDINO (hereinafter referred to as "SUBSCRIBER GROUP") and NATIONAL HEALTH CARE SYSTEMS OF CALIFORNIA. INC. (dba DENTICARE. and Mission Dental Health Plan), a California corporation (hereinafter referred to as the "PLAN") which operates a specialized health care service plan subject to the licensing requirements and operational regulatory standards enforced by the Commissioner of CorporaliDos of the State of Californja.under the Knox-Keene Health Care Service Plan Act of 1975. as amended. The effective date of this agreementshallbe JAN. .rst 19 ljO . The address of ''''e principal administrative office of the PLAN is 18662 MacArthur Blvd., Suite 101, Irvine, California 92715. Telephone numbers are (714) 752-1757. (714) 833-1900. or TOLL-FREE in Northern California (BOO) 432-7019. or TOLL-FREE in Southern California (BOO) 432-7158. PART I. DEFINITIONS A. "AESTHETIC DENTISTRY" means dental procedures which are performed purely for cosmetic purposes. 8. "BENEFITS" and "COVERAGE" mean those dental care services available under the GROUP SUBSCRIBER AGREEMENT in which a MEMBER is enrolled. C. "CHilD" includes all natural, adopted, foster, and stepchildren. D. "COPA YMENT" isan additional fee charged to a SUBSCRIBER or ENROLLEE which is approved by the California Commissioner of Corporations who regulates the PLAN pursuant to the Knox-Keene Act, provided for in the PLAN contract, and disclosed in the EVIDENCE OF COVERAGE/DISCLO- SURE FORM. E. "DENTAL FACILITIES" mean those centers selected by the PLAN to provide dental services for any MEMBER. F. "DEPENDENT" includes the following individuals only if they reSide or work within the PLAN'S service area (within 30 miles of a general dentist PLAN PROVIDER): (1) The lawful spouse of a SUBSCRIBER. (2) An unmarried DEPENDENT CHILD of a SUBSCRIBER, up to the CHILD'S nineteenth birthday. (3) An unmarried child of a SUBSCRIBER, up to the CHILD'S twenty-fourth birthday, who is a full time student and is wholly dependent on such SUBSCRIBER for support. (4) COVERAGE shall also be extended beyond the nineteenth year and twenty-fourth year age limitations when a DEPENDENT CHILD can be certified by the PLAN as incapable of self-sustaining employment by reason of mental retardation or physical handicap and is chiefly dependent upon the SUBSCRIBER for support and maintenance, provided proof of such incapacity is furnished to the PLAN by the SUBSCRIBER within 31 days of the request for such proof by the PLAN. Recertification of such incapacity may be required by the PLAN, but not more frequently than once annually after the two year period following the DEPENDENT'S attainment of age nineteen. A newborn CHILD shall be covered from moment of birth and a minor adopted CHILD shall be covered from the time the CHILD is placed in custody of the adoptive parent. G. "DISCLOSURE FORM" means the forms or materials containing such information regarding the BENEFITS, services and terms of the PLAN contract as the Commissioner may require so as to afford the public, the SUBSCRIBER and ENROLLEES with a full and fair disclosure of the provisions of the PLAN in readily understood language and in a clearly organized manner. H. "ELECTIVE DENTISTRY" means dental procedures which are unnecessary to the dental health of the patient, as determined by a PLAN dentist. I. "EMERGENCY CARE" means services rendered for alleviation of severe pain or bleeding and/or immediate diagnosis and treatment of unforeseen conditions, which, if not immediately diagnosed and treated may lead to disability, dysfunction or death. J. "EVIDENCE OF COVERAGE" means any certificate, agreement, contract, brochure, or letter of entitlement issued to a SUBSCRIBER or ENROLLEE setting forth the COVERAGE to which the SUBSCRIBER or ENROLLEE is entitled. K. "EXCLUSION" is any provision of the GROUP SUBSCRIBER AGREEMENT whereby coverage for a specified hazard or condition is entirely eliminated. L. "GROUP SUBSCRIBER AGREEMENT" refers tothis