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CI,Q OF SAN BERNARDIQ) - REQUEOr FOR COUNCIL
N
From: Mary Jane Perl ick
Dept: Personnel
Date: January 28, 1987
REC'Do-MHIH. OFF, Subject:
1m FEB -5 ,or 3: 07
Resolution to authorize he execution of
agreement with Mission Dental Health Plan
for General Dentistry and Orthodontic Bene-
fits effective January 1, 1987
/'
Synopsis of Previous Council action:
The City previously entered into an agreement with Mission Dental Plan on October 15,
1979, with amendments thereto, to provide group dental and orthodontic services to
employees and their dependents.
Recommended motion:
Adopt resolution to execute the terms of agreement for one year with Mission Dental
Plan effective January 1, 1987, with no change in rateso
4tL "t"
gnatu re
Contact person: Mary Jane Perl ick
Phone:
x5161
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Finance:
N/A
/1/11
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Supporting data attached:
Yes
Ward:
FUNDING REQUIREMENTS:
Amount:
No add'l cost
Source:
Council Notes:
75.0262
1-28-87
Agenda Item No.,l.d..
CI,Q OF SAN BIERNARDICb - REQUEOr FOR COUNCIL ACQ)N
STAFF REPORT
The city's existing agreement with Mission Dental, providing
general dental services (including orthodontic care) expired on
December 31, 1986. The attached agreement was received from
Mission Dental on January 16, 1987, with no increase in rates for
calendar year 1987.
Monthlv Rates Effective Januarv 1. 1987 for General Dentistrv
$ 7.00
$12.00
$15.00
Subscriber
Subscriber and one dependent
Subscriber and two or more
dependents
Orthodontic care is provided at no additional fee to general
dentistry subscribers and such care is available to non-
general dentistry subscribers at a monthly rate of $3.00.
1-28-87
75-0264
RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
3 EXECUTION OF AN AGREEMENT WITH MISSION DENTAL HEALTH PLAN FOR
EMPLOYEES I GENERAL DENTISTRY PLAN WITH ORTHODONTIC BENEFITS,
4 EFFECTIVE JANUARY 1, 1987.
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RESOLUTION NO.
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 executive on behalf of said City an Agreement with Mission
incorporated herein by reference as fully as though set forth
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at length.
I HEREBY CERTIFY that the foregoing resolution was duly
adopted by the Mayor and Common Council of the City of San
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Bernardino at a
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day of
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meeting thereof, held on the _
, 1987, by the following
AYES:
NAYS:
ABSENT:
City Clerk
1-28-87
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8 Approved as to form:
The fotegoing resolution is hereby approved this
___ day of _ __________, 1987.
Mayor
of- tlle- City ot' San
Bernardino
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GROUP IUIISCIlIB!R AClR&M!NT
(PLAN -82-V )& 810R
ThlaAg*"*"llrnadeandh8Culecllhll Fir...t dayol Jllnuarv 1887
byandbelween City of San Bernardino (hereInIfter~Io."SU8SCAIBERGROUP"lanclNAT~LHEALTHCARE
SYSTEMS OF CALIFORNtA, INC. (cIba OENTICAAE. and MIUiOn 0enIaI tteeIth F'tM).. c.Nfom6a corpcnt6on I........,......... eo. the "PlAN1
whk:h opem.. . apeclaHud hMIttI CI,. MrvIce plan autJtect to the IIctnI6ng requlNmlntl and ~ NQUIItoty ...... tnforced by 1M
==~"~.ot~~undeflhe,Kno.-~HaIItlC."ServiClP\pActoflI75,"arnended.TheeHectivedeteol_
The IIddreu oIttleprlnctpal ~lMttIiljve office of lhe PLAN II 18882 MKArthur Blvd., SoI.'01, Irvine, CaUromill 12715. T~ numberl....(7104)
752-1757, (714) 833-Ulaci, or TOLL-fREE in Northern CIIlllornla (800) 432-7018. Of TOLl-FREE in Southern CalUomIa (1001432-71511.
PART L DIPINITIONI
A. "AESTHETIC DENTISTRY" meant dental procedurw whiCtla,. performed puNt)I tor coelMtic ptIfpOMI.
B. "BENEFITS" and "COVERAGE" mean thaM dental CUll Ml'Vicw available under &he GROUP SUBSCRIBER AGREEMENT In which, MEMBER Is
enrolled.
C. "CHILO" includes aU nalural, adopted. Jostel'. and stepchildren.
D. "COPAYMENT" isanaddltionalleechargedtoaSUBSCRIBERor ENROLLEEwtllctl i,approved ~ Cltlfom... CommIuionerotCorpo(8tlonlwno
S~R~'FO~r:,PlAN pursuant to'~he Knox.Keene Act, provided lor in the PLAN contract, and d In the EVIDENCE OF COVERAGElDISCLo-
E "DENTAL FACILITIES" mean Ihose centers selected by the PlAN to.> provide denWl Nr'IIc:eI'Of any MEMBER,
F. "DEPENDENT" inClujjeS the following individuals only illhe)' reside or work within tM PlAN'S ..rvice area (within 30 milel of a general denlist PlAN
PROVIDER)
(1) The lawful spouse 01 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 lwenty-fourth birthday, who ita full time student and is wholly dependent on such
SUBSCRIBER lor support
(.) COVERAGE shall also be extended beyond the nineteenth year and twanty.fourth year ~ limitMlons when a DEPENDENT CHILD can be
certified by the PLAN.. incapable 01 self-sustainmg employmenl by reuon of INnIlI retlrdllionor phyaal hlndlcap and it Chiefly dependenl
upon the SUBSCRIBER lor support and meintenance~ j)rovkled proof of such lncapKity II fumllMcl fo Ih, PlAN by ",. SUBSCRfBER within 31
days of the request lor such proof by the PLAN. RecertlllcatiOn of suen InclpllClty ~ be required by the PLAN, but not more trequenUy than once
annually after the two year paood lollowing lhe DEPENDENT'S atllinment of.ga nIneteen.
