HomeMy WebLinkAbout29-Personnel
CI.c' OF SAN BERNARDO - REQUE:)T FOR COUNCIL ic'~iON
From: Mary Jane Perl ick
Personnel Director
Dept: Per sonne 1
RE::'D. - l'O~"'!Kl3fRf!sol uti on to authori ze the executi on
I of agreement wi th Mi ss i on Dental Health
1';': Dei' 23 F" 3: eTjln for General Denti s try and Ortho-
dontic Benefits effective January 1, 1986
Date: October 21, 1985
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:
Approved the resolution to execute the terms of agreement for one year with Mission
Dental Plan effective January 1, 1986, with no change in rates.
~/~i-~
- SignatuD
Contact person: Mary Jane Perl ick
Phone: x5161
Supporting 1ata attached: ---'ies
Ward: N/A
FUNDING REOUIREMENTS:
Amount: No add 11 cost
Source: Existina budaet
Finance: j/'"" C L ./
Council Notes:
75-0262
Agenda Item ~ ~
-
_1-
-
-
Clk OF SAN BERNARD~O - REQU~T FOR COUNCIL Ac-rtON
STAFF REPORT
The City's existing agreements with Mission Dental to provide dental services
(including a plan for orthodontic care) expires on December 31, 1985, The
attached agreement was received from Mission Dental on October 21, 1985, with
no increase in rates.
Monthly Rates Effecti ve January 1, 1986
$7.00 Subscri ber
$12.00 Subscriber and one dependent
$15.00 Subscriber and two or more
dependents
Employees participating in the orthodontic care plan (81-0R) ~ will pay a
subscriber rate of three dollars ($3.00) directly to the dental plan. This fee
is not charged to those employees participating in the basic dental plan. The
maximum benefit to the subscriber for the Orthodontic Program will remain at
$1375.00.
75-0264
',,-.
"'-.-'
,,,.......
1
JUSOLUTJO~ NO.
2 RESOLU~]ON OF THE CITY OF SAN BEFNARDINO AUTHORIZING THE
EXECUTION OF AN AGREf~ENT ~ITH MISSION DENTAL HEALTH PLAN FOR
3 El~PLOYEES' GEM,PAL DENTISTRY PLAN hITH ORTHODO',nC BE1'EFITS,
EfFECTIVE JANCARY 1, 1986.
4
BE IT RESOLVED BY THE I'.AYOR AN'D COrl,I'jON COij'-KIL OF THE C]TY
5 OF SAN BERNARDINO AS FOLLOKS:
6 SECTION 1. The Mayor is hereby authorized and directed to
7 eXEcute on behalf of said City an AgrEement with Mission Dental
8 Health Plan, relating to employees' general dentistry plan with
9 orthodontic benefits, effective January 1, 1986, which a9rEe~ent
10 is attached hereto, marked Exhibit "An, and incorporated herein
11 by reference as fully as though set forth at length.
12 I HEREBY CERTIFY that the foregoing resolution was duly
13ladopted,bY
14 Betnardlno
the Mayor and Corr,rr,on Council of the City of San
at a
_ _________________ meeting thereof, held on
15 the
_,___ day of
,_____________________, 1985, by U,e
16 following vote, to wit:
17
AYES:
--_._-----_._----_._---._---~._-------_._-_.__._._....---..------..---------
]8
-.-----.-.-.. ---- -_.._._--- ._---------~--_.__.__._--~-------- ----
19 NAYS:
-.----.. ---.---------. _.._--~-_.._--,- -..--- --~~-_.._-_._-_.__._----~----_._-_._--
20
21
22
23
ABSENT:
City Clerk
The foregoing resolution is hereby approved this _____ day
24 of
25
_.,-------~--,--_._-,-~-,
1985.
26 Approved as to form:
27 fi!:-,-' '/.f2~::,-~.u
28 City-Attorney-----
Mayor of the City of San Bernardino
\,
-
- -
-
(.~j)UP SUB&CRIBE::l AGREEMENT
(PLAN- p~-V) GRPf 900476
'" BI-OR
This Agreement is IT,ade and e.""uIM I";, _. 21 st day 01. OCTOBER ______ ,19__~_5_~
b~' ilnd be:weo..n .l:JTX 9f.SA!il_BEF:~ARD~N9...,. (he-'e'f..f1~1 'e'er'~d lOllS "SU8~CRIS[R SROUP"I_i1Cld r.,tATIONAL HE"LTH CARE
SYSTEMS OF CAU~ORNIA_ jNC (oba DENTICARE. a'It! MIssion De'1:al Hl:allh Pian), a Cal,fornla cu,;:,~"(lt,on (he'e,nafler rele"ed to as the "PLAN")
wh.ch operal.;ls II s~c,ah~li'd health care ser~,ce pian subject 10 the I.cer.s,ng fi'QuHefTOenls and Ope'31l0"',al .egw:a10')' sta'li:::ards enlOfc;ed by the
Comm;ssir.>ne, Of CO'.i>CI.a',ons of Ihf Stateot C"li1ornJ.i! ....',cler the Knc);..Keene Heal1l'1 Care Se--v;ce Plan Act 011975. a~ i1me'ldocl. The affective dateofthis
agreemenl!>hallbe...I.A.N lS.t.__________~'9_li!:l_______
ThE' address of thE' prir-oc'pa! ..dmini~kah't' off.cE' 01 the PLAN 's ,P.662 Mal;;Ar1hur Bl~d. Suite 101,lrvir.e, C<lliI01"'1I 92715 Telephone numbe'~ are (714)
752.H:.7, (714) e3:>.1~, or TOLl.FREE In Nu"ht:ln Cllhf,:,!n;a ,B:lO) 432.7019 or TOlL.fRtE in 5outl'.ern CaLlurn,s (!'\.JOi 4:~2.7158
PART I. DEFlNITlO"lS
A. "AE~THE1IC DENl IS1 RY" m,.1>r.~ o...r,:al p'o.:,..:!"r"" w~,,:t, ,llE.' ,....<1oll"r,d purely lor !;.osmet,c rl.Jl~','ses
8 . BENEfiTS" and "COVERAGE' mlar, Ihos,," ;;:e~,!al COIlE' se"'c.!;~ ava.!abl(' undel IhE' GROUP Sl'~S(:R:ClEH J>.GR( E.MENT Ii" WhiCh II MEMBE.R is
&mol,&d
C "CHILD";nc!u,je, al! r.al,,'al. ilcj:)pled. 1:,;sler, ar.c:'SIE-"c,h,idlen
o COPA"ME....T'".~ a... addll'wr.a' !€'.. Ch..''J''C to a SlIBSC?;BEI'l or E"-IelOll EE ...hiCh is appre~ed bylhE' Caiil,:)rn,a COf',mi,S'O:"lerot Corporal;O"'~ whO
rf'gu'atE-S Ihe PL.!"'" p,,'~~anl 10 th~ I(nc~-Kpe"e Act. ;:.rc.-.dc-d 10' in tM PLA'" (,onlr1lcl, and d'~clc~e-d ir, fh" E,iIDE....CE OF COVEP.J>.GE.,D1SClO-
SURE FOl=\M
E . DE...T AL FACILITIES" ,~,~an tC":':>f- ce~te<s ~e:.~cl('d by t~.€ PLA"Ilo p'o~"je dt:n!al se'\';~es fOl a,"y Mt:I,ABER
