Loading...
HomeMy WebLinkAboutStaff Report 327-05DISCUSSION A Request For Proposals (RFP) was conducted with the assistance of the City's benefit broker with the intent to seek a third-party claims administrator who can reduce claims costs while providing high quality customer service, as well as being able to administer the City's current "incentive model" plan design. The City's dental plan has a unique incentive plan design that pays an increasing share of the treatment cost provided that the indi vidual utilizes the plan once during each calendar year, recognizing that preventative care will help to control future treatment costs. The percentage of payment is as follows: First year of eligibility Second year of eligibility Third year of eligibility Fourth year of eligibility 70% 80% 90% 100% Two proposals were recei ved from Delta Dental and MetLife. The savings the City would realize by changing to Delta Dental would be $61,951 each year with a 5% renewal cap for the administrative fee cost in the third year. The savings the City would realize by changing to MetLife would be $147,702 annually with a 5% renewal cap for the administrative fee in the second and third year. Human Resources staff carefully reviewed each firm's qualifications and the recommendation is to select Delta Dental for its extensive dental network and expected reduction in claims costs. Delta Dental also has the capability to administer the City's unique "incentive model" plan design. City employees will also experience a savings in their claim costs when they visit a Delta Dental- contracted dentist as dentists agree to a lower contracted fee structure. While the savings by changing to MetLife would be greater, the City has not experienced quality service with MetLife recently with its long-term disa~ility plan. In contrast, Delta Dental has a superior reputation for quality customer service and has provided dental administration services for many more years than MetLife. The City's Purchasing Ordinance allows for selection based on performance rather than cost. RESOURCE IMPACT The expected annual savings for dental administration services and claims cost is $61,951 annUally. Funds for dental plan administration costs are included in the 2005-2007 Adopted Budget in the General Benefits and Insurance Internal Service Fund and will be adjusted to reflect the change in lowered costs. POLICY IMPLICATIONS This request does not represent a change in existing policies. ENVIRONMENTAL REVIEW This is not a project under the California Environmental Quality Act. CMR: 327:05 Page 2 of3 ·~ • J 2.6 Every enrolled employee and Dependent meeting the preceding conditions of eligibility is an Enrollee. However, Delta will not provide Benefits for any employee or his or her Dependents unless (1) the employee is included on the list of Primary Enrollees submitted as required by this Article (or any revision or correction of such a list), and (2) the appropriate payments are made as required by Article 3 of this Contract, for the months in which Delta provides covered dental services. 2.7 The Contractholder will compile and furnish Delta with an initial report of all Primary Enrollees,showing their federally aSSigned Social Security numbers, their dates of hire and location codes. The initial report shall be provided to Delta or prior to the effective date of this Contract. The Contractholder also agrees to report all persons electing continued coverage under Article 10, showing their federally assigned social security numbers and date of election. 2.8 The Contractholder may continue to submit subsequent eligibility reports monthly or may report only additions or deletions to the initial report. If the report is not updated by the Contractholder or has not arrived or been processed for the current month, Delta will extend the last report received to process claims. The extension of the eligibility report does not waive the requirement that the Contractholder provide an updated report to Delta each month indicating additions or deletions from any previous report. The Contractholder shall pay, as set forth in Article 3, all Premiums applicable for Primary Enrollees reported in the updated report. 2.9 Enrollees are not eligible during a period the Primary Enrollee does not report to work on a regular basis and is not actively employed as determined by the Contractholder. Eligibility resumes on the first day of the. month following the return to active employment if amounts due to Delta for Enrollees have been paid. Eligibility can continue without interruption if the Contractholder continues to report the employee as a Primary Enrollee and amounts due to Delta are paid on the employee's behalf. 2.10 A Primary Enrollee absent from work due to a leave of absence governed by the "Family and Medical Leave Act of 1993" (P.L. 103-3) will not be subject to Section 2.10. 2.11 A Primary Enrollee absent from work due to a leave of absence governed by the "Uniformed Services Employment and Re-employment Rights Act of 1994" (P.L. 103- 353) will not be subject to Section 2.10. Such Primary Enrollee shall have the right to continue coverage for up to 24 months while he or she is on military leave. If the Primary Enrollee elects this continued coverage, he or she must submit the payments necessary to the Contractholder. 4 (g) Sealant Benefits include the application of sealants only to permanent first molars through age eight and second molars through age 15 if they are without caries (decay) or restorations on the occlusal surface. Sealant Benefits do not include the repair or replacement of a sealant on any tooth within two years or its application. (h) Direct composite (resin) restorations are Benefits on anterior teeth and the facial surface of bicuspids. Any other posterior direct composite (resin) restorations are optional services and Delta's payment is limited to the cost of the equivalent amalgam restorations. (i) Crowns, Inlays, Onlays or Cast Restoration are Benefits on the same tooth only once every five years while the patient is an Enrollee under any Delta plan, unless Delta determines that replacement is required because the restoration is unsatisfactory as a result of poor quality of care, or because the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissues since the replacement of the restoration. (j) Prosthodontic appliances that were provided under any Delta plan, including but not limited to fixed bridges and partial or complete dentures, will be replaced only after five years have passed, unless Delta determines that there is such extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory. Replacement of a prosthodontic appliance not provided under a Delta plan will be made if it is unsatisfactory and cannot be made satisfactory. (k) Delta will pay the applicable percentage of the Denti~t's Fee for a standard cast chrome or acrylic partial denture