A newborn CHILD shall be covered 'rom moment 01 birth and a minor adopted CHILD shall be covered lrom the lima the CHILD is placed in
cuslody 01 the adoptIve parent
G. "DISCLOSURE FORM" means the lorms or materials conlllining such information regllrding the BENefiTS, Mt'Yicea and IIIr"" Of the PLAN contract
as the Commissioner may reqUIre so as to afford the public, the SUBSCRIBER and ENROLLEES with a full and tair dilcloeure of the provisions of the
PLAN In readily undertolood language and In a clearly organized manner".
H. "ELECTIVE DENTISTRY" means dental procedur81 which are unneceasary to the dental health of 1M pa.tient, II O8l8rminecl by a PLAN dentist.
I ""EMERGENCY CARE" means services rendered for alleviation 01 MYeRl pain or bleeding and/Of immediate dtagnosis and trealment 01 unloreaaan
conditions, which. il not immediately diagnosed and treated may Ind 10 dlubltity, dysfunction Of dea.th
"EVIDENCE OF COVERAGE" means any certilicate, agreement, connct, brochu.... or I8tIef Of entitlement illlUed to a SUBSCRIBER or ENROLLEE
setting 'orlh the COVERAGE 10 WhICh the SUBSCRIBER or ENROLLEE Is entitled.
K ~~~~~~ON" is any provision 01 Ihe GROUP SUBSCRIBER AGREEMENT Whereby COY8I"8g8 for a specified hazard or condition is entirely
L "GROUP$UBSCRIBER AGREEMENr' relers tolhis Agreement PLAN andanySUBCRIBER GROUPand which eslllblisheathetermsand conditions
whiCh govern the BENEFITS made available 10 any MEMBER by PLAN.
M. -L1MITATION~ is any provision other Ihan an ExCLUSION which reslrlcla coveragt under the GROUP SUBSCRIBER AGREEMENT.
N. "MEMBER" and 'ENROLLEE" mean any SUBSCRIBER or DEPENDENT, who is enrolled under lhe GROUP SUBSCRIBER AGREEMENT and II
entitled to the BENEFITS available under the GROUP SUBSCRIBER AGREEMENT in return fOf lhe peyment requked 10 be made to the PLAN under
such GROUP SUBSCRIBER AGREEMENT
O. "PARTICIPATING DENTISTS" mean Ihose dentlats selected by the PLAN 10 provide dental servicea IOf MEMBERS.
P. "PLAN" IS National Health eare Syalems of California, Inc
a "PLAN PROVIDER" or '"PLAN DENTIST" retets 10 a provider of dental servlcellicenMd by the Slalllto deliver orfumlah theee servlcea. which hea a
contract with lhe PLAN to render services to any MEMBER in ICCOI"d&nC* with the prOViaiOn of the GROUP SUBSCRIBER AQREEMENT in which a
MEMBER is enrolled. The names.locationa, hours of service and other information reoarcting PlAN PROVIDER, PLAN DENTIST Of fKilltlea may be
obtaIned by contacting the PLAN office
R "PREPAYMENT FEE'" IS the amount payable each month by the SUBSCRIBER GROUP 10 obtain BENEFITS provided under the GROUP
SUBSCRIBER AGREEMENT
S. "SERVICE AREA" conSiats Ollhose geographic regions which are within a 30 mile rMllua from the general dentlll PLAN PROVIDERS.
T. '"SUBSCRIBER" II the person whO is relponslble lor payment to the PLAN, or whoaeemploymenl Of other mtllS, ..cept for lamily dependency, II a
basis for eligibility lor membership in Ihe PLAN.
U. "SUBSCRIBER GROUP", is lhe organization or company which has entered Into a GROUP SUBSCRIBER AGREEMENT wtth the PLAN under which
BENEFITS a... made avaIlable to aliQible group MEMBERS and thair DEPENDENTS.
V. "SUBSCRIPTION cosr means the prepHl charge pakl by or on behalf of SUBSCRIBERS Of ENROLLEES,
W. "SURCHARGE" means an additional tee whIch is charged to a SUBSCRIBER Of ENROLLEE for a cowenld I8I'Yice but which Is not 8P9<<W8d by 1M
CommiSSioner, provided lor in Ihe PLAN contracland dlacloMd in the EVIDENCE OF COVERAGEID!SCLOSURE FORM,
X. "USUAL ANDCUSTOMARY FEE" means the amount which a DENTAL PROVIDER normally or ulually cha~ the ma)OrIty of his palienll ton
partICular service ThiS lerm IS used mterchangeably WIth "FEE-FOR-SERVICE."