Agreement PLAN and any SUBCRIBER GROUP and which establishes the terms and conditions which govern the BENEFITS made available to any MEMBER by PLAN. M. "LIMITATION" is any provision other than an EXCLUSION which restricts coverage under the GROUP SUBSCRIBER AGREEMENT. N. "MEMBER" and "ENROLLEE'. mean any SUBSCRIBER or DEPENDENT, who is enrolled under the GROUP SUBSCRIBER AGREEMENT and is entitled to the BENEFITS available under the GROUP SUBSCRIBER AGREEMENT in return for the payment required to be made to the PLAN under such GROUP SUBSCRIBER AGREEMENT. O. "PARTICIPATING DENTISTS" mean those dentists selected by the PLAN to provide dental services for MEMBERS. P. "PLAN" is National Health Care Systems of California, Inc. Q. "PLAN PROVIDER" or "PLAN DENTIST" refers to a provider of dental services licensed by the State to deliver or furnish these services, which has a contract with the PLAN to render services to any MEMBER in accordance with the provision of the GROUP SUBSCRIBER AGREEMENT in which a MEMBER is enrolled. The names, locations, hours of service and other information regarding PLAN PROVIDER, PLAN DENTIST or facilities may be obtained by contacting the PLAN office. R. "PREPAYMENT FEE" is the amount payable each month by the SUBSCRIBER GROUP to obtain BENEFITS provided under the GROUP SUBSCRIBER AGREEMENT. S. "SERVICE AREA" consists of those geographic regions which are within a 30 mile radius from the general dentist PLAN PROVIDERS. T. "SUBSCRIBER" is the person who is responsible for payment to the PLAN, or whose employment or other status, except for family dependency, is a basis for eligibility for membership in the PLAN. U. "SUBSCRIBER GROUP" is the organization or company which has entered into a GROUP SUBSCRIBER AGREEMENT with the PLAN under which BENEFITS are made available to eligible group MEMBERS and their DEPENDENTS. V. "SUBSCRIPTION COST" means the prepaid charge paid by or on behalf of SUBSCRIBERS or ENROLLEES. W. "SURCHARGE" means an additional fee which is charged to a SUBSCRIBER or ENROLLEE for a covered service but which is not approved by the Commissioner, provided for in the PLAN contract and disclosed in the EVIDENCE OF COVERAGE/DISCLOSURE FORM. X. "USUAL AND CUSTOMARY FEE" means the amount which a DENTAL PROVIDER normally or usually charges the majority of his patients for a particular service. This term is used interchangeably with "FEE-FOR-SERVICE." PART II. ELIGIBILITY RULES A. Persons Eligible to Become Subscribers Any person who: 1. is an active full-time employee or MEMBER of a collective bargaining unit, association or club or an elected official of SUBSCRIBER GROUP or who is a retired employee of SUBSCRIBER GROUP. 2. has not previously been terminated under INDIVIDUAL or GROUP AGREEMENT because of fraud or deception in the use of the Services or facilities of the PLAN or knowingly permitting such fraud or deception by another, and 3. has applied for membership, on forms supplied by the PLAN, and 4. resides or works within PLAN'S service area (within thirty miles from a general dentist PLAN PROVIDER). B. Eligible DEPENDENTS may be enrolled at the time the SUBSCRIBER enrolls or any time thereafter by filling out the forms supplied by the PLAN and paying the applicable prepayment fee. C. Date of Eligibility 1. All persons including the SUBSCRIBER and eligible DEPENDENTS have applied for membership and for whom the appropriate SUBSCRIPTION COST has been paid prior to the 20th day of the month shall be eligible for BENEFITS commencing on the 1st day of the following month. 