F . DEPENDENT"" ".,~I"j,:,~ It:~ to:,:-....;ng .n:::'. "j"a'~ c,nly If tt,ey res,d... 0' ....Or~ with,n the PL,ll,N'$ ~e""'Ck ,,'~a {....ilh,r, 30 mil!<s ot a ge....!<lal denl,~t PLAN
PROVIDER)
(1) The !aw/ul s.'Cu!>I:' of a SU<:<SCRiBER
(2) An u,-,"",3<:''''c:' DU'E"JDENT CHtL D 0' a SUBSC,,:8CR up 10 P'f' CHILD S ninateenth blrthtlay
(:>1 An Ur,millfied "hila 0' a S:JB,sCR:etR, up 10 Iht' CHILDS :we....ly.j,JuF1h birtr,c:'ay, who 's a fuli lin,e S'"j",: t and:s ....hOlty depe....jenI0r'l SuCh
SUBSCR:BEI'l lor ~,'i"'port
(4) COVERAGF ~~,all i1'!>O b!< ~~Tel1d!;d bey'--,nd Ihe r.."el!<!;l1lh :..~ar a'.d twenty.lourth yeal a:;le 1o..."t",t"J"'~ ....he" a DEPE"JDENT CHILD can be
co:-rti!ied by the PLA~ as .r.;ar'~ble Of "e!f-sL'S:i1lr",,~ <<:T,p10yrT1",n! by I..ason Of menfal re~ardat,;:.rt 01 ph,'s,ca' har,d'c.a~ ar,d i~ ch;elly dependenl
upon Ihe SuE'-SCRI8ER to' s'-'Pr>,:,r: and n-:air.~eC,a"cf pro-'<ded proof 01 Such inc!tpacity IS furnished tolhE PLAN by the SUBSCRIBE? within 31
tlay~ ,~ftt>e rBq,)est fo' s,,(,t' prool by t".e PLAN Re:'er1.licabon 01 SUCh incapa!;.ilymey bE< r..qujrr,d by the PLAN, but not mo'elreq"entlythanonC8
annc.alt,' atter the t....e year "e"(.Id lollo""",g Ihe (Jl:.PEN;)E"IT'S alla",menl of age ~.ii'1eleen
A ne...t>orn CHit D sr,ali be c.)vero:-d hom rT.c>ment of birth and a minor aclopled CHILD !.hal: ~ co_ered l'om the lime the CHILD is placed in
cus1udy 01 the ad.ophe ~arent
G DISCLOSURE FORM-- mfan~ tr,elorms or fT'aler:ai~ !;,Ontain,ng SuCh ,nlor''''8t<on 'egarrj.n9the BENEFITS ser..icesandlermsollhe PLAN conl'act
as I~E' Con.miss.c'ner rT:a), 'E'qCh'e ~o 80 \0 allold Ihe p'.'bloc the SUBSCRIBER and E"'ROLl EES wilh a lul! ar'd ~air dlsclosu'e 01 the pro..i!.i"n!. of lhe
PLAN ir. readily u"de'~h:>od la'1gua';;e ane <n a clearly {.rgan"led mannef
H "ELECTivE DENTISTRY-- means denial prJ,:,edu'f'S Which are unne('i'SSa")l10 the de..tai ~ealth 01 Ihe pet,(<nl as determined by a PLAN ::Ienlist
I 'EMERGE""CY CARE'- means !>e''''rrce!> rE-"je'i'd lor alle~:ah0n e' SNere pain or ble.edlng a'.d,or iro.mej:ate ,j.agnos,s a',d t'ealmenl 01 unfore!.een
cond,li"n~, which. il not imrr>e,j,a1e1y diag'1()!>"'d and h"_aled "".ay INd 10 d'>.abilily, dysll.Jnct'on or d~ath
'EVI()E"lCE OF CO'JEP.AGE" ",r-ans "ny (;ertl"ca~e ag'eerToo:-nt. con('aCI brOChu'e or iet!er o( entitlemenl issCJ~d 10 a SUBSCA:BER or EN~OLLEE
~tlr"g tur1r. the COVERAGE tc wl1,!;.h the Si,;BSCR:BE.F1 or ENROlLEE;s ent,tled
K ~EXCLUSION";s any prO~ls'on 01 the GROUP SUBSCRIBER AGREEMENT whereby co~e'Il';le 101 a $pec;!ied l1a~ard or conclition is enti'ely
elim,"a~ed
l "GROuP S\JBSCR:BEP ASREEMEN,' rel",,~ 10 tl'"s Ag'<-emenl PLA"I! ane" ilny SlIBCRIBER GROUP ane' Nt;,ch e$:abl;sl1e~ tt'fle,msandcondilions
which go~ern the BENEFITS (T,,-,je ala !a~le 10 an} ME'.t.BER by PLAN
M "LIMn AT ION" is any pro~ision Olh!<r trar, an EXCLUSIO~ ....h:C" f"'s1ricl~ c0\1e'a2e under the GROUP SUBSCRIBEA AGREEMENT
N 'MEMBER" and "ENROLLEE' m('"n a0y Sl:BSCR:8ER or DEPE"'DENT, ....ho is enrolled under tt.E' GROUP SUBSCRIBER AGREE"-"ENT and is
enl.tied 10 Ihe BE"-;EFITS a~II':i1ble und€:' l'l", GROUP Si..IBSCR:B[R AGREEMENT In relurn fOI th", paymenl rE'Quired 10 be made lothe PLAN under
~ucr. GROUP SUaSCRIBER AGREEMENT
o . PARTICIPATI"-I(:. DENTIS .S" me".... t~.(,sejenlist~ $e1c-c!"d by t~e PLA.. 10 pro~id€ den~al se~ice~ 10' MEMBERS
P . PLAN" is Nat.or,al Heallh Cale Systems o! CablOlnia. Inc
a . PLAN PROVIDER" or' PLAN DENTIST" rel!<'~ te a pro.,.de' of de,,!ar ~ervices licens.ed by the S~ale 10 deli_el 01 furn'Sh these ~e'V;ces. which ha~ a
c.onlract ...:th Ihe PLA"" 10 'ender ~ec~'ce~ IC af', ME'''SER ir.llccerdance ....ith the pro~ision 01 the GROUP SiJBSCRIBE.R AGREEMENT in whictl a
MEMBER,s enrolled The n,,'TIes, i"cal.ons hours 01 se...ice and Olher ,nlormatoOr'l regarding PLAN PROVIDER. PLAN DENTIST or facilities may be
obtal".<>1 by con~act,ng the PLAN oH.ce
A 'PREF'AYMENT FEE-- IS the amount PI;!)le eaCh month by the, SUBSCR:BtR GROUP 10 ob~ain BENEFITS plo~;jed under the GROUP
SUBSCRIBER AGREE'I.ENT
S "SERVICE AREA-- con~,sl~ oltn,:>se g"(',;raph,c re'J;on~ whiCh are within II :30 mile, radius hom the general dent,s: PLAN PROVIDEAS
T . SuBSCRiBER-- 'slhe pe~!>ol'\ who i$ '(',p;:.nS'ble 10' ~aymel'\llo Ihe PLAN, 0' whose employment or othe' slatu~, e~cepllol lamily dependency. is a
bas~s IOf e"g'bil.ty for ",ernt>er$h'p ir'l the PLAN
U "SUBSC.~IBE.R GROUP' is th~ Ol';l"n;,al<on 0' campa"y wh,ch has ent!<red inlo a GROUP SUBSCRI~E.R AGREEMENT with the PLAN undecwhich
BENEF- : S are fT,ade lH-lIiiable, to el,giblt' g'ou;" MEMBE8S snd Iheir DEPENDENTS
V 'SUBSCRiPTION COST'" m!;ar,s the p'c<pa,d Cl'.alge paid by O' 0" behall 01 SUBSCRIBERS or ENROLLEES
W 'SUl'lCHARGE" ",eans an add'f.ona' !ef whi(,h is (,1'.a'9t'd Ie a SUBSCRIBER or ENROLLEE lor a cove'E-c service, but wh.ch i~ 1"101 appro~ed by lhe
Comm,ss,onel, prc~'ded for In Ihe PlA'" !;.onl'ac~ and d's.clo$ed I'" the EVIDENCE OF COVERAGE/DISCLOSURE fORM.
