Loading...
HomeMy WebLinkAbout18. 17-502 OCTOBER 10, 2017 17-502 RESOLUTION (CARRIED 6-0 LOST LAID OVER WITHDRAWN ) PURPOSE: APPROVE EMPLOYEE HEALTH INSURANCE AGREEMENT WITH ANTHEM BLUECROSS BLUESHIELD AND DENTAL INSURANCE AGREEMENT WITH DELTA DENTAL OF WISCONSIN INITIATED BY: ADMINISTRATIVE SERVICES WHEREAS, the City of Oshkosh requested proposals for Employee Health Insurance for 2018; and WHEREAS, the proposal submitted by Anthem B1ueCross B1ueShield meets the requirements of the request for proposals, will allow the City of Oshkosh to realize cost savings over the current City plan, and provide the least disruption to our employee population provider relationships; and WHEREAS, Delta Dental of Wisconsin offers the most advantageous Dental plan to meet the City's requirements. NOW, THEREFORE, BE IT RESOLVED by the Common Council of the City of Oshkosh that the proper City officials are hereby authorized to enter into and take those steps necessary to implement an appropriate agreement with Anthem B1ueCross B1ueShield for participation in the Anthem B1ueCross B1ueShield health benefit plan in substantially the same form as the attached sample agreement, any changes in the execution copy being deemed approved by their signatures. BE IT FURTHER RESOLVED that the proper City officials are hereby authorized to enter into and take those steps necessary to implement an appropriate agreement with Delta Dental of Wisconsin for participation in the Delta Dental of Wisconsin dental plan in substantially the same form as the attached sample agreement and endorsements, any changes in the execution copy being deemed approved by their signatures. BE IT FURTHER RESOLVED that money for this purpose is hereby appropriated from: Acct. No. XXX-XXXX-6306-XXXXX Health Insurance XXX-XXXX-6308-XXXXX Dental Insurance TO: Honorable Mayor and Members of the Common Council FROM: John Fitzpatrick, Assistant City Manager/Director of Administrative Services DATE: October 5, 2017 RE: Employee Health and Dental Insurance Agreements BACKGROUND As Council is aware, through your direction and as a matter of good practice, the City regularly reviews our contract agreements and benefit structures in order to provide the best benefits possible for our staff at the most cost effective level possible for our taxpayers. With these thoughts in mind, and in consideration of the expiration of our agreements with Wisconsin Counties Association (WCA)/Group Health Trust (GHT) and Delta Dental of Wisconsin at the end of 2017, city staff and Associated Benefits Risk and Consulting (ABRC) have been taking the appropriate steps to establish relationships with providers for health and dental benefits for 2018. ANALYSIS After evaluating current medical plan costs the decision was made to conduct a comprehensive request for proposals (RFP). The outcome of the RFP and the corresponding analysis resulted in a significant financial savings by moving from WCA/GHT to Anthem Blue Cross Blue Shield. In addition to reducing the projected budget increase for health insurance we discussed with Council in Budget Workshop #1 from an 8% increase to a 4.6% decrease, the move to Anthem Blue Cross Blue Shield also provides the least disruption to our employees in regard to the providers they currently had established relationships with, through WCA/GHT. The dental plan was also assessed and the vendor with the most effective plan for the City continues to be our current provider, Delta Dental of Wisconsin. The projected increase for dental services in 2018 is 4%. Anthem and Delta agreements/applications are for 2018 only. FISCAL IMPACT Staff is estimating an approximate savings of $391,128 for our combined health / dental programs in 2018. Although the city employee focus group on health insurance, staff and City Manager Rohloff are pleased with the outcome of this year's process, all parties understand that it will be necessary to evaluate our plan in 2018 due to the one year agreement in order to consider what changes may be necessary in order to preserve the best benefits possible for our staff at the most cost effective level possible for our taxpayers moving forward. RECOMMENDATION Based on the analysis conducted, staff recommends approval of the aforementioned employee health and dental insurance agreements with Anthem B1ueCross B1ueShield and Delta Dental of Wisconsin. Please let me know if you have any questions regarding this matter and thank you as always for your assistance and support. Respectfully Submitted, John M. Fitzpatrick Assistant City Manager / Director of Administrative Services Attachments: Health Insurance RFP Summary Approved: Mark A. Rohloff City Manager Anthem Health Insurance Sample Group Contract Delta Dental Group of Wisconsin Declaration Page & Contract Delta Dental Group of Wisconsin 2018 Declaration Page cc: Pam Resch, HR Manager W City of Oshkosh HEALTH COVERAGE ALTERNATIVES Effective: January 1, 2018 Carrier L GHT �neiwork LIGHT Anthem, :,: ' m.- ��health Current / Rr.r-I Current I Rr.rwal Option I -As r Provide Network/Plan Type Transit All Other Em to ees Transit A110ther Lurelo, eesTransit All OlherEm to ees Provide Network/Plan Type UHC Choice Plr�: UHC Choice Plus POS POS Well Priori CIC Well Priori CIC Dedudible In -Network (Single / Family) $0/$0/$0 $500 / $1,000 $0/$0 $500 / $1,000 $0/$0 $500 / $1,000 Out -of -Network (Single / Family) $600 / $1,200 / $1,800 $1,000 / $2,000 $600 / $1,800 $1,000 / $2,000 $600 / $1,200 $1,000 / $2,000 C.i.s. In -Network 100% 80% 100% 80% 100% 80% Out -of -Network 75% 60% 75% 60% 80% 60% Outof-PoekdMax I Ludes Deductible I Ludes Deductible I Ludes Deductible Includes Deductible Includes Deductible Includes Deductible In -Network (Single / Family) $4,000 / $8,000 / $8,000 $3,000 / $6,000 $4,000 / $8,000 $3,000 / $6,000 $4,000 / $8,000 $3,000 / $6,000 Out -of -Network (Single / Family) Unlimited Unlimited $8,000 / $16,000 $6,000 / $12,000 $8,000 / $16,000 $6,000 / $12,000 Lifetime Maximum Unlimited Unlimited Unlhnitsd Unlimited Unlimited Unlimited Office Visits In -Network $20 Cop ty Ded, 80% Coins $20 Copay Ded, 80% Coins $20 Copay Ded, 80% Coins Out -of -Network Ded, 75% Coins Ded, 60% Coins Ded, 75% Coins Ded, 60% Coins Ded, 80% Coins Ded, 60% Coins Sped a !at In -Network $20 Copay Ded, 80% Coins $20 Copay Ded, 80% Coins $20 Copay Ded, 80% Coins Out -of -Network Ded, 75% Coins Ded, 60% Coins De& 75% Coins De& 60% Coins Ded, 80% Coins Ded, 60%Coins RoutfnePreventtve Care In -Network 100% Coverage 100% Coverage 100% Coverage 100% Coverage 100% Coverage 100% Coverage Out -of -Network Ded, 75% Coins Ded, 60% Coins Ded, 75% Coins Ded 60% Coins Ded, 80% Coins Derl. 60% Coins Inpatient Hospital Services In -Network $300 Copay, 100% Coins Ded, 80% Coins $300 Copay Ded, 80% Coins $300 Copay Ded, 80% Coins Out -of -Network Ded, 75% Coins Ded, 60% Coins Dee, 75% Coins De& 60% Coins Ded, 80% Coins Ded, 60% Coins Outpatient Hospital Services In -Network $150 Copay, 100% Coins Ded, 80% Coins Ded, 80% Coins $150 Copay Ded, 80% Coins Out -of -Network Ded, 75% Coins Ded, 60% Coins Ded 60% Coins Ded 80% Coins Ded 60% Coins Urgent Care In -Network $20 Copay, 100% Coins Ded, 80% Coins $75 Copay Ded, 80% Coins $20 Copay Ded, 80% Coins Out -of -Network Ded, 75% Coins Ded, 60% Coins De& 75% Com, De& 60% Coins Ded 80% Coins Ded 60% Coins Emergency Room In -Network $100 Copay, 100% Coins $150 Copay, Ded, 80% Coins $100 Copay $150 Copay, Ded, 80% Coins $100 Copay $150 Copay, 80% Coins Out -of -Network $100 Copay, 100% Coins $150 Copay, Ded, 80% Coins $100 Co $150 Copay, Ded,80% Coins $100 Co $150 Copay, 80% Coins Prescription Drugs -In -Network $2,3501$4,700MOOP Rx $4,750/$8,300 MOOPRx Ties I/Tier2/Tier3 $0/$5/$30/$60 $0/$10/$30/$60 $0/$10/$25/$50/$50/$80 $0/$10/$25/$50/$50/$80 $5/$30/$60 $10/$30/$60 Mail Order Prescription Drugs Tier l/Tier 2/Tier 3 $0/$10/$60/$120 $0/$20/$60/$120 $0/$25/$60/$150 $0/$25/$60/$150 $10/$60/$120 $20/$60/$120 Rates Plan 1 Plan 2 Tmtal Current enewal Currmt Renewal Option 1 Option 2 Employee 7 113 120 $815.40 937.71 $739.90 $850.89 $774.63 $702.91 $777.73 $705.72 Employee+1 4 91 95 $1,630.80 ,875.42 $1,479.80 $1,701.77 $1,549.26 $1,405.81 $1,555.46 $1,411.43 Family 11 256 267 $2,039.04 ,344.90 ;$478,314.60 $1,850.24 $2,127.78 $1,937.09 $1,757.73 $1,944.84 $1,764.76 Monthly Totals $34 660.44 859.55 $691,931-94 $795,722.76 $32,927.44 $657,336.42 S33,059.19 $659,965.05 Arcual Totals $415,925.28 $8,303,183.28 $9,548,673.06 $395,129.28 $7,888,037.04 $396,710.28 $7,919,580.60 Combined Plan Totals $8,719,108.56 $10,026,987.66 $8,283,166.32 $8,316,290.88 Arcual % of IncreaseDecri 15.0% -5.0% 4.6% Annual Dollar Increase/Der $1,307,879.10 ($435,942.24) ($402,817.68) EMPLOYEE Preminm (12%) Car rmt Renewal Currmt Renewal Option 1 Option 2 Employm $97.85 $112.53 $88.79 $102.11 $92.96 $54.35 $93.33 $84.69 Employee+1 $195.70 $225.05 $177.58 $204.21 $185.91 $168.70 $186.66 $169.37 Famil $244.68 $281.39 $222.03 $255.33 $232.45 $210.93 $233.38 $211.77 Ou�ite Clinic Clinic funding o£$200,000, $20k Wellness Credit & HRAs 12% Rate Cap / Clinic funding of $190,000 Clinic funding of $200,000 & $20k Wellness Credit NOTE: Final rates sabj ect to medical avderwrifivg. NOTE: Company. logos are for ivformafion Fnnposes oily. Agents me independent aid am sot affifiatm with the company. NOTE: This benefit compacts® will sot replace the benefit gid that is fiunished by Network Health Plan/Network Health Insarance Capomtiov aid approved by the Office .Ether Commissioner of Insurance. Ori atmulm•d ofcare and legal drily to the insured in providing irrsurance products mrd services is to follow the instructions of the insured in good faith Thia mvsfihrtea onlyasummary .Ether Health plan involved The acNal covhact or play document mast lie covsalted todetermivethe govemivg covhacNal provisiove,fimitatiove, or exclasiova There is vo guarevtee, expressed orimpfied by Associated Benefits aid Risk Covsulfivg or vevdere of play provieiove arz4i17 5OOppveght@2017A,,o.I,dF...a�G..p,LLCCAFG)A,,o.t,dB®,fil.dR�,kCo.,Wl.g�,zmark,I.g.,.,,dbyAFG. GAFK 9 , ­scbotocttost:re­o1Ra 0tte_np­517 Anthem® B1ueCross B1ueShield Group Contract This Group Contract ("Contract") is entered into by and between ("Employer") and [OPT — PPO Blue Cross Blue Shield of Wisconsin] [OPT — HMO Compcare Health Services Insurance Corporation] [OPT — ALL POS Compcare Health Services Insurance corporation and Blue Cross and Blue Shield of Wisconsin, which are severally liable for the benefits offered under the Booklet] d/b/a Anthem Blue Cross and Blue Shield ("Anthem") (Employer or Anthem individually referred to as "Parry" and together collectively referred to as the "Parties") upon the following terms and conditions: ARTICLE 1— PURPOSE Employer has requested Anthem provide health insurance coverage to its eligible Employees or other individuals as described in the Booklet. Upon Anthem's receipt and acceptance of Employer's signed application and payment of the first premium, this Contract will be deemed executed by Employer. This Contract supersedes any prior agreements between the Parties regarding the subject matter of this Contract. Anthem's standard policies and procedures, as they may be amended from time to time, will be used in the performance of services specified in this Contract and the provision of benefits contained in the Booklet. ARTICLE 2 — DEFINITIONS In this Contract, the following terms will have the meanings shown below. Capitalized terms used in this Contract that are not defined below are defined in the Booklet. A. Anniversary Date. The date indicated in Schedule A that this Contract will renew. B. Booklet. The Certificate of Coverage that describes the medical or other health care benefits provided by Anthem, including any amendments or schedules. C. Contract. The entire agreement between the Parties including: (1) this Contract and any amendments and schedules; (2) the Booklet and any amendments; (3) the Employer application; and, (4) any individual enrollment information, as each may be updated from time to time. PPo Blue Cross Blue Shield of Wisconsin, d/b/a Anthem Blue Cross and Blue Shield Independent licensee of the Blue Cross and Blue Shield Association. HMO Compcare Health Services Insurance Corporation, d/b/a Anthem Blue Cross and Blue Shield. Independent licensee of the Blue Cross and Blue Shield Association. POS Compcare Health Services Insurance Corporation and Blue Cross and Blue Shield of Wisconsin, d/b/a Anthem Blue Cross and Blue Shield. Independent licensee of the Blue Cross and Blue Shield Association. Use this at the end on all 3 OANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. WIGC2013 1 04252013 D. Employee. Actively employed individuals, owners, partners or other individuals designated by Employer who meet the eligibility criteria in the Booklet and any additional eligibility criteria indicated on Schedule A. These individuals must complete any probationary period required by Employer and satisfy Anthem's underwriting rules, consistent with applicable laws. Retirees are also eligible for coverage under this Contract, if indicated on Schedule A. E. Group Health Plan or Plan. A benefits plan established by the Employer as described in the plan documents, which includes the Booklet. F. Member. An individual, including the Subscriber and any dependents, that meets the eligibility criteria and has enrolled for coverage under this Contract. G. Subscriber. An Employee that meets the eligibility criteria and has enrolled for coverage under this Contract. ARTICLE 3 — OBLIGATIONS OF ANTHEM A. Anthem will provide medical or other health care benefits under the terms of this Contract and the Booklet. Anthem will not provide benefits for health care services provided: (1) before a Member's first day of coverage under this Contract; (2) after the termination of coverage; or, (3) during any period that full premium has not been paid, except as required by law. B. Anthem will provide either electronic or paper copy of materials such as Booklets, ID cards and provider directories, as permitted under applicable law. Employer will assist in the distribution of materials if requested by Anthem. Anthem will provide paper copies of electronic materials, upon request. C. Anthem will process the enrollment of eligible individuals, subject to the terms of this Contract and receipt of applicable premium. Anthem will maintain current Member eligibility information submitted by Employer. D. Anthem will process claims, including investigating and reviewing the claims to determine what amount, if any, is due and payable according to the terms and conditions of this Contract and the Booklet. Anthem has the right to make benefit payments to either Providers or Members as described in the Booklet. Anthem will coordinate benefits with other payors, including Medicare. Anthem will give notice in writing when a claim for benefits has been denied. The notice will provide the reasons for the denial and the right to an appeal of the denial under the terms of the Booklet. E. Anthem is responsible for pursuing recoveries of claim payments as appropriate. Anthem shall determine which recoveries it will pursue. However, Anthem will not pursue a recovery if the cost of collection is likely to exceed the recovery amount, or if the recovery is prohibited by law or an agreement with a Provider or other vendor. F. Employer is responsible for complying with Employee Retirement Income Security Act ("ERISA") reporting requirements, as applicable; however, Anthem will provide Employer available data necessary for preparation of the ERISA Form 5500. The Booklet provided by Anthem does not satisfy all requirements of ERISA for a Summary Plan Description, but may be incorporated into the Summary Plan Description issued by Employer. Anthem is under no obligation to provide any other type of data reports to Employer, except as otherwise agreed to by the Parties or required by law. WIGC2013 2 04252013 G. hi addition to the benefits described in the Booklet, Anthem may facilitate the provision of wellness programs offered by Employer. Employer will pay any fees for these wellness programs, if indicated in Schedule B. H. Anthem shall not: (1) adjust premiums based on genetic information; (2) request genetic testing, except to determine medical appropriateness; (3) collect genetic information from a Member in connection with enrollment; or, (4) for any other underwriting purpose. ARTICLE 4 — OBLIGATIONS OF EMPLOYER A. Employer will provide initial eligibility information in the format agreed to by the Parties, as well as notice of additions, deletions, and changes to enrollment. Employer will also provide any information reasonably required by Anthem to administer this Contract, including information regarding: (1) eligibility for enrollment and termination of Members; (2) changes in single or family coverage status; (3) changes due to Medicare eligibility; or, (4) contribution and participation levels. B. Employer will notify each Employee as the Employee becomes eligible for