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CITY OF SAN Bl!RN.DINO - REQUEST FOt COUNCIL ACTION
Gordon R. Johnson
From: Director of Personnel
Subject:
Third Amendment to Agreement with Mission
Dental Health Plan Extending Term for Ad-
ditional 2 Year Period and Adding a High-
Option General Dentistry Plan wit Ortho-
dontic Benefits
9:-~'I' -' n"'I" O~,.
"_..1 ./. ,'I.., :'1 II. r r.
Dept: Personnel
~~'.": ""1 "). "! 0- 5~
I .' ''''I "": J,. <oJ .,)
Date: May 9, 1988
Synopsis of Previous Council action:
The Council originally entered into an agreement with the Mission Dental Health Plan on
January I, 1984, to provide a General Dentistry Plan with Orthodontic benefits. The plan
has been renewed on a yearly basis thereafter.
Recommended motion:
Adopt resolution.
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. Si~ture
Contact person: Gordon R. Johnson
Phone:
5161
Supporting data attached:
Ward:
FUNDING REQUIREMENTS:
Amount:
Source:
..1I \ {~--
Finsnce: ;~,t;;;r'"
Council Notas:
75_0262
Agenda Item No. c:2 G
CITY' OF SAN _RNADINO - R.QUI!ST POt COUNCIL ACTION
STAFF REPORT
Th~ City has had agreements with Mission Dental to provide
d~ntal services (including a plan for orthodontic care) to
employees who do not elect John Hancock medical coverage.
Starting January 1, 1988, Mission Dental has made a second
plan available to our employees known as the High O~tion
Plan.
Below is a summary of the major differences between the t\~O
plans:
r10NT!:!.LY_~RE'uur1
LON OPTION
Subscriber
Subscri':>er + 1
Subscriber + 2 (Family)
$ 7.00
$12.00
$15.00
!jIGH OPTION
$12.00
$18.00
$24.00
COSTS OF_CERTAIN PROCEDUR~S
Single Root Canal Theral?Y
Bi-Rooted Canal Therapy
Acrylic Crown
Recementation Per Unit
Single Extraction w/local
t\nesthetics
ORTHODO~~IC ~AXIMUM
BENEFIT
$ 90.00
$115.00
$ 90.00
$ 12.00
$ 7.00
$40.00
$50.00
$55.00
NO CHARGE
NO CHll,RGE
$1375.00
$1375.00
NOTE: In addition, any employee, whether enrolled in a
~ai~er or John Dancock medical plan may elect to
enroll in the Orthodontic Care Plan ONLY by paying
a subscriber rate of $3.00 directly to the dental
plan. This fee is not charged to those employees
participating in either the Low Option or High Option
ba~i~ dental plans. The out-of-pocket costs to the
subscriber of the Orthodontic Care Plan r~mains at
$1375.00 PLUS any of the fees specified under addi-
tional charges.
75-0264
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RESOLUTION NO.
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RESOLUTION OF TIlE CITY OF SAN BERNARDINO AUTHORIZING THE
4 EXECUTION OF A THIRD AMENDM~NT TO AGREEMENT WITH MISSION
DENTAL HEALTH PLAN EXTENDING THE TERM FOR AN ADDITIONAL TWO
S YEAR PERIOD AND ADDING A HIGH-OPTION GENERAL DENTISTRY PLAN
WITH ORTHODONTIC BENEFITS.
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BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF TaE
7 CITY OF SAN BERNARDINO AS FOLLOWS:
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SECTION 1. The Mayor of the City of San Bernardino is
9 hereby authorized and directed to execute on behalf of said
10 City a Third Amendment to Agreement with Mission Dental
11 Health Plan extending the term for an additional two year
12 period, and to add a High-Option general dentistry plan
13 with orthodontic benefits, copies of which are annexed
14 hereto and incor?orated herein as Exhibit "A".
15 I HEREBY CERTIFY that the foregoing resolution was duly
16 adopted by the Mayor and Common Council of the City of San
17
18
Bernardino at a
meeting thereof, held
on the
day of
, 1988, by the follow-
19 ing vote, to wit:
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AYES:
Counc ilmembers
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N/\YS:
ABSENT:
City Clerk
28 Cont inued
Pagel
09 MAY 1988
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RESOLUTION TO EXECUTE A THIRD
THE MISSION DENTAL PLAN TO ADD
AND TO PROVIDE A HIGH-OPTION
ORTHODONTIC BENEFITS.
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AMENDMENT TO AGREEMENT WITH
TWO YEARS TO THE AGREE~ENT
GENERAL DENTISTRY PLAN WITH
The foregoing resolution is hereby approved this
day of
, 1988.
Evlyn Wilcox, Mayor
City of San Bernardino
Approved as to form and legal content:
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::J City
,~
Attorney
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4 THIRD AME~mME~~ TO AGREEMENT
S (G~neral oentistry Plan with Orthodontic Benefit)
6 THIS THIRD ^~ENDMENT TO AGREEMENT is entered into effective
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January 1, 1988, between MISSION DENTAL HEALTH PLAN, here-
I inafter referred to as "Plan", and the CITY OF SAN BERNAR-
DINO, hereinafter referred to as "Group". Plan and Group
I agree
as follows:
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1. R~~it.a:J,~.
(a) Plan arid Grou~ entered into an aqreement on
13 January 10, 1934, effective January 1, 1984, relatinq to a
14 General Dentistry Plan with orthodontic benefits.
15
(b) The ~arties now desire to amend the agreement
16 to add two years to the agreement.
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(c) The parties now desire to amend the agreement
18 to add a High-Option dentistry plan with orthodontic bene-
19 fit:;.
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2. T1rm. The term of the agreement :;hal1 be extend-
21 .ed for an additional period of two years commencing on Jan-
22 uary 1, 1988, and terminating on December 31, 1989.
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3. Other Provisions. All other terms, conditions and
24 covenants of the agreement shall remain the same and be in
25 full force and effect.
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Page 1
09 r4l\Y 1988
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IN WITNESS WHEREOF, the parties hereto have executed
this Third ~mendment to ~greement on the
day of
MISSION DENT~L HE~LTH PLAN
BY
Title
CITY OF S~N BERN~RDINO
12 ~TTEST:
By
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Evlyn Wilcox, Mayor
City of San Bernardino
-cIty Clerk--
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Aporoved as to form and legal content:
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U J i
_~-L~il~
U y Attorney
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DENTICARE
Mission Dental Health Plan
One Park Plaza, Suite 430. Irvine, California 92714. (714) 553-1sn
May 2, 1988
Mr. Doug Chandler
City of San Bernardino
300 North "D" Street
San Bernardino, California 9241B
Dear Mr. Chandler:
This letter represents our confirmation of the two (2) year rate and
co-payment guarantee for Plan V and Plan S effective January 1, 1988.
Thank you for your continued support.
Carl E. Bozzo,
Chairman
Chief Executive Officer
CEB:mcc
cc: William Hornbaker, D.D.S.
TOLL FREE Telephones: Northern California 1(800) 432-7019, Southern California 1(800) 432-7158
QIlOUP.UBIC_~
(PLAN _ 82-V I
77-8
Th6I~."""IIhdU8CUledthil day 01 .1'
by.. ~ CITY OF SAN BERNlUlDDI) (heNiMfW""'" to. "SU8SCRI8EA GROUP") and NATtONAL HEALTH CARE
SYSTEMS OF CALIFOfIINIA. INC. (.. DENTtCAAE.Iftd.....-on DemII....... ....... c.IIIomIa __..... (I_..A4hIr...... to_...""'-AN"')
wNctt ..... . .p-'_...... ..... c.-. ... pAen IUbtIct to .. ......... ~ and ............. .~ ........ entorcIId by ..
~'R' 'JI'~"'ofCorporatioMOI"'''''oI~ undiIIIMKnmt-KeentHNlthc...SlMCePIMAct0l1m.........n..........OIthiI
.....,.....bII .:.:.k.1 11_ .