PART II. ELIGIBILITY RUlES
A Persons Eligible to Become SUbSCrlbefS
Any pertoon who:
1. IS an active lull.time employee or MEMBER ola collective bargaining unit,lUOClation or dub or an elected official of SUBSCRIBER GROUPer
who is a retired employee 01 SUBSCRIBER GROUP. '
2 has not prayiously been lerminated under INDIVIDUAL or GROUP AGREEMENT because of fraud or deception in the UBI of the ServIcea or
tacilitiaa 01 the PLAN or knowingly permitting such lraud or deception by another, and
3 has applied for membershIp, on lorms supplied by the PLAN, and
4 resides or works WIthin PLAN'S service area (within thIrty milellrom a general dentist PLAN PROVIDER).
B. Eligible DEPENOENTS may be enrolled at the time the SUBSCRIBER enrolls or any time lhereatler byfllling out lhetorma IkIPPiIed by the PLAN and
paying the appticable prepayment'".
C. Date of Eligibility
" All persons including theSUBSCRIBERancl eligible DEPENDENTS have applied Iormembetahip andforwhomtM&ppfopria_SUBSCRIPTIQN
COST has been paid prlor to the 20th day 01 the month shall be eliglbkt tor BENEFITS COInl'l'llN'Ong on 1M 111 day of 1M following month.
2 All pel'SOnS including the SUBSCRIBER and eligible DEPENDENTS who hI\ft applied IOf membership and tor whom the ~
SUBSCRIPTION COST has been paid belween the 20th day of the month and lhe lut day of the month shall be -"o!bIe fOf BENEFITS
cOmml'nClng the 1st day 01 the second month thereafter
PART III. EFFECTIVE DATE AND TERMINATION DATI!
All pt'rlK>ns become ellQible lor servlcas at , 2-0 t A, M 01 the ellective dati inCticalecf on this GROUP SUBSCRIBER AGREEMENT providing they rnNI
an the ehglbiNly requirements TermInatIon date IS based on lhe events and conditionslllled under PART )(.
PART IV, PAIHC"AlIENEFITS AND COVERAGES
A ENROLLEESareentilled to dental servlClS as set torth in the Benefit Schadulewhich iSaltKtladuAttachmentA. ThIlSchaduJa~thadlnlll
services which are available to ENROLLEES wlthoul ct\arge (desiGnated.. MNo ChargeR in the Schad.....) and thoaa......tor which ENROLLEES
are obIlgatadtopay the PlAN DENTAL PROVIDER, TheamountollUCtl COPAYMEN'tSwhich IMPLANDENTAl PACMDER IaDlnnlaldlOc:Mrgt
ENROLLEESforlpectlic dental services is set lorth underthe haacling"COPAYMENTREOUIREO.RTha EXCLUSIONSANOlIMI"'ATIONS~
to Ihe Benefit Scnedule are set lorth ImmedIately lollowlng ENROLLEES MUST UTILIZE A PLAN DENTAl PROVIDER UNLESS A PROPER
REFERRAL TO A NON. PLAN PROVIDER HAS BEEN MADE
THE BENE'IT SCHEDULE AND PRINCIPAl EXCLUIIQNI AND UMITAnONl ARI AnACHED "lIno AI AnACHIIINT A. THE
ATTACHMENT A IS AN INTEGRAL PART OF TttIS AORI!EMlNT AND MUIT B! III!AD IN CON.IUHC11ON WITH THE MIT OF'"
AGREEMENT,
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PllllllC>>ALVO.....-ANDu.TA~'-'I. ~
1. ......toWhlch...MEM8ERilentlttedu WofUr'.Compel .-...,....01 PlAN....prow6dethe~....timllor......
bUt the MEM8IR...,....... and deIhwr orWkeIUCll 0IhIr -=tion bI '**'Iry to ..,,.lMt the PlAN i. .-irnbufMd
1Dr...... pnMdecI by WarIIWI Col...... '.. ThII EXCLUSION doli not'" to FTogrMl.
2. s.mc.. wtIich In the opinion ofthe~ncldentIet... not ~tcw................. hMIth.
a. o.n.......u- included for general dentistry subscribers, orthodontics for non-general
.. ...THET1C DENTISTRY_ llUbscribers shall be p<<nided for the fee set forth in Attachment B.
5. OrIIIl.IfIIIY.wquIrIngthe..aitlgolhcturwordl.lanTlOl..
.. T~oflNlligl..ldll.ey8orneop.m..
7. Oi~ofdrugllnotnormallylUpplledln'''''''offlce.
.. In the event lMt petient: ct.ireI to be hoIpItaIlDd lOr III'lY ""1 proceOure, COlt will be borne by tM peti<<rt
.. ServIcM wtlich...~mburMblebyIMUlWICIIor~undlrM)'otMfgrouporhMllh- .bpieM. TM PlAN.nau provkIetheMfViCel
_ IN timl of ,... but the MEMBEA IhIII uecue.1UCtl docu""'* ......,. to .....,. ... the PlAN It reItnburIed for Iuch BENEFITS.
10. LoeIorlheftotdllnturelorbrldgewortl.
1'. Any procedure of impllinl8tiOn.
12. o.n.ral~.
13. s.MceI tMt C8nnot be perforn'l..:I becauIe of the ~ hMIlh 01 the petienl.
B. eel1aln 18rvlcnare IUbjllCt 10 a COPAYMENT (~naCI herein.. an IlddltlOnalamount SUBSCRIBER or DEPENDENT IIhaII ~ PARTICIPATING
DENTISTS directly), aallleMlln lha aQCMd s.neI'lI ScNduII.