enrollment, and will collect and submit to Anthem enrollment or waiver of coverage information. Employer will also keep a record of Employees who do not apply. All information provided by Employer to Anthem will be true, accurate and complete to the best of its knowledge. In addition, Employer will provide an open enrollment period as agreed to by the Parties and consistent with state and federal law. C. Employer will timely notify Anthem of any Member termination or loss of eligibility for coverage. Anthem may limit retroactive terminations to a maximum of 60 days prior to the date notice is received. Also, if Anthem has provided benefits for individuals no longer eligible, Anthem may collect from Employer any paid claim amounts not otherwise recovered by Anthem. D. Employer must comply with Anthem's contribution levels, participation levels, and other applicable underwriting rules that are consistent with applicable laws. E. Employer will promptly notify Anthem if there is a change in Employer's status as either a large group or small group, as defined under applicable law. In such event, Employer will provide all information requested by Anthem about its status. F. If Employer maintains a Grandfathered Health Plan, as that term is used in the Patient Protection and Affordable Care Act ("PPACA"), Employer will not make any changes to such Plan, including changes to Employer contribution levels, without giving Anthem advance written notice of the intent to change such Plan. Also, at Anthem's request, Employer will confirm in writing that it has not made changes to its Plan that would cause the Plan to lose its grandfathered status. If Employer makes changes to a Grandfathered Health Plan without notice to Anthem, the Plan may lose grandfathered status, and significant penalties or fines may be assessed against Employer and Anthem. If Employer makes changes to its Plan and does not provide advance notice to Anthem, Employer agrees to reimburse Anthem for any penalties, fines or other costs assessed against Anthem. WIGC2013 3 04252013 G. Employer agrees to distribute and deliver to its Employees and dependents, the Summary of Benefits and Coverage ("SBC") provided by Anthem as required by federal law. The SBC must be provided with open enrollment materials or, if Employer does not hold an open enrollment, at least 30 days prior to the Anniversary Date. Employer will issue an updated SBC if the benefits change between the time of original distribution and the effective date of coverage. SBCs must also be provided to new enrollees and special enrollees. Employer may distribute the SBC either electronically or by paper, subject to the requirements of applicable law. If requested by Anthem, Employer will certify its compliance with the SBC distribution requirements. Employer agrees to reimburse Anthem for any penalties, fines or other costs assessed against Anthem, if Employer fails to comply with these requirements. Employer will timely notify Anthem of requested benefit changes prior to the Anniversary Date. A request for benefit changes after the renewal of this Contract may delay the effective date of the benefit changes by at least 60 days and require a notice of material modification. H. Employer is responsible for all applicable requirements pertaining to COBRA administration, unless otherwise agreed to in writing by Anthem. If Anthem has agreed to perform any COBRA administration duties on behalf of Employer, such arrangement will be described in a separate agreement. L PPACA requires a small group benefit design to meet certain minimum levels of actuarial value. The amount of Employer's contribution to any HRA, HSA or Wrap Plan is included in the calculation of these actuarial values. Employer must notify Anthem if it changes its contribution amount to any HRA, HSA or Wrap Plan, and agrees to reimburse Anthem for any penalties, fines or other costs assessed against Anthem resulting from Employer's change in contribution. If Employer offers multiple benefit plans insured by more than one carrier, Employer will offer Anthem coverage to all Employees at terms and contribution levels that are no less favorable than those offered by other carriers. ARTICLE 5 — CHANGES TO CONTRACT AND BOOKLET A. Anthem may modify the terms of the Booklet by giving at least 30 days advanced written notice, or 60 days advance written notice in the case of an adverse change, prior to the Anniversary Date of this Contract. Employer can also propose changes to the terms of the Booklet at any time by giving written notice of any such requested change to Anthem. The effective date of such requested changes to the Booklet shall be agreed to by the Parties. In addition, Anthem may modify the terms of this Contract, other than the terms of the Booklet and the premium rates, by giving 30 days advanced written notice to Employer of such changes. B. Anthem may change the premium rates or other amounts due under this Contract by providing written notice to Employer at least 60days before the effective date of such change if the premium rate will increase by more than 25% of the then current premium rate. However, such notice requirement will not apply to changes in premium rates that are the result of changes in benefit provisions required by state or federal law, or changes requested by Employer. C. An amendment to this Contract will not be effective unless signed by an officer of Anthem. If any change to the Contract or the Booklet, including premium amounts, is unacceptable to Employer, Employer has the right to terminate coverage under this Contract by giving written notice of termination to Anthem before the effective date of the change. Payment of the new amount in the event of a premium rate change, or continued payment of the current amounts in the event of a WIGC2013 4 04252013 Contract or Booklet change only, will constitute acceptance of the change by Employer, without the necessity of securing Employer's signature on the schedule or amendment. The schedule or amendment will then become a part of this Contract. ARTICLE 6 — PREMIUM AND GRACE PERIOD A. The premium rates for coverage under this Contract are provided in Schedule B. Premium rates are based on the data provided by Employer, consistent with applicable laws. Anthem may retroactively modify the premium rates if the data provided is inaccurate or new data is submitted that varies from the data previously provided to Anthem. B. The full invoice amount, including premium, taxes, fees or assessments, must be paid in advance by Employer on or before the invoice due date. Anthem does not have an obligation to accept a partial payment. Employer must make payments regardless of any contributions to those payments by Subscribers. Even if Employer has not received an invoice from Anthem, Employer is still obligated to pay, at a minimum, the prior invoice amount. C. Employer is entitled to a 31 day period beginning on the invoice due date (the "Grace Period"), for the payment of any premium or other amounts due. If, during the Grace Period, Employer pays the full amounts owed, this Contract will remain in force D. Anthem may assess additional fees or charges if indicated in Schedule B. E. For any rebate due and payable by Anthem as a result of the medical loss ratio ("MLR") requirements of PPACA or applicable state law, all such rebates paid will constitute a return of premium. Employer will promptly provide Anthem with any information needed to calculate the rebate amount. Anthem reserves the right to pay the rebate to either Employer or Subscribers. If Anthem pays the rebate to Employer, Employer will promptly refund to each Subscriber his or her proportional share of the rebate according to the requirements of PPACA. On request, Employer will provide to Anthem documentation required under PPACA of the distribution of the rebate to Subscribers. Employer agrees to provide such documentation within the time frame designated by Anthem. If Anthem receives a claim relating to the amount of the Subscriber's rebate, Employer will cooperate with Anthem and provide Anthem with information required to investigate the claim. If Anthem is required to pay additional amounts to a Subscriber due to Employer's failure to provide accurate information, make a refund, or refund less than the amount due, Employer must reimburse Anthem for such additional amounts paid. This provision survives the termination of the Contract. ARTICLE 7 — TERMINATION A. Employer may terminate this Contract at any time by giving Anthem advance written notice of termination; however, the termination will be effective at the end of the month in which notice is given, except as otherwise agreed to by the Parties. Employer must pay the amounts due for each Subscriber covered through the effective date of termination of this Contract. Unless Employer provides advance notice of termination, this Contract will automatically renew on each Anniversary Date, upon Employer's payment and Anthem's acceptance of premium. WIGC2013 5 04252013 B. The Contract will terminate: (1) automatically, without notice, on the last day of the Grace Period, if premium or other amounts due remain unpaid. Anthem's receipt and deposit of a payment through its automatic payment procedures or other procedures will not be deemed acceptance of a late payment or waiver of termination. (2) with written notice to Employer that the Contract will be terminated due to Employer's failure to comply with Anthem's contribution or participation requirements or Employer's failure to supply information necessary to substantiate the contribution or participation levels. Anthem will give Employer an additional 60 day period in which to satisfy the participation level requirements. (3) with written notice to Employer, if Employer commits fraud or makes an intentional misrepresentation of material fact with respect to this Contract. (4) with written notice to Employer, as required by applicable law, that the Contract will be terminated because Anthem is discontinuing the particular type of health benefits product elected by Employer, Anthem will no longer issue group health coverage within the small or large group market, or for any other reason permitted by law. (5) with written notice to Employer, if there is no longer any Subscriber under the Plan who lives or works in Anthem's service area. (6) as of the date Employer's membership in an association, labor union or other entity applicable to Employer's coverage ceases, or the date that entity's coverage with Anthem ceases. C. Employer will promptly notify Members that this Contract is or will be terminated, and will provide any notice regarding a Member's right to other coverage. Anthem will not provide benefits coverage for medical services rendered after the effective date of termination, except as otherwise provided in the Booklet or required by law. D. Anthem reserves the right to cancel coverage with 30 days prior written notice to any Member who engages in material misrepresentation or fraud. E. If this Contract terminates for nonpayment of an invoice amount due, Employer may request reinstatement of this Contract according to Anthem's policies and procedures, which may include the payment of a reinstatement fee. Anthem will determine whether the Contract will be reinstated, and notify Employer of its decision. If Anthem reinstates the Contract, the coverage will resume as of the date the Contract terminated. If Anthem does not reinstate the Contract, it will return any unearned premium to Employer. ARTICLE 8 — NOTICES A. Any required notice under this Contract will be deemed sufficient when made in writing and delivered by first class mail; personal delivery; electronic mail, as permitted by law; or overnight delivery with confirmation capability. Such notice will be deemed to have been given as of the date of the mailing. Anthem will provide notice to Employer's principal place of business as shown on Anthem's records. Employer will provide notice to its designated Anthem representative. B. If requested by Anthem, Employer will distribute notices and other communications to Members. Employer will notify all Members of the termination of this Contract. WIGC2013 6 04252013 ARTICLE 9 — LIMITATION ON ACTIONS AND GOVERNING LAW A. No action may be brought to recover benefits for any service covered under this Contract unless the required notice or proof of claim has been given to Anthem within the time frame required under the Booklet, and such action is commenced no later than 3 years following the date that the notice or proof of claim has or should have been provided to Anthem. B. Except to the extent preempted by ERISA or any other applicable federal law, this Contract will be governed by and construed according to the laws of Wisconsin. All claims or actions arising under this Contract will be heard in a court of competent jurisdiction in Wisconsin. ARTICLE 10 — NO WAIVER No failure or delay by either Parry to exercise any right or to enforce any obligation under this Contract, in whole or in part, will operate as a waiver to enforce compliance with such right or obligation in the future. No course of dealing between Employer and Anthem will operate as a waiver of any right or obligation under this Contract. ARTICLE 11— ASSIGNMENT Neither Parry may assign all or part of this Contract without first obtaining the written consent of the other Parry. However, subject to applicable laws, Anthem may assign all or part of its duties and obligations to: (1) another qualified insurance carrier under an assumption reinsurance arrangement; (2) any affiliate or successor in interest of Anthem; or, (3) another qualified insurance carrier surviving a merger, reorganization, sale, or similar event involving Anthem or Anthem's assets. Any assignee under this Contract must continue to fulfill all Contract obligations. ARTICLE 12 — SERVICE MARKS This Contract constitutes a contract solely between Employer and Anthem. Anthem is an independent corporation operating under a license with the Blue Cross and Blue Shield Association ("Association"), an association of independent Blue Cross and Blue Shield Plans, permitting Anthem to use the Blue Cross and/or Blue Shield Service Marks in the State of Wisconsin. Anthem is not contracting as the agent of the Association. Employer has not entered into this Contract based upon representations by any person other than Anthem. No person, entity, or organization other than Anthem will be held accountable or liable to Employer for any of Anthem's obligations provided under this Contract. This paragraph will not create any additional obligations on the part of Anthem, other than those obligations contained in this Contract. ARTICLE 13 — CONTRACT ADMINISTRATION A. Anthem has the discretionary authority to construe the Contract and any disputed or doubtful terms of the Contract, and to determine eligibility for benefits under the Contract. Anthem also has the discretionary authority to resolve all questions arising under the Booklet and to establish and amend the policies and procedures with regard to the administration of benefits under the Booklet. In addition, Anthem has all powers necessary or appropriate to carry out its duties in connection with the performance of services under this Contract. Anthem's authority to determine eligibility for benefits shall be exercised consistently with the provisions of the Contract, the Booklet, Provider agreements, and applicable law WIGC2013 7 04252013 B. Anthem may waive or modify any referral, authorization, or certification requirements, benefit limits, or other processes contained in the Booklet if such waiver is in the best interest of the Member or will facilitate effective and efficient claims administration. C. Anthem may institute, from time to time, pilot or test programs regarding disease management, utilization management, case management or wellness initiatives. A pilot or test program may impact some, but not all Members. Anthem reserves the right to discontinue a pilot or test program at any time without notice. D. Anthem will have sole responsibility for resolving appeals from claim decisions, consistent with state and federal law. If Employer receives a question or complaint regarding benefits under this Contract, Employer will advise the Member to contact Anthem. E. All statements made by Employer and any Member will be considered representations and not warranties. Additionally, no statement, other than a fraudulent misrepresentation, will be used to contest the validity of coverage after the Contract has been in force for two years. F. Anthem assumes only those responsibilities that are expressly stated in this Contract. Nothing contained in this Contract will be construed to deem Anthem as Plan Sponsor, Plan Administrator or a Named Fiduciary for purposes of ERISA. G. Anthem may delegate any of its responsibilities under this Contract without the consent of Employer. Anthem shall remain responsible to Employer for fulfilling its