2. All persons including the SUBSCRIBER and eligible DEPENDENTS who have applied for membership and for whom the appropriate SUBSCRIPTION COST has been paid between the 20th day of the month and the last day of the month shall be eligible for BENEFITS commencing the 1st day of the second month thereafter. PART III. EFFECTIVE DATE AND TERMINATION DATE AU persons become eligible for services at 12:01 A.M. of the effective date indicated on.this GROUP SUBSCRIBER AGREEMENT providing they meet all the eligibility requirements. Termination date is based on the events and conditions listed under PART X. PART IV. PRINCIPAL BENEFITS AND COVERAGES A. ENROLLEES are entitled to dental services as set forth in the Benefit Schedule which is attached as Attachment A. This Schedule establishes thedentsl services which are available to ENROLLEES without charge (designated as "No Charge" in the Schedule) and those services for which ENROLLEES are obligated to pay the PLAN DENTAL PROVIDER. Theamount of such COPAYMENTS which the PLAN DENTAL PROVIDER is permitted toeharge ENROLLEES for specific dental services is set forth under the heading "COPA YMENT REQUIRED." The EXCLUSIONS AND LIMIT ATlONSapplicable to the Benefit Schedule are set forth immediately following. ENROLLEES MUST UTILIZE A PLAN DENTAL PROVIDER UNLESS A PROPER REFERRAL TO A NON-PLAN PROVIDER HAS BEEN MADE. THE BENEFIT SCHEDULE AND PRINCIPAL EXCLUSIONS AND LIMITATIONS ARE ATTACHED HERETO AS ATTACHMENT A. THE ATTACHMENT A IS AN INTEGRAL PART OF THIS AGREEMENT AND MUST BE READ IN CONJUNCTION WITH THE REST OF THE AGREEMENT. PRINCIPAL EXCLUSIONS AND LIMITATIONS OF BENEFITS 1. Services to which the MEMBER is entitled under any Worker's Compensation Law or Act. The PLAN shall provide the services atthetime of need. butthe MEMBER shall execute and deliver such documents or take such other action as may be necessary to assure that the PLAN is reimbursed for benefits provided by Worker's Compensation. This EXCLUSION does not apply to Medi~CaI Program. 2. Services. which in the opinion of the attending dentist. are not necessary for the patient's'dental health. 3. Orthodontics. 4. AESTHETIC DENTISTRY. 5. Oral surgery requiring the setting of fractures or dislocations. 6. Treatment of malignancies. cysts or neoplasms. 7. Dispensing of drugs not normally supplied in a dental office. 8. In the event that patient desires to be hospitalized for any dental procedure, cost will be borne by the patient. 9. Services which are reimbursable by insurance or reimbursable under any other group or health service plans. The PLAN shall provide the services at the time of need but the MEMBER shall execute such documents necessary to assure that the PLAN is reimbursed for such BENEFITS. 10. Loss or theft of dentures or bridgework. 11. Any procedure of implantation. 12. General anesthesia. 13. Services that cannot be perlormed because of the general health of the patient. B. Certain services are subject to a COPAYMENT (defined herein as an additional amount SUBSCRIBER or DEPENDENT shall pay PARTICIPATING DENTISTS directly), as listed in the attached Benefit Schedule. C. In order to make an appointment MEMBERS must telephone the number of the dental office which they have selected. The first appointment scheduled will usually be for the purpose of taking a complete set offull mouth x-rays, examination, developing a treatment plan and determining an estimate of costs. During the first appointment MEMBERS will be provided with their prescribed treatment plan and with the fees for each dental procedure. MEMBERS must pay the fees listed on their description of Principal BENEFITS AND COVERAGES directly to the dental office where treatment is received. D. The PLAN will pay up to a maximum of $50.00 per contract year per MEMBER for out-of-the-area, emergency services rendered to MEMBERS who require such services when they are more than thirty (30) miles from a PLAN DENTAL PROVIDER. MEMBERS can determine whether or not they are more than thirty (30) mites away from a PLAN DENTAL PROVIDER by telephoning one of the PLAN telephone numbers. Such telephone numbers shall be readily accessible to MEMBERS and are contained on the first page of this Agreement. MEMBERS must telephone the PLAN prior to obtaining out-of-the-area EMERGENCY CARE. However, when it is not possible for the MEMBER to provide prior