C. In order 10 mllka an aP90inlmenl MEMBERS muat WIephone the number of the dantaI office wI'IICh they have NlacIad.
The first appolntmenltehedulecl will uauaily be lOr the purpoae of taking. complele'" of full mouth x-faYS. examinMlon. deYatoping a treatment plan
and determining an Hllmate of COllI.
Dunng the Ilrst aP90intmenl MEMBERS wi" be PfO'IIded with their PNKribed t"".,...m pIIIn and wIItl the"" lor NCh dllntaI proc<<tUQI. MEMBERS
muat PlY the '-lIMed on their deacrlplion of PritIdIlII BENEFITS AND COVERAGES dlrectty to the dental oHtce wMnt tteMmanI II recaived.
D. ThI PlAN will pay up to a maldmum of 150.00 per contracl year per MEMBER kw out4-1tle-...... emergency aeMceI rendered to MEMBERS wOO
,..,lreauchMMcaa when tMy are mcnlt'lan It'Ilrty (30) rntIeI from a PlAN DENTAL PROV1DER. MEMBERScandetet'mnwhettwor nottneyare
mcnthanthlrty (30) mil.alldYlroma PlANDENTALPAOVIDERby~~PlANtItIphone numbers, 9uctl~nurnbersWlll
==-:::R'G::C~:~E-=--~wr:tt~:::::.rcrr:''::aitiiA-~ME~81=:::*~'':~~ItO:::::
gllo'Wl to lhe PLAN wllt'lln 48 hOuR or u aoon.. poutbIe"*-,,-. EMEAO!NCY BERYnthoM aervicea ~tcwthe....uon 01....
.. or bleeding and/or IrnmediUe~and ~oI ~condItkInI. Whictl.lfnol ~diIlgnoMdand.......Iftay INdto
diNbillty, dylfunc;tlon or death. The PLAN will ntImbu.... ENROLLEES lot auch..... up 10 a mulmum amount 01".00 per connct year per
MEMBER 10r......,icaSby non-plan PfOVIdM,lorout-ol-l...,..EMERClENCYCAREupon"".....,IMb. by"" MEMBEAoI.oopyofthtbiHfromtht
trMtIng denlilt and a cover Iehr from the MEMBER explaining 1M dn:umIUInceI wh6ctl... rile to the emergency t........... MEMBERS mutt
autamlllUCh docurnentdon to tM PLAN wtthln 10 days 01 ,.,.rpt 0I1UCh er'I'III'gerICY ....
In 1M ....nt a MEMBER requifel emergency I8Mca and the MEMBER II leu thMthlrty (30)""'" from. PLAN DENTAL PROVIDER, the MEMBER
mlAtconlaclthePLANDENTALPRO"'IDEAtowtllchheiaaaelgnecforoneofthe~~numberlllltldonthetlrlt""oIthl1~
torecal'" inllructionlalto howtoptoceedtoobtllln~MrVkletftomaPLANPAOVtDER. MEMBERSrM)'obtain EMERGENCYCAAEfrom
a non.plan provider within lhe MNlce..... only"'" cor'ltaCUnD..... ~ DENTAL PROVIDER or 1M PlAN and ~ 8CMNd.. no PLAN
PROVIDER it avaUable. However. il it is not poulb't kw 1M ME~BEA 10 prOvide prior noIlce.COVMlI' w6II ba provIdtd It notice II glYtn to the PLAN
wllt'lln 48 hoursor .. aoon.. poeaIble tottowIng ntCIMpI of 18NiceI. The PlAN wID NImburM INAOLLEES kw 1IUCh.me. upto I mlXlmum amount
01150.00 per contrICl veer Plr MEMBER kw ~ by non-f)IIn ~tor an-.wa EMERGENCY CARE upon j)I.....4Iatto.. by" MEMBER oIa
copy of the billlrom the ItMtlng denUlt and a cower Iehr from lhI MEMBER lIJlPIIINng thec6rcumltlnoltwhlctl OIvit....to thI....,..ncyttMtmenl.
MEMBERS mUll submil thia documentation to tM PLAN rMtlng to IUCtl ~ tNltrnenI wilt*' 10 days oI""fo MMcaI.
The foregoing provllionl relating to thll50 maximum is In ac:Iditlon to the ernerpItICy Pf'IV'WIlM and periodon\Il tnlItmentl retlIICtad tn the Benltil
Schedule.
If a PLAN PROVIDER il.vailable. the MEMBER wijl be Inttructedto_h1morhrlt'. ThlMEMBERwillbI~forcopaymant..dtacribed In the
Altlchment A for any Ireatment receiv<<i. " the ernergtnCY II handled by Ihe enrotIIe.. MIIgned PlAN DENTIST peyment w6II be in IICCOfdance wittI
the non..mergency procedurw.