or a standard complete denture. (A "standard" complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials.) (I) If an Enrollee selects a more expensive plan of treatment than is customarily provided or specialized techniques, an allowance will be made for the least expensive, professionally acceptable alternative treatment plan. Delta will pay the applicable percentage of the lesser fee and the patient is responsible for the remainder of the Dentist's fee. For example: a crown, where an amalgam filling would restore the tooth, or a precision denture, where a standard denture would suffice. (m) Delta will pay for Night Guards or Temporary Tooth Stabilization only if provided in connection with a documented history of or formal treatment plan for active periodontal therapy. (n) Implants are Benefits only when conventional fixed or removable prosthesis cannot provide clinically acceptable service and the patient will derive significantly greater benefit from an implant-borne prosthesis. (0) Covered implant procedures are not benefits unless the dentist requests and receives predetermination from Delta. A second opinion may be required from a dentist and at a location selected by Delta before predetermination will be granted. 8 7.4 The process Delta uses to determine or denY'payment for services are distributed to all Delta Dentists. They describe in detail the dental procedures covered as Benefits, the conditions under which coverage is provided and the limitations and exclusions applicable to the plan. Claims are reviewed for eligibility and are paid according to these processing policies. Delta's Dentist consultants evaluate those claims that require additional review. If any claims are not covered or if limitations or exclusions apply to services the Enrollee has received from a Delta Dentist, the Enrollee will be notified by an adjustment notice on the Notice of Payment or Action. The Enrollee may contact Delta's Customer Service department for more information regarding Delta's processing policies. 7.5 Second Opinions. Delta reserves the right to obtain second opinions through regional consultant members of its quality review committee. This committee conducts clinical examinations, prepares objective reports of dental conditions, and evaluates treatment that is proposed or has been proposed. Delta will authorize such an examination prior to treatment when necessary to make a Benefits determination in response to a request for a predetermination of treatment cost by a Dentist. Delta will also authorize a second opinion after treatment if an Enrollee has a complaint regarding the quality of care provided. Delta will notify the Enrollee and the treating Dentist when a second opinion is necessary and appropriate, and direct the Enrollee to the regional consultant selected by Delta to perform the clinical examination. When Delta authorizes a second opinion through a regional consultant Delta will pay for all charges. The Enrollee may otherwise obtain second opinions about treatment from any Dentist they choose, and claims for the examination may be submitted to Delta for payment. Delta will pay such claims in accordance with the Benefits of the plan. A copy of Delta's formal policy on second opinions is available from Delta's Customer Service department, upon request. 7.6 For services provided by a Dentist who is not a Delta Dentist, Delta will not pay more than the lesser of the fees entered on the claim form reporting such services to Delta or the Prevailing Fees, multiplied by the applicable percentage specified in Article 4 for such service. However, if the Dentist discounts, waives, rebates or does not use good faith efforts to collect some portion of the fees entered on the claim form from the Enrollee, Delta will not pay more than the applicable percentage specified in Article 4 of the lesser of (1) the fees entered on the claim form, reduced by the portion discounted, waived, rebated or not collected, or (2) the Prevailing Fees, reduced by the portion discounted, waived, rebated or not collected. 7.7 Delta will pay a Delta Dentist directly for services provided by that Dentist. Contracts between Delta Dental of California and its Delta Dentists provide that, in the event Delta fails to pay the Dentist, the Enrollee will not owe the Dentist for any sums owed by Delta. 7.8 Delta will pay an Enrollee directly for services provided by a Dentist who is not a Delta Dentist, and those payments are not assignable. The Enrollee is liable to the Dentist for payment to the Dentist for the cost of the service. In addition, Delta will pay for services from dental school clinics by students of dentistry or instructors who are not licensed by the state of California. In the event Delta fails to pay the Dentist who has not contracted with Delta as a Delta Dentist, the Enrollee may be liable to the Dentist for the cost of the service. 12 The California Department of Managed Health Care is responsible for regulating health care service plans. If the Enrollee has a grievance against the health plan, they should first telephone Delta, the plan, at 1-800-765-6003 and use Delta's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available an Enrollee. If the Enrollee needs' help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by the plan, or a grievance that has remained unresolved for more than 30 days, the Enrollee may call the department for assistance. Enrollees may also be eligible for an Independent Medical Review (IMR). If the Enrollee is eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions online. An IMR has limited application to a dental program. Enrollees may request an IMR only if the dental claim concerns a life-threatening or seriously debilitating condition(s) and is denied or modified because it was deemed an experimental procedure. If the group health plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), the Enrollee may contact the U.S. Department of Labor, Employee Benefits Security Administration (EBSA) for further review of the claim or if the Enrollee has questions about the rights under ERISA. The Enrollee may also bring a civil action under section S02(a) of ERISA. The address of the U.S. Department of Labor is: U.S. Department of Labor, Employee Benefits Security Administration (EBSA), 200 Constitution Avenue, N.W. Washington, D.C. 20210. 