X "USUAL AND CUSTOMARY fEE" mean~ I"'~ amounl which a DE....TAl PROVIDER normally or usually Charges the majority 01 his patiel'lls lor a
part.cu!ar s.er~ice Th,!> 1",""~ ,-,s",o ,r.1erc""r,;,-pabl)' wllh '"FEE-FQR-SERVICE"
PART II. ELIGIBILITY RULES
A Persons Elig;ble 10 Become Subscribe's
Any pe,son whO
1 .~ an act've j,jli.!.rr,e employe€- 0' ~EMBF.R o! a (,Ollecl,..", t>argainlng ,-,nit. associat.on or Club 0' an eleCleo official oj SUBSCRIBER GROUP or
....ho 1$ a .et<'td elT'ployee ;:.t S:'-'BSCR:3ER GR,:lUP
has ,"01 P'('",ouS1y been le<mlna1ed unoer I"'DIVIDUAL 0' GROUP AGREEMENT because of Iraud 01 dEfcepl.on in Ihe use of the Services or
'"cilot,!<~ of Ihe PLAN or knOW'''1glr ..erm'U"'9 s'Jct, 1raud 01 dec.epl.on by' another. and
3 r,i1S il~'ploed lor mernj)(,>'shlp, or> 10'fT'S SLJppl,,,,d by Ir.e PlA"'. and
4 les.,jes 0' wO'~s WIth.., PLAN'S service a,ea :....ilh.rt Ih;rty miles /rom II genalal denl'st PLAN PROVIDER)
B EI,g.ble OEPE""DENTS may b.. enrOil!<d a' H.e t.me Ihe SUBSCRIBEI'l enrolls or any time thereafter by lilling ou1 the jo'm~ supplied by the PLAN and
pay.ngt',e appii~..bl", prepaymenllee
C Da1e 01 Eligibility
1 All pe'sons including lhf SUBSCRIBER "nd ehg;bl'" DEPENDENTS r.a~~ appli!;d 10' membership and for ...hOm the appropriate SUBSCRIPTION
COST ~,as been ~,,'d pr'Of 10 Ihe?Oth day of tM month s~,all be ehglb1e, 10' BENEFITS comm!;ncing on the 'st day of Ihe lollowing month
2 All pe'sons ,nclud;ng (he SUBSCRiBER and ei';Jible DEPENDENTS who ha~e applied for membe'!.hip and for whom the appropriale
SUBSCRiPTION COST has been pa'd t.e!wee~. Ihe 20lh day 011he, rr.onth and the last day ot Ihe month shall be eligible lor BENEFITS
commencing Ihe ~sl day 01 the second m~njr, Ihprealter
PART Ill. EFFECTIVE O.b.TE AND TERMI~AT'ON DATE
All pars,:,n!> becomeel;g.bletor !.erv,ces a! '201 A M 01 the ettec1F~e dale indi!;.aled on IhisGROUP SUBSCRIBER AGREEMENT providing they meet
alllhe el';'blh~y r..qurro:-menlS Term,nal.,:,n dalE"s bilH.d on the e~enlS and condlllons 1<!.IEtd under PART X
PART tV. PRINCIPAL BENEFITS AND COYERAGES
A El\jROLLEESare enl,tlpd!o de rIal se"'(;e~ a~ sel !oM:.n thf Beneir: Sct,edule whIch i!> allllched IIsAtlllchmenl A This Sche,duli'establ,she~lhe dental
se'~.ces whicr, a'€' a.a.labl" 10 ENROLL F f S....,tn(\UI : ~."'ge (ces'g~.a1ed as "No Charge-- ,n lhe Schedule) and t....t\se, 5erv,ces fo, wh'ch ENROLLEES
a'''' obllgaledlo pay It,e PLAN DENT AL PF10'v!DlR Tt.~ "....ounl ef sucr. C.OPAYMENTS ...h,ch It'_e PL.-AN DENT Al. PROVIDER:s permiltedtC'Charge
ENROLLEES lor spec,f,( denta'!.ef~.c",~ IS s!<i 1o'1h "r.der tt." to,ad.ng 'COPAYMENT REOUIRED The EXCLUSIONS AND LtMITATIONSapplrcable
10 the Benet.t Sch!'dule a'€' sel lorth 'rr,....."c1a!('ly !01""""9 ENROllEES MUST UTILIZE A PLAN DENTAL PROVIDER UNLESS A PROPER
REJE.RRAL 10 A NON-PLAJ'.. PROVIDE.R HAS BE E~ t.'ADE
THE BENEfIT SCHEDULE AND PRINCIPAL nClUSIONS .AND LIMITATIONS ARE ATTACHED HERETO A.S ATTACHMENT A. THE
ATTACHMENT A IS AN INTEGRAL PART OF THIS AGREEMENT AND MUST BE REA.O IN CONJU""CTION WITH THE AEST OF THE
AGREEMENT.
EX::.~.. i\
,
PRI,,"CIPAl BeLL/SICNS "'~D lIMITATV '..'!,: OF BE~EfjTS
Ser..res 10 ....r,.ch Ih~ MEV.I:IE:R i~e"t,llf"d an) vVo~.ers Co...-t>e"sal,on La... 0 "he PLA~ s"all..,:,.;,j~ the 5.:""~es althE l;me ofnetlCl.
t>ull!-le t..l[MBER shal: e~..cule ano de:"e"-""'tbCw....enI5 0' lake Such ol"e' ac\;ciloo..........Iat t>I:: nl",;!>sSll-Y Ie I'Iss:..o'ethal the PLA.N;\> reimburs.ecl
'or ty~"ell!s pfOy'd~-:l by W~xkef's Co'n~e"..a'lon Thl~ [);CtVSION 1:>es no: a.'ply irnt.-odl-Cal P')oQ'am
2 Se~ices. wh;ch in lhe opin'on of It,(: at!e...d'"lg dent:sl, are not r'ec.-..~sarr 1011h", pa\;enrs'j",nlal !'.<;allh
3 Orlk.jon\ics
.. A[~THETlC DE.NT:5TRY
S Ora' 5<.l'~e'1 ,,,,,qui""9Iheselt,nlj olfr"(I,,res or ,j'sl.:>r_ak:>ns
6 TrealfC1",,,\ol ;nal'gr'Il:)Cies, c,'sls or neJp:ilsrns
7 ~;s;><-ns;"'g 01 d'u95 rlol 00,,<.811) ~."~,pl;,,,j ir, a je"tal 0t1,ce
8 In \h,- e.'en\ t"_al ~'ah','1 d(>s,'...~ tc- toe "c~;:>'laL!..d 10' anI' je,-,\al ~r,,:<,-jure C;erst w,1I ~ b<'>Hle b) IhE- patient
9 Sim,i~e~...-h'c.t M€ r"mb'J's~bl~!:1) '''S-j'anc.",or rei'..bu'!>ilbl" ",r,de' anyvthE-1 grovp O' Maltl' se"Y'c.e r:a'1S The PLAN s".all p'o~i:j€'th('se"Y;cas
alt~.e I:"'E- of Cl(>,.~d but Ihe "I"-'/.8ER st.al' e,(-cdle SAt> ,j(>(u;"oi!'11S ""'L-I":.iIry Ie assu.e thaI t~ PLt!"N 's reirT.bu'~ lor S....ch BE"lEFLTS
10 l QSS ()' t~,..tt ol derrlu'I"S or b"dii.'",')rk
11 Any pl'~~_",j'.1'e 01 irr';:.laCltat,on
12 Gen",'a! anC!st~,esia
13 SH..-'Cd I~.at :.an"01 be pe'1o....ed ~",~a,;$.. of I"E '<I"O'.t.r31 "'e.allh of the p;,~;enl
B Ce'-<,air "e.vic",s a'e s.,b)i>Clto a CCPAY'~E~T (def",,-d r.,,-ei[1 as ar a,jdil;0"a: am.Jur'JI SUBSCR;BER or D[Pi:....CENT,,~ al: pay PARTIC:PATlNG
DE"<TI5o"l"S di'Kt'y). as Is~ed ", l'.e aT:ilC''11''':; B-'!,')el'1 SC.,(,-,j.1le
C In (),je' I;. "'a~e an "i:-po.nlme('\ MEMBES:<S rn';5tlel',"~'\Clf)E-lhi;! nunbe' o( lhe de....ial olf,ee w....Ch t...ey l',ll'<f !>e:.,.cled
The t;,S! a"..e,r:'~.enl ,,,~,,-,:LI,,,~ will "~';al'y :;'t !,:.' \'lE- p'J' p,::>,.. o! tii~,f)g.. curr,pltTt ~;:,\::.1 lul' rr"Jutt, ~-'r:ys e'iirn'~;;l'~)f'l, db,,:oping al'eal ".,,,,nl pl!in