MEMBERS will pa,y lhe COPAYMENTS nlisted In the attIChed deIcrIptlon of Principal BENEFITS AND COVERAGES under "COPAYMENT
REQUIRED" for uch procedure completecl, ThHe COPAYMENTS muat be J)Ild dirtctly to the dant.al oftIoI vm.r.lfHtment Is receiwtd
PA"'- V. OTHER CHARGlEIICOPAYIIINTI
MEMBERS will pay the COPAYMENTS allisted in !tie attached deIct'lpllon of Principal BENEFITS AND COVERAGES under "COPAYMENT
REQUIRED" for MCh procedure completed. These COPAYMENTS mUlt be plid directly to the dantaI office where t....tment is received
PART VI. DENTAL RICORDI
The denlalrICordl 01 SUBSCRIBER and DEPENDENTS concernlng......,icH performed hentundtf _"remain the propllfty of the PARTICIPATING
DENTISTS
PART VII. CHOtct: OF DENTAL PROYJDIERIDENTAL fACIUTlU
A. Each PLAN MEMBER 1$ ancouragedfol86eCladentllt lromamongthePLAN PROVIDERS, EnrOlled MEMBERS of a family muatUllltheNmedenUlt.
The PLAN shall auiltttMI PLAN MEMBERIn lIlIlectlngadenttsl ~1UCh MEMBERreq.....auch...-..nce.lnkwmationreglrdlngtheaeMcel
available and the lOcation and hOUrsof PLAN PROVIDERSmaybllobtalned byCIIIlngthePLANoItioI"OI'IIoflhe~numMrlliltedabove.ln
any event, the PLAN MEMBER should contacl the PlAN at one of the toil-fAIl numbers IodrltlnninewheltMlrthe PlAN PROVIDER they hMe-'ec:ted
Is "lIIavaHabIe. In the IlVWII of an emergency. lhe PLAN should bI contactICI at the Mft'II numbIfL
B. Dental'servlces prooricIed by thili Agntlment are Itmtted toservlcal performed by thoNdantIsts wondng In PLAN DENTAL FACILITIES. orthOM outlldt
dentistl dealgnaled by PLAN or by a PLAN DENTIST In connection wfth......"...... fot eIelIr*a treanent or conauttation.
C. The PLAN,...,.... the right to reauign MEMBERS -MY' lime to a dltJarwrt PLAN DENTAL FAClUTV 01 MEMBER'S choice.
D. MEMBERS m.y cnlnge lacilllies with a thirty (30) clay written notice and 1It)pf(W. of the PLAN.
E. Only licenSed PARTICtPATING DENTISTS shall hlWl the right to lxamlne MEMBERS and to dtlermine the proteMionII aervIceI to be perll)rmed
purtuanllo thl. GROUP SUBSCRIBER AGREEMENT.
F. Llabi+1ty of SUBSCRIBER or ENROLLEE lor payment
(1) In the event the PLAN lall.to pay a DENTAL PROVIDER wiltl whom the PlAN haa a contracllorMINlce. the MEMBER ....11 not be liable totM
DENTAL PROVIDER lor any lums owed by the PLAN.
121 IntheevenltM PLAN failllO pay II noncontracting DENTAL PROVIDER. theMEMBER IMY beliab'-lOthe nonconlrlCtlng DENTAL PROVIDER
lor the COlt of aerviceI rendered
(3) Upon thetermlnalion ola PROVIDER contrllcl between !he PLAN ancla contracting DENTAL PROVIDER, the PlAN shall be IIaR*l lor cOWNd
servi<:es I1IfldeI'ec:I by the DENTAL PROVIDER (other lhan lor copayrnentl) to the MEMBER who rNlna e1ig1b1Hty undaf tMlNDIVIDUAL or
GROUP SUBSCRIBER AGREEMENT or by operation of law under thecartl oIthe DENTAL PROVIDER at the tlml of auch twmIMtlon until the
Hrvicel being rendtrecl to the MEMBER by the DENTAL PROVIDER n cornpletM, un.... the PLAN makea reaaonIbtt and medically
appropriate provillon for tha allumption olsoch 18rv1ee1 by a con~ PAOVIOER.
PART VIII. RIENl!WAL PROVlltONI
A. After the conlract period, the SUBSCRIBER GROUP may renew this GROUP SUBSCRIBER AGREEMENT.lUtlieCtto any changes In COPAYMEN1'
or the BENEFIT package made by PLAN. by filling out II renewallorm and paying all mon.. due.
PART IX. INDIVIDUAL CONTINUATION OF BEHlEflTI
A. The MEMBER who ~mn ineligible lor GROUP COVERAGE may apply within Ihlrty (30) daY' tram the date of termination of IN GROUP
COVERAGE to continueCOWlrage under an INDIVIDUAL SUBSCRIBER AGREEMENT of the type lor which he or..... Itthenel6glble. Convet'IIon to
Individual ~ shall apply 10 I_he DEPENDENT(S). inCluding. DEPENDENT SpouIeandl DEPENDENTCHILD.oIthecorwertlng MEMBER .In
lOCUtk>>n, a CHILD who becOm.. IneligIble al a lamlly DEPENDENT can cotlV*t to indIvidual cover. upon the IIfI'II condillonlaa applied to a
MEMBER. Such appllcallon lnay be accepted Of rejected at the option of the PLAN; no 1UI0000000tic tigM 01 IndlvidUll contInUltion of benIfIta exllts.
ThoH terminated pursuanllo Section X.A(2)and Section X,B(") mIIY not ba ohreclthe opportunity 10 convert to incllvidual coverIQlt.
B. 1M PlAN reserves lhe oplion to offer converllon' prlvlleglllotM MEMBER wtIoblicomeSIneligitIIIforcoverlgeundtrtt'llaGROUPSUBSCRlBEA
AGREEMENT due to the lermination of this Agreeman!. Shoukl corwerIlon to incllvldulll coYer'lgl be offered 10 the MEMBER, appMc:ItIon mull ba
made within (30) days of notice of ineligibility to conlinue coverage under a SUBSCRIBER AGREEMENT of the lypetorwtllch hi or.... II inIIIgIbtI.