TtlII.... ot... Drinci.....rnlntWattve oHiotof 1M PLAN I. OnepetkPlaza, Suite 430. irviN. CalikJmilll271". T..... nurnberl... (714)
553-'577. (n4) 5U007S5, Of TOLL-FREE in Ncwthem CaMfotNII (800) 432-7011, Of TOLL-FREE in SouttrIm CeIifom6II (100) 132-11.
,NIT L....-noNI
A. -AESTHETIC DENTlSTRr mMM __ ~ wNch aN perlormecI ~ for coemetic purpoIIL
B. "BENEFITS" and "COVERAGE"' "'"" thole dental CIlfe...we.. ~ under the GROUP SUBSCAI8ER AGREEMENT in which. MEMBER ..
.......'
C. "CHILD" includelalll'llllural, edoptMf. foMef. and IlePCh6ldren.
o "COPAYMENT" is an addit~ feect\lorgecltoaSU8SCRIBER or ENROLLEE which islClPJOVId bytheCllifomilComrNllionerOl~'who
regullll" the PLAN pur....ant 10 the Knox-Keene Act. ptOviC*t,or In the PlAN contract. and diIcIo8ed in the EVIDENCE OF COVEAAGElDISClC>
SURE FOAM.
E. "OENTAL FACILITIES" meln thOMc:enlMSteIectlId by the PLAN to) provide.......... for any MEMBER.
F. "DEPENDENT" includes 11M IcMlOWlng Individualaonlyif they"'" or work with,"tM PlAN.SMMce..... (wilttin3Dmi"OIlgeneqldentiat PlAN
PROVIDER)
(1) The lawful spouse oIa SUBSCRIBER.
(21 An unmarned DEPENDENT CHILD ole SUBSCRIBER. up to 1M CHILD'S ni....-.nth birttlday.
(3) An unma".ed chitd of a SUBSCRIBER. up to thlt CHILD'S twenty-fourth birthday, who.. a full lima .tudant and i. whOlly ~ on auctl
SUBSCRIBER for suppoft
,4' COVERAGE shllll alsO be exlended bayonet the niM*nll'l .,..,. and twenty.fourth. year. IImiIatlons When a DEPENDENT CHtLD can be
certified by the PlAN as incapable oI""-sustainlng emplOyment by fWIOI'I of manta! rwtardation orphylical hI~MCI ilcNIIIty depandan1
upon the SUBSCRIBER for support and mllntManCe. prcMcIad proot ofsuctl ~ iI tumiltllCltothe PLAN bythl SUBSCRllIEA within 31
daya of the request for .uch proof by lhe PlAN. Recer1mcaUon 01 suctllncapacity mIy be NqUiNd by1he Pl.AN. bull'lOl: I'flCftfNQuenlty than once
aMullly"'" Iha two yNI' periOd toItowing the DEPENDENTS.nairWNnI of.~.
A newborn CHILD &heM be covered from monwnt Of bir1h and a minor ~ CHllD....1 be cover.t from the tima the CHILD iI placed in
custody at Iha adopbvtI parenl
G. "DISCLOSURE ,FOAM" ","ns the fOfm. or material. con~ning such information ,.garding the BeNEFITS. ....... and tenn. of 1M PLAN contract
.1 the COmm....oner may requIre sou to aHord the public. the SUBSCRIBER and ENRoLLEES with a fuI and lairdisdoaure of the proviStOM oU..
PLAN in readily underslOOd language and In a c_rty org&nlZ<<I manner.
H. "ELECTiVe DENTISTRY- muns denial f)focMUrae. which are ~ to'" dental hMtth of thI ~tien1... datarminacl by a PLAN dantlSt
I. "EMERGENCY CA,RE" mean. serviCeS_ rendered tor alleYialion of..,.. pain OI......ing andIOIlmmlldiale diagnosis and veatmant of unfor....
conctnlOtl.. which. II not "nnMKhately dl8QnoMd and trMt<<f may '-ad to disabitity. dyafunctlOtl or dNth.
J '"EVIDENCE OF COVERAGE'" meln. any cer1iliCa1a. agreement. contract. broChure. or 1atter00en1iltement ilIsuad to a SUBSCRIBER 01 ENROLLEE
setting lorm the COVERAGE to which the SUBSCRIBER or ENROLLEE" antilted.
K. "EXCLUSION" is any prOVISion of the GROUP SUBSCRIBER AGREEMENT whereby cover. for a .pecified hazard or condition is enliNly
eliminated.
L "GROUP SUBSCRIBER AGREEMENT" reters to Ihl.AgreerMnt PlAN and anySUBCRIBER GROUPandwhtchestabltsheslheterrnsandCOndlhonl
whICh govern tl'll BENEFITS made available to .ny MEMBER by PLAN
M, "LIMITATION" i..ny provisiOn other Ihan an EXCLUSION which ,",rids c:ovtnga under the GROUP SUBSCRIBER AGREEMENT.
N. "MEMBER" Ind'ENROLLEE" mean any SUBSCRIBER or DEPENDENT. who is enrolled under 1M GROUP SUBSCRIBER AGREEMENT a~ is
entltted 10 the BENEFITS avall.bIe unaer the GROUP SUBSCRIBER AGREEMENT In retum lor the Pf.ymenl requited to be rnacIt 10 lhe PlAN under
such GROUP SUBSCRIBER AGREEMENT.
o "PARTICIPATING DENTISTS" mean those dentists seleCted by tf1e PLAN to provide dantal services lor MEMBERS.
P '"PlAN" is National Health Care Syslem' at Californ... Inc.
a "PLAN PROVIDER" or "PlAN DENTIST" refer. to a provider 01 dental services Ik:ensed by the State to deliver or lurnish theM MNiceI. which I\U a
contract wilh the PLAN to render "I'IIC" to any MEMBER in KeOrdance wIll'l1M pnMsiOn of the GROUP SUBSCRIBER AGREEMENT In which.
MEMBER i. enrot'-d, The names, locations. hOurs Of service and other Informatton regarding PlAN PROVIDER. PlAN DENTIST or fKlMtieI may be
obtained by contacting Ihe PLAN oHlce
R "PREPAYMENT FEE" IS the Imount payable each month by the SUBSCRIBER GROUP to obtain BENEFITS provided under !he GROUP
SUBSCRIBER AGREEMENT
S "SERVICE AREA" conSISt. 01 those geographic regions which are within a 30 mile radius lrom the general dentilt PLAN PROVIDERS,
T "SUeSCRIBER" is the person who tl responsible for payment to Ii'll PlAN. or whOM emp60ymant or other .tat.... excepllor family ~y, i. a
baSIS lor eligibility lor membershtp tn the PLAN.
U. "SUBSCRIBER GROUP" is the organization or company whICh t\as _ententd into a GROUP SUBSCRIBER AGREEMENT with the PlAN UnMrwhlctl
BENEFITS are made available 10 eligible oroup MEMBERS and their DEPENDENTS.
V '"SUBSCRIPTION cosr means the prapeid charge paid by or on behatf of SUBSCRIBERS or ENROLLEES.
W "SURCHARGE'" mean. an additional lea which is cnarged to a SUeSCRIBER or ENROLLEE lor a eDYtNd service but wNch i. not approved by the
CommllllK)f'llf, provided lor In the PLAN Conlfact and di8ClOMd in the EVIDENCE OF COVERAGElDISCLOSURE FORM.
x "USUAL AND CUSTOMARY FEE'" mean. the amount WhICh a DENTAL PROVIDER nDflMlly Of usually charges'" ma;ortty of hil patienlS lor.
pantcular MrvICe ThiS term IS used mterchangeably With "FEE-FOR-SERVICE."
PART II. ELIGIBILITY RULES
A Persons EligIble to Become SubscrIbers
Any person who
1 IS an active luU-tlme employee or MEMBER 01. coUecltY8 bargainIng unit. aasodation or club 01 an aIected oHlciaI of SUBSCRIBER GROUP or
whO IS a retired employea 01 SUBSCRIBER GROUP. .
2 has not previously been Iermlnated under INDIVIDUAL or GROUP AGREEMENT becau" 01 fraud 01 deception in the u.. of the 5efVICH or
laclllt.. ollhe PLAN or knOWingly permitting such lraud or deceptlOtl by anothel..nd
J has applied lor membership, on lorms supplied by the PLAN. and
4 resides or wor1l.s Within PlAN'S S8fYtC8 area lWlthin thirty mites Irom a C)If1.al dentist PLAN PAOVIDER).