a"c 'j",:",-,,;nin9 ",r. t'sllr'.~le 0' COMS
O",;r'9 t~.e <"s' ,,;';';Jin:,r_~'l1 '-I.U..-19ERS...-i1' t>I'- ;;'("',:li"~ wi", tt,~i, j:o,t,s(,i~,<,d t'~3,'7lenl pian and ",;th the f"",~ (0' each oenlal ~':>cedu'e MEMBERS
m.:s' pal I~e t~"'~ Ii~i",d ;>t, th"" ,j('~c'.p!,v'" of P""':_','al 8E~lFlTS AND COvERAGES d".:-cll~ 10 Ihe d"ntal c,(!,,;e w!',6-'e :'talrt".ent 's re,_er'.ed
o Tt,,,- PL~'" will p~)' up Ie a 'T.a""'ulT; o' $"(. 0C o.er 'unl-"e: 7'!'ilr ~'e' t-..lEMBlR I"r out-01-\he a'ea, e''''ergenc, s",'..-;ces ;e"c",rd? lc M[MBE!=!~ WhO
r..Q'.1<'e, ~,-,crl S8',"~es w"'e~.lh",) are ,r,,~,!: I~,;,'l Ihl~~' (30, miles hom a Pc.A"" DE!<O"!' AL PROVIDE!=! l.J[M8Ei"lS ca., d('~e',T,i~_c ....~'elhe' or not they are
m,~"etl'.ac, \hL~y:~Oj r,i,,~ ~...-ay [,om a PLA>,J DE"'T AL P!'<OVIDER b) lei",p>,(.onin9 on.. ollhe PLA"Ite:..ph'Jne 'luf'",be,rS Sucr.lel€'phone num~rsshall
be ,,,,,,:jil'~' "Cc.,,"~~~le 10 MI:'vI8F_RS ",r"j ate c;-Jr,!","(-d (.on Ihe I"s! page of t"l'5tl,g'~ment l"'EMBERS rn'-'5t ~",:;;-phone the PLAN p';or loob~a,ning
ovt-o!-I~,;;-ar('a E'J1tR'.,E"'CY CARE Hc"'';ve', wher'J 'I I!. r'Ol poss,bl~ 'ollhe 'vIEMBER 10 p'O.'OE pr,o. ""I.ce cc..e'1>ge ....,li bE' p'o~'ded If not'ce IS
gvl:n 10 ~~,e, PLA'" ....,th.e'.:8 hOu's 0' ii, ~O'Jr as ;')~,S'blE' Ih.,'ea!ter EI..,ERGE"lCY SERVICES a'e, IhoSE !-(,~I/,(.e5 'e.qud<"d 10' lho alie..,al,on 01 se..ere
pa,r 0' blE'",d.n~ ,;c,d '0' ,n'r:"l",j.a~e d'~Qr'c's:s.and, 1'<"tn-,e'lI ol...r.lore~;;-en cO'ld,t,ons, wh,eh, If not ,rr,meo'alely dLa9r'J::!>eC Ilnd Iruled may ;ead to
Ij,!>..olbty dysf...rocl,or. O' Joalh The PLAN w,lI 'elmbu'Se, ENROLLEES 10' Sl.ICh services up 10 a IT,a...,m,,,,, amo~nl ol $50 00 per confract yea' per
MEMBER fa, 5e'II'c."'5 by ..oro-p:an p'J,';d,,'!. 10' oJI-ol-P,e-a'(''s E'..lERGE'>ICY CARE' upon p'eser'Jli1I'On by t.,,, MEMBE!=! of acopyOlthebill homthe
treal'''9 dent,st "rod II ce.e' leHe, f,olT' t~E'..lEMBER e~p!a;nir'9 the Ci'cumsta....ces which'~eve r'M! lelhe el"'.e'i1ency \teatn.enl MEMBERS must
s'.1bm,t s..reh dc>cwme'lla"iJr. I" the PLAN wII~lIr. ;l(',jar5 01 tece,p! 01 $uCI'- em<l";jenCy 5,,"""ce
1r'J Ir,e e,'e'11 a 'J.(lJ1SER reqJ;".s "me':l!mc) serv,ce ",nd thE MEMBER isle% 11'."nlh,r1y (30) mile~ flonr, a PLA"-i DENT AL P!=!OVlDER lhe MEMBER
musf cor'a.::t n,e PLA'" DEI'{; Al PROVIDER IC w~,a, he;s a~signed atone oflhe Pi..AN'S telephone n'.1mb€:rs 1r~I(>d 0;, Iheli-sl ~ageollhis Ag,;:,emenl
te. 'eca'.~ ".struCI,"";. as 'Cone.. lC P'Cl~""'C 10 vb!a,'" er-r,B'i);;nC} ~er...cesIr01T a PLAN ?ROVIDER MF:MBERS r"'.ay ob~a,'" E'..-1E.I"lGENCV CARE f'om
a non-p!a" pr?..-,je' ",,'lh," Iht ~F"'::~ a'~a.;lnt)..fle' cunt"ct,tlQ It,ei. ass;ilc.(<d DeNTAL PI"lOVIDER '" lhe Pi..A"<and t>ei'l~ advosM !t,al no PlAN
P!=!OVICE~ r5 a'a'!ab:e HQ",e,et, tf ,I 's no' P(l; ."b:e (0' tr,e MEMBER 10 p'o<lde pno, not'ce co..e'lige w,11 be- ;>'0.',j",1 ,I c,u~rce.s grven to l!"Ie PLAN
wil~..r'_ 45 hO:.J'5 0' a~ 5:>0" as j)05sible tOII:",'i"9 'dce'pl ()! Si;"Yices The PLAr, will 'e;mb"r!>e ENROLLE ES 10' suc~ s,e...ices ,-,pIc a iT.lillimurt". amount
o' sso or per c~r,t'IiC! yEoa' pE-r MEI-,I.BER lor 5"..i:es b) 1'>0",p1ar. p,o..ije'510r in-area EMERGE.....CY C.tr..RE upon pres"ntaf,on by lhe MEMBE.!=! Of a
('o;:,y ot the btl: I'o",lhe \. eal,r'9 lj"nt:SI and a ("o.e' iet~e' I,orr, tr.e MEMBER e.pla,n;ng Ihe circumstances wh,ch g,..e r:se 10 the eme'9.:.nc)' tre:almenl
ME'vlBE!=!S mus' S:IPm'l t...,s dXun'e",tilt,on IC the PLAN ',,:al,-,!;; 10 s"ct, err';:":lency :r<<atmenl w,thln 90 days of 'ece,pl 10 S<e"Y.ces
Th" IOfE-gO;'l9 p.C'..,s,on5 relat,n9 to I~'e $:'( n~a"mulT. 's t'" abj,l,ot'10 the: e"''''llene; p'e.'enli..e and per,o,l!:,nlal t'eatmenlS lellc<ct~ in Ihe Benefit
Sc>,eclule
If a PLA" PRO'.'IDER', ",a;:able, tt'e '~!::I,.lSER wil: bE; i"str"eled Ic see him 01 her, The MEMBEP Will be 'e5;;>on5::,le1o' "opa,men~ a!>desC'ibed in the
AII",ch",en: A 10' iln)' t'fa\me-,l 'E':e'."'d If Ir.~ err.e'~,""'cy is r,iI',died by tho: emollet-'s !>s,signed PLA"-l DE""TIST peyrne"~ "di ~;n acco.dance wilh
the 'lon--emelgen;y p'''~.:.d;J'es
MEMBE!=!S w.II pay the COF~YMENTS as I;sldd in I~'~ al!i1Ch~t! d~sc"p1ion 01 ?rinc<pai BE'>IEFITS A'>ID COVERAGES under 'COPAVMENT
!=!EOUI!=!ED" 10' each proc€'d",'e cOIT';Jieted "r"''''s~ CO;:AYME~TS must toe pa,d di'eclly 10 the den\a~ c>tf;c~ ""here I'estrr,en!;s re>;e;l/\!'Cl
PART V O.HER CHAAGES'COPAYME~TS
MEMBE!:IS will ;:.ay thE' COPAYME"OTS a~ IrstE'd in the al~achE'd de~c"pt,on 01 Pr"'Clpal BE"-lEFITS A"lO COVEP.AGES under "COPAVMENT
REOLiIREO' 10' ('i1Ch p'xedw'e com..i"Il'-d The!>e CDoAYMENTS must bE- ..aid j"ectty 10 Ihe den\al ofhce ....I',e'e IrealmentlS tet;ei~ecl
PART VI. DE.~TAL RECORDS
Tr,e, jen!al 'eco'd501 SUaSCRlgEP a',o CEPEI<,)CENTS c.on~~,n;ng se......ces perfo,m..d hereunde' shal: ,,,,mair, the p''Jperty olthe PARTICIPATING
OE""1"I5oTS
FA.RT VB CHOICE OF DENTAL PROvlDEA OENTAL I'AClLlTlES
A Eilcr. Pl."'" MEMBER '5 er.co,-,'a;Jed I' ~e:",ct iI d","II51 lr.:>rT a"'0r'J9 Ihe PLAN PROVIDERS E'l'01!e.: ME'..lBERS o'a lamily rr'Jsl '-'sethe sa~e denlist.