obligations under this Contract. ARTICLE 14 — RELATIONSHIP OF THE PARTIES Employer and Anthem are separate legal entities. Nothing in this Contract will cause either Parry to be deemed a partner, agent or representatives of the other Party. Neither Parry will have the expressed or implied right or authority to assume or create any obligation on behalf of the other Party. ARTICLE 15 — INTERPLAN PROGRAMS A. Anthem has a variety of relationships with other Blue Cross and/or Blue Shield Licensees, generally referred to as "Inter -Plan Programs." When Members access Covered Services outside of Anthem's geographic service area, the claims for those Covered Services may be processed through one of these Inter -Plan Programs. In those cases, the claim will be presented to Anthem for payment according to the rules governing these Inter -Plan Programs. A general description of the Inter -Plan Programs is provided below. Typically, when a Member obtains medical care outside Anthem's geographic service area, the Member accesses care from a Provider that has a contractual agreement ("Participating Provider") with the local Blue Cross and/or Blue Shield Licensee in that other area ("Host Blue"). But in some cases, a Member may obtain care from a Provider outside Anthem's geographic service area that does not have a contractual agreement with the Host Blue ("Non -Participating Provider"). Additionally, depending on the Member's benefits, Anthem may cover only a limited number of services, such as emergency or urgent care, outside of Anthem's geographic service area. Please refer to the Booklet for more information on what services are covered outside of Anthem's geographic service area. WIGC2013 8 04252013 B. B1ueCard® Program. Under the B1ueCard Program, when a Member receives Covered Services within the geographic area served by a Host Blue, Anthem is responsible for meeting its claims payment obligations under this Contract. Under these circumstances, the Host Blue is responsible for contracting and handling interactions with Providers in its service area. The financial terms of the B1ueCard Program are described generally below. There may be some cases that are not directly referenced in this description; however, in those cases, Anthem's action will be consistent with the spirit of this description. (1) The calculation of a Member's payment responsibility for Covered Services processed through the B1ueCard Program will be based on the lower of the Participating Provider's billed charges or the Host Blue's negotiated price. (2) Host Blues may use various methods to determine a negotiated price, which depend on the terms of their provider contracts. The negotiated price may be based on the actual price which is a negotiated payment without any other increases or decreases. The negotiated price may also be based on an estimated price, which is a negotiated payment reduced or increased by a percentage to take into account; (i) certain payments negotiated with the Participating Provider; and, (ii.) other claim and non -claim related transactions. Such transactions may include, but are not limited to: anti -fraud and abuse recoveries; Participating Provider refunds not applied on a claim -specific basis; retrospective settlements; and performance -related bonuses or incentives. hi addition, the negotiated price may be based on an average price which is a percent of the billed covered charges representing the aggregate payments negotiated by the Host Blue with: (i) all of its Participating Providers; or, (ii) a subgroup of similar Participating Providers, taking into account other claim and non -claim related transactions. Such transactions may include the same ones as noted for the estimated price above. Host Blues using either an estimated price or an average price may prospectively increase or decrease such prices to correct for an over or underestimation of past prices. In this case, the actual payment may reflect additional amounts or credits for claims that are: (i) already paid to Participating Providers; or, (ii.) anticipated to be paid to or received from Participating Providers. The amount paid is final; no future price adjustment will result in increases or decreases to the pricing of past claims. The B1ueCard Program requires that the price submitted by a Host Blue to Anthem remain a final price, regardless of any future adjustments based on the use of estimated or average pricing. (3) A small number of states require a Host Blue to either: (i) use a basis for determining a Member's cost share that does not reflect the entire savings realized, or expected to be realized, on a particular claim; or, (ii.) add a surcharge. Should a state require a cost share calculation method that differs from the method described above, or requires a surcharge, Anthem will calculate a Member's cost share in accordance with the applicable law. (4). Recoveries from a Host Blue or a Participating Provider can arise in several ways. These include, but are not limited to: anti -fraud and abuse recoveries; Provider audits; credit balance audits; utilization review refunds; and unsolicited refunds. In some cases, the Host Blue will engage a third party to aid in identifying and/or collecting recovery amounts. The fees of such a third parry may be applied against the recovery. Recovery amounts determined in this way will be applied in accordance with Inter -Plan Program rules, which generally require correction on a claim -by -claim or prospective basis. WIGC2013 9 04252013 C. Negotiated National Account Arrangements. As an alternative to the B1ueCard Program, claims for Covered Services may be processed through a negotiated national account arrangement with one or more Host Blues. If Anthem has arranged with one or more Host Blues to provide customized networks, then the terms of any such arrangement will determine the payment amount. A Member's cost share will be calculated based on the lower of either: (i.) the billed amount; or, (ii.) the price that Anthem has negotiated with the Host Blue under the national account arrangement. D. Non -Participating Providers. When Covered Services are provided outside of Anthem's geographic service area by a Non -Participating Provider, the amount of a Member's cost share will generally be based on either: (i.) the Host Blue's Non -Participating Provider payment; or, (ii.) the pricing arrangement required by applicable state law. In these cases, the Member may be responsible for the difference between: (i) the Non -Participating Provider's billed charges; and, (ii) the payment Anthem will make for the Covered Services. In some cases, Anthem may pay a claim from a Non -Participating Provider based on the Provider's billed charges. In other cases, Anthem may pay a claim from a Non -Participating Provider based on the payment Anthem would make to a non -contracting Provider inside Anthem's geographic service area. This may happen when the Host Blue's payment for the Covered Services would be more than Anthem's payment for the same Covered Services. Also, Anthem may negotiate a payment with a Non -Participating Provider on an exception basis. In any of these exception cases, the amount of a Member's cost share will be the difference between: (i.) the Non -Participating Provider's billed charges; and, (ii) the payment Anthem will make for the Covered Services. ARTICLE 16 — HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT A. All capitalized terms used in this Article have the same meaning as defined in the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). B. Anthem may disclose Summary Health Information to Employer for purposes of obtaining premium bids from other carriers or third party payers, or amending or terminating the Plan. C. Anthem may disclose Personal Health Information ("PHI") to Employer for it to carry out Plan administration functions, but such disclosure may occur only after receipt of certification from Employer that: (1) Employer's Plan documents comply with the privacy requirements of HIPAA; (2) Employer has provided notice to affected individuals as required by HIPAA; and (3) PHI will not be used for the purpose of employment-related actions or other actions not related to administration of benefits under the Plan. D. Anthem will comply with any additional disclosure restrictions required by state and federal law. ARTICLE 17 — MISCELLANEOUS A. Anthem agrees to treat all proprietary information about Employer's operations and its Plan in a confidential manner. Employer agrees to treat all information about Anthem's business operations, discount information, and other proprietary data in a confidential manner. Neither Party will disclose any such information to any other person without the prior written consent of the Party to whom the information pertains. However, Anthem may disclose such information to its legal advisors, lenders, business advisors, and other third parties for commercial or research purposes. Anthem may also make such disclosures as required or appropriate under applicable WIGC2013 10 04252013 securities laws. If a Parry is required by law to make a disclosure of any proprietary information, the disclosing Party will immediately provide written notice to the other Party detailing the circumstances of and extent of the disclosure. B. Each Parry retains ownership of the materials and processes it develops in connection with the services provided under this Contract, and neither conveys ownership rights in its materials and processes nor acquires ownership rights in the other Parry's materials and processes by entering into this Contract or performing its obligations under this Contract. Nothing in this Contract shall impair or limit a Party's right to use and disclose its materials and processes for its own lawful business purposes. C. By performing the services under this Contract, Anthem is not engaged in the practice of medicine; it merely makes decisions regarding the coverage of services. Providers participating in Anthem networks are not restricted from exercising independent medical judgment regarding the treatment of their patients, regardless of Anthem's coverage determinations. D. If any provision of this Contract is found to be invalid, illegal or unenforceable under applicable law, order, judgment or settlement, such provision will be excluded from the Contract and the remainder of this Contract will be enforceable and interpreted as if such provision is excluded. ANTHEM BLUE CROSS AND BLUE SHIELD (Signature) Paul C. Nobile President Effective Date of Group Contract: (Date) WIGC2013 11 04252013 Anthem. a BlueCross B1ueShield Company Name Group Number Association Name Effective Date: xx/xx/xxxx SCHEDULE A Effective Date of this Addendum is 12:01 a.m. on: x/xx/xxxx This Addendum applies to the Employer and its affiliated companies as agreed to in writing by Anthem. SECTION I — ANNIVERSARY DATE The Anniversary Date of the Contract shall be: x/x SECTION II — ELIGIBILITY Subscribers who meet the criteria below shall be eligible for coverage under this Contract. Family members of a Subscriber shall be eligible for coverage if they meet the definition of Dependent contained in the Booklet. All active full-time hourly and salaried Employees working at least 30 hours per week and who work in states in which Anthem provides coverage shall be eligible for coverage under this Contract. Coverage for eligible new Employees shall be effective on as long as the application form is received within 30 days of the effective date of the coverage. ANTHEM BLUE CROSS AND BLUE SHIELD (Signature) Paul C. Nobile President PPO Blue Cross Blue Shield of Wisconsin, d/b/a Anthem Blue Cross and Blue Shield Independent licensee of the Blue Cross and Blue Shield Association. HMO Compeare Health Services Insurance Corporation, d/b/a Anthem Blue Cross and Blue Shield. Independent licensee of the Blue Cross and Blue Shield Association. POS Compcare Health Services Insurance Corporation and Blue Cross and Blue Shield of Wisconsin, d/b/a Anthem Blue Cross and Blue Shield. Independent licensee of the Blue Cross and Blue Shield Association. Use this at the end on all 30ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. WIGC2013 12 04252013 Anthem® B1ueCross B1ueShield Company Name Group Number Association Name Effective Date: xx/xx/xxxx MONTHLY PREMIUM RATES AND PRODUCT(S) ELECTED SCHEDULE B Effective Date of this Addendum is 12:01 a.m. on xxxxxxx This Addendum applies to the Employer and its affiliated companies as agreed to in writing by Anthem. The Employer will pay a per Subscriber per month fee calculated by adding the sum of the rates for each of the Member categories set forth in the tables below: Coverage Subscriber Only Subscriber + Souse Subscriber + Subscriber + One Dependent Children Subscriber + Family ANTHEM BLUE CROSS AND BLUE SHIELD (Signature) Paul C. Nobile President PPo Blue Cross Blue Shield of Wisconsin, d/b/a Anthem Blue Cross and Blue Shield Independent licensee of the Blue Cross and Blue Shield Association. HMO Compcare Health Services Insurance Corporation, d/b/a Anthem Blue Cross and Blue Shield. Independent licensee of the Blue Cross and Blue Shield Association. POS Compcare Health Services Insurance Corporation and Blue Cross and Blue Shield of Wisconsin, d/b/a Anthem Blue Cross and Blue Shield. Independent licensee of the Blue Cross and Blue Shield Association. Use this at the end on all 30ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. WIGC2013 13 04252013 AMENDMENT This Group Contract ("Contract") is entered into by and between ("Employer") and [PPO Blue Cross Blue Shield of Wisconsin] [HMO (other than WellPriority) Compcare Health Services Insurance Corporation] [HMO (WellPriority) Wisconsin Collaborative Insurance Company] [POS (other than WellPriority) Compare Health Services Insurance Corporation and Blue Cross and Blue Shield of Wisconsin, which are severally liable for the benefits offered under the Booklet] [POS (WellPriority) Wisconsin Collaborative Insurance Company and Blue Cross and Blue Shield of Wisconsin, which are severally liable for the benefits offered under the Booklet] d/b/a Anthem Blue Cross and Blue Shield ("Anthem") (Employer or Anthem individually referred to as "Parry" and together collectively referred to as the "Parties") upon the following terms and conditions: This Amendment revises the Group Contract, form number WIGC2014 as described below. It supersedes any provision in the Group Contract with which it may be in conflict. In the Group Contract, the provisions identified below (Article 3.G. and Article 15) are deleted in their entirety and replaced with the following: Article 3, G. G. In addition to the benefits described in the Booklet, Anthem will make available identity theft protection services to Members. Anthem may also facilitate the provision of wellness programs offered by Employer and Employer will pay any fees for these wellness programs, if indicated in Schedule B. Depending on the wellness program elected by Employer, the program may offer a wellness engagement credit to Employer when Member's satisfy certain participation requirements set by the program, provided the Employer renews with Anthem, which credit is indicated in Addendum C. Article 15 I. Out -of -Area Services Overview Anthem has a variety of relationships with other Blue Cross and/or Blue Shield Licensees, referred to generally as "Inter -Plan Arrangements." These Inter -Plan Arrangements operate under rules and procedures issued by the Blue Cross Blue Shield Association ("Association"). Whenever Members access healthcare services outside the geographic area Anthem serve[s] (the "Anthem Service Area," the claim for those services may be processed through one of these Inter- Plan Arrangements. The Inter -Plan Arrangements are described generally below. Typically, when accessing care outside the Anthem Service Area, Members obtain care from Providers that have a contractual agreement ("participating providers") with the local Blue Cross and/or Blue Shield Licensee in that other geographic area ("Host Blue"). In some instances, Members may obtain care from Providers in the Host Blue geographic area that do not have a contractual agreement ("nonparticipating providers") with the Host Blue. Anthem remains responsible for fulfilling our contractual obligations to you. Anthem's payment practices in both instances are described below. WIGC Amendment LG (2/17) WIGC2013 14 04252013 If the plan you are purchasing is an HMO plan, Anthem covers only limited healthcare services received outside of Anthem's Service Area. The Benefit Booklet describes what those services are. Any other services will not be covered when processed through any Inter -Plan Arrangements, unless authorized by Anthem. Providers providing such Covered Services may be considered nonparticipating providers. Inter -Plan Arrangements Eligibility Claim Types Most claim types are eligible to be processed through Inter -Plan Arrangements, as described above. Examples of claims that are not included are prescription drugs obtained from a pharmacy and most dental or vision benefits. A. B1ueCard® Program The B1ueCard® Program is an Inter -Plan Arrangement. Under this Arrangement, when Members access Covered Services outside the geographic area Anthem serves, the Host Blue will be responsible for contracting and handling all interactions with its participating providers. The financial terms of the B1ueCard Program are described generally below. Liability Calculation Method Per Claim Unless subject to a fixed dollar copayment, the calculation of the Member liability on claims for Covered Services will be based on the lower of the participating provider's billed charges for Covered Services or the negotiated price made available to Anthem by the Host Blue. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue's healthcare provider contracts. The negotiated price made available to Anthem by the Host Blue may be represented by one of the following: (i) An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; or (ii) An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim- and non -claim -related transactions. Such transactions may include, but are not limited to, anti -fraud and abuse recoveries, provider refunds not applied on a claim -specific basis, retrospective settlements and performance- relatedbonuses or incentives; or (iii) An average price. An average price is a percentage of billed charges for Covered Services in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers or a similar classification of its providers and other claim- and non -claim -related transactions. Such transactions may include the same ones as noted above for an estimated price. WIGC2013 15 04252013 Host Blues determine whether or not they will use an actual, estimated or average price. Host Blues using either an estimated price or an average price may prospectively increase or reduce such prices to correct for over- or underestimation of past prices (i.e., prospective adjustment may mean that a current price reflects additional amounts or credits for claims already paid or anticipated to be paid to providers or refunds received or anticipated to be received from providers). However, the BlueCard Program requires that the amount paid by the Member is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. The method of claims payment by Host Blues is taken into account by Anthem in determining your premiums. B. Negotiated Arrangements As an alternative to the BlueCard Program, claims for Covered Services may be processed through a negotiated account arrangement with one or more Host Blues. If Anthem has arranged with one or more Host Blues to provide customized networks or other negotiated arrangements, then the terms of any such arrangement will determine the payment amount. A Member's cost share will be calculated based on the lower of either (i) the billed amount; or (ii) the price that Anthem has negotiated with the Host Blue under the negotiated account arrangement. C. Special Cases: Value -Based Programs BlueCard Program Anthem has included a factor for bulk distributions from Host Blues in the premium for Value -Based Programs when applicable under this contract. Negotiated Arrangements If Anthem has entered into a Negotiated Arrangement with a Host Blue to provide Value -Based Programs to Members, Anthem will follow the same procedures for Value -Based Programs as noted above for the BlueCard Program. D. Inter -Plan Programs: Federal/State Taxes/Surcharges/Fees In some instances federal or state laws or regulations may impose a surcharge, tax or other fee that applies to insured accounts. If applicable, Anthem will include any such surcharge, tax or other fee in determining premium. E. Nonparticipating Providers Outside Anthem Service Area 1. Allowed Amounts and Member Liability Calculation When Covered Services are provided outside of our service area by non -participating providers, Anthem may determine benefits and make payment based on pricing from either the Host Blue or the pricing arrangements required by applicable state or federal law. In these situations, the amount the Member pays for such services as deductible, copayment or coinsurance will be based on that allowed amount. Also, the Member may be responsible for the difference between the amount that the non- participating healthcare provider bills and the payment Anthem will make for the Covered Services as set forth in this paragraph. Federal or state law, as applicable, will govern payments for out -of -network emergency services. WIGC2013 16 04252013 2. Exceptions In certain situations, Anthem may use other pricing methods, such as billed charges, the pricing Anthem would use if the healthcare services had been obtained within the Anthem Service Area, or a special negotiated price to determine the amount Anthem will pay for services provided by nonparticipating providers. In these situations, the Member may be liable for the difference between the amount that the nonparticipating provider bills and the payment Anthem makes for the Covered Services as set forth in this paragraph. F. Blue Cross Blue Shield Global Core Program General Information If Members are outside the United States (hereinafter: "B1ueCard service area"), they may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Covered Services. The Blue Cross Blue Shield Global Core Program is not served by a Host Blue. The Benefit Booklet describes what services are covered under the Blue Cross Blue Shield Global Core Program (e.g., emergency only) and how to submit a claim. WIGC2013 17 04252013 fin the Group Contract, Addendum C is added if Group purchases the applicable wellness program identified in Article 3.G.: ADDENDUM C TO GROUP CONTRACT WITH This Addendum C is an Amendment to the Group Contract ("Contract"), as of the signature date below. This Addendum shall supplement and amend the Contract between [PPO Blue Cross Blue Shield of Wisconsin] [HMO (other than WellPriority) Compcare Health Services Insurance Corporation] [HMO (WellPriority) Wisconsin Collaborative Insurance Company] [POS (other than WellPriority) Compcare Health Services Insurance Corporation and Blue Cross and Blue Shield of Wisconsin, which are severally liable for the benefits offered under the Booklet] [POS (WellPriority) Wisconsin Collaborative Insurance Company and Blue Cross and Blue Shield of Wisconsin, which are severally liable for the benefits offered under the Booklet] d.b.a. Anthem Blue Cross and Blue Shield ("Anthem") and Group. This Addendum shall govern the Contract Period(s) from 1 -to {. If there are any inconsistencies between the terms of the Contract and this Addendum, the terms of this Addendum shall control. WELLNESS ENGAGEMENT CREDIT The following wellness engagement credit applies depending on level of member participation: • [10% - 50%] of eligible members participate in [2-6] designated activities = credit of [1% - 5%] based on prior year annual medical premium [25% - 75%] of eligible members participate in [2-6]designated activities = credit of [3% - 10%] based on prior year annual medical premium [50% - 90%] of eligible members participate in [2-6] designated activities = credit of [5% - 15%] based on prior year annual medical premium] Anthem Blue Cross and Blue Shield [WCIC: John Foley, President] [BCBSWI & CCB: WIGC2013 18 04252013 Paul Nobile, President] WIGC2013 19 04252013 POLICY ENDORSEMENT NO. 616 - 0 - 08032016 Attached to and forming a part of the Contract to Provide Dental Care Benefits between City Of Oshkosh and Delta Dental of Wisconsin, Inc. It is agreed and understood that Declarations, Section 7, Monthly Premium will be replaced with the following, effective January 1, 2017 and ending on December 31, 2017: Single Coverage (employee, 1 Party) $33.33 Family Coverage (employee and spouse, 2 Party) $67.60 Family Coverage (employee and child, 2 Parry) $67.60 Family Coverage (full family, 3+ Party) $127.43 Denta[RateEadorse 10.08 DELTA DENTAL OF WISCONSIN, INC. A NOT-FOR-PROFIT SERVICE CORPORATION CONTRACT TO PROVIDE DENTAL CARE BENEFITS DELTA DENTAL PPO Declarations The term of this Contract between City of Oshkosh and Delta Dental of Wisconsin, Inc., P.O, Box 828, Stevens Point, Wisconsin will be January 1, 2016 through December 31, 2016, This Contract will be automatically renewed, subject to the provisions of Article VIII. This Contract is issued in consideration of the Group's Application and advance payment of initial Premium. Delta Dental and the above-named Group agree to the obligations and provisions of this Contract. The limit of Delta Dental's liability for Benefits is as stated in this Contract. Delta Dental's obligations are subject to all other terms and conditions of this Contract. Claim settlement under this Contract is based upon a predetermined methodology, which may be less than the provider's billed charge. See Article I, Section 1.21 of the Master Group Contract for a more detailed explanation. DELTA DENTAL OF WISCONSIN, INC. zz��. BY: z2 Dennis L. Brown President DATE: November 16, 2015 1. CONTRACT NUMBER(S): 00616 - 00000 2. REQUIRED ENROLLMENT: (a) 85 % of all Eligible Employees must be enrolled. 85 % of all Eligible Employees with Dependents must be enrolled for dependent coverage. (b) The following percentage of the premium must be employer funded: 85 % Single Coverage (employee, 1 Party) 85 % Family Coverage (employee and spouse, 2 Party) 85 % Family Coverage (employee and child, 2 Party) 85 % Family Coverage (full family, 3+ Party) (c) If enrollment drops below 10% of initial enrollment, Delta Dental reserves the right to review the Rates or to terminate coverage. (d) In addition to this Delta Dental plan, the following Delta Dental Benefit options and/or other dental plans will be offered to this Group's employees: no other dental plans offered. (e) Changes in enrollment status will be considered during an Open Enrollment Period 30 days prior to the Contract renewal date, with changes becoming effective on the renewal date. 3. TERMS OF ELIGIBILITY: (a) Eligibility begins: For eligible new employees, eligibility begins the first day of the month following the waiting period. (b) For eligible new employees who start on the first day of the month through the fifth day of the month, the waiting period is the first day of the following month. Any start day after the fifth day of the month, the waiting period is 31 days. (c) For employees enrolling their Dependents: Dependent children are eligible through the end of the month in which they attain age 26, regardless of student status, or if age 26 and beyond, to the date they lose eligibility due to the Dependent's inability to meet all of the requirements contained in Section 3.1 (b) of the Master Group Contract. (d) Part-time employees are covered; minimum hours worked must average at least 20 per week, 1,200 per year. (e) Any change in coverage selection because of marriage, divorce or death causing a change in enrollment status will be effective the first of the month following the qualifying event. 4. DEDUCTIBLE LIMITATIONS: Delta Dental shall not be obligated to pay any Deductible indicated in the Declarations, in whole or in part, during the term of this Contract. The Deductible for Dental Procedures provided by Delta Dental PPO Dentists is $50 per Subscriber and per Covered Dependent, per Benefit Accumulation Period; however, no family will pay more than $150 per Benefit Accumulation Period in Deductibles regardless of the number of family members covered. The Deductible for Dental Procedures provided by Delta Dental Premier Dentists is $50 per Subscriber and per Covered Dependent, per Benefit Accumulation Period; however, no family will pay more than $150 per Benefit Accumulation Period in Deductibles regardless of the number of family members covered. The Deductible for Dental Procedures provided by Noncontracted Dentists is $100 per Subscriber and per Covered Dependent, per Benefit Accumulation Period; however, no family will pay more than $300 per Benefit Accumulation Period in Deductibles regardless of the number of family members covered. 5. MAXIMUM CONTRACT BENEFITS PER PERSON: The maximum total Benefit payable in any Benefit Accumulation Period is limited to the amount specified below. The maximum total Benefit per Subscriber and per Covered Dependent, per Benefit Accumulation Period for Dental Procedures provided by Delta Dental PPO Dentists is $1,500, and $1,000 for Dental Procedures provided by Delta Dental Premier Dentists, and $500 for Dental Procedures provided by Noncontracted Dentists. In no case will the maximum total Benefit exceed $1,500 regardless of the network chosen. G. ORTHODONTIC MAXIMUM BENEFIT: Delta Dental's obligation for orthodontic Benefits is limited to the lifetime maximum specified in this Item of the Declarations. The maximum lifetime orthodontic Benefit is $2,000 for Dental Procedures provided by Delta Dental PPO Dentists for each Covered Dependent child to age 19. The maximum lifetime orthodontic Benefit is $2,000 for Dental Procedures provided by Delta Dental Premier Dentists for each Covered Dependent child to age 19, The maximum lifetime orthodontic Benefit is $.00 for Dental Procedures provided by Noncontracted Dentists for each Covered Dependent child to age 19. In no case will the maximum lifetime orthodontic Benefit exceed $2,000 regardless of the network chosen. 7. MONTHLY PREMIUM: Single Coverage (employee, 1 Party) - $30.86 Family Coverage (employee and spouse, 2 Party) - $62.59 Family Coverage (employee and child, 2 Party) - $62.59 Family Coverage (full family, 3f Party) - $117.99 8. SCHEDULE OF BENEFITS, LIMITATIONS AND COVERAGE PERCENTAGE: This Contract provides the following Benefits subject to the Coverage percentage listed for each Benefit and subject to any applicable Deductible. The Coverage and Coinsurance percentages may vary based upon the network membership of the treating Dentist at the time the Dental Procedure is completed. The application of the Deductible, if any, also may vary based upon the network membership of the treating Dentist at the time the Dental Procedure is completed. For example, if the Coverage percentage shown is "80," that Benefit is 80% of the Maximum Plan Allowance, after satisfaction of any applicable Deductible. In the same example, the Coinsurance (the amount the patient must pay) would be the remaining 20%. If the Coverage percentage shown is "0", that Benefit is not provided in the Group Contract. The Benefit Accumulation Period begins on January 1, 2016 ends on December 31, 2016, and thereafter shall be the 12 month period beginning on January 1, 2017. PPO = Delta Dental PPO Dentist Premier = Delta Dental Premier Dentist NC = Noncontracted Dentist Does Deductible Coverage Percentage Apply? Yes/No PPO Premier NC PPO Premier NC Benefit Examinations two times per Benefit N N N 100 100 50 Accumulation Period. Full mouth series x-rays at sixty month intervals; either individual films, or panoramic N N N 100 100 50 film, including bitewings. Bitewing x-rays no more frequently than one time per Benefit Accumulation Period (limited N N N 100 100 50 to a set of four films). Routine prophylaxis "' (teeth cleaning) or periodontal maintenance procedure two times per Benefit Accumulation Period. N N N 100 100 50 Routine prophylaxis. Y Y Y 80 50 25 Periodontal maintenance procedure. Does Deductible .................... Coverage Percentage Apply? Yes/No PPO Premier NC PPO Premier NC Benefit Topical fluoride applications two times per Benefit Accumulation Period for Covered N N N 100 100 50 Dependent children to age 19. Space maintainers for retaining space when a N N N 100 100 50 primary tooth is prematurely lost. N N N 100 100 50 Emergency treatment to relieve pain. Topical application of sealants for Covered Dependents to age 14. Application is limited to the occlusal surface of permanent molars which are free of decay and restorations. Benefits for sealants are limited to one N N N 100 100 50 application per tooth per lifetime. y y y 80 80 40 Amalgam (silver) restorations. Composite (tooth colored) restorations for y y y 80 80 40 anterior teeth. Stainless steel crowns — one per tooth in a three y y y 80 80 40 year period. Endodontics including root canal treatment and y y y 80 50 25 root canal therapy. y y y 80 50 25 Surgical endodontic treatment. Non-surgical periodontics including procedures necessary for the treatment of diseases of the gums and bone supporting the teeth — treatment y y y 80 50 25 is limited to once per quadrant every 24 months. Surgical periodontic treatment; treatment is y y y 80 50 25 limited to once per quadrant every 36 months. y y y 80 80 25 Non-surgical extractions. Oral surgery (cutting procedures) and surgical extractions including pre -operative and post - y Y y 80 50 25 operative care. Does Deductible Coverage Percentage Apply? Yes/No PPO Premier NC PPO Premier NC Benefit Crowns, inlays, or onlays are provided when teeth are broken down by denial decay or accidental injury and