B Eligible DEPENDENTS may be enrolled alll'llllme the SUBSCRIBER enrOlts or any lime IherNtter by lilling 0U1 1M forms ~ by the PLAN and
paying lhe applicable prepayment lee
COale 01 EIIglblllly
1. All personllnclu<hng the SUBSCRIBER and eligible DEPENDENTS hawe apptiad IormemberShip and 100whom1heapproprialaSU8SCAIPTION
COST has been paid prior 10 the 20Ih day ot tf1e mon1tt shall be e1igibM! tor BENEFITS commencing on "'lst day of ""1oIIOwing month.
2 All persons mc1udlng lhe SUBSCRIBER and eligible DEPENDENTS who haVe applied lor marntJentlip a~ tor whom the appropriate
SUBSCRIPTION COST has been p..d belween the 20th day 01 the month and ttla lall day Of the month snail be eligible tor BENEFITS
commeRClnglhe ls1 day ollne second month the,..lt.r.
PART III. EffECTIVE DATE AHD TERMINATION DATE
All pe~ns tleComeehgible tor S8I'1ICft at 12:01 A...., 01 the effective data Indicated on thi.GROUPSUBSCRIBER AGREEMENT prowdlng they meet
all the eligIbility requirements TerrrllnallOtl date I' based on the events and conditIOnS ltIIed under PART X.
PART IV, ",WC"AL IENEflTS AND COVERAQEI
A ENROLLEES are 8fllllled 10 dental HfVICHassetlOf'th In Ihe Benefil Schedule whICh is.nacMd ..Allachment A. Thi.SchNu..........theGen1al
..rvlCes WhICh ar. al/allaDle 10 ENROLLEES Without charge tdeslgnated as "No Charge" in the Schadu..) and thOeItarVicaI tor wNch ENAOlLEES
are ot>>igated to pay Ihe PLAN DENTAL PAOVIDER. Theamountolsuch COPAYMENTS wNchlMPlAN DENTAL PROVIDER ispetminedl0Ctwga
ENROUEESlorspecl'lc dental MfIIlCIIlSset lortn underlhe heading "COPAVMENT REOUIRED."Ttle ExCLUSIONSANDUMITATlQNSappttcabla
10 Ihe Beneltl Scnedule are sel torth Immedtately lollowlng ENROLLEES MUST UTILIZE A PLAN DENTAL PROVIDER UNLESS A PROPER
REFERRAL TO A NON-PLAN PROVIDER HAS BEEN MADE.
THE BENEfiT SCHEDULE AND PRINCIPAL IXCLUSlONS AND LIMITATIONS ARE A"ACHED 'HaRtro AI AnA~NT .. THE
A"ACHIlENT A IS AN INTEORAL PART Of THIS AORIE_NT AND MUST BE READ fN COH.tUNCTlON WITH THE HIT OF THE
AQRt:t:MENT.
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Gtoq> .900476
Gtoq> .901128
82-V
77-8
1. ~~iI=:=:;;:Com.... .~Act. TJIePLAN.... prowidI...........timeol.....
bUttheMEMBERIhaII eaecwMd dIfioMtuehdoc.umentt<<tMelUCh,**KtIOn _ mlYbe~lO___thallthePLANI'''mblINed
for...... provided bIr WorUt'Ii CoI'npell.....V.. 1lMt &1(e. . "ON'" not appty to MedI-CeI ~
2. s.rwc. which In the opinion of.. MIlIf'IdIng dInUIl... not......., tor.. ...................
3. OiltlGdolltlca.
4. AESTHETIC OENTtSTRY.
$. ar.I tufIII'V ,.quiring the Mftin9 01 fraetuNI Of diIIocMlons.
8. T,..rnent 01 rMIignancia cyItI 01 MOPlMmI.
7 Dispenaing 01 drugs not nonnatIy IUppIied in . dental offa.
8. In tM event Nt palten' ..... 10 be hOIprlMnd tor any dental PfOCl'dUIW. coit will be bOtne by the petienI.
9. SeMc.whict\a,.,..rnbursabN byl.......anceOl Ntrnburubleunder.-.yotNrgrouporhelllthMrlklep!MI, The PlAN....PfOVidIiIhe~
..the time of ...... but.. MEMBa1............1UCh c:Ioc:ufnenII '*-Y 10........... PlAN." Nimb&ned lor tueh BENEFITS.
10. laM 01"'" of dentu,. or bridgewcM1l.
11. Any procedure of implantatiOn.
12. o.n.ral anestheaili.
13 ServieelINiI unnOl be perlormed becliuu oIlhe ~.I hNIIn of the~.
B. c.n.in ..me.. If. sub)8Cl to a COPAYMENT (defined heNin.. an IIddttionat amount SUBSCRIBER or DEPENDENT 1hIlII_ PARTICIPATING
DENTISTS directly), ..lIMed in the ettacned Benefit $ctwd..
C In order 10 I'I'Wke an appointment MEMBERS must t~ the nurntler of the dentIIl offICe which they hIve~.
The first appolnlmenlscheduled wlll....suatty be for the purpose Of taking. cornpIMe Nt of full mouth ...qya. examinatiOn. dwIIoping. treMmenI plan
and determining In ..IImMI of costs
DUrin9 the first appointment MEMBERS wit! be provided Wllh theif pNeCriblld tNetment pIIIn and with the__ for MCt'I denali procedute. MEMBERS
muat PlY the feelllsled on the" description of Principal BENEATS AND COVERAGES dkectty to the....... offici.......,.............
D. The PLAN will pay up 10. m.lumum of S50.00 pet' contrKt year pet MEMBER lOr OUI-of-tN-arN. _._~............... to MEMBERS who
requlre.uc".SltfvlCet wn.n I"", .re mortIlI'Ian tIUrty (30) mlleslroml PLAN DENTAL PROVIDER. MEM8ERSCMcIIIennIne......OI'noIthey*'
rnorethan thirty (3O)1fII......y lrom. PlAN DENTALPAOVlDERby~oIthePLAN""""'numIlen.Suoh""""'~"'"
be rMdily accesSIble 10 MEMBERS.nd are contained on 1M firIt ~ of Itl6I . MEMBERS muM.......... 1M PlAN prior eo oIMifting
Oul-of-tfle-.r.. EMERGENCY CARE However. when it.. not poeItbIeforthe to.ptOVIdepriornoMol'~"beprowidld"noticeil
given to Ihe PLAN WIthin 48 hour. or as soon as posIib6et~. EMlAGENCY SERVtCES..thoIe.... MqUiNd tor..1IIIIIviIIion Of....
PAin or tMeedtng .nd/or Immedl.te diagnolll and. trutmltnt of ~ conct6tIcIM. which. II noI.il.... ~.~'} ~ _........ may IMd to
dllablllly. dysfunction or deMh. The PLAN will rlllmbut'M ENROLLEES tor SUCh ~ up 10 I muifnunI amount of 15O.CIO.. conII'act yMr per
MEMBER forser'l'Cesby non-pl.n proVldef'lIOf out-of-lhe-araEMERGENCY CARE upon ~Dy"'MEMBERoI'ClOPfolthebIMfromthe
lre.tlng dentist .nO . cover lener 110m tM MEMBER explalni"9 the citcumItII~ which gIwe.... eo the .....OI'~, .............. MEMBERS must
submit such documenl.tlon to the PLAN wiltun 80 eMV' oIl'8CIIIpt 0I1UCh .......o-.~, MMot.