7.12 The Benefits that Delta provides are limited to the applicable percentages of the Dentist's fees or allowances specified in Article 4. The Contractholder requires the Enrollee to pay the balance of any such fee or Allowance, known as the "Patient Copayment," as a method of sharing the costs of providing dental Benefits between the Contractholder and Enrollees. If the Dentist discounts, waives or rebates any portion of the Patient Copayment to the Enrollee, Delta only provides as Benefits the Dentist's fees or allowances reduced by the amount that such fees or allowances are discounted, waived or rebated. ARTICLE 8 -OTHER DELTA OBLIGATIONS 8.1 Delta shall encourage Delta Dentists to submit a standardized claim form before providing service, showing the patient's dental needs and the treatment necessary in the professional judgment of the Dentist. Delta shall predetermine, from the claim and other data, what would be payable by Delta and an Enrollee for the proposed service under the terms of this plan as of the date of predetermination. Such predetermination shall not constitute a guaranty or authorization of Benefits under this Contract, and any actual payment by Delta will depend upon the patient's eligibility and remaining annual maximum when completed services are reported to Delta. Delta shall advise Delta Dentists to notify the patient of all information provided by Delta in the predetermination. 14 ARTICLE 9 -TERMINATION AND RENEWAL 9.1 This Contract may be terminated for the following causes: (a) By Delta, if the Contractholder fails (1) to give Delta a list of all Primary Enrollees, as required under Article 2, or (2) to permit the inspection of the Contractholder's records as called for under' Article 2,' provided the Contractholder has been duly notified of such failure (and billed for amounts due, if applicable) and at least 15 days have elapsed since the date of notification. (b) By either the Contractholder or Delta, upon expiration of a Contract Term. 9.2 If Delta terminates this Contract under paragraph 9.1 (a), all Benefits end and Delta is released from all further obligations of this Contract, effective the last day of the month in which written notice of termination is given. The Contractholder will remain liable to Delta for the full amount of all Dentist's Statements paid or otherwise discharged by Delta pursuant to this Contract, including claims discharged by Delta pursuant to this paragraph, plus $8.01 per Primary Enrollee per month of such amount as provided in paragraph 3.1, less amounts actually paid by the Contractholder to Delta. 9.3 A party choosing to terminate this Contract at the end of a Contract Term must give at least 30 days written notice of termination to the other party. If Delta wants to change the administration or Benefits effective at the beginning of the next Contract Term, Delta will give at least 60 days advance written notice of such changes to the Contractholder. Such an advance notice will have the effect of a notice of termination as of the end of the Contract Term, unless the Contractholder agrees to the new Contract provisions. 9.4 If the Contractholder notifies Delta in writing of its intention to terminate this Contract as of any date other than the end of the Contract Term, such termination will be treated as termination under paragraph 9.1(a). 9.5 If this Contract is terminated for any cause, Delta is not required to predetermine services beyond the termination date or to pay for services provided after such termination date, except for the completion of Single Procedures begun while this Contract was in effect which are otherwise Benefits under this Contract. 9.6 All Benefits end for all Enrollees, when this Contract ends, and Delta will not provide any right to continuation, renewal or reinstatement of Benefits to such persons in that event. 9.7 Delta must notify the Contractholder in writing of any termination by Delta under paragraph 9.1, and the Contractholder shall promptly mail a copy of such notice to each Primary Enrollee and provide Delta with proof of mailing and the date. 9.8 Open Enrollment Periods will coincide with CalPers open enrollment each year. 16 ARTICLE 10 .,. OPTIONAL CONTINUATION OF COVERAGE 10.1 . The federal Consolidated Omnibus Budget Reconciliation Act (or COBRA, pertaining to certain employers having 20 or more employees) and the California Continuation Benefits Replacement Act (or Cal-COBRA, pertaining to employers with two to 19 employees), both require that continued health care coverage be made available to "Qualified Beneficiaries" who lose health care coverage under the group plan as a result of a "Qualifying Event." Enrollees may be entitled to continue coverage under this plan, at the Qualified Beneficiary's expense, if certain conditions are met. The period of continued coverage depends on the Qualifying Event and whether the Enrollee is covered under federal COBRA or Cal-COBRA. 10.2 DEFINITIONS The meaning of key terms used in this Article are shown below and apply to both federal and Cal-COBRA. Qualified Beneficiary means: 1. Enrollees who are enrolled in the Delta plan on the day before the Qualifying Event, or 2. A child who is born to or placed for adoption with the Primary Enrollee during the period of continued coverage, provided such child is enrolled within 30 days of birth or placement for adoption. Qualifying Event means any of the following events which, except for the election of this continued coverage, would result in a loss of coverage under the dental plan: Event 1: The termination of employment (other than termination for gross misconduct), or the reduction in work hours, by the Primary Enrollee's employer; Event 2: The death of the Primary Enrollee; Event 3: Divorce or legal separation from the Primary Enrollee; Event 4: A dependent child ceaSing to meet the description of dependent child; Event 5: As to dependents only, a Primary Enrollee becoming entitled to Medicare. 10.3 PERIODS OF CONTINUED COVERAGE UNDER FEDERAL COBRA Qualified Beneficiaries may continue coverage for 18 months following the occurrence Qualifying Event 1. This 18-month period can be extended for a total of 29 months, provided: 1. A determination is made under Title II or Title XVI of the Social Security Act that an individual is disabled on the date of the Qualifying Event or became disabled at any time during the first 60 days of continued coverage; and 17 2. Notice of the determination is given to the employer during the initial 18 months of continued coverage and within 60 days of the date of the determination. This period of coverage will end on the first of the month that begins more than 30 days after the date of the final determination that the disabled individual is no longer disabled. The Primary Enrollee must notify the employer/administrator within 30 days of any such determination. If, during the 18-month continuation period resulting from Qualifying Event 1, the Primary Enrollee's Dependents experience Qualifying Events 2, 3, 4 or 5, they may choose to extend coverage for up to a total of 36 months (inclusive of the period continued under Qualifying Event 1). The Primary Enrollee's Dependents may continue coverage for 36 months following the month in which Qualifying Events 2, 3, 40r 5 occur. Under federal COBRA law only, when an employer has filed for bankruptcy under Title II, United States Code, Benefits may be substantially reduced or eliminated for