notice, coverage will be provided if notice is given to the PLAN within 48 hours or as soon as possible thereafter. EMERGENCY SERVICES are those services required for the alleviation of severe pain or bleeding and/or immediate diagnosis and treatment of unforeseen conditions, which, if not immediately diagnosed and treated may lead to disability, dysfunction or death. The PLAN will reimburse ENROLLEES for such services up to a maximum amount of $50.00 per contract year per MEMBER for services by non-plan providers for out-of-the-area EMERGENCY CARE upon presentation by the MEMBER of a copy of the bill from the treating dentist and a cover letter from the MEMBER explaining the circumstances which gave rise to the emergency treatment. MEMBERS must submit such documentation to the PLAN within 90 days of receipt of such emergency service. In the event a MEMBER requires emergency service.and the MEMBER is less than thirty (30) miles from a PLAN DENTAL PROVIDER, the MEMBER must contact the PLAN DENTAL PROVI DER to which he is assigned or one of the PLAN'S telephone numbers listed on the first page of this Agreement to receive instructions as to how to proceed to obtain emergency services from a PLAN PROVIDER. MEMBERS may obtain EMERGENCY CARE from a non-plan provider within the service area only after contacting their assigned DENTAL PROVIDER or the PLAN and being advised that no PLAN PROVIDER is available. However, if it is not possible for the MEMBER to provide prior notice, coverage will be provided if notice is given to the PLAN within 48 hours or as soon as possible following receipt of services. The PLAN will reimburse ENROLLEES for such services up to a maximum amount of $50.00 per contract year per MEMBER for services by non-plan providers for in-area EMERGENCY CARE upon presentation by the MEMBER of a copy of the bill from the treating dentist and a cover letter from the MEMBER explaining the circumstances which give rise to the emergency treatment. MEMBERS must submit this documentation to the PLAN relating to such emergency treatment within 90 days of receipt fa services. The foregoing provisions relating to the $50 maximum is in addition to the emergency preventive and periodontal treatments reflected in the Benefit Schedule. If a PLAN PROVIDER is available, the MEMBER will be instructed to see him or her. The MEMBER will be responsibleforcopaymentasdescribed in the Attachment A for any treatment received. If the emergency is handled by the enrollee's assigned PLAN DENTIST payment will be in accordance with the non-emergency procedures. MEMBERS will pay the COPAYMENTS as listed in the attached description of Principal BENEFITS AND COVERAGES under "COPAYMENT REQUIRED" for each procedure completed. These COPAYMENTS must be paid directly to the dental office where treatment is received. PART V. OTHER CHARGES/COPAYMENTS MEMBERS will pay the COPAYMENTS as listed in the attached description of Principal BENEFITS AND COVERAGES under "COPAYMENT REQUIRED" for each procedure completed. These COPAYMENTS must be paid directly to the dental office where treatment is received. PART VI. DENTAL RECORDS The dental records of SUBSCRIBER and DEPENDENTS concerning services perlormed hereunder shall remain the property of the PARTICIPATING DENTISTS. PART VII. CHOICE OF DENTAL PROVIDER/DENTAL FACILITIES A. Each PLAN MEMBER is encouraged to select a dentist from among the PLAN PROVIDERS. Enrolled MEMBERS of a family must use the same dentist. The PLAN shall assist the PLAN MEMBER in selecting a dentist whenever such MEMBER requests such assistance. Information regarding the services available and the location and hours of PLAN PROVIDERS may be obtained by calling the PLAN office atone of the telephone numbers listed above. In any event, the PLAN MEMBER should contact the PLAN at one of the toll-free numbers to determine whether the PLAN PROVIDER they have selected is still available. In the event of an emergency, the PLAN