,t\t PU".... shal! a~slsl IhE PLAr--.. 1,I,EM3E.R;; ~elect,.,; a dentos~ ",hen(>~e' S'jC~' MEMBER 'equests sueI'. a!>~,st&.'-':::e ;nfo,rr,at;or, ,ega'd;nglhe services
a'!l.,at:t arid Ihe 10Cill<,. ".,j -,Ou'S o~ PLA/'.; PROVIDERS r"':";ay be ob~a.r",.,j by calhng the PLAN olf,ce a! o...e Of I'>e te;ephone numt>e'5i,stee abo..e. In
"'~, e.'ent. the, PLAI<,) "I f:",.1BEF. 5"0,Jld cor,:"c: tht PlA"J at an", o!the 101l-lare '"\umb"r5tode\etm;"''' whe-Ih<<, t~,e, PLAN PROV'DER they h!l.t selecled
tS ~I'" a.'a':able, In Iht e"l>nl C' an t'''''''Q<-''cy, tl)e PU"'''-i s>-'o'..rlo bt' con'ac!ed al the !>.!Ime numt.el'$
B De":a: 5e'II'ces pr:!v,dl-cl by thiS Ag'eemenl a'e I,rn,ted!e 5t'"'~es .,erlv'med by Ir'05€- dentists wo-~rnw ,n PLA"-i DENTAL FACILITIES. orth~Ov!s;dtl
de,-,tl~~s jes;gnal<<d b'y PLA"l 0' b)' a PLAN DENTIST tr' conr,e-clton wilh a referral made 10' definite t'a!llment 0' ccms....llalion
C The PLAN 'es",'\o"s the r.ghtlO 'eas,,'gn MEMBERS al any lime 10 a dlffe'ent PLA'>I DENTAL FACIliTY of MEIvIBEA'S Choice.
D MEI,.lBERS ma) c.hang", 'aci!i:ies w'lh a Ih,rty {JOi day wr;"en nOlice and app'o"a: ollhe PLAN
E Only hcen&",cl PAHTICIPATI/l.jG DENTISTS shai: ha..e Ihe "ghllO e~amine MEMBERS and 10 determine Ihe p.olessional s.ervices 10 be perlormed
purS..ranllo lh'~ c.;:tOUP SUBSCRIBE.R AG!=!EEI..IEN1"
L.aO'i'ty 01 SUBSCRIBER or E"lFlOlLEE 10' pa,'m",nl
(1) In the e..enllhe PLAN li1i+51~. pay a DE!<OT Al PROVlOER wltr, whom thE PLA"I has 3 conl'aCI fo' service lhe MEMBER shall no! be liable 10 the
OE'>IT AL P!=!OVIDER 10! any sums o.....d b, Ihe Pl...AN
(2i in I~E" e.'enl Ihe PLA'" fads to pay a "oncont'aclln9 DENT AL P!=!OVIDE!=!, Ihe, MEMBER may be liabie lothe r'Jor\conj'IlCling DENTALP!=!OVIDER
lor thecasl ofse,,'ices rer,de'ed
(3' Upon 11'>e lE"mlr,at,)" of a PRO'''IDE''l co"lract b..lweer,lhe PLAN a"ld & con!'acting DEN1" AL PROVIDE.R, Ihe PLAN shall be l;able lor cOlle'ed
se,...ces tend<-red t, Ih~ DENTAL PROViDER lolhe' 1I'.an 10' eOp~ymenls) 10 the MEMBER who reta,ns el,gtb,hty under the I"lDIVIDUAL Of
GROUP SUBSCRIBeR AGRE.EMENT Ot by operat,on of law u'lde. the ca.e of Ihe DENTAL P!=!OVIDER allhe time 01 suet, term;nillion until the
!>e'v,;::es be;ng 'e',derecl to the MEMBER by Ihe DENTAL PROVIDER are compleled, unless Ihe PLA.N makes reasonable and medically
"P~'OP"&t,,, prO~'5'0n 10' the assumpl,on of s"ch s;:,rv<ces by a conl'act,ng PROVIDER
P~RT VIlt. RENEWAL PROVISIONS
A ABe. Ihe conl'ilC' period, Ihe SUBSC!=!LBE,R GROUP may r",.ew Ihls GROUP SUBSCRIBER AGREEMENT, subject 10 any changes in COPAYMENT
or I"'e BENEFIT pac~age made by PLAN by ftlirng 0,,1 a 'ene..allo.m and paYing all mon'es due
PART IX, INDIVIDUAL CONTINUATION Of BENEFITS
A ThE MEMBER whO becomes ",el'9.b1e f:Jr GROUP COVERAGE may arply wilhin thirty (30) days lrom I'>e dale ollerm,nalion 01 tne G!=!OUP
COVERAGE 10 con""ue co,e'age, unde' ion I"-iDIVIDUAl SUBSC!=!IBE!=! AG!=!EEMENT Of Ihe type lor wh,eh he o. she is Ihen eligible Con"efsion to
,M 'vidual co.'er"9(' s",all apply to the DEPENDEN1IS) ,nClud;ng a DEPENDENT Spouse and a DEPENDENT CHilD, of Ihe cor,..-er1ing MEMBER _In
(lde,hor'J a CHILD w~.o ~pcom'.'5 or,el'9,bl'.' 115 a !amrly DEPEI\IDENT can c.onl/en 10 ,nd'~,duat co..e,age upon the same condll'ons as appl'ed 10 a
MEf..-1BER Suc~, application l'nay be II(Ce;:>Ipd 0' te~('(!ed allhe "pl,on 01 Ihe PLA.N_ nc aulomal,c r'9nt of lr'Jdl..,dulll COr'JI,'luatoor'J 01 beneftlS eKisls
Those te'mor,a!€'d pu'sl,;a,,1 Ie SeCI,on X Ai2i ar'Jd SecI,:;on X B14) may nol be olfe'ed Ihe opponu'l'ly 10 eon~er1lo indiv,dual co..e,age
B The PLA~ re!>!':'..-es thE-option loaffe' con..e's;on p"""ege5 lothe MEMBER who becomes ,nel'9,ble 10' co..e'lIge u"der Ih,s GROUP SUBSCRIBER
AGREEI..IEN1" due to Ihe lerm,O'_<lI,O" 01 th's Ag,eemenl Should eon..ers;on 10 indr~idual co..erage be offered 10 the MEMBER application mvst be
IT;ajf' wrll),,, (30 days of notrCE' 01I'leiI9Ib,I,I) to (onl,nuE' co..e'age uncle' e SUBSCRiBER AGREEMENT Of the tyPE' 10' wh,ch >'Ie Of she is "'el,g,ble
Con~er510n to I"j'"dual CO"e,'~9E- st-,al! arplt to lhe DE.,'ENDEN1"15), mclud,ng /I DEPENDENT Spouse and DE.PENDEN1" CHILD. of Ihe cOr'J..ert,ng
MEMBER upon the sa",e, te.m5 a.-,d co"d.t,on~ as apploed 10 the con..ert,ng MEMBER
C A ro,'e'ea DEFENDEN1 SPO.JSE who c!;ase~ 1C t>E" a qwal'!'~d !amily ME:MB!:R b,' reason ot lerm,r.ali::r~. Of rnanillge O' dtath 011he employee or
SU8SC,,;SE.'" w,11 bf allo.ded Ihe $;':'",1" (,,""e's,on rrghls "nd cOr'Jd'100ns Il'ilf\!ed Ie MEMBERS u',de' th,~ S~CI,on IX. s"h~eclions A and 8
PA.RT X TERMI"IATlON OF BENEFITS
A ElE"-ilf It~, ~.r,ilt' Ct,,~'" '.Jj:'un Ir'E'Ic>llr""c,g ('~..nls
1 Fa,jc..e o~ MEMEllR I"par tt'e PREPAYMEN~ f' E (1:; SU:Jsv,l,e' G'l'Up If H'f S.JB5oCRI8ER has :...."r, Ou!y "~I;'.<-~ ""c bdl..d for thE" chargf'ar'dal
leasl ':.da)s "'a~e'i1psed s,nce thE' dalE. of "Olll,callon Ho,",ever, mtne e,ent I~,al an E"<!=!OLlEE 's undt"go,~,gHl;a:rr.enll::l' ano....go;ngcondition,
he she may c;ont,nue te re,:e:ve \Iealmenl 1<0'" a Pl.-AN PROVIDER. bul musl a9'€'e 10 pay PPDVIDER on a "lee fo' serv'ce" or . usual and
("ustoma') fet/'bas,s
F'i1..rd 0' df-~,epll"" In Ihe use o( IhE" se'..'ce5 0' (ilcrlllr('~ ot I"~ PLAN or ~nowln9:y pe'm,n.n9 suc.h ('auel 0' OE"cept'Of\ by !If'lolher
.