may no longer be restored adequately with a filling material. Coverage for the purpose of replacing a defective existing crown, inlay or onlay will be provided only after a five year period from the date on which the defective item was last supplied, whether or not Delta Dental paid for the original Dental Procedure as a Benefit under this Contract. Porcelain veneers on crowns are Benefits on the Y Y Y 50 50 25 six front teeth, bicuspids, and upper first molars. Prosthetics, including fixed bridgework, implants, partial dentures, and complete dentures to replace missing permanent teeth. Coverage for the purpose of replacing a defective existing fixed bridge or partial/complete denture will be provided only after a five year period from the date on which the defective item was last supplied, whether or not Delta Dental paid for the original Dental Procedure as a Benefit under this Contract. Porcelain veneers on crowns or pontics are Benefits on the six front teeth, bicuspids, and upper first molars. Fixed bridges, partial/complete dentures or implants are provided where chewing function is impaired due to missing teeth. A fixed bridge or implant and implant related procedures may be a Benefit if no more than two teeth are missing in the dental arch in which the bridge is proposed. Delta Dental will provide for replacement of missing teeth with the least elaborate procedure when three or more teeth are missing in the dental arch. Coverage for initial replacement of teeth is not limited to those lost while a Subscriber or Y y Y 50 50 25 Covered Dependent. Repairs and adjustments to prosthetic appliances. Denture reline and rebase is a Y Y Y 50 50 25 Benefit once in any three year period. Does Deductible Apply? Yes/No Coverage Percentage PPO Premier NC PPO Premier NC Benefit Covered orthodontic appliances and treatment, related services for orthodontic purposes to include examination, x-rays, extractions, photographs, and study models, subject to the orthodontic maximum benefit. Repair and replacement of orthodontic appliances are not covered. Delta Dental calculates all orthodontic treatment schedules according to the following formula: - 25% of the total Maximum Plan Allowance (subject to the Coverage Percentage stated herein and any applicable Deductible) is considered the initial payment to be paid by Delta Dental. - The remainder of the Maximum Plan Allowance is divided by the months of treatment and the resulting amount is paid monthly by Delta Dental (subject to the Coverage Percentage, any applicable Deductible and the orthodontic maximum Benefit stated herein.) If orthodontic treatment is stopped for any reason before it is complete, Delta Dental will suspend all monthly payments. Coverage includes orthodontic treatment in progress. Treatment is in progress if an appliance or banding has been placed and the patient is receiving treatment by the attending orthodontist according to a current treatment plan. Liability for orthodontic treatment in progress shall extend only to the unearned portion of the treatment in progress (that portion occurring after enrollment) and Delta Dental shall be the sole determinant of this unearned amount eligible for coverage. However, there are no Benefits available for Dental Procedures, including orthodontic treatment in progress, N N N 50 50 0 after coverage terminates. OPTIONAL PROCEDURES Delta Dental will pay the applicable Maximum Plan Allowance for the least expensive Dental Procedure that is adequate to restore the tooth or dental arch to contour and function, but only if that Dental Procedure is a Benefit of this Contract. The Subscriber or Covered Dependent will be responsible for the remainder of the Dentist's fee if a more expensive Dental Procedure is selected. The Coinsurance and Deductible will apply regardless of which Dental Procedure is selected. V6PKJPQAJVM11.03.2015 DD PPO Dee Wimplant pix (V6) 03.2013 POLICY ENDORSEMENT NO. 00616 00000 - 11032015 Endorsement to Declarations This Endorsement is attached to and forms a part of the Master Group Contract to provide dental care Benefits between City of Oshkosh and Delta Dental of Wisconsin, Inc. and supersedes any previous endorsement provided to you regarding Evidence -Based Integrated Care Plan, ("EBICP"), This Endorsement modifies the group dental Benefits afforded by your Master Group Contract, Declarations, and any Insuring Agreement Endorsements attached thereto, issued by Delta Dental of Wisconsin, Inc. and must be read in conjunction therewith. All terms and conditions of your Master Group Contract, Declarations, and any Insuring Agreement Endorsements attached thereto remain in effect except as modified by this Endorsement. Please read this Endorsement carefully. Please be advised that on January 1, 2016, the following Evidence -Based Integrated Care Plan ("EBICP") Benefits are provided under your Policy. To participate in EBICP, eligible dental plan enrollees or their Dentists are required to set the appropriate health condition indicator online at deltadentalwi.com or a Delta Dental of Wisconsin representative will assist in setting the EBICP indicator by telephone. The EBICP Periodontal Disease health condition indicator will be automatically updated when non-surgical or surgical periodontal procedures are processed by Delta Dental of Wisconsin. The EBICP Benefits are as follows: Periodontal Disease 1. With an indicator of surgical or non-surgical treatment of Periodontal Disease, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis. 2. With an indicator of surgical or non-surgical treatment of Periodontal Disease, a participant is eligible for topical fluoride application beyond the age limitation of the Master Group Contract. Diabetes With an indicator of a Diabetes diagnosis, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis. Pregnancy 1. With an indicator of Pregnancy, a participant is eligible for one additional dental visit for adult prophylaxis or periodontal maintenance during the pregnancy. High Risk Cardiac Conditions With an indicator for High Risk Cardiac Conditions, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis. High risk cardiac condition indicators are: o History of infective endocarditis o Certain congenital heart defects (such as having one ventricle instead of the normal two) o Individuals with artificial heart valves o Heart valve defects caused by acquired conditions like rheumatic heart disease o Hyper tropic cardiomyopathy which causes abnormal thickening of the heart muscle o Individuals with pulmonary shunts or conduits o Mitral valve prolapse with regurgitation (blood leakage) Suppressed Immune System Conditions I. With an indicator for Suppressed Immune System Conditions, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis. 2. With an indicator of Suppressed Immune System Conditions, a participant is eligible for topical fluoride application beyond the age limitation of the Master Group Contract. Kidney Failure or Dialysis Conditions I. With an indicator for Kidney Failure or Dialysis Conditions, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis. Cancer Related Chemotherapy and/or Radiation I . With an indicator for Cancer Related Chemotherapy and/or Radiation, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis. 2. With an indicator of Cancer Related Chemotherapy and/or Radiation, a participant is eligible for topical fluoride application beyond the age limitation of the Master Group Contract. THIS ENDORSEMENT IS PART OF THE MASTER GROUP CONTRACT, DECLARATIONS AND INSURING AGREEMENT REFERENCED HEREIN AND SHOULD BE KEPT WITH THOSE DOCUMENTS. EBICPIIEndGen4.2009 MASTER GROUP PPO CONTRACT Issued by DELTA DENTAL OF WISCONSIN, INC. All claims are settled based on a specific methodology. The eligible amount of a claim may be less than the provider's billed charge. Dental Benefits under the Contract are provided by Delta Dental of Wisconsin, Inc. ("Delta Dental" or the "Company"). ARTICLE I DEFINITIONS 1.1 "Benefit" or "Benefits" means those dental Benefits that are covered by the Company under the terms of this Contract as specified in the Schedule of Benefits. 1.2 "Certificate" means the Benefit Handbook(s) and Certificate(s) issued to a Subscriber insured through the Group. The Certificate outlines the Benefits provided by the Master Group Contract. 1.3 "Coinsurance" means the percentage of the Maximum Plan Allowance paid by the Subscriber or Covered Dependent for a specific Benefit each time ,such Benefit is provided under this Contract, subject to the Coverage Percentage. 1.4 "Contract" means the Master Group Contract, Declarations, and any other endorsements attached to the Master Group Contract, together. 1.5 "Contract Term" means the period commencing and terminating on the dates shown in the Declarations, and each annual period thereafter during which the Contract remains in effect. 1.6 "Copayment" means the dollar amount specified in the Declarations that a Subscriber or Covered Dependent is required to pay directly to a Delta Dental PPO Dentist or Dental Specialist for each Dental Procedure received that is a Benefit under the Contract, as specified in the Declarations. The Copayment is applied to the fee for Benefits that Delta Dental contracts with the Delta Dental PPO Dentist to pay or to the Maximum Plan Allowance for Benefits, whichever is applicable. 1.7 "Coverage Percentage" means the percentage of the Maximum Plan Allowance paid by the Company for a specific Benefit, as specified in the Declarations. 1.8 "Covered Dependent" means a Dependent who: (a) is listed in the documents necessary for coverage under the Contract, (b) has been accepted by the Company as a Covered Dependent, and (c) for whom the appropriate premium has been paid. 1.9 "Declarations" means the document(s) labeled "Declarations" and which lists the Group name, the Contract term, coverage limits, coverage option(s), and other information particular to the Group. 1.10 "Deductible" means the specified dollar amount that a Subscriber or Covered Dependent is required to pay each Contract Term before the Company will pay for Benefits as specified in the Schedule of Benefits. The Deductible is applied to the fee for Benefits that the Company contracts to pay or to the Maximum Plan Allowance for Benefits, whichever is applicable. 1.11 "Delta Dental PPO Dentist" means: (a) Any Dentist who has entered into a Delta Dental PPO Dentist Agreement with Delta Dental to provide or arrange for the provision of Dental Procedures to Subscribers and Covered Dependents, and who abides by such uniform rules and regulations as prescribed by Delta Dental. (b) Any Dentist who is a member or shareholder of a professional dental corporation or other entity that has entered into a corporate Delta Dental PPO Dentist Agreement with Delta Dental on behalf of its member, shareholder or employee Dentists. 1.12 "Delta Dental Premier Dentist" means: (a) Any Dentist who has entered into a Delta Dental Premier Dentist Agreement with Delta Dental to provide or arrange for the provision of Dental Procedures to Subscribers and Covered Dependents, and who abides by such uniform rules and regulations as prescribed by Delta Dental. (b) Any Dentist who is a member or shareholder of a professional dental corporation or other entity that has entered into a corporate Delta Dental Premier Dentist Agreement with Delta Dental on behalf of its member, shareholder or employee Dentists. 1.13 "Dental Procedure" means dental treatment provided by a Dentist or a licensed hygienist employed by a Dentist and reported to Delta Dental using the Code on Dental Procedures and Nomenclature (CDT). 1.14 "Dentist" means a person duly licensed to practice dentistry in the State of Wisconsin or in the state or country in which the Dental Procedures are rendered. 1.15 "Dependent" means a person who has satisfied the criteria for eligibility listed in Paragraph 3.1(b). 1.16 "Eligible Employee" means an employee or member of the Group who has satisfied the criteria for eligibility listed in Paragraph 3.1(a). 2 1.17 "Emergency" and "Urgent" mean a serious condition that manifests itself by acute symptoms of sufficient severity, including severe pain, to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate professional attention will likely result in any of the following: (a) Serious jeopardy to the person's health or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child. (b) Serious impairment to the person's bodily functions. (c) Serious dysfunction of one or more of the person's body organs or parts. 1.18 "Grievance" means any dissatisfaction with the administration, claims practices, or provision of services by the Company that is expressed in writing by or on behalf of a Subscriber or Covered Dependent. 1.19 "Group" means the employer, association, union or other organization contracting with the Company to provide Benefits to its Eligible Employees or members and their Dependents, if applicable. 1.20 "Master Group Contract/Contract" means this Contract. It is the group dental insurance policy issued by the Company to the Group in which Delta Dental agrees to provide dental Benefits to Subscribers and Covered Dependents. The Contract includes the group application, the Declarations (including the Schedule of Benefits), the Master Group Contract, and any attached addenda, appendixes, endorsements, schedules or riders. 1.21 "Maximum Plan AIlowance" means the total dollar amount allowed under the Contract for a specific Benefit. The Maximum Plan Allowance will be reduced by any Deductible and Coinsurance the Subscriber or Covered Dependent is required to pay. 1.22 "Non -contracted Dentist" means a Dentist who is not a member of any of Delta Dental's provider networks. 1.23 "Open Enrollment Period" means an enrollment period during which time Eligible Employees and/or Dependents may apply to become Subscribers and/or Covered Dependents, and existing Subscribers may apply to change to another provider network or coverage option, if available, or elect to terminate coverage. 1.24 "Premium" means the total monthly fee due based on the number of Subscribers multiplied by the applicable Rate. 1.25 "Rate" means the monthly fee required for each Subscriber, including Covered Dependents if any, in accordance with the terms of the Contract. 1.26 "Schedule of Benefits" is a listing of the specific Benefits and Benefit limitations for dental Benefits provided under the terms of this Contract. The Schedule of Benefits is attached to the Declarations. 3 1.27 "Subscriber" means an Eligible Employee or member of the Group who: (a) has completed and signed the documents necessary for coverage under the Contract, (b) has been accepted by the Company as a Subscriber, and (c) for whom the appropriate Premium has been paid. 1.28 "Urgent Care Grievance" means any dissatisfaction with the administration or claims practices of or provision of services by the Company that requires immediate dental attention. Such grievance must be delivered in writing to the Company. See Grievance Procedures, Article VII. ARTICLE II RESPONSIBILITIES OF THE PARTIES 2.1 Responsibilities of Group. (a) Initial Enrollment. Subject to any Open Enrollment Period and the effective date of this Contract, the Group shall offer to all of its Eligible Employees the opportunity to subscribe for themselves and their Dependents to the Benefit option(s) chosen by the Group in lieu of any other benefit plan(s) offered by the Group. New employees who become Eligible Employees will be given the opportunity to enroll themselves and any Dependents. (b) Open Enrollment. During the Open Enrollment Period, if applicable, and only during such period unless otherwise specified in this Contract, the Group shall allow Eligible Employees to elect coverage or change coverage. Each Eligible Employee must complete the appropriate enrollment form and return it to the Group during the Open Enrollment Period. The Group will report these changes to the Company. If the Company approves coverage, the effective date of coverage will be the Contract renewal date. It is the Group's responsibility to verify that the employee is eligible. Upon request the Group agrees to provide to the Company proof of employee eligibility. The Company may periodically audit Group's records regarding eligibility in accordance with Paragraph 4.1(d). (c) The Group agrees to collect and remit to the Company the monthly Premium for all Subscribers and Covered Dependents. The Premium will be due and payable by the first day of the month for which coverage is provided. (d) The Group agrees to provide to the Company, in a form approved by the Company, the enrollment information requested by the Company for each person who becomes a Subscriber or Covered Dependent within 31 days of the date the Subscriber or Covered Dependent enrolls. In addition, the Group agrees to provide the Company with any subsequent change in a Subscriber's or Covered Dependent's enrollment. This includes, but is not limited to: (i) eligibility for Medicare; 2 (ii) loss of eligibility for coverage under this Contract due to termination of employment, divorce or death of the Subscriber; (iii) the addition of newly acquired Dependents, or (iv) the deletion of Covered Dependents. (e) The Group agrees to submit subscriber enrollment data to the Company on no less than a monthly basis, reporting all changes in Subscribers and Covered Dependents entitled to receive Benefits. The effective, termination, or change date for a Subscriber must not be more than 90 days prior to the date on which the change was requested or the last renewal date of the Contract, or the last day of the month in which a Benefit payment was made on behalf of the Subscriber or Covered Dependent, whichever is later. The Group will be liable for claims incurred after the termination or change date and prior to the date of receipt and acceptance of the notice by the Company. (f) The Group is responsible for: (i) timely delivery of the Company's standard identification card(s) (if applicable), and Certificate(s) to each Subscriber; (ii) advising the Subscriber of Benefits changes in a timely manner; and (iii) notifying the Subscriber of cancellation of this Contract. (g) The Group agrees to notify the Company within ten days of a change in its legal status, expansion of business, dissolution of business, merger, acquisition, or any other significant business operational change. 