In the evflnt. MEMBER requlI'ft emergency I8n1'ICe and the MEMBER II... thM thirty (30) mi'" lrom a PLAN DENTAL PROVIOER. tM MEMBER
must contact the PLAN DENTAL PROVIDER to whICh he..anignedOl'oneoltNPLAN'SlItephonenumberl-.donthellrtlPllll'Of~"""""
to recetWttnltructions.SIOhowto procMCIlooblain_....~.c,. MrViCetkoml PlAN PROYIDER. MEMBERSlMyoblain EMERGENCY cARE from
a non-pl.n provider wllhln the service.... onty after contactinQ theW...... DENTAL PROVIDER 01' III PlAN and................. no PlAN
PROVIDER II .vallable However, 1llllS not poHIblelor lhe MEMBER to provide priOI notice. COWIdgewill be pnMded II notice. QIiVM to the PlAN
within 48 noursor assoon as poSSIble foltowtng!'Kelpt of senricel. The Pt..ANwitI NimburM EHAOLLEE$1or1llCh ....upto.....wnumamount
01 $50,00 per contract ye.r per MEMBER lor serviCft; by non-ptan ~ lor irHnlI. EMERGENCY CARE I,IpCiI'I t"'~.latiOI\by the MEMBER of a
copy 01 the ~II from thetre.tlng dentist and .cover.......fromtN MEMBERhplaining ..ci~~Oive.....to..emerglIncyll'Ntrnent.
MEMBERS must submit Ihls documentatIOn to lhe PlAN relating to SUCh en_o-"v treatment wiIhii'l90 daya of receipt to MMCeI.
The tOntgOlng prOVISions relating 10 the S50 m.ximum ism addihon to the ernervency prwvenhWt.nd periodontaI......ments teftected in the Benefit
Schedule
II a PLAN PROVIDER Isavail.ble.the MEMBER wHl beinatructedto... hlmortw. The MEM8ERwillbeNapOlllib6eIor~t"dIIc'ibedinthe
Attachment A tor .ny treatment rec81ved. IIlhe emergency il hendled by the enrot!M', autgned PLAN DENTIST payment wit! be in acc:ordance WIth
lhe non-emergency procedures.
MEMBERS will cay Ihe COPAYMENTS as listed in the anached description of Principal BENEFITS ANO COVERAGES undrlf ~COPAYMENT
REQUIREO"lor each crocedure comcleted, These COPAYMENTS must be Plid dil'Ktty 10 the dental office....lrNtment il ~
PART Y. OTHER CHA.RQ!S/COPAVMENTS
MEMBERS Will cay the COPAYMENTS .s listed tn the allacl'led de.SCriptiOn of Principat BENEFITS ANO COVERAGES uncler~COPAYMENT
REQUIRED- tor each procedure comcleted These COPAYMENTS mUlt be paid dir-=Ity to the dental office where ,,..tmenl il receivecI
PART VI. DENTAL RI!CORDS
The dent.1 recordS 01 SUBSCRI BER and OEPENDENTS concerning ..rvM:eS performed heNUnder ShIll remain the property of the PARTICIPATING
DENTISTS
PART VII. CHOICE OF DENTAL PROViDeR/DENTAL FA-ClUTlE.
A. Each PLAN MEMSER ISfl~oyraged to select a dentist from among the PlAN PROYIDERS. Enrollect MEMBERS ofl famlty mustuaethe..medentiat.
The PLAN shall aulSt the PLAN MEMBER in selecting. dentist wMnever IUCfI MEMBER requeIb aucI'l assiItancII.lnIormetion regIfding the..w:.
available and the location and hours 01 PLAN PROVIDERS may be obtained by calling 1M PLAN offiCe at one 01 the teIIpttone""",**, tiIMd Ibove.ln
any event. lhe PLAN MEMBER Should cont.ct lhe PLAN at oneoftnetott-""numbel'llOcteWrmtne___1M PlAN PAOYIOEAthey.,.......
IS stilt available In the event 01 an emergency. the PLAN should beconlKled M the..me numtJeq.
B. Dental services prOVided by thiS Agreemem.re limited 10 IfIr'VICeSperformed ~thOMdenltIIIwortI.lngtn PlAN DENTAL FACILITIES. Ol'lhOaeou'"
dentiSts deslgnateO by PLAN or by a PLAN DENTIST in connection wtth a ,.,.".. INdlIor definite InIlltfMm or coneuttItion.
C. The PLAN reserves Ihe right 10 re.sslgn MEMBERS at any time 10 a dihNnt PlAN DENTAL FACILITY of MEMBER'S choice.
D MEMBERS m.y Change faCilitIes with. thirty (30) ciay wnhen notiCe and appoval or the PlAN.
E Only licensed PARTICIPATING DENTISTS shall h.ve the right to ..amine MEMBERS and to determine the prolellionll MNioeIto be per10nned
pursu.nllo t"IS GROUP SUBSCRIBER AGREEMENT.
F Llablhty 01 SUBSCRIBER or ENROLLEE lor paymenl
(11 In the evenllhe PLAN lalls 10 pay a DENTAL PROVIDER with whom the PLAN hu. contract IOf' MMCe.the MEMBER Shall not be lilbIe to the
DENTAL PROYIDER lor any sums owed by the PLAN
(2) In theevent the PLAN fads 10 pay. nonconlracllng DENTAL PROVIDER. the MEMBEA may be liable tothe noncontraeting DENTAL PROVIDER
lor the cosl 01 servIces renoered
(31 Upon Ihe lermlnatlon 01 a PROYIDER contr.ct between lhe PLAN.nd a contracting DENTAL PROVIDER,IM PlAN shell be llIIbIe for cownd
ser....ces renO.reo by the DENTAL PROVIDER lother Ihan for copayments) to the MEMBER whO .....,. eltgibillty under the INDIVIDUAL or
GROUP SUBSCRIBER AGREEMENT or by oper.tlon 01 law under the care of the DENTAL PROVIDER.. 1M It.... 01 such tenntnation untM the
serviCes betng rendered 10 the MEMBER by the DENTAL PROVIDEFt .... completed. un.... the PLAN .,... ~ and medIcaIty
appropnate provIsIOn lor Ihe assumplion 01 SUCh H/'V1C8I by a contracbng PROVIDER.
PART VIII. RENEWAL PROVISIONS
A. Alter the contract period. the SUBSCRIBER GROUP may renew this GROUP SUBSCRIBER AGREEMENT. subIKI toa"" Cf\ItIQeS in COPAYMENT
B' Of" the BENEFIT package m.oe by PLAN. by lilting Oul. renewallorm .nd paying all man... due,'s.. ~ C AddModumlD GrOW) ~ ~
PART IX.INDIYIDUAL CONTINUATION OF BENEfiTS
A. The MEMBER whO beComes IneI'9lbte lor GFtOUP COVERAGE may .ppIy within thifty (30) d.ys lrom the ctme 01 termination 01 the GROUP
COVERAGE to continue coverage un08f en INDIVIDUAL SUBSCRIBER AGREEMENT of "" type for wtIiCh he or "". then....... Conversion to
Individual coverage sn." .pply to the DEPENDENT(S). Including. DEPENDENT Spou",andl DEPENDENT CHlLD.ot...conwerang MEMBER .In
addition. a CHILD who becomes Ineligible as . family DEPENDEN,T c.n convert to lndlvldUlt c~age upon the 11IM cond.itiorlI.. applied 10 a
MEMBER Such accllcallon rnay be accepled or rel8Cled Illhe Option 01 '~e PLAN; no automatIC nght 01 indMdual continuation Of tIenefits ex..
Tho..termlnated cursu.ntto SectIon XAI2) anO Sechon )(B(-4) may nol be oHered the O9POI"Wnlly to convet1: to ulclMcluaI coveNOI.
B. The PLAN reserYM the OCllon 10 oller conversion priVileges to lhe MEMBER whO beComes inlligiblelorcoverage undrIfrhiaGROUPSUBSCRIBER
AGREEMENT due to the lermlnallOn olltlis Agreemenl, Shoufd conwrsion 10 IndMdUIII coverage be oItetwcIto 1M MEMBER, _!ClItion mUll be
maOe wllhln i301 days 01 nollce ollnellglblhly to contlnue coverage under. SUBSCRIBER AGREEMENT 01 the typelor wtwdl heOt ShlIs inltigible.
ConverSIOn to IndiVidual coverage shall.pply to the OEPENDENT(S). inciuding a DEPENOENT SpGUM:~ DEPENDENT CHtLD, 01 1M converting
MEMBER upon the ..me terms.nd conditions as applMld to the COnverting MEMBER.