\.
-
-
3 Iflt>f SUBSCR'Bt.R G"100P :&~",'m;"al~d, SueSCFlIBEP. ,~d: to(- O~l(d.j 1M" "r\'Ofl Of ,;.0":'....,,031'0" 01 benef,:~ u"'::j(,. ar, i"ld",cbai Ag'",emenIU
d..!.cr,~d In A"l>cM:nenl A MEMBE.R !.~,i'" -';l'..e" 3C >;jay~ pUO' I'\OI,ce of term'''a~' '",>1 SU8SCP.IBE.R GROUP.
e BEN[FITS &"'al; CE'BSe upon tl>e lo!l;::wi"ii e'..... ".,tl the SIJBSCR'BER or MEMBER I)" "en Ilo!,'ied anc at leilsl 15 days hal. eiaps.f:'d since s.aid
nOI,I,c31'on
1 Upon dale olenlcyinlol"t:.t,me 'l'lihta'} s.er>,ce
2 Upor- Cille of DEt"E-.OE",T CHll DRENS rr.il"'l>ge
3 Upon DE;:>iO"IDENT CHILD 8I103.,,,')g ":;Ie 0119 or:24 or pr'OI r"w:a.e wM' I~'€' €l~""..l;,,n Of a DEPENDENT CHilD that 1',3; ~e" cer1,lLed t'y the
PlAN as ,n(',i1"ab1e 01 self's':s~a,I'''''w employ.~;en\ by ,,,,ason of me"tai '",ta'dal,OI" 0' phys,ca, .'"',al'd,cap a....d 's eh,el'y de~r)d'i!'" vpon the
SUBSCRIBER 10' ~'4!PO~ and rT'a,""er,ance p'ov.de.:! p'ool 0' Such ,n(.ap,,<:IIy IS ILJrn,~h..d to the PLAN by t"'e SUBSCRIBEP. wlIh,n 31 da)'s of the
req"lest k.' Such p',oof by the PLA"" Reee'lIf'cabo'" Q1 sue" inccap(;lci!y may b€ 'eq<Ji'('d by Ih€ PLAN, bul nol mo'e f'eCl,-,ently than Of'S" annually
afte' Ihe !....O-tea, pe';:xj foliC-WIng the DE.PE~DENT CHILD'S a!1ainmo::nl olsge r)ine:t:en
.. If it t><.Gomes i.,.,.,r's~;ble. a'ler 'ea~o"able e!lurts to es:"'~': .,., ar,d rr,ai'1\alr a :.al,slaCl'Jry de"Iisr-pa\'e'1t 't':a~ic.rshi!: w,~'" a"\, I~EMBER
5 Illhe SUBSCRIBE!=; ha~ t~en te, 'nir,.ll",d horr. Ihe GRC" ':- 0' has vOI...":anly lelt ~alO GROUP In s'-'ch cas.e SUdSC~:gE.R S a"c hi5 el,gible
DEPENDENTS BE"'EFnS will telm,',;;;te
6 Ir. Ihe e.enll.,e arJ;:,I.cab;" s<;>j:'e)....'Cor,r, Nh;U' ~I" je~~t!..d i" th.. Sf: "'1::., 11 S SCHF. DIJLE \At\it(.hrnE:,.,t A:, are '"r?t ;,a.o It (".0~',~~ rn,=.,~~ ilr& ,,;;>t made
lor one 'a""i'\, m",rr,be' on'y I"-il' ;><"50"'5 6E'~[fITS ,,"'II; ~&"IT';r,llle
FART XI CA"lCFLLATION
A "'Clt_,(> 01 (".llnce:!at.(,,., 5',i1lt be mari~e 101h~ SI.IBSC"18E.R at Ihe S,;BSCRi9I::.R S add'f'~~Of r..co'C, ""d I" 5"ch evenl of Cll"Cel:al<or. 0\ Ml::MBER
A The M[M3E.P 'N.I; ~,a..~ :he ~"';'Clt1J."tyl~' '.3... th~ Ci'lr,~.(:r!:at,or. ,~',ii'....t'j ty' t~lf' CUf"lm;~,~;,ne' 01 C(J'por"I;~"S "",Jer 5li'(I,or 1365 O't!,~ KnC'~,Y."'ene
AoI
B Th", PLA"Is"la!' '/dh'f, Ihlrly ,:32, '~a)'~ .~f ':~"(.cti,,,k!n ,.-1,...", loth!;- U['~:~[R \',e >-,'o-'ara portion o'lhe r-'ur_O'} ;'_'1'dl01h", P:",I.,\i ..."Iet CO"i'~r'onds 10
ilny une,p"ed pe',od fo' ....,,'C., pily''l8r,1 ",W] t>003n 'i'ee _<>d, IClget~e' w,II'. aITlO'-'rl\~ jue or> c:a,ms, 11 an)'. k$S a.,y a"-'ounl$ dUI; PLAN
C Ac["'p~a'lce by \,,~ Pi.."'.... Of t',€' P'0.'''' ME'",S[R PRlPAYMENT ,Ef all", lerm;nal_on of lh'~ GROUF" SU8SCRIB[R AGREEME"'T "'''.: Nill-,out
lequlr;n~ a ne'" ,,~,plt(at'or, ~',al; '.c" .~'~\(: 1',<- (0'01' ,,~';',5 1hough il ~,,,(j r,e,.:.' I.:.' .Tt,"ii1I-:-d un:,.s, the PLA",: .....;;>-"r".ve (5:, b...5i"<;55 de\,5 of rh;€"pl 0' l>;'Jeh
;;atl'l(:r.reilher
1 'elundo patmE:nt or
2 i5sCles 10thI:' GROUF a "e,,"' G~OUP S.;BSCRiBlF, 4GREE"-IENT a(,corr,;-anied br W,iUE:ll noli,,1:' s'ati"9 ,~ieil.rly Ihc~e '""s;><-ccI5 ill wh,en the new
co";'a,,l d,llers frorr, Ihe l",rm;r;31€'d c0'llract in BEo..;EFI1S COViRAGf S, or olhe'w,se
D The provislQns 01 Ihls Par. appl~ lCo a:: le,rr""at.ons, mcluding lho~e d",~cri:'03d _n Part X Ollh;s Ag'~e-rn6rnt
E II Ie-,mir.ation ac,,-,'s dele to fa't,,'e 10 rr.a"e CCPAn,.1EN1S, RElt':ST A~ EI"'ENT OT BENEFITS will NCur al the t.~girlning 01 Ihe ne~l "",onth alter
paym6rnt 01 del,nq',J",nl ~,ay.,.,,,n~J. ha_f be..n rr,,,de
PART XII, RIGHT OF PLAN TO CKANI3E BE'-IE.FlTS
A PLAN le5,,'~e5 tt'e ',gt,1 10 c".ange Ihe- 8E"IEFITS, COPAYME"ITS OR PRU''''YME...,T FEES 10 MEMBERS
B T~,e PLA,N s'"'.all r"\oT c€"crfas.e Ir "ny mane,.,.r \~e BE....EFITS 5rat...d In t~,e GROUP SU8SCR:BER AG::tEEME"'T e.ct'p! afte' a p",ioo of alleasl If,..ty
(:<\0,' ca~'~ I'om "r'd al~er th.. ~'C'S:3;re .:aid ",,,j r',ad.r'g 10 th", other p~") alth" alt,e, p"rt{s li,jdra~5 01 '('co'd ""Ih 1101; PLAN of ...r.t1",r, noti::e 01 s'-,ch
p'OP0l\..dchar,ge
C ThE Pl"A... \>hall r,OI incr",,~€, c,r de, If,~~e t~.;:. F'REF-AYMENT FEES or DECREASE BE"lEfIT~,e.:epl al:",r a ,,~r;(.!do! allea5r tl1i~y {3~~ ja)'5 'rorT' Cind