2.2 Responsibilities of Delta Dental (a) Benefits Generally. In consideration of the Premium paid by the Group, the Company agrees to provide to Subscribers and Covered Dependents the Benefits described in the Contract for the Benefit option(s) chosen by the Group. (b) The Rates for coverage are stated in the Declarations of this Contract. Each month's Premium will be calculated based upon the number of current Subscribers, and according to their enrollment status. The Company will notify the Group of any future change in the Rate at least 30 days (60 days if the increase is more than 25%) prior to the date of Contract renewal. (c) Upon initial enrollment, the Company will provide the Group with the Company's standard identification card(s) (if requested), Certificates, Declarations and Schedules of Benefits in sufficient quantity for the Group to distribute to each Subscriber. The Company may provide, at the Group's request, camera-ready language which the Group may print and distribute to Subscribers. Group agrees that it will not modify the camera-ready language provided by the Company. (d) The Company has the sole authority to make Benefit determinations. (e) The Company reserves the right to make payment for Benefits directly to Subscribers. This provision will control even if the Subscriber has assigned the Subscriber's rights to the payment of Benefits. (f) Delta Dental will pay up to the Maximum Plan Allowance for Benefits minus the Subscriber's and Covered Dependent's applicable Deductible and Coinsurance as set forth in the Delta Dental PPO Declarations and in the Schedule of Benefits. (i) For Dental Procedures provided by a Delta Dental PPO Dentist, the Subscriber or Covered Dependent will be responsible for his/her applicable Deductible and Coinsurance percentage set forth in the Delta Dental PPO Declarations and in the Schedule of Benefits. (ii) For Dental Procedures provided by a Delta Dental Premier Dentist or by a Non -contracted Dentist, Delta Dental will pay up to the Maximum Plan Allowance for the Dental Procedures performed minus the Subscriber's or Covered Dependent's applicable Deductible and Coinsurance percentage set forth in the Delta Dental PPO Declarations and in the Schedule of Benefits. (iii) For Dental Procedures provided by a Non -contracted Dentist, the Subscriber or Covered Dependent will be responsible for any balance remaining after Delta Dental pays up to the Maximum Plan Allowance. (iv) The Subscriber or Covered Dependent also will be responsible for payment for any Dental Procedures that are not Benefits under the Contract, regardless of whether they were provided by a Delta Dental PPO Dentist or a Delta Dental Premier Dentist, ARTICLE III ELIGIBILITY; ENROLLMENT; EFFECTIVE DATE OF COVERAGE; TERMINATION OF ENROLLMENT 3.1 Eligibility (a) Employees: (i) Any employee who averages the number of hours of employment stated in the Declarations and who has completed the waiting period as established under Item 3 of the Declarations. (ii) An employee no longer meeting such conditions who has elected to continue coverage under Paragraph 3.6. 2 (b) Dependents: (i) The Eligible Employee's lawful spouse. (ii) The Eligible Employee's children (including any unmarried children's children until the Employee's child is 18), including step and adopted children and children placed for adoption with the Eligible Employee, who are less than 26 years of age; (iii) Notwithstanding (i) and (ii) above, the Eligible Employee's adult Dependent children, including step and adopted children and children placed for adoption with the Eligible Employee may be covered under this Contract if the adult child satisfies all of the following: (A) The child is a full-time student, regardless of age; and (B) The child was under 26 years of age when he or she was called to federal active duty in the National Guard or in a reserve component of the U.S. armed forces while the child was attending, on a full-time basis, an institution of higher learning; and (C) The child re -enrolled as a full-time student within 12 months of returning from active duty. (iv) A Dependent child over age 26 who is financially dependent on the Eligible Employee because of physical or mental incapacity that commenced while covered under this policy and prior to the Dependent child reaching age 26, provided a physician's certificate of disability is submitted within six months following the Dependent child's 26'h birthday. The Company reserves the right to request proof of continued disability from time to time, but not more often than annually after the two-year period immediately following the Dependent child's attainment of the limiting age, (c) If an Eligible Employee or Covered Dependent is activated while in the Reserve or National Guard, coverage terminates at the time of departure for active duty. Covered Dependents of activated Reserve and National Guard personnel may elect continuation of coverage as described under Paragraph 3.6. Upon return to civilian status, the Eligible Employee or Covered Dependent will be reinstated on the date he/she returns to work. 3.2 Effective Date of Eligible Employee's Coverage The effective date of coverage for a Subscriber is specified in the Declarations.,,,. An Eligible Employee who waived coverage because he/she was covered under other insurance may elect coverage to be effective on the first day of the month following the loss of such other coverage. The Eligible Employee must apply for such change in coverage within 30 days of the event causing the loss of the other coverage. 7 3.3 Effective Date of Eligible Dependent's Coverage Except as otherwise stated in this Paragraph 3.3, if the Eligible Employee chooses family coverage, if available, the effective date of a Covered Dependent's coverage is the effective date of the Eligible Employee's coverage. Any change in coverage selection (single or family) because of marriage, divorce, or death causing a change in enrollment status will be effective as specified in the Declarations. Coverage of a newborn child of a Subscriber is effective on the child's date of birth. The Subscriber must notify the Company within 60 days of the birth of a child. Additional Premium will be required if the Subscriber is not enrolled for family coverage. When additional Premium is required, Premium will be charged from the first day of the month following the date of birth. If the Premium payment is not made, coverage for the newborn child will cease on the 61st day after birth unless within one year after birth the Subscriber pays the Company all past due Premium and 5z/s% interest per year on any past due Premium. If the Subscriber notifies the Company and pays the additional Premium, if any is required, within 60 days of an adoption or placement for adoption, the adopted child's coverage will be effective on the date of adoption, the date of a final order granting adoption, or the date the child is placed for adoption, whichever comes first. An Eligible Employee who waived coverage for his/her Dependents because his/her Dependents were covered under other insurance may elect coverage for his/her Dependents to be effective on the first day of the month following the loss of such other coverage. The Eligible Employee must apply for such change in coverage within 30 days of the event causing the loss of the other coverage. 3.4 Enrollment Eligible Employees must elect coverage during the initial eligibility period specified in the application for enrollment or during an Open Enrollment Period, if applicable, in order to receive Benefits. Persons not eligible during an Open Enrollment Period may be enrolled immediately upon attaining eligibility. The Group agrees to complete and furnish to the Company on or prior to the first day of every month eligibility data in a format approved by the Company showing all Subscriber change information. The Company will be obligated to provide Benefits only to Eligible Employees and Dependents who are enrolled and are reported on the list of Subscribers submitted by the Group and for whom the appropriate Premium has been paid under Article TV of this Contract for the period for which Benefits are provided. The Open Enrollment Period is the period of time in which Eligible Employees and Subscribers may elect or change coverage, if such period is offered to the Group in the Declarations. Except as otherwise stated in this Contract, if an Eligible Employee declined coverage for himself/herself, or family coverage if family coverage is available under this Contract, then election of coverage or a change to family coverage may only occur during the Open Enrollment Period. Any changes made will be effective on the renewal date of the Contract. 8 3.5 Termination of Subscriber and Covered Dependent Coverage (a) Subject to any rights to continue coverage provided under Paragraph 3.6, enrollment under this Contract of any Subscriber or Covered Dependent may be terminated, or renewal of enrollment refused by the Company, under the following circumstances: (i) The Contract is cancelled or not renewed under Article VIII. If cancelled, coverage ends on the effective date of cancellation. If nonrenewed, coverage ends on the expiration date. (ii) The date on which the Subscriber or Covered Dependent loses eligibility. Eligibility of employees shall terminate on the last day of the month on which full-time employment terminates. Dependents of an employee are eligible until the employee's eligibility terminates or until loss of Dependent status, whichever occurs first, Loss of Dependent status shall occur on the date on which the Dependent ceases to meet the requirements contained in Section 3.1 (b) herein. (iii) Upon ten days' written notice if the Subscriber or Covered Dependent knowingly perpetrates or permits another person to make a material misrepresentation in obtaining Benefits under this Contract. (iv) Termination of coverage of a Subscriber shall automatically terminate the coverage of any Dependent of that Subscriber on the same date that the Subscriber's coverage terminates. (b) Upon termination of Subscriber or Covered Dependent coverage as indicated above, no further Benefits shall be provided under this Contract to a terminated Subscriber or Covered Dependent. 3.6 Continued Coverage Under Title X of the Consolidated Omnibus Reconciliation Act of 1985 (COBRA), Subscribers and Covered Dependents in employer groups of more than 20 employees ("Qualified Beneficiaries") are permitted to elect continuation of coverage under this Contract upon the occurrence of any of the following "Qualifying Events": (a) Subscriber: (i) Termination of employment, voluntary or involuntary, except for reasons of gross misconduct; or (ii) Reduction in hours to fewer than the minimum required to be an Eligible Employee under this Contract. (b) Covered Dependents: (i) If the Covered Dependent is the Subscriber's spouse: 0] (A) Death of Subscriber; or (B) Termination of Subscriber's employment, except for reasons of gross misconduct; or (C) Reduction of Subscriber's hours to fewer than the minimum required for eligibility for coverage under this Contract; or (D) Divorce or legal separation from Subscriber; or (E) Subscriber's Medicare entitlement. (ii) If the Covered Dependent is the Subscriber's child: (A) Child ceases to be a Dependent; or (B) Death of Subscriber; or (C) Termination of Subscriber's employment, except for reasons of gross misconduct; or (D) Reduction in Subscriber's hours to less than the minimum required to be eligible as a Subscriber under this Contract; or (E) Subscriber becomes entitled to Medicare; or (F) Parents become divorced or legally separated. The Group must provide notice to the Subscriber and to Covered Dependents, as applicable, of the right to elect COBRA continuation coverage. A Covered Dependent whose coverage is terminated due to divorce, legal separation or cessation of eligibility for Dependent coverage must provide the Group notice of such event within 60 days of its occurrence. An election of continuation coverage must be made within 60 days beginning on the later of the date of the Qualifying Event or the date the Subscriber receives notice of election rights. The COBRA election by a Subscriber or covered spouse is deemed an election by all others who would lose coverage as a result of the same Qualifying Event unless otherwise specified in the election or the Covered Beneficiary independently elects COBRA continuation coverage. If election of COBRA continuation coverage is timely, the coverage begins on the date of the Qualifying Event and ends on the earlier of: (a) Eighteen months after the Subscriber's employment termination or reduction in hours. (b) Twenty-nine months after the Qualifying Event for 10 (i) a Qualified Beneficiary who is determined to be disabled under the Social Security Act at anytime during the first 60 days of COBRA coverage and who notifies the Group of such determination within the first 18 months of COBRA coverage; and for (ii) any nondisabled Qualified Beneficiaries with respect to the same Qualifying Event. (c) For Qualified Beneficiaries other than the Subscriber, 36 months after the date of the initial Qualifying Event for all other Qualifying Events. (d) The date on which the Qualified Beneficiary receiving continuation in coverage fails to make a timely payment of Premium. The Company will not reinstate COBRA continuation coverage once terminated for nonpayment of Premium. (e) The date on which the Group ceases to offer this Contract to any of its employees or members. {f) The date on which coverage begins under another group dental plan, as applicable. However, a person who has elected COBRA continuation coverage and whose new plan contains a pre-existing limitation clause can maintain COBRA continuation coverage until all pre-existing limitations under the new plan are satisfied. (g) The date the Qualified Beneficiary becomes entitled to Medicare benefits. The first Premium must be paid to the Group within 45 days of the election of COBRA continuation coverage. Future Premium payments must be paid by the first day of each month. In accordance with ERISA Section 602(3), premium for a qualified disabled person will be 150% of the single, family, or other applicable Rate for the coverage during months 19 through 29 of COBRA continuation coverage. The premium for all other COBRA continuation coverage will not exceed 100% of the Rate in effect for the Group during months one through 18, and will not exceed 102% of the Rate in effect for the Group during months 19 through 36, if applicable. ARTICLE IV PREMIUMS; DEDUCTIBLES; INSURANCE; COVERAGE REQUIREMENTS 4.1. Premiums (a) Premiums payable by the Group under this Contract are based on the number of Subscribers and the applicable Rate under each Benefit option at the time of initial enrollment and are adjusted monthly to reflect the current number of Subscribers. If the number of Subscribers reported by the Group for any month during the term is less than the number of Subscribers reported for the first month of the Contract Term by greater than 10%, or drops below the required minimum enrollment identified in the Declarations, the Company may adjust the Rate or terminate this Contract as provided in Paragraph 8.1(b). 