retired employees and their Dependents, or the surviving spouse of a deceased retired employee. If this Benefit reduction or elimination occurs within one year before or one year after the filing, it is considered a Qualifying Event. If the Primary Enrollee is a retiree, and has lost coverage because of this Qualifying Event, he or she may choose to continue coverage until his or her death. The Primary Enrollee's Dependents who have lost coverage because of this Qualifying Event may choose to continue coverage for up to 36 months following the Primary Enrollee's death. lOA PERIODS OF CONTINUED COVERAGE UNDER CAL-COBRA (groups of 2 -19) In the case of Cal-COBRA, Delta will act as the administrator. Notification and premium payments should be made directly to Delta. Notifications and payments should be delivered by first-class mail, certified mail, or other reliable means of delivery. Individuals who are eligible for coverage under the federal COBRA law are not eligible for coverage under Cal-COBRA. The employer must notify Delta in writing within 30 days of the date when the employer becomes subject to COBRA. Qualified Beneficiaries may continue coverage for 36 months following the month in which Qualifying Events 1, 2, 3, 4 or 5 occur. If, during the 36-month continuation period resulting from Qualifying Event 1, the Qualified Beneficiary is determined under Title II or Title XVI of the Social Security Act to be disabled on the date of the Qualifying Event or became disabled at any time during the first 60 days of continuation coverage; and notice of the determination is given to the employer during the initial period of continuation coverage and within 60 days of the date of the social security determination letter, the Qualified Beneficiary may continue coverage for a total of 36 months following the month in which Qualifying Event 1 occurs. This period of coverage will end on the first of the month that begins more than 30 days after the date of the final determination that the disabled individual is no longer disabled. The Qualified Beneficiary must notify the employer or administrator within 30 days of any such determination. 18 5. The individual first obtains coverage for dental benefits, after the date of the election of continued coverage, under another group health plan (as an employee or dependent) which does not contain or apply any exclusion or limitation with respect to any pre-existing condition of such person, if that pre- existing condition is covered under this plan; 6. Entitlement to Medicare. The employer or Primary Enrollee shall notify Delta or the administrator within 30 days of the occurrence of any of the above events. Once continued coverage terminates, it cannot be reinstated. 10.8 TERMINATION OF THE EMPLOYER'S DENTAL CONTRACT If the dental contract between the employer and Delta terminates prior to the time that the continuation coverage would otherwise terminate, the employer shall notify a Qualified Beneficiary (either 30 days prior to the termination or when all Enrollees are notified whichever is later) of that person's ability to elect continuation coverage under the employer's subsequent dental plan, if any. The employer must notify the successor plan of the Qualified Beneficiaries receiving continuation coverage so they may be notified of how to continue coverage under that plan. The continuation coverage will be provided only for the balance of the period that a Qualified Beneficiary would have remained covered under the Delta plan had such plan with the former employer not terminated. The continuation coverage will terminate if a Qualified Beneficiary fails to comply with the reqUirements pertaining to enrollment in, and payment of premium to the new group benefit plan within 30 days of receiving notice of the termination of the Delta plan. 10.9 OPEN ENROLLMENT CHANGE OF COVERAGE A Qualified Beneficiary may elect to change continuation coverage during any subsequent open enrollment period, if the employer has contracted with another plan to provide coverage to its active employees. The continuation coverage under the other plan will be provided only for the balance of the period that a Qualified Beneficiary would have remained covered under the Delta plan. ARTICLE 11-GENERAL PROVISIONS 11.1 No agent has authority to change this Contract or waive any of its provIsions. No change in this Contract is valid unless approved by an executive officer of Delta and included in this Contract by written amendment. 11.2 The provisions of this Contract are severable. If any portion of this Contract or any Amendment of it is determined to be illegal, void or unenforceable by any arbitrator, court or other competent authority, all other provisions of this Contract will remain in effect. 20 APPENDIX B CODE ON DENTAL PROCEDURES AND NOMENCLATURE NOTE: All the listed procedures may not be benefits under the terms of your contract. Refer to your contract for your specific benefits. D0100 -D0999 DIAGNOSTIC Clinical oral evaluations D0120 Periodic oral evaluation D0140 Limited oral evaluation -problem focused D0150 Comprehensive oral evaluation -new or established patient D0160 Detailed and extensive oral evaluation -problem focused, by report D0170 Re-evaluation -limited, problem focused (established patient; not post-operative visit) D0180 Comprehensive periodontal evaluation -new or established patient Radiographs/diagnostic imaging (including interpretation) D02l0 Intraoral -complete series (including bitewings) D0220 Intraoral -periapical first film D0230 Intraoral -periapical each additional film D0240 Intraoral -occlusal film D0250 Extraoral -first film D0260 Extraoral -each additional film D0270 Bitewing -single film D0272 Bitewings -two films D0274 Bitewings -four films D0277 Vertical bitewings - 7 to 8 films D0290 Posterior -anterior or lateral skull and facial bone su'rvey film D03l0 Sialography D0320 Temporomandibular joint arthrogram, including injection D0321 Other temporomandibular joint films, by report D0322 Tomographic survey D0330 Panoramic film D0340 Cephalometric film D0350 Oral/facial photographic images Tests and examinations D04l5 Collection of microorganisms for culture and sensitivity D04l6 Viral culture D0421 Genetic test for susceptibility to oral diseases D0425 Caries susceptibility tests D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures D0460 Pulp vitality tests D0470 Diagnostic casts Oral pathology laboratory D0472 Accession of tissue, gross examination, preparation and transmission of written report D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report 1 Resin-based composite crown, anterior 02390 02391 02392 02393 02394 Resin-based composite -one surface, posterior Resin-based composite -two surfaces, posterior Resin-based composite -three surfaces, posterior Resin-based composite -four or more surfaces, posterior Gold foil restorations 02410 Gold foil -one surface 02420 Gold foil -two surfaces 02430 Gold foil -three surfaces Inlay I onlay restorations 02510 Inlay -metallic -one surface 02520 Inlay -metallic -two surfaces 02530 Inlay -metallic -three or more surfaces 02542 Onlay -metallic -two surfaces 02543 Onlay -metallic -three surfaces~ 02544 Onlay -metallic -four or more surfaces 02610 Inlay -porcelain/ceramic -one surface 02620 Inlay -porcelain/ceramic -two surfaces 02630 Inlay -porcelain/ceramic -three or more surfaces 02642 Onlay -porcelain/ceramic -two surfaces 02643 Onlay -porcelain/ceramic -three surfaces 02644 Onlay -porcelain/ceramic -four or more surfaces 02650 Inlay -resin-based composite -one surface 02651 Inlay -resin-based composite -two sUrfaces 02652 Inlay -resin-based composite -three or more surfaces 02662 Onlay -resin-based composite -two surfaces 02663 Onlay -resin-based composite -three surfaces 02664 Onlay -resin-based composite -four or more surfaces Crowns -single restorations only . 