C. A cOYefed DEPENDENT SPOUSE wno cea...to be. Qu'llfied tamily MEMBER by reason of termination 01 marriagII or dMtn 01 the employee or
SUBSCRIBER Will be .fforded the same conversion r'9hts and conditions orantad to MEMBERS under this Section IX. su~1OIII A and B
PART I. Tl!RIIlNATION OF BENEFITS
A BENEFITS shatt cease upon the lollowlng evenlS
1 Failure 01 MEMBER to pay Ihe PREPAYMENT FEE to Subscriber,Grouptf lheSUBSCRIBER has bMnOuty nOll"adancl billed lorthecnargeanclM
leasl15 d.ys h.. elapsed Since lhe clale of notification. However. In lheevent triM an ENROLLEE is underQOing trMtrnent lor an onoGlftQ ConcllbOn.
hellhe may contInue 10 rece,~e Irealmenl Irom a PLAN PROVIDER. but must .gree to pay PROVIDER on. "fee lor servICe"' or "usual and
customary lee bas.s
.
3. lithe SU~ER GROUP Is termk\ated, SUB$CR1BERwItI blon.r.d"'opt~tinuation oIbeMfitlundtt an tndMduaIAgreemtnl.
delcrit*t ~I A. MEMBER Ihatl be glven 30" pnor noticlI 01 termI......CJi SUBSCRIBER GROUP.
8. BENEfiTS...... CMM upon the 1Q6lowing eventl. if the SUBSCRIBER or MEMBER hU bMn notitted and at'" 15 days ha eIapMd ..nee M6d
-,
1. Upon dIIIe 01 ent1"I in10 IuI-tirM mtIiWy MMce.
2. Upon ;EDEPENOENT CHILDREN'S mani."
3. Upon DE DENT CHILD MtaininQl-oe of " Of 24 Of prlol merrIege with the.-pbOn oil DEPENDENT CHtLO It\It hUbeWl cenified by the
PlAN 8& ~ of Ml'-lUItalning employment by raaon of menllll .......deIkIn or ~ ~ and fa chieIty cNlpendInt.upon the
SUBSCRIBER forsuppon and ~'_provkted proolot lUCh6ncapKityialurnisMdlolM PlANby"'SU8SCRt8~wilhin31 daytofthe
~ fclf such proof by.... PlAN. Aecer1dication of such inC..-:IlY may be rtIqUifed by the PlAN. but not more ~then once .nn~
.her the two-v-' period 1otIowi"O the OEPENDENT CHILD'S.n.InrMnI at -oe nineteen.
4. If it becomeS tn'lpouible. .'lef reas0nab6e efforts. 10 estllt.:..n and maintain I .....actory denliat~patl.nl .....'tOftShip wttl'llny MEMBER
5. It the SUBSCRIBER..... been terminated 'rom the GRC 'r or has voIuntanty 1eft..1d GROUP. In such ~ SUBSCRIBER'S and """'9ible
DEPENDENTS' BENEfiTS will temv....te
6. IntheeventtheapplableeopaymentlwhlCh lredetailedinthe BENEFITS SCHEDULE (AItKhmenI A) ant not ~id.lf CopIyments__ nottMde
'Of one lamil.,. member only tnet peraon'. BENEFITS will terminate.
pART 1[1 CANCELLATION
A notice 01 Cllne.II.l1on IhIIll be maIled tothe SUBSCRIBER at 1M SUBSCRl8ER'Saddressof record. and In SUCh eventot CIInct1l..tioi101 MEMBER:
A The MEMBER WIll have lhe opportunity to have the CIIncetlation revIeWed by the ComlTltAionef of eorporMion. under SectiOn 1315 of the Knoll-Ktene
Ac"
8 The PLAN shall wIthin Ihn"ly (301 days 01 CIIncellation return tothe MEMBER the pro-rata ponionof the money palcl to the PLAN whiCh COfrespondalO
any unellpued periOd fer which payment had been received. logether with amounts due on claims. If any..... any amountS due PLAN,
C Acceptance by the PLAN of the proper MEMBER PREPAYMENT FEE after terminatIOn ollhis GROUP SuBSCRIBER AGREEMENT and withOut
reqUiring a new appllcallon shalt relnSlalelhe contract as Ihough it had never terminated unless the PLAN within 1M (5) bu..... days 01 receipt of SUCh
payment ellher
1 ,efuAOS payment or
is.ues to tne GROUP a new GROUP SUBSCRIBER AGREEMENT IlCCOmPlnled by wrlllen notic.statlng clearly those respec:tlll\ whICh the new
contract dllters Irom Ihe t.rmlnated contraelln BENEFITS. COVERAGES. or othefWise.
o The provIsions ollhls Part apply 10 alll8fmlnahons. Including thOse d..Cflb8d in Pan X ot thl' Agreemenl
E. Illermlnatlon occurs due 10 lallure 10 make COPA YMENTS. REINSTATEMENT 01 BENEFITS will occur at lhe beginntng of the n.llt monlh after
payment of delinquent payments have been made
PART XII. RIGHT OF PLAN TO CHANGE .ENEFITS
A Pl...N meN" Ihe rlghl to change the BENEFITS. COPA YMENTS OR PREPAYMENT FEES to MEMBERS.
B The PL...N shall nOI decrease In any manner lhe BENEFITS slated In ltIe GROUP SUBSCRIBER AGREEMENT ellcept after. periOd 01 a' ....t thirty
1301 Days Irom and aile' Ihe postage paid and mailing to the other party a' lhe otn.r perty's addl'ftS 01 record With the PLAN of wnnen notice 01 such
proposed change
C The PtAN ,hall not Increase or decrease Ihe PREPAYMENT FEES or DECREASE SENEF/T$ellcep! atter a penOd olat least lhu1y 13D1 days !rom and
atterpostage paId maIling to $BId MEMBER at the MEMBER'S aOdressot recordwilh IhePl"'Nof wrillen nolICeof'uchpr~ increueordecr.....
NotitiCatlon of allerahon or re...ISlOn given 10 the SUBSCRIBER GROUP Representatll/8 mu.t be dlSHminllted to the SUBSCRIBERS and lhe
ENROLLEES In lhe GROUP no later Inan tnlrty 1301 days Irom receipt thereof and must provide thirty (301 driI nottCtl to the MEMBER prior to SUCh
Inc,.... Of deCrea.. In PREPAYMENT FEES or decrease In BENEFITS.
PAJIIT XIII PREP"'VMENT FEE
A The PREP"'YMENT FEE IS Ine montnlv lee requlfed 10 malnlain co...erage under IhlS GROUP SUBSCRIBER AGREEMENT.
THE PREPAYMENT FEE SCHEDULE IS ATTACHED HERETO AS A TT"'CHMENT B. THE PREPA VMENT FEE SCHEDULE IS...N INTEGR"'L PART
OF THIS "'GREEMENT "'ND MUST BE READ IN CONJUNCTION WITH THE REST OF THE AGREEMENT.
MEMBERS 01 a SUBSCRIBER GROUP shan pay PREP"'YMENT FEES directly totheSUBCRIBER GROUP which will In lurn pay the PlAN. MEMBER,
should check With SUBSCRIBER GROUP to determine the deadllne.net methOd of payment tor hi' contflbutlOt11t any. to the PREP"'VMENT FEES
SUBSCRIBER GROUP shaU then forward Ine PREPAYMENT FEE to Ihe PLAN, Monlhly PREPAYMENT FEES must be receiYed by the PLAN on or
betorethetwentlelh day 01 the montn 10 msur. ehglblllty for serVice on Ihe lirst day ot thetoltowlng monlh, Sucr. payments "'allbe madeat or sent 10'
National Health Care Syslerns 01 California, Inc.