should be contacted at the same numbers. B. Dental'services provided by this Agreementare limited to services perlormed by those dentists working in PLAN DENTAL FACILITIES, or those outside dentists designated by PLAN or by a PLAN DENTIST in connection with a referral made for definite treatment or consultation. C. The PLAN reserves the right to reassign MEMBERS at any time to a different PLAN DENTAL FACILITY of MEMBER'S choice. O. MEMBERS may change facilities with a thirty (30) day written notice and approval of the PLAN. E. Only licensed PARTICIPATING DENTISTS shall have the right to examine MEMBERS and to determine the professional services to be perlormed pursuant to this GROUP SUBSCRIBER AGREEMENT. F. Liability of SUBSCRIBER or ENROLLEE for payment: (1) In the event the PLAN fails to pay a DENTAL PROVIDER with whom the PLAN has a contract for service, the MEMBER shall not be liable to the DENTAL PROVIDER for any sums owed by the PLAN. (2) In the event the PLAN fails to pay a noncontracting DENTAL PROVIDER, the MEMBER may be liable tothe noncontracting DENTAL PROVIDER for the cost of services rendered. (3) Upon the termination of a PROVIDER contract between the PLAN and a contracting DENTAL PROVIDER, the PLAN shall be liable for covered services rendered by the DENTAL PROVIDER (other than for copayments) to the MEMBER who retains eligibility under the INDIVIDUAL or GROUP SUBSCRIBER AGREEMENT or by operation of law under the care of the DENTAL PROVIDER at the time of such termination until the services being rendered to the MEMBER by the DENTAL PROVIDER are completed, unless the PLAN makes reasonable and medically appropriate provision for the assumption of such services by a contracting PROVIDER. PART VIII. RENEWAL PROVISIONS A. After the contract period, the SUBSCRIBER GROUP may renew this GROUP SUBSCRIBER AGREEMENT, subject to any changes in COPAYMENT or the BENEFIT package made by PLAN, by filling out a renewal form and paying all monies due. PART IX. INDIVIDUAL CONTINUATION OF BENEFITS A. The MEMBER who becomes ineligible for GROUP COVERAGE may apply within thirty (30) days from the date of termination of the GROUP COVERAGE to continue coverage under an INDIVIDUAL SUBSCRIBER AGREEMENT of the type for which he or she is then eligible. Conversion to individual coverage shall apply to the DEPENDENT(S), including a DEPENDENT Spouse and a DEPENDENT CHILD, ofthe converting MEMBER .In addition, a CHILD who becomes ineligible as a family DEPENDENT can convert to individual coverage upon the same conditions as applied to a MEMBER. Such application may be accepted or rejected at the option of the PLAN; no automatic right of individual continuation of benefits exists. Those terminated pursuant to Section X.A(2) and Section X.B(4) may not be offered the opportunity to convert to individual coverage. B. The PLAN reserves the option to offer conversion' privileges to the MEMBER who becomes ineligibleforcoverage under this GROUP SUBSCRIBER AGREEMENT due to the termination of this Agreement. Should conversion to individual coverage be offered to the MEMBER, application must be made within (30) days of notice of ineligibility to continue coverage under a SUBSCRIBER AGREEMENT of the type for which he or she is ineligible. Conversion to individual coverage shall apply to the DEPENDENT(S), including a DEPENDENT Spouse and DEPENDENT CHILD, of the converting MEMBER upon the same terms and conditions as applied to the converting MEMBER. C. A covered DEPENDENT SPOUSE who ceases to be a qualified family MEMBER by reason of termination of marriage or death of the employee or SUBSCRIBER will be afforded the same conversion rights and conditions granted to MEMBERS under this Section IX, subsections A and B. PART X. TERMINATION OF BENEFITS A. BENEFITS shall cease upon the following events: 1. Failure of MEMBER to pay the PREPAYMENT FEE to Subscriber Group if the SUBSCRIBER has been duly notified and billed for the charge and at least 15 days has elapsed since the date of notification. However, in the event that an ENROLLEE is undergoing treatment for an ongoing condition, he/she may continue to receive treatment from a PLAN PROVIDER, but must agree to pay PROVIDER on a "fee for service" or "usual and customary fee" basis. 