02710 Crown -resin-based composite (indirect) 02712 Crown -3/4 resin-based composite (indirect) 02720 Crown -resin with high noble metal 02721 Crown -res'in with predominantly base metal 02722 Crown -resin with noble metal 02740 Crown -porcelain/ceramic substrate 02750 Crown -porcelain fused to high noble metal 02751 Crown -porcelain fused to predominantly base metal 02752 Crown -porcelain fused to noble metal 02780 Crown -3/4 cast high noble metal 02781 Crown -3/4 cast predominantly base metal 02782 Crown -3/4 cast noble metal 02783 Crown -3/4 porcelain/ceramic 02790 Crown -full cast high noble metal 02791 Crown -full cast predominantly base metal 02792 Crown -full cast noble metal 02794 Crown -titanium 02799 Provisional crown 3 Endodontic retreatment D3346 Retreatment of previous root canal therapy -anterior D3347 Retreatment of previous root canal therapy -bicuspid D3348 Retreatment of previous root canal therapy -molar Apexification/ recalcification procedures D3351 Apexification/recalcification -initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352 Apexification/recalcification -interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) D3353 Apexification/recalcification -final visit (includes completed root canal therapy ...;.. apical closUre/calcific repair of perforations, root resorption, etc.) Apicoectomy/ periradicular services D3410 Apicoectomy/periradicular surgery -anterior D3421 Apicoectomy/periradicular surgery -bicuspid (first root) D3425 Apicoectomy/periradicular surgery -molar (first root) D3426 Apicoectomy/periradicular surgery (each additional root) D3430 Retrograde filling -per root D3~50 Root amputation -per root D3460 Endodontic endosseous implant D3470 Intentional reimplantation (including necessary splinting) Other endodontic procedures D3910 Surgical procedure for isolation of tooth with rubber dam D3920 Hemisection (including any root removal), not including root canal therapy D3950 Canal preparation and fitting of preformed dowel or post D3999 Unspecified endodontic procedure, by report 04000 -04999 PERIODONTICS Surgical services (including usual post-operative care) D4210 Gingivectomy or gingivoplasty -four or more contiguous teeth or bounded teeth spaces per quadrant D4211 Gingivectomy or gingivoplasty -one to three contiguous teeth or bounded teeth spaces per quadrant D4240 Gingival flap procedure, including root planing -four or more contiguous teeth or bounded teeth spaces per quadrant D4241 Gingival flap procedure, including root planing -one to three contiguous teeth or D4245 D4249 D4260 bounded teeth spaces per quadrant Apically positioned flap Clinical crown lengthening -hard tissue Osseous surgery (including flap entry and closure) -'-four or more contiguous teeth or bounded teeth spaces per quadrant D4261 Osseous surgery (including flap entry and closure) -one to three contiguous teeth or D4263 D4264 D4265 D4266 D4267 D4268 D4270 D4271 bounded teeth spaces per quadrant Bone replacement graft -first site in quadrant Bone replacement graft -each additional site in quadrant Biologic materials to aid in soft and osseous tissue regeneration Guided tissue regeneration -resorbable barrier, per site Guided tissue regeneration -nonresorbable barrier, per site (includes membrane removal) Surgical revision procedure, per tooth Pedicle soft tissue graft procedure Free soft tissue graft procedure (including donor site surgery) 5 D6070 Autment supported retainer for porcelain fused to metal FPD (predominantly base metal) D6071 Autment supported retainer for porcelain fused to metal FPD (noble metal) D6072 Abutment supported retainer for cast metal FPD (high noble metal) D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) D6074 Abutment supported retainer for cast metal FPD (noble metal) D6075 Implant supported retainer for ceramic FPD D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) D6078 Implant/abutment supported fixed denture for completely edentulous arch D6079 Implant/abutment supported fixed denture for partially edentulous arch Other implant services D6080 Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis D6090 Repair implant supported prosthesis, by report D6094 Abutment supported crown -(titanium) D6095 Repair implant abutment, by report D6100 Implant removal, by report D6190 Radiographic/surgical implant index, by report D6194 Abutment supported retainer crown for FPD -(titanium) D6199 Unspecified implant procedure, by report 06200 -06999 PROSTHODONTICS, FIXED (Each retainer .andeach pontic constitutes a unit in a fixed partial denture) Fixed partial denture pontics D6205 Pontic -indirect resin based composite D6210 Pontic -cast high noble metal D6211 Pontic -cast predominantly base metal D6212 Pontic -cast noble metal D6214 Pontic -titanium D6240 Pontic -porcelain fused to high noble metal D6241 Pontic -porcelain fused to predominantly base metal D6242 pontic -porcelain fused to noble metal D6245 Pontic -porcelain/ceramic D6250 Pontic -resin with high noble metal D6251 Pontic -resin with predominantly base metal D6252 Pontic -resin with noble metal D6253 Provisional pontic Fixed partial denture retainers -iniaysl onlays D6545 Retainer -cast metal for resin bonded fixed prosthesis D6548 Retainer -porcelain/ceramic for resin bonded fixed prosthesis D6600 Inlay -porcelain/ceramic, two surfaces D6601 Inlay -porcelain/ceramic, three or more surfaces D6602 Inlay -cast high metal, two surfaces D6E?03 Inlay -cast high metal, three or more surfaces D6604 Inlay -cast predominantly base metal, two surfaces D6605 Inlay -cast predominantly base metal, three or more surfaces D6606 Inlay -cast noble metal, two surfaces D6607 Inlay -cast noble metal, three or more surfaces D6608 Onlay -porcelain/ceramic, two surfaces 9 07856 Myctcmy 07858 Jcint reccnstructicn 07860 Arthrctcmy 07865 Arthroplasty 07870 Arthrccentesis 07871 Ncn-arthrosccpic lysis and lavage 07872 Arthrcsccpy -diagncsis, with .or withcut bicpsy 