One Park Plaza. Suile 430. III/lne Califo,nia 92714
8 Payments receIVed by the PLAN or Its authomed agenl. pllor to lhe due date. win ma.e MEMBERS 01 lhe SUBSCRIBER GROUP and U~tr eligIble
DEPENDENTS eligible for BENEFITS commenCing on Ihe due date lor the P8nOd paid tor, Payments recetved aner the due lUlte Will make MEMBERS
and thlllt eligible DEPENDENTS elig.ble lor BENEFITS on lhe due date oflhe subsequent month, MEMBERS should conlacllhe SUBSCRIBER
GROUP to determine lne deadline and method of payment to the Group
C Tile PLAN will not f(lcrease or decrease Ihe PREPA VMENT FEES or decrease BENEFITSellcept alter a pellod ot at I.ast thlny (301 day.lrom and atter
postage paid malllAg 10 said MEMBER at MEMBER'S address of record Wilh the PLAN at wrlnen nollce 01 such proposed incr.... or decrene
Noldicatlon 01 alteration or reVISion given 10 Ihe SUBSCRIBER GROUP Representative muSI be disseminated 10 ltIe SUBSCRIBERS and ENROLLEES
In lhe GROUP no lale' Ihan Ihll'ly 1301 days from receipt thereof and mu.' provide Ihlrty (301 dlYs notice to the MEMBER priOr 10 such mcrease or
decrease In PREPAYMENT FEES or decrease In BENEFITS
D Each MEMBER shall payor arrange 101 paymenl 01 applicable COPAYMENTS, if any_ as provided m Anachment A_In caseottailure Id doso. the rights
of MEMBERS or 1helr eligIble DEPENDENTS may De terminated on tiheen 115) dayS' nOIIC' and may be r'Instated only by renewed appllCallon anet
r&enrollment In accordance wllh all reQUlremenls 01 thiS Agreement, Any applicable COPA YMENTS are detailed In the BENEFITS schedule.
ENROLLEES will no! De terminated t1ased upon tallure to pay "lee tor service" or "usoaland customary I.... for saNIC.. nol covered by the PL"'N
,...RT XIV. U....ILITY OF MEU.ERS IN THE EVENT OF NONP"'VMENT.V THE DENTAL PLAN
In Ihe evenl the PLAN failS 10 pay a PLAN PROVIDER Wllh whom Ihe PLAN has a contract lor servICe. the MEMBER snail not be lilble to the Pl...N
PROVIDER tor any sums owed by tne PLAN In tne event that the health Pl....N 'a'" to Ply a nonConllactmg provtQer. the MEMBER may be liable to !he
noncontractlng provlaer for me cosl 01 the services rendered
P.....T XV. TERMINATION OF PROVIDER
Upon lermlnahon Of a PROVIDER contract. Ine PLAN shall beltabl.,other Ihan lor COPAYMENTS) for covered seNlcesrendftrect by such PROVIDER
10 a SUBSCRIBER or ENROLLEE wno relams ellglblllly under Ihls GROUP SUBSCRIBER AGREEMENT or by operallon ot law ano who IS uncler lhe
care 01 saId DENTAL PROVIDER at Ihe ltme 01 SlIch fermlnation. until the care being rendered to said SUBSCRtBER or ENROlLEE by SUCh
PROVIDER IS comoletel;! or unlll !ne PLAN makes reasonable and medically approprlale proviSIOn to' the ass.umpllOt1 01 such 'eNtcn by another
contracting PROVIDER
PART XVI. GENERAL PROVISIONS
A ThIS Agreement. IncluOlng any amendments thereto, conslIlules lhe entire agreemenl betweeo the parties
B The PLAN II s"b,ec!to tne reQulremenls 01 Chapter 2 2 01 DlvrSiOn 2 olth. Health and Salety Code 01 the Slate 01 California and Subchapter 5.5 of
Chapter 3 01 Tille 10 of lhe Ca\l'orn,a Admlnls!rallVe Code. and any prOVISion reqUired to tJe In Ihrs contract byelther 01 theabove snail bmd the PLAN
whelher Of nOI provided," tne contracl
C ThiS Mem~fshlP Conllacl replaces and cancelS all other contracls. II any. .ssued to MEMBER herein
o In the evenl 01 anv conllovefsy oelween the MEMBER. a DEPENDENT. or the helrs-at-lawor personal represenlabves olaMEMBER or DEPENDENT.
as the case may be. and the PLAN as indiVIduals or otherWise. whether IAVotvlng a claim In tort. conlract or otl'lerwIM. wtlk:h ar. not .dequatety
resOlved In the opinIOn 01 the MEMBER, a DEPENDENT. or hells-at.law or personal representatlv' ola MEMBER or DEPENDENT, by the PLAN'S
grievance orocedures the same snail be submitted 10 arbllrallon In accordanc. With the rules 01 the Amencan ...rt)ltratlon Auoclatlon. a:\d IUdgment
on lhe award rEo-nde'ed Oy tne ArOltralor or A,brlrators may beentered,n any Court haVing lunsdlCtlon tneteot, Artlitratlon may not be Initiated, nowe.-,
unllllhe grIevance proeeaures nave been eKhauSled Thus.the complaint must have been given notICeof thedisposlbonOl his~nl bytne PLAN,
have appealed to the Pubhc Policy Commlllee wnlcn has rendered adecIlK)n and given nollcethereol tothecompililnant. pnorto Initiatll"9arbitretion.
Arbltrallon may be In,haled by any MEMBER by sending a letter to Ihe PLAN ollICe In the ....entat arOllratlon. the prevailing party In said proceedtnvs
sh.ll be entitled 10 an award ot reasonable attorneys' lees and any costs incurred
E The PLAN WIll provl<l(> wllllen notlte with.n a reasonable lime to MEMBER In Ihe event 01 any termInatIon or breach ot contract by. or inability 10
pertorm 01. any corlllacllnq PROVIDER Illhe MEMBER may be materiallV and adversely aHeeted thereby
F Any nohce under lhls Con1faCI mav be Qlvp.n by Unllecf States mall. poslage paid. addressed as tollows
Nation.al Health Cara Syslems 01 Call1o,nia. Inc.
Ona Park Plaza. Suite 430
Irvine.Ca"lornia 92714
II to a MEMBER
To lne late!>1 address provlrJeO lor tne MEMBER on enrollmenl or change 01 add'ess !orms aclually Delivered 10 lhe PLAN.
1110 lhe SUBCRIBf:.R GROUP
em OL.sl\IL~INJ--
R)(~!U)E~'BATI5.,' i('o'Z>.c"''''~-
T"It'pnOnE'--,-~1
Conlact PeflOon _~_
,~
31?~ -q-OM
~""" (,~?~/Iea.
1:'/ A . --:..
.
^ t:wo(2) wars ^
G. Term. ThiI Agw....... ....-n in tona and effect tor~'" from...,....,....
H. WHATPOLLOWI AM"''''''''' aaeM- , AND.....-AL 1Jt(:'I--.-rR AND ....,.-=~"ACI....-r A) AND'" PIlIIPAy..
1IIII1'..ICI_.....CAnACI..,.~ AMNOTAn~COIfI'ACTYCKM ...-r..........,.ATMOIITMI
PLAN..,........ PUION. OII.y TOLL...... MOa'nIlfllI ('&. aMRA.-....... 011 TGLL..... ~
,.- I'" .-..~
n.-..-.n' ICIIIDLU AND fllllMYIIINT .... SCHmIU AMIfdOIIAL'AIITa OI""~ AND -..T" IlIAD"
COIt-.,..,..""""....,. OITMI~.
IN WITNESS 'MIEAEOF, thiS ~.. lIMn..-cuted. of OW.., and
NATO
ATTACHMENT B
PREPAVMENT FEE SCHEDULE
IIOHTHLV DUEl:
82-V
. 7.00
77-5
$U.OO
SUBSCAIBER GROUP
Su........
By
Cl'lY OF SAN BERNl\RDIID
$18.00 ,U.OO
Subscnber and one dependent
$24.00 c: 15.. 00 Subscriber ancllwO Of more depenMnll
~I JAonttlly Admln.stratlon Fee
",-..-
--
AGENTIENROLLER
. 0037
WlLLIl\M H. 1DRNBl\l\ER. D.D.S.