Converlion to individual coWlt'age IhallaPl)ly to tM DEPENDENT(S).lncluding a DEPENDENT S90uM IInd DEPeNDENT CHILD. of the~
MEMBER upon 1M lime Mrn'll anet condItionl.. aP91ied to the converting MEUBER.
C. A CCMntd DEPENDENT SPOUSE who CMMIlo be a Qualified lamlly MEMH1II by NaIOI'l of *""ndon of rl'\IITlIaJt or deIth of the emptoyM or
SUBSCRIBER will be atlorded the same conversion rights and condItklnl trlnled 10 MEMBERS under this Section rx.1IUbMcUonI A ancI B.
PART X. TMMlNATlON Of' "HE"'"
A. BENEFITS .haI1 CHM upon the 100IowIng ewntll
1. FailureofMEMlEAtopayttul PREPAYMENT FEEtoSubact'ibarGrouplltheSUBSCAIBER haltlMndulynoCllied and biMadlorthecNr'gltanCllf
leall 15day1h11elepMdlllnclthedll.ofnollflcatlofl. ~.lnthe.......thalInENROlLEEltundlr1lOlnalNllmlnllorlrlongolngcondltiOn.
he/she may continue 10 receive t,..tmentlrom . PLAN PROVIDER, but mull agree 10 pay PAOVIOER On a ''I.. for 1IrVice" or "usu.a and
custOmllry lee" bull.
/,; () 2 Fraud or deception In the UH oflhe servIces or facillllllli of the PlAN or knowingly permlnlng luch fraud or deceplioo by another
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deectttMldinAttechmentA.MEMBER 3O__prior~Of BEAGAOUP.
.. BENEFITS.....l>>Ue upon the foIkM1ng the SUBSCRIBER or MEMBER "- noufiIId Met at... 15 dIys hM ~ tinee'"
_.
,. Upon dMe Of enIJy Into ,....... mIIbry MI'V\CII.
2. Upon'" Of DEPENDENT CHllDRENS~.
3. Upon DEPENDENT CHILD ..ining. of tlor 24 or priOr.....m.ge wtth u.aJCGeption oIa DEPENDENT CHILD1haIt.I been<*tlfied by the
PLAN . ~ of IIIfI1uUlnlng emptoyment by ...-on of ....... tIItaIddon or ~ hIndIcap and .. ch_ ~ upon ...
SUBSCAIBERforlUpPOrt8nd.............provIded proofOfIUCh~.IurnIIhedIo...PLANby...SU8SCRII&A....31 dlyaOfthe
NqUIIt lor IUClh proof by.. PlAN. Ai..-1tI'I tIll ~ n of such IfapecIly mey be...... by the PlAN, but not moNi fNquentIy .._once annuIIly
...... the ~ period IoIIowIng the OEfIEN)ENT CHILD'S dIinrMnI 01. ""*-t,
4. If II ~ lmpouible, IIfI<< reuonable eftofta. to ..tIIt;;.tI and maintM'la utIefKtory dentiIt-JlMient relMiOnship with any MEMBER
$. "the SUBSCRIBER _ been tenninated from "" GAC', 'I'" or hu voluntarily 11ft Nld GROUP. In IUCh CUlt SUBSCRIBER'S and his eligible
DEPENDENTS' BENEfiTS wII ",m1Mte.
t. Intheewtnt:theapptlc:ablecopaymentswhieh .,.Cletli'-<:!Intt. BENEFITS SCHEDULE (AMchmentA).. not plld.lfCopayment..,.not ll\8de
lor one family member only ttIIt pettOn'. BENEFITS will tennlMte.
PAIn' XI CANClUAnON
A notiCe 01 Clnceltatlon shall be mailed to the SUBSCRIBER al the SUBSCRIBER'S Iddras of NCord. and in such lMlnt Of cancelll1ion 01 MEMBER;
A. The MEMBER will....ve the Of)pOftunily to have the CIIncelll1ion revlewMi by the CommiMioner of Corpofl1ion1 undW Section 13M ollhe Knox.Keene
Act,
B. The PLAN ,shall within Ihirty 130j days of CIIncellalion relurn to the MEMBER the pro-rI18 portion of lhe moM}' r-id 10 the PLAN wttich correepondslo
My uMxPlred pwiod lor whiCh P8yment h8cl been recetved. togMher with amounta due on cl8i...... If any. leu 8ft)' amounts dw PLAN
Acceptance by the PLAN of the proper MEMBER PREPAYMENT FEE attw termin8tlon 01 this GROUP SUBSCRIBER AGREEMENT and without
requiring a',.w applicallon ahall reinsUlte the conll'Kt nlhough It Met never tarminI1ad unleu the PLAN within five (5) buaineu dayI, of receipt of such
payment eIther
1. refunds P8ymenl. ()(
2. issues to the GROUP I new GROUP SUBSCRIBER AGREEMENT ICCOmpanled by written notice ..ating clurty thOll8 respects in which the new
contract differs from the lerminated conlract in BENEFITS, COVERAGES. or otherwise.