07873 Arthrcsccpy -surgical: lavage and lysis .of adhesicns 07874 Arthrcsccpy -surgical: disc repcsiticning and stabilizaticn 07875 Arthrcsccpy -surgical: syncvectcmy 07876 Arthrcsccpy -surgical: discectcmy 07877 Arthrosccpy -surgical: debridement 07880 Occlusal crthctic device, by repcrt 07899 Unspecified TMO therapy, by repcrt Repair of traumatic wounds 07910 Suture .of recent small wcunds up tc 5 cm Complicated suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure) 07911 Ccmplicated suture -up tc 5 cm 07912 Ccmplicated suture -greater than 5 cm Other repair procedures 07920 Skin graft (identify defect ccvered, Iccaticn and type .of graft) 07940 Ostecplasty -fcr crthcgnathic defcrmities 07941 Ostectcmy -mandibular rami 07943 Ostectcmy -mandibular rami with bcne graft; includes .obtaining the graft 07944 Ostectcmy -segmented .or subapical -per sextant .or quadrant 07945 Ostectcmy -bcdy cfmandible 07946 LeFcrt I (maxilla -tctal) 07947 LeFcrt I (maxilla -segmented) 07948 LeFcrt II .or LeFcrt III (cstecplasty .of facial bcnes fcr midface hypcplasia .or retrusicn) -with cut bcne graft 07949 LeFcrt II .or LeFcrt III -with bcne graft 07950 Ossecus, cstecpericsteal, .or cartilage graft .of the mandible .or facial bcnes - 07953 07955 07960 07963 07970 07971 07972 07980 07981 07982 07983 07990 07991 07995 07996 07997 07999 autcgencus .or ncnautcgencus, by repcrt Bcne replacement graft f.or ridge preservaticn -per site Repair .of maxillcfacial scft and/cr hard tissue defect Frenulectcmy (frenectcmy .or frenct.omy) -separate prccedure Frenulcplasty Excisicn .of hyperplastic tissue -per arch Excisicn .of periccronal gingiva· Surgical reducticn .of fibrcus tubercsity Sialclith.otcmy Excisicn .of salivary gland, by repcrt Sialcdcchcplasty Clcsure .of salivary fistula Emergency trachectcmy . Ccrcncidectcmy Synthetic graft -mandible .or facial bcnes, by rep.ort Implant -mandible fcr augmentati.on purpcses (excluding alveclar ridge), by repcrt Appliance remcval (nct by dentist whc placed appliance), includes remcval .of archbar Unspecified .oral surgery procedure, by repcrt 13 Professional visits 09410 House/extended care facility call 09420 Hospital call 09430 Office visit for observation (during regularly scheduled hours) performed 09440 Office visit -after regularly scheduled hours 09450 Case presentation, detailed and extensive treatment planning Drugs 09610 Therapeutic drug injection, by report 09630 Other drugs and/or medicaments, by report Miscellaneous services 09910 Application of desensitizing medicament no other services 09911 Application of desensitizing resin for cervical and/or root surface, per tooth 09920 Behavior management, by report 09930 Treatment of complications (post-surgical) -unusual circumstances, by report 09940 Occlusal guard, by report 09941 Fabrication of athletic mouthguard 09942 Repair and/or reline of occlusal guard 09950 Occlusion analysis -mounted case 09951 Occlusal adjustment -limited 09952 Occlusal adjustment -complete 09970 Enamel microabrasion 09971 Odontoplasty 1,..2 teeth; includes removal of enamel projections 09972 External bleaching -per arch 09973 External bleaching -per tooth 09974 Internal bleaching -per tooth 09999 Unspecified adjunctive procedure, by report Note: This Appendix represents codes and nomenclature excerpted from the version of Current Dental Terminology (COT) in effect at the date of this printing. COT coding and nomenclature are the copyright of the American Dental Association, and have been accepted as the standard for data transmission purposes under federal Aqministrative Simplification regulations. For the purposes of this Appendix, Delta's administration of Benefits, Limitations and Exclusions under this Contract will at all times be based on the then-current version of COT whether or not a revised Appendix B is provided. Notes in italic type have been added by Delta Dental for clarification. 15 III. CONTRACTHOLDER RESPONSIBILITIES A. Contractholder is responsible for the delivery and accuracy of all Enrollee eligibility that it, or its employee(s), provide(s) to Delta pursuant to this Agreement. Any errors or delays shall be adjusted as set forth in Article 3 of the Contract. Contractholder is responsible for any and all hardware, software, or any other equipment, application or transmission capability to access the Delta website. Contractholder shall be responsible for the selection of its Internet access provider (lAP) or Internet service provider (ISP) and shall hold Delta, and its computer processing subsidiary, Deltanet, Inc. (Deltanet), harmless for any and all transmission or update delays, failures or errors caused by Contractholder's acts or omissions or caused by the ISP's acts or omissions. B. Contractholder agrees, and shall require its employees to agree, to strictly maintain the confidentiality of the logon ides) and password(s) and to provide them only to those employees who will transmit or update Enrollee eligibility pursuant to this Agreement. Delta will provide a logon id and password that is specific to each Contractholder employee who will be permitted to update eligibility through this web access. Contractholder and each such employee may not transfer a logon id or password to another employee. Contractholder agrees to hold Delta and Deltanet, harmless for any and all potential breaches of (:onfidentiality resulting from or arising out of the transmission or update of Enrollee eligibility information through Internet connections. Contractholder shall indemnify Delta and Deltanet from and against any liability 'or loss Delta or Deltanet may incur by reason of any covenant, condition or warranty contained in the Contract relating to confidentiality or the interception of transmission over the Internet by unknown third parties except for any such breach caused by Delta's or Deltanet's error or omission. C. Contractholder agrees to install and implement any desktop upgrades and/or configuration changes necessary to continue to update Enrollee eligibility information pursuant to this Agreement. IV. DELTA RESPONSIBILITIES A. Upon receipt of the Executed Agreement, Delta will provide the logon ides) and password(s) necessary for Contractholder to access the eligibility update section of Delta's website. B. Delta will provide Contractholder with a description of a standard desktop configuration that Contractholder must utilize to access, transmit and update eligibility information to Delta through Delta's website. In no event shall Delta be responsible to provide Contractholder with any hardware, software, ISP or any other equipment, application or transmission capability. C. Delta shall not be liable to Contr'actholder for any indirect, special, incidental, exemplary or consequential damages (including, without limitation, lost profits) related to this Agreement or resulting from Contractholder's access to or inability to access Delta's website, or the eligibility update section of the website, arising from any cause of action whatsoever, including contract, tort, warranty, strict liability, or negligence, even if Delta has been notified of the possibility of such damages. 