2. Fraud or deception in the use of the services or facilities of the PLAN or knowingly permitting such fraud or deception by another. " ,. ., 3. If the ~UB?CFfIBER GAUUP is terminated. SUBSCRIBER ;i11 ~ Off~red the option of continuation of benefits unde; an Individual ).greement as described In Attachment A. MEMBER shall be given 30 days prior notice of termination of SUBSCRIBER GROUP. B. BENEFITS shall cease upon the following events, if the SUBSCRIBER or MEMBER has been notified and at least 15 days has elapsed since said notification. 1. Upon date of entry into full-time military service. 2. Upon date of DEPENDENT CHILDREN'S marriage. 3. Upon DEPENDENT CHILD attaining age of 19 or 24 or prior marriage with the exception of a DEPENDENT CHILD that has been certified by the PLAN as incapable of selt-sustaining employment by reason of mental retardation or physical handicap and is chiefly dependent upon the SUBSCRI BER for support and maintenance, provided proof of such incapacity is furnished to the PLAN by the SUBSCRIBER within 31 days of the request for such proof by the PLAN. Recertification of such incapacity may be required by the PLAN, but not more frequently than once annually after the two-year period following the DEPENDENT CHILD'S attainment of age nineteen. 4. If it becomes impossible, after reasonable efforts, to estl'tt.iish and maintain a satisfactory dentist-patient relationship with any MEMBER. 5. If the SUBSCRIBER has been terminated from the GRC'_ 'v or has voluntarily left said GROUP. In such case SUBSCRIBER'S and his eligible DEPENDENTS' BENEFITS will terminate. 6. In the event the applicable copayments which are detailed in the BENEFITS SCHEDULE (Attachment A) are not paid. If Copayments are not made for one family member only that person's BENEFITS will terminate. PART XI CANCELLATION A notice of cancellation shall be mailed to the SUBSCRIBER at the SUBSCRIBER'S address of record, and in such event of cancellation of MEMBER: A. The MEMBER will have the opportunity to have the cancellation reviewed by the Commissioner of Corporations under Section 1365 ofthe Knox-Keene Act. B. The PLAN shall within thirty (30) days of cancellation return to the MEMBER the pro-rata portion of the money paid to the PLAN which corresponds to any unexpired period for which payment had been received, together with amounts due on claims, if any, less any amounts due PLAN. C. Acceptance by the PLAN of the proper MEMBER PREPAYMENT FEE after termination of this GROUP SUBSCRIBER AGREEMENT and without requiring a new application shall reinstate the contract as though it had never terminated unless the PLAN within five (5) business days of receipt of such payment either: 1. refunds payment, or 2. issues to the GROUP a new GROUP SUBSCRIBER AGREEMENT accompanied by written notice stating clearly those respects in which the new contract differs from the terminated contract in BENEFITS, COVERAGES, or otherwise. D. The provisions of this Part apply to all terminations, including those described in Part X of this Agreement.. E. If termination occurs due to failure to make CO PAYMENTS, REINSTATEMENT of BENEFITS will occur at the beginning of the next month after payment of delinquent payments have been made. PART XII. RIGHT OF PLAN TO CHANGE BENEFITS A. PLAN reserves the right to change the BENEFITS. COPA YMENTS OR PREPAYMENT FEES to MEMBERS. B. The PLAN shall not decrease in any manner the BENEFITS stated in the GROUP SUBSCRIBER AGREEMENT except after a periOd of at least thirty (30) days from and after the postage paid and mailing to the other party at the other party's address of record with the PLAN of written notice