al\e' postage pa;(j ma:1ln9 te J.a.jMEMBE~ allhf ME'..lBER'Saddles.5 olr..CO',j with the PLAN 0' .....'i1\"'n '"lOhce,<;>f s,-,ch "'Copol\ed ,nc'e3~€'0' drcrease
Notl/,eat,on 01 alle'lIt,on or ,ev'5,on grver, to thE: SUBSCRIBER GROUP FI<-p,..~,,',lat've must t:>e dIS5em,r.1>tee 10 Ihe SUBSCRIBERS and the
ENROLLE.ES in the GROUP no late' Ihar Ih,rty (30) ea)'s (.orr. 'e"e.ptlhe'eof and m",~1 prOv'de Ihirty ()OJ cays nOI_ce to Il'.e MEMBER pfiof Ie such
inc.'ease or deoeaH In P1=lEFAYMENT FEESo, doc'ease Ir_ BE'<I:.F'TS.
PART XIII PREPAYMENT FEE
A The PREFAYME!\Il FEE r5 the rr,oc,th"y fee' ...qulled 10 ",.a.n:a,,; ce->e'ilge ~ndE:r IhlS GROUP S'.J8SCRIBER AGRE[I"'ENT
Tf-iE PREFAYloI1E"'l f [E SCHE DU:...E 15 A TT ACHED I~ERE. Te AS A TT AChMENT B THE F'REFAYMENT FEE SCHEDULE tSA"IINTEGRAL PART
OF THIS AGREP"'ENT "!\Ie MU~1 8[: READ IN (:ONjU"lCTlON WITH THE RE5T OF THE ASFI[EMENT
MEMBERS of Ii SllBSCRIBE~ GROUP $~,al: pal' Pf<E.F"'YMEl\iT 'EES di',-"otl, lolhf SUBCRIBER GROUPw"'c~ WI!' in lu,npa~ Ih(; PLA'" MEMBER
ShOuld ctlfoc~...,tr, SUBSCRIBE.R GROUP 10 d"t",m,n" It,e d~lldll"e ane mell-,:;>d Of paymenllol hi~ CQntribur,on if a'1Y, lothe PREPAYMENT FEES
SUBSCRiBEf' GROUP 5hal! ~"en 10''''''G the PREPA'fMENT FEE 10 t'le PLA.N M<;>nthly PREPA"ME.....T FEES musl be re:eived by the P~AN on or
belo'!! the Iwe"I,e(h cay of tr,e monl" to i~s,,'<, eIt9,01l,I,lo' s.1!f.,ce on the k51>::e, 01110" lOIle-w_ro9 rrlu'1I~, S,-,c~, pa~ment! shal' t>e (".ade .II O' senl10
Nat.O"'.al H",allh C"re S).,terr:5 01 Calil"''',a_ Inc
18662 MacA'1~u' 91.d Sc,,'e 101, i'v.ne Cal;IOm'l! 92i15
8 Paymenls re~e".,d b)' the PLAN 0' ,~s a",lh::>,.Zi:'O a;jenl prio' 10 Ihe dJf" eaTe, wll: rr:.Il.~E: MEMBERS of the SL'BSCRIBER GROUP arId t~ei' ehgible
DE'?ENDE"lTSel.g.bl" to' 9E~EFITScorr,'nenCI"g or, If,€, juE- cate 10' IhE- pfr:r,od pa,d 10' Patmenl5 'E'~e'~'~c a!le' the due dale ",rll [".a"" MEMBERS
and Ihe" e1;9_bl.. DEPE"'DE....TS el,~,bl" 10' BE"'EFITS on th€' dwe dale 01 Ih€' sub~t"quenl monl', MEMBE!'lS should conlact the SUBSCRIBER
GROUP 10 det""mir1€, Ihe- de~1:""f "r.d rnE:thod 01 payrrlenllo the Gloup
C The PLAN wii: n,:)1 inv, il$f or :j<-l't ~~€- tr,€- PR[P"'YMENT FEES en d~C'(,a~f BE"lEFITS "~c,,,pt alter 3 ;:>E'no<:J 01 at ;",asllhirty (30j cays horr.anc" after
p,'stage pa.d rr,adlf,g Ie ~a,'J M(I.r18ER a: MEWoBER!: "dd'~ss 01 '<'CurG wMltr-.e PLAN of .....:Ien noliCE- 0' S;J(h p'oposed incr",sse O' decrease
Notil,::al<)f'lOr all", at'0f, or 'e.:s,o', g..en 10 :',e 5UE'.SCFI:8E.R GROUP Rf'p'E'sental,vf m,,~1 be d'5S!:rm''lal",d 10 lhe SUBSCRIBERS ana ENROLLEES
in I"e GROUP "0 :ater !"af' t.W!, :3(1, Ga)'s I':;'ITI '...::e,pll'l,,'eo1 and mc;s' p'O._d1O thi~y (30j carl. notice 10 Ihe MEMBE~ pnor \0 s,-,ch Inc'ease or
d~'t-a~e ir, PREP'" ",~ENT FEES or d<-v"a~e ,f' SE'..:EFITS
D Each MEMSfP ~.alr r,ay 0' a"Il"g"lo' peyl'"'enl 01 apph~at>lE' CQP,I,.YME"'TS. i1 an)' a~ pro"idli'd in Atrachrr:en: A Incas.. ol'ailu'el, doso, the fights
at r.....EMBERS 0' the.' e"glbi<, DEF'ENDE...i5 (",a) boc 1""rHl~alli'o on !<fleen (15) cays' nollce and may De reln~taled,only by 'e"e...ae applicatIon and
,,,en,o;;rne'" ,r "C((:Jr,j~nce wII~ ali lE-q,....'e~"nt5 of Ih,~ Ag'H:me'll. Ary appl.c.;ble COPAYMENTS afe dNarled II'> th& BE"'E.FiTS schedule
E",lqOLLEES will not be: I€rm,r.atc'd ~a~<-c upor, fa;:u'€' Ie- pay '-let: 10' s""vlce" or "u5L;al and CL:sl:;'fT".ary lee' for services nol (o"erE!d by lhe PLAN,
PART XIV, LIABILITY OF MEMBERS IN THE EVENT OF NONPAYMENT BY THE DENTAL PLAN
In lhe evenl the PLA.... fails 10 pay a PLAN PROVIDER with whom the PLA'" "a_~ a conl,aetlor s-ervice: the MEMBER shall not be liabl& 10 Ihl! PLAN
Pj:lOVIDERfo, any SUtl":5 ov>",j by the PLAN In Ih.. event lhal ll-,e h"allh PLA"l fal!sto paya noncontr/tclmg p'o".::le'. Ihe MEMBE.R ma~ be Ioablelothe
nOr"lconlractir>g p,ov.je' 101 Ir'e cosl Of tr-.e ~erv;ce5 .el'de'ed
PART XV. TERMINATION OF PROVIDER
Upon te,mi,at,on of a PROVIOER cor,l'acl 1M PLAN 5!,al1 be liable (oll-,e, Ihar, fO' COFAYME"ITSI 10' coveree ~erv.ce~ rec"je'ed b)' SJCh PROVIDER
10 a SUBSCRiBER or EN"lOLl EE ",too re-H,n5 f'1;gibill!~ und",' Ihls GROUP SUBSCRIBER AGREEMENT or by Jperalion 01 law and who's ,-,.,de, lhe