D. TM provisions Ollhis pan apply to an terminations. including thoee dalcribed In Put X of ttlts Ag....ment .
E. If terminl1ion occura due 10 'Iilure to make COPAYMENTS. REINSTATEMENT of BENEFITS will occur et the beginning ollhe next month aflef
P8yment ol dellnquenl P8yments have bMln made,
PART XII. RIGHT Of P\.AN TO CHANQl8ENEFITS
A. PLAN reserves the right to changa the BENEFITS, COPAYMENTS OR PREPAYMENT FEES to MEMBERS.
B. The PLAN Shall not decreue In any manner the BENEFITS statld in the GROUP SUBSCRIBER AGREEMENT except a_ a period ol.t least Ihirty
(30) d.ys from and after the postage paid and mailing to lhe other P8rty 11 theother r-rty'a add....oI record with the PLAN 01 written notice 01 such
proposed chen""
C. The PLAN Shall nOl increase or decrease the PREPAYMENT FEES()( OECREASE BENEFITSpeept after aperiodolat....t thirty (30) days from.nd
alter posl.ge r-id mailing to Mid MEMBER at the MEMBER'S add....oI record with the PlANar written notice of IUCh propoeacl inc...... ()( ctec.......
Notlfic;ation of alleration or revision given 10 lhe SUBSCRIBER GROUP ~ """" be diueminated to the SUBSCRIBERS and lhe
ENROLLEES in the GROUP no later lhan thirty (30) days from fKelpt thereof and muat prO'ridII thirty (30) dayI, notICe 10 the MEMBER prior to such
IncrelSe Of decreue In PREP....YMENT FEES or dec......in BENEfiTS.
PART XIII PRlPAYMENT FIEI!
A. The PREPAYMENT FEE is the monthly fee required to maintain ~ undef this GROUP SUBSCRIBER ....GREEMENT,
THE PREP....YMENT FEE SCHEDULE IS ATTACHED HERETO....SA TTACHMENT B. THE PREPAYMENT FEE SCHEDULE ISAN INTEGRAL PART
OF THIS AGREEMENT AND MUST BE READ IN CONJUNCTION WITH THE REST OF THE AGREEMENT.
MEMBERS of a SUBSCRIBER GROUP thall p.y PREPAYMENT FEESdlfKllytotheSUBCAIBER GROUPwtliCh will in tumr-vtI\rtPlAN. MEMBER
should check with SUBSCRIBER GROUP to determine lhe dMdIlne and lMIhocl of PI)'m8flI for hlacontributlon If .ny. tothe PREPAYMENT FEES
SUBSCRIBER GROUP lhall. then forward the PREPAYMENT FEE 10 the PLAN. Monthly PREPAYWENT FEES mUlt be rKeMd by the PLAN on or
belore the twentieth clay of the monlh to insure eligibility lor service on the Ilrst day of tht folloWing month_ Such P8yments lhall be made at or senl to:
Nalional Heellh Care Syslems of Calilornia. loe
18682 MacArthur Blvd.. Suilt 101. Irvine. Calil()(nia 92715
f=layments received by the PLAN. or illauthorilfld agent, priOr to the due dala, will make MEMBERS of lhe SUBSCRIBER GROUP and their eligible
DEPENDENTS eligible tor BENEFITS commencing on the due dale lor the period pakl tor. P8yments r~eived after the due date will make MEMBERS
and their eligible DEPENDENTS eligible for BENEFITS on the due date of tl\rt lubNquent month. MEMBERS Ihould con'-CI the SUBSCRIBER
GROUP to determine the deadline Ind method of paymenl to the Group.
The PlAN wUl not incr.... or decrease Ihe PREPAYMENT FEES ()( dacrene BENEFITS except aher a periOd 01 at leall thirty (30) days from .nd a_
pollage paid mailing 10 said MEMBER al MEMBER'S acklreas of record wittl the PlAN 01 wrIl1en nolice of such proposed increase or dac.......
Notification of alterltion ()( revIsion given to Ihe SUBSCRIBER GROUP Representative mUll be diueminated to the SUBSCRIBERS and ENROLLEES
in the GROUP no later than Ihirty (30) dayslrom receipt lhe,reof and must provide thirty (30) days notice to lhe MEMBER priOr to such Increase ()(
decrease In PREPAYMENT FEES or decrease in BENEFITS
Each MEMBER shall payor arrange for P8ymenlof applicable COPAYMENTS, If any." provided in Attachment A, In case 01 failure to dOlO, the rights
01 MEMBERSor their eligible DEPENDENTS may be terminated on Ilfteen (15) clays' noIice and may be relnstated,only by renewed IIClI>>icaIion and
r"nrollment In accordance wilh all reqUIrements of thIS Ag..-ment. Any appttcabte COPAYMENTS are detailed in the BENEFitS schedule'.
ENROLLEES wilt not be terminated based upon I.ilure to pey "lee for Nl'VicaM or Musual and cuatornary fee- tor Mrvicaa not covered by the PlAN.
PART XIV. LlMILtTY Of MIMII!JIIIN THE EYIHT or NOM'AYIIINT 8V THE Dl!NTAL PLAN
In the event the PlAN leila to pIIy a PLAN PROVIDER with whom the PLAN _ a contract lor 1Mlrvice. the MEMBER ahall not be liable to the PLAN
PROVIDER for any sum, owed by Ihe PL.AN, In lhe event that lhe hHllh PLAN lalla to P8Y' nonconlracting prov+d8r. the MEMBER may beliabla to the
noncontracting provider I()( ltIe COlt of the servicel rendered.