of such proposed change. C. The PLAN shall not increase or decrease the PREPAYMENT FEES or DECREASE BENEF~TS except after a period of at least thirty (30) days from and after postage paid mailing to said MEMBER at the MEMBER'Saddressof record with the PLAN of written notice of such proposed increase or decrease. Notification of alteration or revision given to the SUBSCRIBER GROUP Representative must be disseminated to the SUBSCRIBERS and the ENROLLEES in the GROUP no later than thirty (30) days from receipt thereof and must provide thirty (30) days notice to the MEMBER prior to such increase or decrease in PREPAYMENT FEES or decrease in BENEFITS. PART XIII PREPAYMENT FEE A. The PREPAYMENT FEE is the monthly fee required to maintain coverage under this GROUP SUBSCRIBER AGREEMENT. THE PREPAYMENT FEE SCHEDULE IS ATTACHED HERETO AS ATTACHMENT B. THE PREPAYMENT FEE SCHEDULE IS AN INTEGRAL PART OF THIS AGREEMENT AND MUST BE READ IN CONJUNCTiON WITH THE REST OF THE AGREEMENT. MEMBERS of a SUBSCRIBER GROUP shall pay PREPAYMENT FEES directly tothe SUBCRIBER GROUP which will in turn pay the PLAN. MEMBER should check with SUBSCRIBER GROUP to determine the deadline and method of payment for his contribution if any, to the PREPAYMENT FEES. SUBSCRIBER GROUP shall then forward the PREPAYMENT FEE to the PLAN. Monthly PREPAYMENT FEES must be received by the PLAN on or before the twentieth day of the month to insure eligibility for service on the first day of the following month. Such payments shall be made at or sent to: National Health Care Systems of California, Inc. 18662 MacArthur Blvd., Suite 101, Irvine, California 92715 B. Payments received by the PLAN, or its authorized agent, prior to the due date, will make MEMBERS of the SUBSCRIBER GROUP and their eligible DEPENDENTS eligible for BENEFITS commencing on the due date forthe period paid for. Payments received after the due date will make MEMBERS and their eligible DEPENDENTS eligible for BENEFITS on the due date of the subsequent month. MEMBERS should contact the SUBSCRIBER GROUP to determine the deadline and method of payment to the Group. C. The PLAN will not increase or decrease the PREPAYMENT FEES or decrease BENEFITS except after a period of at least thirty (30) days from and after postage paid mailing to said MEMBER at MEMBER'S address of record with the PLAN of written notice of such proposed increase or decrease. Notification of alteration or revision given to the SUBSCRIBER GROUP Representative must bedisseminated to the SUBSCRIBERS and ENROLLEES in the GROUP no later than thirty (30) days from receipt thereof and must provide thirty (30) days notice to the MEMBER prior to such increase or decrease in PREPAYMENT FEES or decrease in BENEFITS. D. Each MEMBER shall payor arrange for payment of applicable COPA YMENTS, if any, as provided in Attachment A. In case of failureto do so, the rights of MEMBERS or their eligible DEPENDENTS may be terminated on fifteen (15) days' notice and may be reinstated only by renewed application and reenrollment in accordance with all requirements of this Agreement. Any applicable COPA YMENTS are detailed in the BENEFITS schedule. ENROLLEES will not be terminated based upon failure to pay "fee for service" or "usual and customary fee" for services not covered by the PLAN. PART XIV. LIABILITY OF MEMBERS IN THE EVENT OF NONPAYMENT BY THE DENTAL PLAN In the event the PLAN faits to pay a PLAN PROVIDER with whom the PLAN has a contract for service, the MEMBER shall not be liable to the PLAN PROVIDER for any sums owed by the PLAN. In the event that the health PLAN fails to pay a noncontracting provider, the MEMBER may be liable to the noncontracting provider for the cost of the services rendered. PART XV. TERMINATION OF PROVIDER Upon termination of a PROVIDER contract. the PLAN shall be liable (other than for COPA YMENTS) for covered services rendered by such PROVIDER to a SUBSCRIBER or ENROLLEE who retains eligibility under this