" ,
o
o
ATT ACHMENT A
YOUR DENTAL PLAN
GROUP PLAN 82-V
PRINCIPAL BENEFITS AND COVERAGES
MEMBER SERVICES
PREVENTIVE:
Full moulh .........,
S;"gte..m
EacIl__Nm
0tII eaIIftlNllQn1lftd ~
Offici VlIIII
T_m cIlMntnQ 10l"ll PI' ~l
,--....-
P,.....I..,. dentll ~bon
0-_
Ernergetw:v ,....trNl'lt - p...... per viIi1
-
RESTORA TIVli DENTISTRY:
Pin bul1C1-uP under "ling
Amatg.m fUlor.bOtII Pl'"'*V w.c":
c.v.lIes lnvolvtftg one tOOlh surf...
ClVltlft InYOMng two looth surfecll
CoI\IltlllS In\lOMftQ dV.. ,01 mote
tOOf'" surflCel
AmeIgam '.IOt.1ioM ~1 ....
c.v.tHtS InvoMng one tooth ""lace
CaY.ltlIS ;nvoMng fINO tooth sutfac.s
c.v.lttS lnvatvtng thr.. or more
IOOII'l ",rfac:.
5tdalive bUe
Sihelte. Ac:rvl+e, ~"11C Restor.bOM
One sur'leI fllll";
Two or mor, surface fllhnos
Pin ',Ienl.on '* t0011'1
CROWN AND BRIDGE:
Acrv'1C crown
Aervlic 'Nfl" metal crown
POl'C8Ittn crowtl
Parcelll" w.lh metll crown
Full CRIwn
314 crown
St.IW'lless Steel IPnrNIV 01 '_"**,II
00w.I Pin
Pin BUlld-Uo
PONTICS:
c.st lurlltaryl
Steel'S flClng
POraNi" DIked _m me...
ActytIC _11'1 met8l
R.cer,,'l1,l!OI'I: '*' unit
MEMBER PAYS
1_ "-' ScnGIIoI
MEMBER PAYS
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
12
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
7
MEMBER SERVICES
PROSTHrncs:
CompIet. ~ dentute
Comp6et. fNndibuAIf denture
.....,. UIIIIW 01 ~.... ~
-.-----
TeMtl Md dIIOI..... 1M' UN(
PII'iII ~ fJI ..... WICI'l ciIIaN CDtIIII
-"-..................-
----
T eed'l ."d cIIIPI pu, per unit
S!mDIe su.t bteliers - ...,.
..~.tM tUfMlal.. IndQIIt
S~t.
Denture .......tS
Office rettne - co6d cure - acrylic
DenNN ,....... IIebor.ftWV .... ...
ItO"" denlure ,., Ino teeth IrwoIwdl
Aeo&ICe fQQtft
'ORAl SURGERY:
SinP ..tr8CbanI
T.... imDKbOf'l
PIttiaIty botly imPICtlOn
ComcMl. bony impKbOn
lnua-arll I &0 of .osc:-
Local anesthtbCS
,.
,.
'401
12
173
12
:!C
.
1II
'2
:rl
,.
,.
a
7
:rl
42
,.
18
NO CHARGE
12
15
la
'PERIODONTICS:
Emergent."V 1,..lrnent
SubglnQIVe! Cl.l;reIUQI. roal ... '*' ouedrlnt
Gingivestamy 1M' ~r."t linc:ll.l6nt past
IurQtCllveIIlSl
GingiYecwnv. OIHOUS or rnuca1JinONel auroerv
per QUldran' hndudeS l)QIt su'9iCII 'lilitS1
GinQN<<lornv. .,..unenl per toOU'l I.....
than si. tMtht
la
18
:!C
91
90
'27
lOB
1!5S
121
121
311
311
18
lOB
'ENDODONTICS:
Pulp c.aQOlnQ
Pulpcnomv
AeceIolQtlon IC.oH. temDQtetY tellOfItion
'*' toathl
AOQI Clnals
Si~l. tooted can. ther..,
BI-rooted cane! tt'leraov
Tn-rooted can.. uweov
AC)lC08C1omv hncludtn9 f1IlinQ Of roat CInIt
at In. ume time)
AOICOCtomy l~t. procecsurel
7
14
18
90
"5
1401
121
'II
1!!Ii
127
'2
""
,.
ANY PROCEDURE NOT USTED IS AVAILABLE ON A FEE FOR SERVICE BASIS.
'As porla<med by. __ prlCtitionlr,
. p"".,., _ 0.. Jill 12 _~ 4 ftN u~w/. eu~tomMY
Mtd . '''0 __ ,.. ,UCRI ,f gold i$
~ or fWIUitWd.
EACH PARTICIPATING DENTAL OFFICE IS
INDEPENDENTLY OWNED AND OPERATED
CAll US TOll FREE WHEN YOU MOVE, CHANGE EMPLOYMENT OR CHANGE TELEPHONE
NUMBERS. IT Will HELP US TO SERVE YOU BETTER. Good DenUlI He8lth ia an In.....ll....nt.
DENTAL PLAN
18662 MacArthur Blvd., Suite 101
Irvine. California 92715
AG
10
,
o
o
PLEASE READ
SERVICES NOT RENDERED
" lie"';"". wllicll... provided will10ul co.ltol/le Member by any municipality.
county or o__oillion. Sarvic.. '0 wlllcllllle __ i. enlltled u_
.ny Worker'. Com_~on \.ow or Acl. TIll. ..cluaion d_ nol apply 10
Medl-c.l Program,
2. Servic... which in the opiniOn Of tl'l. attending dentist are not necMUry tor
th. parient" dlntal health.
3, OnIlOdonllc.,
.. Cosmetic. elective or I..thltic denUstry.
5. Or'l surgery reqUiring Ihe MUing at 'r.ctu.... or dislocation,.
e. Treatment 0' mlllgn.nei... cystl or neoplasm.. or cong.nit.1 malformation..
7. Dispensing 0' drugs not normally supplied in I dental aHic..
I. In thl Ivent that patient d.,i,., to be hospitalized tor any dlntal procedure.
cost will bl bo,n, by the ~ti."L
9~ Services which are 'etmburslble by insurance or reimbursabJe under any
ath,r group or h'llth s.rvic. plans.
10. lou or theft 0' dentures or bridgework.
11. Any procedure of implantation or Ixperimenta' procedures.
12. Genera' anesthesia when not IVlilable by your Ir..ting office.
13. Services 1hlt can not be performed because of Ihe general health of the
patient
REMEMBER, WE ARE HERE TO HELP YOU. IF YOU HAVE ANY
, QUESTIONS OR PROBLEMS. PLEASE CALL US.
No. C.Ufornl. Members TOLL FREE 1 (100) 432-7011
So. CaIHom" Members TOLL FREE 1 (100) 432-7151
O..-nge County Members 752-1757
THANK YOU
Administratiw OffIce
DENTAL PLAN
18662 MacArthur Blvd.. Suite 101
Irvine. California 92715
Copyfttftt . "" _ NaItOll" ........ ear. Sys....... IIIC.
. .. .' .
o
PLAN 77-S
o
ATTACHMENT A
PREPAID GROUP DENTAL PLAN
DESCRIPTION OF BENEFITS AND COVERAGES
PROSTHETICS:
Maxillary denture (Upper) $140
Mandibular dentura (Lo_r) 140
Partial dentura cast trame, base tee 150
Acrylic partial, cast clasps 150
Teeth or clasps per unit NO CHARGE
Stress breakers per unit NO CHARGE
Denlure adjustments NO CHARGE
Partial adjustments NO CHARGE
Office raline, cold cure NO CHARGE
Laboratory raline 24
Repair broken danture NO CHARGE
Replaca tooth NO CHARGE
oAl....- .., . __ .............. - TIMt _ ...-.. ...._ 01 gold.
ANY PROCEDURE NOT LISTED IS AVAILABLE ON A FEE FOR SERVICE BASIS.