PAIlY XV. TERMINAnON Of' PROVIDER
Upon terminatIOn of a PROVIDER contl'Kl. the PLAN shall be liable (OIher Ih.n for COPA YMENTS)I()( covered aerviCn rendeIwd by such PROVIDER
10 a SUBSCRIBER or ENROLLEE who retIIins eligibility underthll GROUP SUBSCRtBER AGREEMENT or by operation of law and who I, under the
care 01 said DENTAL PROVIDER at the time 01 such ltrmmatlon. until the CIIre being rendered to saicI SUBSCRIBER or ENROlLEE by such
PROVIDER is completed. or until the PLAN makes reason.bIe and medlcalty appropril1e provtaion I()( ltIe uaumption of SUCh services by another
contracting PROVIDER.
PART XVI. GENERAL PROVISIONS
ThiS Agreement, including any amendments lhereto, con,lilutellhe anUre agreemenl belween the partin.
The PLAN is lub)eCIIO the requirements 01 CNlf)I8r 2.2 01 Division 2 oHhe Heelth and Safety Co6e 01 the State 01 California and SUbchapter 5.5 of
Chapler 30f Title 1001lhe Califofnla Adminlslratlve Code, and any provllion requlrecftobe In thll contract byettherof lheabove"'all bind the PLAN
whether or not provided in the contract.
This Membership Contract replaces.nd cancels all other conlracts. If any. luuecl to MEMBER herein.
In the event of any conlroversy between the MEMBER. I DEPENDENT. or the h8lra-at-law or perton8l repreaentall..,. of a MEMBER or DEPENDENT,
n the case may be. and the PL.AN. as indIVIduals or Olherwlse, wtIe!tler inVOlving a claim in tort. conlract ()( otMrwiae. wIWCh are not adaqUidalv
resolved in the opinion of the MEMBER. a DEPENDENT. or helrs.at.law or personal ,....ntatlve ola MEMBER or DEPENDENT, by the PLAN'S
grievance procedures. the same lhall be submitted to arbilration in accordance with the roles 0111'18 AlMrican Arbitratton Auociation. and jUdgmant
on theaward rendered by the Arbitrator or Arbitrators may beentered Inany Court havlng;urteclicllon Ihereol. ArbttraIIon may noI belnitiated,~.
untillhe gnevlnce procedur.. h..... been exhausted, Thus. the compl8inl must have b88fl given notlceoi' the dlapolition of hlscomptalnt by the PLAN,
have appealed tolhe Public Policy Commilleewhlch ha,rendarlid adec:lSiOnand given nollcelhlnoftothe~,priortoiNhatinga~.
ArbItration may be InlIllied by any MEMBER by Mnding a letter to tM PLAN office. In lhe event of arbitration, the prevalHng paIty In aaId procaednga
Ihall be anlilted 10 an award 01 reaaonabla allomeys' tees and any coats lncurflld
The PLAN will provide wriltan notice within a re.son.ble tima 10 MEMBER in the event 01 .ny termination or brMCh 01 contract by. or Inablflty 10
perlorm 01. any conlraCling PROVIDER If the MEMBER may be materially and adversely.fIeeted thereby.
F. Any notice under thiS Contract may be given by United Ste... mail. poataga paid, addteued .foIlow1:
National Health Care Systems of California. Inc.
1866:? MacArthur Blvd,. $uile101
Irvine. California 92115
If 10 a MEMBER
To the latest address provided 'or !he MEMBER on enrollmenl or change 01 ackIreaa f()(ms actually delivered 10 the PlAN
1110 Ihe SUBCRIBER GROUP
City of San Bernardino
300 North "0" Street
San Bernardino. California 92418
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G. Term. Thll AgNelMfd IhIII NmIIn In lon:lt."Qror one (l))'MI' trom _.n.ctive.n
H. WHAT POLLOWI..1MI......,.1CHIDI... AND fRllle.... pl'!l ....... AND ~A11ONI CA"~= THE PREPAY.
lIIJfr"'ICMDIUCA"~&: AMIIOTAnACHIDCONTACTYOtMIIIPLOYII.-m- ATIVI 011 THE
PLAN IY IIAIL,.......... 011I1' . TOLL..... NQIITHINrI ~""IPCR'A" c-. aa.J011 011 TOLI.... II muTHERN
Cl\LIICnIIIA___na.
TIll""'" aClBUU AND......YIIIHT ... ICHmULI AM IN1'aCIRAL PAIlTS Of' THIS AClMIfIlENT AND.,.T H READ IN
~WI1H1MIMS1'OFTHI"-..r.
IN WffNESS WHEREOF. .. AgrMmenI.... ~.-c:utMi _ Of 1M day WId v-r"'" wrmen 1IbCM.
NATIONAl.. HEAlTH CARE SYSTEMS OF CAliFORNIA, INC.
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ATTACHMENT B
PREPAYMENT FEE SCHEDULE
MONTHLY DUel:
By
SUBSCRIBER GROUP
7 . 00 Subscriber
By
, 12.00 Subscriber and one dependent
, 15 00 Subscriber and two or more dependenlS
, Monthly Administration Fee
$ 3.00 Ortho only.
$ -0- ortho with General Dentistry
OJverage
AGENTIENROLLER
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William H. Hornbaker. 0.0.5.
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