2 APPENDIX D HIPAA BUSINESS ASSOCIATE AGREEMENT: GROUP HEALTH PLAN CITY OF PALO ALTO DELTA GROUP #2795 RECITALS Whereas, the administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and related regulations require that contracts between covered entities and entities known as business associates comply with enumerated standards and requirements; Whereas, the Contractholder executes this Business Associate Agreement on behalf of the Group Health Plan; . Whereas, Delta's administration of the group dental program makes Delta a business associate of the Group Health Plan as described or defined under HIPAA; Whereas, the purpose of this Business Associate Appendix is to satisfy the HIPAA standards and requirements; Now therefore, in consideration of the mutual promises below, the Contractholder, the Group Health Plan and Delta agree as follows: SECTION 1 -DEFINITIONS 1.1 "HIPAA" shall mean the administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and related regulations, Title 45 Parts 160 and 164 of the Code of Federal Regulations, as amended from time to time. 1.2 "Protected Health Information" (PHI) shall have the same meaning as defined in HIPAA and shall apply to those individuals who are eligible and/or enrolled in the Group Health Plan's dental benefit program administered by Delta. 1.3 Terms used, but not otherwise defined, in this Business Associate Appendix shall have the same meaning qS those terms have in HIPAA. SECTION 2 -BUSINESS ASSOCIATE AGREEMENT 2.1 The provisions of this Section 2 control over any provision in this Contract that conflicts with this Section 2. 1 e. Contractholder's Uses and Disclosures :Contractholder shall use and disclose PHI only in compliance with HIPAA and for the purpose of providing plan administration functions to the Group Health Plan. Plan administrative functions are defined as administration functions performed by the plan sponsor of a group health plan on behalf of the group health plan and excludes functions performed by the plan sponsor in connection with any other benefit or benefit plan of the plan sponsor. 2.3 Appropriate Safeguards. Delta agrees to use appropriate safeguards to prevent its use or disclosure of PHI other than as provided for by this Business Associate Appendix. 2.4 Mitigation. Delta agrees to mitigate, to the extent practicable, any harmful effect that is known to Delta of a use or disclosure of PHI by Delta in violation of the requirements of this Business Associate Appendix. 2.5 Reporting of Disclosures of PHI. As soon as practical after discovery, Delta shall report to the Group Health Plan, or its designate, any use or disclosure of PHI by Delta not provided for in this Business Associate Appel1dix of which Delta becomes aware. 2.6 Agents and Contractors. Delta shall ensure that any Delta agent or subcontractor to whom Delta discloses PHI agrees, in writing, to be bound by the same restrictions and conditions that apply to Delta through this Business Associate Appendix. 2.7 Access to and Availability of PHI. Delta shall, in accordance with HIPAA and as appropriate: a. Provide access to . the requested PHI within Delta's or its agent's or subcontractor's possession. The Group Health Plan shall as soon as practicable forward to Delta any requests the Group Health Plan receives from the individual. Delta shall be responsible for responding to the Group Health Plan or individual who sent the request to Delta. If the response is to be sent to the ,Group Health Plan, Delta shall send the PHI to the Group Health Plan within 15 days of Delta's receipt of the request. b. Amend, notify appropriate recipients of any amendment, and incorporate any amendment to the requested PHI within Delta's possession or its agent's or subcontractor's. The Group Health Plan shall as soon as practicable forward to Delta any requests the Group Health Plan receives from the individual. Delta shall be responsible for responding to the Group Health Plan or individual who sent the request to Delta. If the response is to be sent to the Group Health Plan, Delta shall send the response to the Group Health Plan within 45 days of Delta's receipt of the request. c. Provide an accounting of ·disclosures of PHI as required by HIPAA. The Group Health Plan shall as soon as practicable forward to Delta any requests the Group Health Plan receives from the individual. Delta shall be responsible for responding to the Group Health Plan or individual who sent the request to Delta. Delta agrees to track, and request that its agents or subcontractors track, all such disclosures of PHI that would be required to respond to a request for accounting of disclosures of PHI as required by HIPAA. If the response is to be sent to the Group Health Plan, Delta shall send the accounting to the Group Health Plan within 45 days of Delta's receipt of the request. 3 c. In the event of any termination of this Business Associate Appendix, Delta shall return or destroy all PHI that Delta still maintains in any form and shall retain no copies. If return or destruction is not feasible because such PHI is necessary to fulfill Delta's legal responsibilities or other management and administrative purposes, Delta shall retain the PHI and shall continue to protect the confidentiality of PHI as required by this Business Associate Appendix. Delta shall limit any use or disclosure of PHI to those purposes that make the return or destruction of PHI infeasible. Delta agrees to require that any PHI in the possession of its agents or subcontractors retained, returned or destroyed, as applicable. d. The following sections shall survive termination of this Agreement: 2.7, 2.8, 2.10, 5.2 and 5.3. 2.11 Notice of Privacy Practices. The Contractholder represents and warrants that the Group Health Plan's notice of privacy practices shall not, subject to HIPAA's requirement, limit or restrict Delta's use or disclosure of PHI as necessary for Delta to perform the services described in the Contract. 