GROUP SUBSCRIBER AGREEMENT or by operation of law and who is under the care of said DENTAL PROVIDER at the time of such termination, until the care being rendered to said SUBSCRIBER or ENROLLEE by such PROVIDER is completed, or until the PLAN makes reasonable and medically appropriate provision for the assumption of such services by another contracting PROVIDER. PART XVI. GENERAL PROVISIONS A. This Agreement, including any amendments thereto, constitutes the entire agreement between the parties. B. The PLAN is subject to the requirements of Chapter 2.2 of Division 2 of the Health and Safety Code of the State of California and Subchapter 5.5 of Chapter 3 of Title 10 of the California Administrative Code, and any provision required to be in this contract by either of the above shall bind the PLAN whether or not provided in the contract. C. This Membership Contract replaces and cancels all other contracts. if any, issued to MEMBER herein. D. In the event of any controversy between the MEMBER, a DEPENDENT,or the heirs-at-Iaw or personal representatives of a MEMBER or DEPENDENT, as the case may be, and the PLAN. as individuals or otherwise, whether involving a claim in tort, contract or otherwise, which are not adequately resolved in the opinion of the MEMBER, a DEPENDENT, or heirs-at-Iaw or personal representative of 8 MEMBER or DEPENDENT. by the PLAN'S grievance procedures, the same shall be submitted to arbitration in accordance with the rules of the American Arbitration Association, and judgment on the award rendered by the Arbitrator or Arbitrators may be entered in any Court having jurisdiction thereof. Arbitration may not be initiated, however, until the grievance procedures have been exhausted. Thus, the complaint must have been given notice of the disposition of his complaint by the PLAN, have appealed to the Public Policy Committee which has rendered a decision and given notice thereof to the complainant, prior to initiating arbitration, Arbitration may be initiated by any MEMBER by sending a letter to the PLAN office. In the event of arbitration, the prevailing party in said proceedings shall be entitled to an award of reasonable attorneys' fees and any costs incurred. E. The PLAN will provide written notice within a reasonable time to MEMBER in the event of any termination or breach of contract by, or inability to perform of, any contracting PROVIDER if the MEMBER may be materially and adversely affected thereby. F. Any notice under this Contract may be given by United States mail, postage paid, addressed as follows: National Health Care Systems of California. Inc. 18662 MacArthur Blvd.. Suite 101 Irvine, California 92715 If to a MEMBER: To the latest address provided for the MEMBER on enrollment or change of address forms actually delivered to the PLAN. If to the SUBCRIBER GROUP: Telephone ( Contact Person . . G. Term. This Agreement shall remain in force and effect for one (1) year from the effective date. H. WHAT FOLLOWS ARE THE BENEFIT SCHEDULE AND PRINCIPAL EXCLUSIONS AND LIMITATIONS (ATTACHMENT A) AND THE PREPAY- MENT FEE SCHEDULE (ATTACHMENT B). IF THEY ARE NOT ATTACHED CONTACT YOUR EMPLOYEE BENEFIT REPRESENTATIVE OR THE PLAN BY MAIL, IN PERSON, OR BY TELEPHONE; TOLL FREE IN NORTHERN CALIFORNIA (800) 432-7019 OR TOLL FREE IN SOUTHERN CALIFORNIA (800) 432-7158. THE BENEFIT SCHEDULE AND PREPAYMENT FEE SCHEDULE ARE INTEGRAL PARTS OF THIS AGREEMENT AND MUST BE READ IN CONJUNCTION WITH THE REST OF THE AGREEMENT, IN WITNESS WHEREOF, this Agreement has been executed as of the day and year first written above. NATIO HEALTH CARE SYS - " ATTACHMENT B PREPAYMENT FEE SCHEDULE MONTHLY DUES: By $ 7.00 Subscriber 12.00 $ Subscriber and one dependent $ 15.00 Subscriber and two or more dependents $ Monthly Administration Fee $ 0 Ortho only $3.00jmo Ortho with General Denti stry no charge. SUBZ GROUP By ~-""A. ( . Mayor u~~ (Date: 11-12-85 A:EN7;(~~ WILLIAM H. HORNBAKER, D.D.S. A~ :? }ljrm: . ~~<cV City Attorney