11 (b) The Group agrees to pay the Company the Premium in full by the first day of the month for which coverage is in effect. The Contract provides a 31 -day grace period. If Premiums are not paid on or before the date they are due, they must be paid during the 31 -day period following that date. The Contract will terminate at the end of the grace period if the Premiums have not been paid. The Group is responsible for payment of Premiums for coverage provided during the grace period. (c) In the event the Company is notified of any change to, or termination of, coverage of a Subscriber with respect to which the Group failed to provide prompt notice, the Company will refund or adjust Premium retroactively for a three-month period preceding the date of such notice, provided the Company has paid no claims during that three-month period. No adjustment will be made if Delta Dental has paid claims after the change to or termination of coverage. (d) The Group agrees to permit the Company, by its auditors or authorized representatives, on reasonable advance written notice, to inspect its records to verify the accuracy of lists of Eligible Employees and Dependents prepared by the Group and submitted to the Company. 4.2 Deductible In addition to any other limitations on specific Benefits that are described in the Schedule of Benefits, Benefits also are subject to any Deductible described in the Declarations. Subscribers are required to satisfy any applicable Deductible before the Company is obligated to pay Benefits under the Contract. 4.3 Coinsurance In addition to any other limitations on specific Benefits that are described in the Schedule of Benefits, Benefits will be subject to the Coinsurance indicated in the Schedule of Benefits. Subscribers and Covered Dependents are required to pay any such Coinsurance amounts directly to the provider. 4.4 Optional Procedures Delta Dental will pay the applicable Maximum Plan Allowance for the least expensive Dental Procedure that is adequate to restore the tooth or dental arch to contour and function, but only if that Dental Procedure is a Benefit of this Contract. The Subscriber or Covered Dependent will be responsible for the remainder of the Dentist's fee if a more expensive Dental Procedure is selected. The Coinsurance and Deductible will apply regardless of which Dental Procedure is selected. 4.5 Dental Procedure Incurred A Dental Procedure is incurred on the date it is completed. Dental Procedures are considered for Benefits if they are incurred during the Contract Term and a claim is filed within one year after the date on which the Dental Procedure is incurred. The Subscriber or Covered Dependent will 12 be responsible for payment for any Dental Procedures that are completed after termination of the Subscriber's or Covered Dependent's coverage. ARTICLE V GENERAL EXCLUSIONS This Contract does NOT cover any of the following: 5.1 Any Dental Procedures, supplies, treatment or any other services provided or commenced prior to the effective date of the Subscriber's or Covered Dependent's coverage under the Contract. 5.2 Any Dental Procedures, supplies, treatment or any other services to treat injuries or conditions compensable under worker's compensation or employer's liability laws. 5.3 Charges for completion of forms. 5.4 Charges for consultation. 5.5 Any Dental Procedures, supplies, treatment or any other services excluded as provided in the Declarations. 5.6 Dental Procedures not specifically covered under this Contract. 5.7 Prescription drugs, premedications or relative analgesia. 5.8 Charges for anesthesia other than charges by a Dentist for administering general anesthesia in connection with covered oral surgery (cutting procedures). 5.9 Preventive control programs. 5.10 Charges by any hospital or other surgical or treatment facility, or any additional fees charged by a Dentist for treatment in any such facility. 5.11 Charges for treatment of, or services related to, temporomandibular joint dysfunction. 5.12 Services that are determined to be partially or wholly cosmetic in nature. 5.13 Cast restorations placed on Covered Dependents under age 12. 5.14 Prosthetics placed on Covered Dependents under age 16. 5.15 Appliances, restorations, or procedures for: (a) increasing vertical dimension; (b) restoring occlusion; 13 (c) correcting harmful habits; (d) replacing tooth structure lost by attrition; (e) correcting congenital or developmental malformations except in newly born children; (f) temporary Dental Procedures; (h) splints, unless necessary as a result of accidental injury. 5.1.6 Dental Procedures provided by other than a Dentist or licensed hygienist employed by a Dentist. 5.17 Dental Procedures to treat injuries or diseases caused by riots or any form of civil disobedience. 5.18 Dental Procedures to treat injuries sustained while committing a criminal act. 5.19 Dental Procedures to treat injuries intentionally inflicted. 5.20 Replacement of lost or stolen dentures or charges for duplicate dentures. 5.21 Dental Procedures in cases for which, in the professional judgment of the attending Dentist, a satisfactory result cannot be obtained. 5.22 Local anesthetic is covered as part of a Dental Procedure. General anesthetic or intravenous sedation is a Benefit only when billed with covered oral surgery (cutting procedures). 5.23 If orthodontic procedures are included as Benefits under this Contract, the repair and replacement of orthodontic appliances is not covered. ARTICLE VI COORDINATION OF BENEFITS AND PROCEDURES 6.1 Applicability (a) This Coordination of Benefits (COB) provision applies to This Plan when a Subscriber or Covered Dependent has health care coverage under more than one Plan. "Plan" and "This Plan" as used in this Article VI are defined below. (b) If this COB provision applies, the order of benefit determination rules shall be applied first. The rules determine whether the Benefits of This Plan are determined before or after those of another Plan. The Benefits of This Plan: 14 (i) shall not be reduced when under the order of benefit determination rules, this Plan determines its benefits before another Plan, but (ii) may be reduced when, under the order of benefit determination rules, another Plan determines its benefits first. This reduction is described in Paragraph 6.4 below, Effect on the Benefits of This Plan. 6.2 Definitions In addition to the definitions of this Contract, the following definitions apply to this Article; (a) "Allowable Expense" means a necessary, reasonable, and customary item of expense that is covered at least in part by one or more of the Plans covering the person for whom the claim is made. When a Plan provides benefits in the form of services, the reasonable cash value of each procedure provided shall be considered both an Allowable Expense and a dental Benefit paid. (b) "Claim Determination Period" means a calendar year during which Allowable Expenses are compared with total benefits payable under the policy (without applying COB). It does not include any part of a year during which a person has no coverage under This Plan, or any part of a year before the date this COB provision or a similar provision takes effect. (c) "Plan" means any of the following that provides benefits or services for, or because of, medical or dental care or treatment: (i) Group insurance or group -type coverage, whether insured or uninsured, that includes continuous 24-hour coverage. This includes prepayment, group practice or individual practice coverage. It also includes coverage other than school accident -type coverage. (ii) Coverage under a governmental plan or coverage that is required or provided by law. This does not include a state plan under Medicaid, Title XIX, Grants to States for Medical Assistance Programs, or the United States Social Security Plan whose benefits, by law, are excess to those of any private insurance program or other nongovernmental program. Each contract or other arrangement for coverage under (i) or (ii) is a separate Plan. Also, if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate Plan. (d) "Primary Plan/Secondary Plan": The order of benefit determination rules state whether This Plan is a Primary Plan or Secondary Plan as to another Plan covering the person. When This Plan is a Secondary Plan, its dental Benefits are determined after those of the other Plan and may be reduced because of the other Plan's benefits. 15 When the Company is the Secondary Plan, the Company may reduce the Benefits under this Plan only when the sum of the following exceeds the total Allowable Expense in a Claim Determination Period. (i) The benefits the Secondary Plan would pay for Allowable Expenses in the absence of COB; plus (ii) The benefits that would be payable under other applicable Plans for Allowable Expenses in the absence of COB, whether or not claim is made. The amount by which the Secondary Plan's benefits are reduced shall be used by the Secondary Plan to pay Allowable Expenses not otherwise paid, which were incurred during the Claim Determination Period by the person for whom the claim is made. As each claim is submitted, the Secondary Plan determines its obligation to pay for Allowable Expenses based on all claims which were submitted up to that point in time during the Claim Determination Period. When there are more than two Plans covering the person, This Plan may be a Primary Plan as to one or more other Plans and may be a Secondary Plan as to a different Plan or Plans. (e) "This Plan" means this Contract. 6.3 Order of Benefit Determination Rules (a) General. When there is a basis for a claim under This Plan and another Plan, This Plan is a Secondary Plan, which has its Benefits determined after those of the other Plan, unless: (i) the other Plan has rules coordinating its benefits with those of This Plan; and (ii) both those rules and This Plan's rules described in subparagraph (b) require that This Plan's dental Benefits be determined before those of the other Plan. (b) Rules. This Plan determines its order of benefits using the first of the following rules, which applies. (i) Nondependent/Dependent. The benefits of the Plan that covers the person as an employee, member or subscriber are determined before those of the Plan that covers the person as a dependent of an employee, member or subscriber. (ii) Dependent Child/Parents Not Separated or Divorced. Except as stated in subparagraph (iii) (C) below, when This Plan and another Plan cover the same child as a dependent of different persons, called "parents": (A) the benefits of the Plan of the parent whose birthday falls earlier in the calendar year are determined before those of the Plan of the parent whose birthday falls later in the calendar year; but 16 (B) if both parents have the same birthday, the benefits of the Plan that covered the parent longer are determined before those of the Plan that covered the other parent. However, if the other Plan does not have the rule described in (A) but instead has a rule based upon the gender of the parent, and if, as a result, the Plans do not agree on the order of benefits, the rule in the other Plan shall determine the order of benefits. (iii) Dependent Child/Separated or Divorced Parents. If two or more Plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order: (A) first, the Plan of the parent with custody of the child; (B) then, the Plan of the spouse of the parent with custody of the child; and (C) finally, the Plan of the parent not having custody of the child. AIso, if the specific terms of a court decree state that the parents have joint custody of the child and do not specify that one parent has responsibility for the child's health care expenses or if the court decree states that both parents shall be responsible for the health care needs of the child but gives physical custody of the child to one parent and the entities obligated to pay or provide benefits of the respective parents' Plans have actual knowledge of those terms, benefits for the dependent child shall be determined according to Paragraph 6.3(b)(ii). However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses of a child, and the entity obligated to pay or provide the Benefits of the Plan of that parent has actual knowledge of those terms, the Benefits of that Plan are determined first. This paragraph does not apply with respect to any Claim Determination Period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge. (iv) Active/Inactive Employee. The benefits of a Plan which cover a person as an employee who is neither laid off nor retired or as that employee's dependent(s) are determined before those of a Plan which covers that person as a laid off or retired employee or as that employee's dependent. If the other Plan does not have this rule and if, as a result, the Plans do not agree on the order of benefits, this rule (iv) is ignored. (v) Continuation Coverage. (A) If a person has continuation coverage under federal or state law and is also covered under another Plan, the following shall determine the order of benefits: 17 1. First, the benefits of a Plan covering the employee, member, or subscriber or dependent of an employee, member, or subscriber. 2. Second, the benefits under the continuation coverage. (B) If the other Plan does not have the rule described in subparagraph (A), and if as a result, the Plans do not agree on the order of benefits, this paragraph (v) is ignored. (vi) Longer/Shorter Length of Coverage. If none of the above rules determines the order of benefits, the benefits of the Plan that covered an employee, member or subscriber longer are determined before those of the Plan which covered that person for the shorter time. If a covered person is entitled to coverage under a group health care plan which primarily covers services or expenses other than dental care, and if the covered person first became eligible under the Plans on the same date, this Plan shall be the secondary payor for those services covered by both Plans. 6.4 Effect on the Benefits of This Plan (a) When This Paragraph Applies. This Paragraph 6.4 applies when, in accordance with Paragraph 6.3, Order of Benefit Determination Rules, This Plan is a Secondary Plan as to one or more other plans. In that event, benefits of This Plan may be reduced under this paragraph so that the total benefits paid or provided by all Plans during a Claim Determination Period are not more than the total Allowable Expenses. Such other Plan or Plans are referred to as "the other Plans" in (b). (b) Reduction in This Plan's Benefits. The benefits that would be payable under This Plan in the absence of this COB provision will be reduced by the benefits payable for the total Allowable Expenses in a Claim Determination Period under the other Plans, in the absence of provisions with a purpose like that of this COB provision, whether or not claim is made. When a Plan provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an expense incurred and a benefit payable. When the benefits of This Plan are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable Benefit limit of This Plan. (c) No rule in other Plan. If the Other Plan does not have rules coordinating benefits with those of This Plan, the benefits of the other Plan are determined first. 6.5 Right to Receive and Release Needed Information The Company has the right to decide the facts it needs to apply these rules. The Company may get needed facts from or give them to any other organization or person without the consent of the 18 insured but only as needed to apply these COB rules, Medical records remain confidential as provided by applicable state and federal law. Each person claiming benefits under This Plan must give the Company any facts it needs to pay the claim. 6.6 Facility of Payment A payment made under another Plan may include an amount that should have been paid under This Plan. If it does, This Plan may pay that amount to the organization that made that payment. That amount will then be treated as though it were a Benefit paid under This Plan. The Company will not have to pay that amount again. The term "payment made" means reasonable cash value of the benefits provided in the form of services. 6.7 Right of Recovery If the amount of the payments made by the Company is more than it should have paid under this COB provision, it may recover the excess, at its option, from one or more of: (a) the person(s) it has paid or for whom it has paid; (b) insurance companies; or (c) other organizations. The "amount of payments made" includes the reasonable cash value of any benefits provided in the form of services. ARTICLE VII CLAIMS AND GRIEVANCE PROCEDURES 7.1 Prior Approval of Benefits Your group dental plan does not require prior approval before dental services are provided. However a Subscriber or Covered Dependent, or the Subscriber's or Covered Dependent's Dentist, may request a predetermination of Benefits to obtain advance information on coverage under the Group's plan before services are rendered. Payment, however, is limited to the Benefits that are covered under the Group's plan and is subject to any applicable deductibles, copayments, coinsurance, waiting periods, and annual lifetime benefit maximums. 