2.12 Security Rule Provisions. Delta will comply with the following provisions by April 21, 2005, or such other applicable compliance date. For purposes of this section, "electronic protected health information" (ePHI) shall have the same meaning as defined in HIPAA and shall apply to those individuals who are eligible and/or enrolled in the Group Health Pian's dental benefit program administered by Delta. a. Delta shall implement administrative, physical, and technical safeguards that reasonably and. appropriately protect ·the confidentiality, ·integrity, and availability of the ePHI that it creates, receives, maintains, or transmits on behalf of the Group Health Plan. b. Delta shall ensure that any agent, including a subcontractor, to whom Delta provides ePHI agrees to implement reasonable and appropriate safeguards to protect ePHI. c. As soon as practical after discovery, Delta shall report to the Group Health Plan any Security Incident of which Delta becomes aware. d. Delta agrees to authorize termination of this Business Associate Appendix and the Contract as described in Section 2.11, above, by the Sponsor/Contractholder if the Sponsor/Contractholderhas knowledge that Delta has violated a material term of this Business Associate Appendix. SECTION 3 -DISCLOSURE TO PLAN CONTRACTHOLDER This Section 3 applies if the Contractholder will receive non~enrollment PHI and if this Contract is the group health plan document that must be amended to permit disclosure of non- enrollment PHI to the Contractholder. 3.1 Amendment of the Contract. Delta and Contractholder agree to amend this Contract as set forth in this section to allow the Group Health Plan and/or Delta to disclose non- enrollment PHI to the Contractholder. 5 c. Agents and Subcontractors. Contractholder shall ensure that any agent or subcontractor that will have access to PHI from Contractholder agrees to be bound by the same restrictions, terms and conditions that apply to Sponsor/Contractholder pursuant to this Business Associate Appendix. d. Employment-Related Actions and Decisions. The Contractholder shall not use or disclose PHI for employment-related actions or decisions or in connection with any other benefit plan of the Sponsor/Contractholder. e. Reporting of Disclosures of PHI. Contractholder shall, as soon as possible after becoming aware of an actual or suspected disclosure of PHI in violation of this Business Associate Appendix by Sponsor/Contractholder, its officers, directors, employees, subcontractors or agents or by a third party to which Sponsor/Contractholder disclosed PHI pursuant to this Business Associate Appendix, report any such disclosure to the Group Health Plan. f. Access to and Availability of PHI. Contractholder shall timely and in compliance with HIPAA requirements: i. Make available to the Group Health Plan or Delta, as appropriate, the requested PHI to respond to an individual's request for access to PHI. ii. Provide to the Group Health Plan or Delta, as appropriate, the requested PHI to respond to a request for amendment and shall incorporate any amendment received from the Group Health Plan or Delta. iii. Make available to the Group Health Plan or Delta, as appropriate, the requested PHI to respond to an individual's request for an accounting of disclosures of PHI. The Sponsor/Contractholder agrees to track all disclosures of PHI that would be required to respond to a request for accounting of disclosures of PHI as required by HIPAA. g. Availability of Contractholder's Internal Practices, Books and Records. Contractholder agrees to make its internal practices, books and records relating to the use and disclosure of PHI received from the Group Health Plan or Delta available to the Secretary of Health and Human Services for purposes of determining the Group Health Plan's and Contractholder's compliance with the HIPAA privacy standards. h. Return or Destruction of PHI. Contractholder shall return or destroy all PHI received from the Group Health Plan or its agent that the Contractholder maintains in any form and shall retain no copies when such PHI is no longer needed for the purpose for which the disclosure was made. If return or destruction is not feasible, Contractholder shall continue to protect the confidentiality of PHI as required by this Business Associate Appendix and limit any use or disclosure of PHI to those purposes that make the return or destruction of PHI infeasible. 7 SECTION 5 -GENERAL 5.1 Amendment to Business Associate Appendix. Contractholder and Delta agree to amend this Business Associate Appendix as necessary to comply with federal or state laws or regulations relating to the administrative simplification provisions of HIPAA. 5.2 Indemnification by Delta. Delta agrees to indemnify, defend and hold harmless the Group Health Plan, or the Contractholder on the Group Health Pian's behalf, and their employees, directors, officers, subcontractors, agents or other members of its workforce~ each of the foregoing hereinafter referred to as "Indemnified Party," against all actual and direct losses suffered by the Indemnified Party and all liability to third parties arising from or in connection with Delta's breach of sections 2 or 3 of this Business Associate Appendix. Accordingly, on demand, Delta shall reimburse any Indemnified Party for any and all actual and direct losses, liabilities, fines, penalties, costs or expenses (including reasonable attorneys' fees) which may for any reason be imposed upon any Indemnified Party by reason of any suit, claim, action, proceeding or demand by any third party which results from Delta's breach hereunder. Delta's obligation to indemnify any Indemnified Party shall survive the expiration or termination of this Business Associate Appendix for any reason. 5.3 Indemnification by Group Health Plan or Sponsor/Contractholder. The Group Health Plan, or the Contractholder on the Group Health Plan's behalf, agrees to indemnify, defend and hold harmless Delta and its employees, directors, officers, subcontractors, agents or other members of its workforce, each of the foregoing hereinafter referred to as "Indemnified Party," against all actual and direct losses suffered by the Indemnified Party and all liability to third parties arising from or in connection with the Group Health Pian's or Sponsor/Contractholder's breach of Sections 2, 3 or 4 of this Business Associate Appendix. Accordingly, on demand, the Group Health Plan or Sponsor/Contractholder shall reimburse any Indemnified Party for any and all actual and direct losses, liabilities, fines, penalties, costs or expenses (including reasonable attorneys' fees) which may for any reason be imposed upon any Indemnified Party by reason of any suit, claim, action, proceeding or demand by any third party which results from the Group Health Plan's or Contractholder's breach hereunder. The obligation to indemnify any Indemnified Party Shall survive. the expiration or termination of this Business Associate Appendix for any reason. 5.4 Interpretation. This Business Associate Appendix shall be interpreted to allow the parties to comply with HIPAA, provided, however, that nothing herein shall be construed to grant rights beyond those provided under HIPAA or applicable law. 5.5 No Third Party Beneficiary. Nothing express or implied in this Business Associate Appendix is intended to confer, nor shall anything in this Business Associate Appendix confer, upon any person other than the parties to this Business Associate Appendix and their respective successors and aSSigns, any rights, remedies, obligations or liabilities whatsoever. 9 , . , J