MEMBER SERVICES
Oral Examination
Full mouth x-rays, every 3 yaars!
or as needed
Single x-ray
Each additional x-ray
Emergency, palliative
Specialist consultation
Office visits
Vitality tests
Topical fluoride
Oral hygiene instructions
.PERIODONTICS:
ProphylaxIs, to age 14 (teeth cleaning)
ProphylaxIs, adults (teeth cleaning)
Topical fluOride and prophylaxis
Special consultation
Subgingival currel1age per Quadrant
Root planing per Quadrant
Gingivectomy, per Quadrant
Osseous or muco gingival surgery
per Quadrant
Excision, periocoronal tissue
Excision of hyperplastic tissue
per arch
Vincent's infection
Periodontitis
Periodontosis
Periodontal packing
.ENDODONTICS:
Vltalometer test
Pulp capping
Temporary filling and CaOH
Vital pulpotomy
Culture canat
Single rooted canal therapy
B,-rooted canal therapy
Tn~rooted canal therapy
Hemisection
Root amputation
Apicoectomy and filling canal
Apicoectomy on separate appt,
CROWN AND BRIDGE:
Acrylic crown
Porcelain and metal crown
Porcelain and metal pontic
Full crown
Onlay or :Y. crown
Re-cement crown
Re-cement bridge.
Re-cement facing
MEMBER PAYS
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
$5
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
$20
20
40
40
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
$40
50
60
NO CHARGE
NO CHARGE
50
50
$55
85
85
55
55
NO CHARGE
NO CHARGE
NO CHARGE
MEMBER SERVICES
.ORAL SURGERY
Specialist consultation
Biopsy of oral tissues
Microscopic examination
Post-operative visits (sutures)
Single extractions, local anesthesia
Each additional, local anesthesia.
same visit
General anesthesia
Single extraction
Each additional, same visit
Partially bony impaction
Completely bony impaction
Alveolectomy edentulous
per Quadrant
Alveoplasty and ridge extension
per arch
Palatal torus
Mandibular torus
Intra-oral L & 0, of abscess
Extra-oral L & 0, of abscass
Frenectomy
Local anesthetiCS
RESTORATIVE DENTISTRY:
Primary Teeth,
Amalgam, 1 surface
Amalgam, 2 surfaces
Amalgam, 3 surfaces or more
Permanent Teeth:
Amalgam, 1 surface
Amalgam, 2 surfaces
Amalgam. 3 surfaces or more
Acrylic or Porcelain filling
Fixed spacer, band type
Removable spacer
Pulp capping
Temporary filling and CaOH
Pulpotomy
Stainless steel crown (pnmary)
Stainless steel crown (permanent)
MEMBER PAYS
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
, $20
B
7
40
50
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
$25
30
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
NO CHARGE
.
o
o
PLEASE READ
PRINCIPAL EXCLUSIONS AND UMITATIONS OF BENEFITS
1, Services to which the MEMBER is entitled under Bny Worker's Com-
pensation Law or Act. The PLAN ShBII provide the services Bt the time
of need, but the MEMBER Bhall execute Bnd deliver such documents
or take such other action as may be necessary to Bssure that the
PLAN iB reimbursed for benefits provided by Worker's Compensa-
tiDn . This EXCLUSION does not apply to Medl-cal progrBm,
2, Services, which in the opinion of the attending dentist, are not neces-
sary for the pBtient'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.
S, In the event thBt patient desires to be hospitalized for any dental
procedure, cost will be borne by the patient.
9. Services which are reimbursable by inBurBnce or reimbursable under
any other group or heBlth service plBns. The PLAN ShBII provide the
services Bt the time of need but the MEMBER ShBII 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 performed because of the general health of
the patient. .
REMEMBER. WE ARE HERE TO HELP YOU. IF YOU HAVE ANY
QUESTIONS OR PROBLEMS. PLEASE CALL US.
No. CaI"ornIa Mambe,. TOLL FREE 1 (100) 432-7018
10. CalIfornia Mambe,. TOLL FREE 1 (100) 432.7158
0re1lfB County Mambe,. 752-1757
THANK YOU
Administrative Office
o
o
City of San Bernardino
MISSION DENTAL HEALTH PLAN
ORTHODONTIC PLAN nOR
ORTHODONTIC BENEFIT
M..imum fH chorged '0 tho subscriber will be $1375,00 ptr c.., Extractions and initill
diagnostic X"'YI .r. not included.
PI.n benofiu COYIf 24 months of ulU.1 .nd CUltCll'/lllry onhodontic _to Btntfiu _Iy
to the individuelsubscriber vnly.
Orthodontic tr..tment must be provided by . member of the orthodontic PlMI, who NI'I
.Nic. .gtnmt"t with the Dental PI.n.
If you abide, comply .nd understand the requirements of the Orthodontic Plan YOu shoukl
undtrlt.nd tha' your m.ximum COlt under 'his Onhodon'ic Progrtm is $ 1375.00 plus .ny of ,he
fHllptCifitd undor ADDITIONAL CHARGES,
LIMITATIONS
1. No benefits will be paid for an orthodontic treatment program which began before the
subscriber enrolled in the Orthodontic PI.n.
2. No benefits will be paid for lost or broken appliances.
3, Extractionsl,e not included IS' benefit.
4, Additional fees may be charged bV the doctor for:
a, Clre required in excess of 24 months.
b, Gross non-cooperation.
c, ACCidents occurring during the period of treatment.
d. Cases Involving surgical onhodontics.
e, Cases involving myofunctionaltherlPY.
5, If the subscriber becomes ineligible during the couru of tr.atment. cover. under this
program ..... and it b1comtl tho obligation of tho IUblcriber to pty th. .n'irt rt'
maining balance,
6. Choice of Orthodontist. initially. after treatment begins or upon change of residence
is limited to OnhodontisU participating in this program or who Keept the fees outlined,
ADDITIONAL CHARGES WI LL BE MADE FDR:
Missed .ppoin,monts Iwithou, 48 hours no';ctl . . . . ,$ 5,00
LOll m..al bends, " , , . , . , , . . . . , " . . ' . " . , . .. . $ 5.00
L.ostlbrokln headgear. . . . . . . . . . . . . . . . . . . . . . . . . '15.00
Lost or non.repairable r.tainer . . . . . . . . . . . . . . . . . . 150.00
Initial diagnostic x.rays. . . . . .. . . . . . . . . . . . . . . . . . $60.00
Extractions. . . . . . . . . . . . . . . . . . . . . . . . . . F...for.Service
-----------------
_DENTAL HW.TH......IIlIlOLLIIIHT................".....1 ORTHODONTICS
I v.1 ..0 _T_
... 0" .0
SocIllI$<<Uftl NO La,INa_ . ,
......- z. Code eo..... ....1'.. 0...
..-- --
.......otlmplo.,.,CUnK,lnI mmals~
-.... 8~~
W_
..'-'.- POyou..................
FlrmOfiJnIOnAcllH.., Oemal c.n.. .......
. DV..ONo
---- .-- ...--
LIST All DEPENDENTS TO 8E COVERED
--
-
LIUl ,",me \,1 ollt.,.nll f",IRe'" In,llIIl ,r; ~~.. ....NelNI...........' f,"'NIfte 1"I11et iJo; ...";;:--Yt
... v.
i:"- .
,,~ .
-~. --, ,_. -.-.- T
D.-_.............." .,.b _b .. -.-
. .-,-~.,...................... ..........a ...a
'....... jlUhoCIII'Ift ~-. GlDl,Cro. . ~,_
,...,_.......~........'..aa.._CII'
I' ...... . I8IIt& ,.. -.. __ ..-.
.......~.----
..... ".:-"a'"
a...... u
....
--
---
....
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ATTACHMENT C
NATIONAL HEALTH CARE SYSTEMS OF CALIFORNIA
Addendum to GrDup Subscriber Agreement
Paragraph VIII,B, stated belDw and incDrpDrated herein by this
reference, shall be added to the Group Subscriber Agreement dated
,19_,
"Part VII I. B, The member and/Dr dependents
are eligible to retain coverage under this
Agreement during any CDntinuatiDn of Coverage
periDd or election period necessary for
Subscri ber GrDup 's cDmpl iance with requi rements
of the CDnsolidated Omnibus Budget Reconciliation
Act (COBRA) and any regulations adopted
thereunder, Dr any similar state law requiring
the Continuation of Benefits fDr members and/Dr
dependents, provi ded Subscri ber Group cDntinues
to certify the eligibility Df the member and/or
dependent and the monthly prepayment fees for
COBRA coverage for such members and/Dr dependents
continue to be paid by Dr thrDugh Subscriber
GrDup pursuant tD this Agreement."