7.2 How to Contest a Claim Denial (a) Urgent Care Situations: (i) .,;,,;Method of Notification. Notice of an Urgent Care Grievance will be accepted by the Company if made by a Subscriber or Covered Dependent, or that person's representative, by telephone or in writing directed to: 19 Delta Dental of Wisconsin, Inc. 2801 Hoover Road, P.O. Box 828 Stevens Point, WI 54481-0828 800-236-3712 (ii) Resolution Process. If the Urgent Care Grievance cannot be resolved through informal discussions, consultations or conferences during the first 48 hours after the Company's receipt of the Urgent Care Grievance, the Subscriber, Covered Dependent, or a designated representative may appear before the Company's Grievance Committee to present written or oral information with the right to ask questions before the Grievance Committee. (iii) Time Limitation for Resolution. An Urgent Care Grievance will be resolved, whether informally or by the Grievance Committee, within 72 hours of its receipt by the Company. (b) All Other Grievance Situations Not Including Urgent Care: (i) Denial of a Claim for Benefits. If a Subscriber or Covered Dependent makes a claim for Benefits under the Group's dental plan and the claim is denied in whole or in part, the Subscriber or the Covered Dependent, or his/her service provider, will receive written notification within 30 days after the Company receives the claim, unless special circumstances require an extension of time for processing. The claims decision will be sent on a form entitled "Explanation of Benefits." If additional time is necessary for processing a claim for Benefits, the Company will notify the Subscriber or the Covered Dependent and his/her service provider of the extension and the reason it is necessary within the initial 30 -day period. If an extension is needed because either the Subscriber or Covered Dependent or his/her service provider did not submit information necessary to make a Benefits determination, the notice of extension will describe the required information. The Subscriber or Covered Dependent, or his/her service provider, will have 45 days from receipt of the notice to provide the specified information. (ii) Appealing a Claim Denial. If the Subscriber or Covered Dependent has questions about the denial of his/her claim for Benefits, he/she should contact Delta Dental at 800-236- 371.2. Because most questions about Benefits can be answered informally, the Company encourages Subscribers and Covered Dependents to first try resolving any problem by talking with the Company. However, Subscribers and Covered Dependents have the right to file an appeal requesting that the Company formally review the Benefits Determination. 20 To file a grievance or to appeal a Benefits determination, contact the Company's Benefit Services Department at 800-236-3712, fax your request to 715-343-7615, or mail your request to: Delta Dental of Wisconsin, Inc. 2801 Hoover Road, P.O. Box 828 Stevens Point, WI 54481-0828 The Subscriber or Covered Dependent should provide the reasons why he/she disagrees with the Company's Benefits determination and include any documentation he/she believes supports his/her claim. He/she should include the Subscriber's name, the Covered Dependent's name if applicable, and the Subscriber's Social Security number on all supporting documents. (iii) Resolution Procedure. The Company will acknowledge the Grievance or Benefits determination appeal within five days of its receipt by the Company. The Company will attempt to resolve the Grievance or Benefits determination appeal through informal discussions, consultations or conferences. In the event that the Grievance or appeal remains unresolved, the Subscriber or Covered Dependent, or his/her representative, has the right to appear before the Company's Grievance Committee to present written or oral information and to question the Grievance Committee. The Committee shall advise the Subscriber, Covered Dependent, or his/her representative, of the time and place of the meeting at least seven calendar days before the meeting. If the Subscriber or Covered Dependent does not exhaust the appeal procedures described above, and if he/she files a lawsuit against the Group's plan and/or Delta Dental, as applicable, seeking payment of Benefits, the court may not permit the Subscriber or Covered Dependent to go forward with his/her lawsuit because he/she failed to utilize the Company's grievance/claims appeal procedures. No legal action can be brought against the Company later than three years after the date of the Grievance Committee's final decision on the review of the Benefits determination. (iv) Time Limitations for Resolution. The Company will attempt to resolve all Grievances and Benefit determination appeals within 30 calendar days after receipt by the Company. The Company will inform the Subscriber or Covered Dependent of its decision in writing, If the appeal is denied in whole or in part, the notice will include the following information: (A) The specific reason(s) for the denial of the appeal; (B) The reference to the specific Contract provision(s) on which the denial is based; 21 (C) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of all documents, records, and other information relevant to the claimant's claim; (D) A statement describing any voluntary appeal procedures offered by the Company and the claimant's right to obtain information about such procedures; and a statement of the claimant's right to bring a civil action under Section 502(a) of ERISA; (E) If an internal processing policy or other similar criterion was relied upon in the denial of the appeal, the notice of such denial also will include either the specific processing policy or a statement that such processing policy was relied upon in denying the appeal and that a copy of that processing policy will be provided free of charge to the claimant upon request; (F) If the denial of the appeal was based on a dental necessity, experimental treatment or similar exclusion or limit, the notice of such denial also will include an explanation of the scientific or clinical judgment for the determination, applying the terms of the Contract to the claimant's circumstances, or a statement that such explanation will be provided free of charge upon request; and If the Grievance or Benefit determination appeal cannot be resolved within 30 days from receipt by the Company, the Company will notify the Subscriber, Covered Dependent, or his/her representative, in writing that it intends to extend the period of time for resolution an additional 30 days. The notification will state when resolution may be expected and the reasons for the additional time needed. All Grievances and Benefit Determination appeals will be resolved within 60 days from date of receipt by the Company. The Company's Grievance Committee shall consist of four persons: a consultant chosen by the Company, a representative of Company management, the Company's claim administrator, and a Subscriber in a Company plan who is not a Company employee. The Subscriber or Covered Dependent may resolve any grievance through the Company's Grievance procedure outlined above. The Subscriber or Covered Dependent may also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency that enforces Wisconsin's insurance laws, and file a complaint. The Subscriber or Covered Dependent can contact the OFFICE OF THE COMMISSIONER OF INSURANCE BY WRITING TO: OFFICE OF THE COMMISSIONER OF INSURANCE Complaints Department P.O. Box 7873 Madison, WI 53707-7573 or the Subscriber or Covered Dependent can call 800-236-8517 outside of Madison, or 266-0103 22 in Madison, and request a complaint form. ARTICLE VIII TERM; TERMINATION; NONRENEWAL 8.1 Term This Contract shall remain in force for the term stated in the Declarations as long as the Premium is paid on a timely basis unless terminated sooner as specified in Paragraph 8.2. This Contract will renew continuously and automatically on the anniversary date of the effective date of This Contract unless the Group requests nonrenewal. 8.2 Cancellation (a) The Group may cancel this Contract by giving the Company 30 days' notice in writing. (b) The Company may cancel the Contract by giving Group ten days' notice in writing upon the occurrence of any one or more of the following events: (i) The Group fails to make a required Premium payment within the 31 -day grace period. (ii) For substantial breach of contract if the Group fails to furnish the Company with accurate enrollment data pursuant to Paragraph 3.4 of this Contract. (iii) For substantial breach of contract if the Group permits enrollment which is contrary to specifications in the Declarations, or the initial group application. (iv) For substantial change in the risk assumed if the Group changes the amount of Subscriber contribution or the conditions under which Benefits are offered, including but not limited to flexible benefit plans, flexible spending accounts, cafeteria plans, and the introduction of other plans from which the Subscribers may choose. (v) For misrepresentation if the information relied upon in the application was inaccurately represented and would have caused the Group to be unacceptable to the Company at the time the Contract was issued. (c) Delta Dental may cancel the Contract upon giving the Group 30 days' written notice in the event of any of the following: (i) For substantial breach of contract if the Group refuses to allow the Company (by its auditors or other authorized representatives) to inspect its records in order to verify the accuracy of the Subscriber and Covered Dependent list. (ii) The Group is no longer engaged in the type of business the Company agreed to insure. 23 8.3 Nonrenewal Should the Company exercise its right to nonrenew this Contract, it will give the Group notice of such nonrenewal at least 60 days prior to the expiration date. Nonrenewal may occur if the Group allows enrollment to fall below the amount specified in Item 2 of the Declarations. ARTICLE IX GENERAL PROVISIONS 9.1 Limitation of Liability (a) Nothing herein contained shall interfere with the professional relationship between the Subscriber or Covered Dependent and a provider. In no instance shall the Company be liable for conduct, including but not limited to, tortious conduct, negligence or the wrongful acts or omissions of any provider or other professional practitioner or their agents or employees, in the provision or receipt of health care. (b) No agent has authority to change this Contract or waive any of its provisions. (c) The Group understands and acknowledges that no insurer can guarantee one hundred percent accuracy and that errors will occur from time to time. If a clerical error or other administrative mistake occurs, that error will not deprive Subscribers or Covered Dependents of coverage under the policy that they otherwise would have had and it will not create coverage for Subscribers or Covered Dependents that does not otherwise exist under the policy. 9.2 Rights of Subscribers and Covered Dependents The rights of each Subscriber to receive Benefits are outlined in the Contract and the Declarations attached to this Contract. Nothing contained herein shall limit the right of the Company and the Group, which right is hereby expressly reserved, to amend or terminate this Contract, or to modify the appendixes hereto on a prospective basis from time to time, and any such amendment, termination and/or modification shall automatically be effective as against the Subscribers and Covered Dependents without notice to or consent of any Subscriber or Covered Dependent. 9.3 Entire Agreement This Contract constitutes the entire agreement between the Company and the Group and may not be altered or amended except in writing, provided that specific Benefits and coverage options specified in the Declarations may be modified upon agreement of both parties and will be effective not less than 60 days after the Company delivers updated Declarations to the Group, except as otherwise required by law. 9.4 Endorsements Nothing contained in any endorsement to the Contract shall affect any of the conditions, provisions, or limitations of the Contract, except as expressly provided in the endorsement. This 24 Contract shall govern over any conflicting information provided by the Group to its employees and Subscribers. 9.5 Advertising and Promotion Control The Company reserves the right to control the use of its name and all symbols, trademarks and service marks presently existing, or hereinafter established, with respect to it or to any Company Benefit option. The Group agrees that it will not use such name, symbols, trademarks, or service marks in advertising or promotional materials or otherwise without prior written consent of the Company and will cease any and all usage immediately upon the Company's request or upon termination of this Contract. 9.6 Notices Any request for change to any of the provisions of this Contract shall be in writing except as otherwise specifically provided herein. Such request is considered to be delivered when delivery is in person or when sent by registered or certified United States mail return receipt requested, proper postage prepaid, and properly addressed to: Delta Dental of Wisconsin, Inc. c/o President P.O. Box 828 Stevens Point, WI 54481-0828 9.7 Assignment Neither party shall have the right to assign or otherwise transfer its rights or obligations under this Contract except with the prior written consent of the other; provided, however, that a successor in interest by merger, operation of law, assignment, purchase, or otherwise of the entire business of a party hereto shall acquire all interests of such party hereunder. 9.8 Legal Action No suit at law or in equity shall be brought to recover upon any cause of action arising out of or relating to this Contract, or to Benefits provided hereunder, without exhausting Grievance procedures established by the Company, nor after the expiration of three years from the event upon which any such cause of action is based. 9.9 Governing Law This Contract is delivered in the State of Wisconsin and is governed and construed under and pursuant to its laws. 9.10 Nonwaiver and Severability No delay or failure by the Company to exercise any remedy or right accruing to it hereunder shall impair any such remedy or right or be construed to be a waiver of any such remedy or right, nor shall it affect any subsequent remedies or rights that the Company may have hereunder, whether or not the circumstances are the same. 25 The unenforceability or invalidity of any provision of this Contract as to any person or circumstances shall not render that provision or those provisions unenforceable or invalid as to any other person or circumstances, and in all other respects it and the remainder of this Contract shall remain valid and enforceable. 9.11 Rules and Regulations The Company may, from time to time, establish such guidelines and processing policies as are reasonably necessary or appropriate to administer the Benefits provided under this Contract, and the Group agrees to be bound by any such rules and regulations. 9.12 Oral Statements No oral statements of any person shall modify or otherwise affect the Benefits, limitations, conditions and exclusions of this Contract, convey or void any coverage, increase or reduce Benefits under the Contract, including the Certificate and the Schedule of Benefits, or be used in the prosecution or defense of a claim under this Contract. 9.13 Subrogation If Benefits are paid on a Subscriber's or Covered Dependent's behalf under this Contract, the Company is entitled to all rights of recovery the Subscriber or Covered Dependent may have against any person or organization for the recovery of those Benefits to the extent of the Company's payment. The Company can only subrogate if the Subscriber or Covered Dependent is made whole for damages (is fully compensated for all damages, including any award for loss of employment, pain and suffering, taking into consideration the Subscriber's or Covered Dependent's comparative negligence). The Subscriber or Covered Dependent must sign and deliver to the Company any legal papers relating to that recovery, help exercise these rights of recovery and do nothing to harm these rights. If the Subscriber or Covered Dependent is made whole for all damages from another person or organization for Benefits paid or provided under this Contract, the Subscriber or Covered Dependent must repay the Company to the extent of Benefits paid or provided under this Contract. Master Group Contract PPO V6 (3113) 26 POLICY ENDORSEMENT NO. 616 - 0 - 07052017 Attached to and forming a part of the Contract to Provide Dental Care Benefits between City Of Oshkosh and Delta Dental of Wisconsin, Inc. It is agreed and understood that Declarations, Section 7, Monthly Premium will be replaced with the following, effective January 1, 2018 and ending on December 31, 2018: Single Coverage (employee, 1 Party) $34.66 Family Coverage (employee and spouse, 2 Party) $70.30 Family Coverage (employee and child, 2 Party) $70.30 Family Coverage (full family, 3+ Party) $132.53 DentalRateEndorse 10.08