ca.e 01 sa.a DENTAL PRO';l~DER at Ihe t..,.,e 01 such term,nat,on. "ntlllhe ca'e being 'ende'ed 10 Said SUBSCRIBER or ENROLLEE by s....ch
PROVIDER i~ comp1eled 01 u'1llllt,,,, PLAN ma"€5 'I!e\>onable a"d ml"dlcally appfopr.ate p,ovlsion 10' 11-,e assumption 0'1 such service~ by anolher
...:>r~:ac!lng PROVIDER
PART XVI. GE'-IERAL PROVISIONS
A Thi5 Agr('",m",nt inci,j(jlf'g any a",<-ndment5 1~lerelo, CvnSlitut"'5 Ihe enti'e ag'eement berween the parties
B Tr'le PLAN i~ su':l)ecIIQ the ,€'qu:''''lnen\~ 01 Chaple' :2:? 01 D,v's,on:2 01 the Heallh and Safely Cod" 01 the Slate 01 Calilornia and Subcl'1aple' 5 5 01
C.,aple' 3 01 TIt.€' 10 ollr'le Cal.IN",a Adm,nr51'''lr'.1:' Code. a"d any p' o~rSlon requ"ed 10 b€ rn IhrS oonlraCI by ellhe' of the abOve shall brnd the PLAN
",hel~er 0' rooT p'o".o(<o IIllh" (cor,\'acl
C ,h,S ',.I,-"mt>e'~""p C'Jnl./tct 'e;<!&(<', ;;,r,d :;;",ce!5 all o\~.e' cont'acI5. il any. iss.u<>d rQ MEMBER Ile,ein
o Ir, Ir'e even1 01 any conlrov1Or5)' t>e~W"Con Ih~ ME.I.r18EA. a CEPE"lDENT,o' Ih" ~'ell5'at.!a""01 personat ''''p'e~",nta''vE:5 01 a MEMBER o. DEPENDENT,
a, 'h~ ';:~\>I; may be, ;;,',d the PL'IN a5 ,nd'v,d,-,a'& 0' Crlh"'fw,se. ""'h,,,the' InvolVing II cla,m on 1011. cont'act 0' othecwlse, wh.ell a.e nOl ade-qulltely
'esolved in the QPln'On ollh", MEMBER a DEPENDENT, 0' heirs-aHa... or personal ,ep'esenlahve of a MEMBER 0.' DEPENDENT, by the PLAN'S
9">"'.a....ce pfoced"r..s..lr-.e s.a".,€' 5hall D10 S"bml!ll:'d Ie a,bllrat,on In a(coldanc(> "'Ith lhe rules 01 Ihe Amencar. Arbllral'on Assoc'ahon. and Judgment
on the a"a'd r1Or,'je'ed by the .A.'':l.trat0' or A'blt'alo'~ may:->e enlered InanyCour1 ha"on9Jv"sd,cl,on thereof A,bllrat,on may nol be on,_t;aTed.he-wever.
unlit the gr,e,anOf- p'0:edure5 "a>", tl",en e~',a"sled Thu5, thetomplalnt musT hav€' been g'ven not.ceol tile d.spos.tlon oll1,s complalnl bylhe PLAN.
113_<' apPfaled 10 Ihe P,-,b:'C Pohcy Co.,.,n-;,~r('e ...h.cl1 t.a5 ,ende'e-<:j a d€'cls'on and grven not'cethereollolhe complaonaf'll, pno. 10 In'l.atlng a.bil,allon
A'u.t,at'ur, may be In<t'alt:'d!;y a") M,,),rIBEF! by 5end,"'g alettE:' to the PLAN oll,ee In the evenlol afbll,al.on, Ih10 plevall>ng party in sa,d p'oeeedlngs
~f,a:: be ent,lied Ie ar awa'd Of 'f.il;Of,,,ble attorney5 If-e5 alld any cO$I~ Inc,-,rred
E The PLAN Will prav'df ...""er. not,ee ...ith.n a '~~~Gnob!e lime \0 MEMBER ,n the evenl 01 any term.nalt(m 0' breach 01 cont'act by, or inability 10
pedo,m O!, any (.Onlract"'9 PROVIDER" the MEMBER may bar rr;alenaliy and adve'sel~ atfected the'eby
Any nohee ,...nd",' 11-,'5 Conl'acl may tit- g'.e" by Un,l"o Stales mall, p05tlige pa.d, addressed a510llows
Na!lor.ai Health Ca,,, S)'~tem~ of Cal,lurn,a In(
1866< MacArlhvr Blvd, Su'te 101
Ifv,ne,Califo""ag2i15
IflcaMEMO-:ER
To Ihe late5' IidO'f'~5 pro",jec !orlr'le MEMBER on enrollment 0' c~.a"g€ o! addre~5 lorms aClually dehwr"ed 10 Ihe PLAN
If to Ihe SU:JCRI6E.R GROUP
Tf"leprlon" (
CO"\d(1 P".~:)n
.
L
-
-
-
-
-
~ :~:T Tfh~l:~:;:~!ES;~~'::~~:'TI~~H;~Q~~ ;~~~~'::~';:~L~i.~~~~'~:WT "nONS ,_TTACHMENT A) AND THE PREPAY.
MENT FEE SCHEDULE (ATT.ACHMENT B) If THEY Ai'lE NOT ATTACHED CONTACT YOUR EMPlOYEE BE~EFtT RE.i"RESE",U,TIVE OR THE
PUN BY M.....'l.IN Pl:RSON, OR BY TElE.PrlONE~ TOLL FREE iN NORTHE.RN C4.11fO;:V4IA (SClO) "32:-70\9 OR TOLL FREE IN SOUTHERN
CALlfO~NIA (&:xl) "32.11S1.
THE BENEFIT SCHEDULE AND PRE.PAYMENT fEE SCHEDULE A.RE tNHGRAL PARTS Of THIS ....GREEMENT AND MUST BE REA.O IN
CONJUNCTION WITH THE REST Of THE AGREEMENT.
IN WITNESS WHE.REOF, this A~reern","II-,as ooen ~~<"C"_u~",c' as 01 the day a~,d yell' 1,'s1 ....r;:len a~..e
ATTAO,'''",B . NAT> 'ALH(AcTHCA:;:;:22a~
?SE.FAYME...1 HoE ~C~~EI)UlE
"'ONTHI.. Y DUES:
7.00
<;Jt's"bef
12.00
_ S'.}~'s,:,.t>~. Q;,-j 0"': :j~;:." "j",nl
$,15.00
S'.,b~v;::Je' a',.~ !."...o 'J' fT..:.':' 1,,,,, ..:J",nls
_ 1.~0'.t"':r t,d"..,...~t. ,..:,.:.r. Fee
$, 0
Githa only $3,OO(mo.
Ortho with General O~nt;stry
no charge.
SUBSC"IIBER G;o!OUP
By
"1ayor
'V!:c.~77'f)l /,4 /
~7f/14{t,,/yj;,,-6L~
WILLIJ~ H. HORNBAKER, D.D,S.
Approved as to fo~m:
~~'I"'I./1 -_~.
t.:;" ;-1.-/'//~.I...;t:')'Y~
Ci ty-A orney'-'- ..-----~-------------
\
"..I