HomeMy WebLinkAbout8.8 Participate in American Business Dental Trust r
CITY OF DUBLIN Lf 0
AGENDA STATEMENT
CITY .COUNCIL MEETING DATE: March 26 , 1984
SUBJECT Authorization to participate in American Business
Dental Trust
EXHIBITS ATTACHED California Dental Health Plan Proposal; Resolution
Authorizing Participation in American Business Dental
Trust
RECOMMENDATION Adopt Resolution
FINANCIAL STATEMENT: Total maximum cost to the City approximately $4 , 000
per year
Sufficient funds to provide this benefit have been
included in the 1983-84 budget
DESCRIPTION Staff has contacted several insurance brokers and _
requested proposals for dental insurance coverage . Due to the small size of
the group to be insured, the availability of comprehensive plans is limited.
Three brokers provided the City with ten ( 10 ) carriers which specialize in
providing benefits to small groups . A thorough comparison of each
alternative was completed and the options were discussed with the employees .
The proposal offered by California Dental Health Plan offers- many advantages
to the City and its employees .
First, the rate structure is divided into three tiers. In,many of• the other .
plans evaluated, an employee and one . dependent would be required to pay the
family rate. also, this plan offers the option for employees to - select a
panel , provider program. This option applies -the concept : Kaiser uses in
health care to dental care . The City is not '. required =to =- have - a minimum
number of employees select this .option. . The..'employee willthave a choice of -.. ,
programs once each year during open enrollment: Finally, the cost of this
type ' of iasurance is competitive with other proposals._
In order to implement this benefit effective May 1, 1984 , it will be
necessary for the Council to adopt the attached resolution.
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COPIES TO:
ITEM NO. .�
r ( '
y�}
.141
iCalif®rnla
,-.
enta0
H ealth
Plan'ith1
y
California
Dental
Health 6 53 South "B" Street - Tustin CA 92680
Plan (714) 731-6133
DENTAL HEALTH PLAN PROPOSAL _
FOR
CITY OF DUBLIN
1'
Presented By
Harold Hill
.'r California Dental Health
`"z'• Plan
653 South "B" Street
Tustin, California 92680
714 730-0145
December 13, 1983
$00
California
Dental
H ealth
Plan
California Dental Health Plan is pleased to submit a swing
plan proposal to you as you choose a quality dental health
care program for your employees.
CDHP offers the employees and their eligible dependents. high
quality dental care through a choice of two plans. One
hundred percent participation of eligible employees is
- required on either plan. Following is °a brief description:
Plan ~I, - Indemnity Plan
American Business Dental
Fully insured by Federal Home Life Insurance Company
This plan gives the employee the .'option of -choosing-..his,,or,
her own dentist. Some of the benefits are:
Plan annual maximum per calendar year -
Deductible (maximum of $125 per family) $50
Part I - Preventive procedures '(no deductible) 100%*
.Part II - Routine procedures ;,r, ;::- , ;;� ,,..; 80$*
Part III - Major procedures 50%*
' Part IV - Orthodontia 50$*
$1000 lifetime maximum when ,such.I r_eT_f,�
treatment begins one year after a
dependent.!s;-effective =datef4of ,, I�vxis,.�+ CPak
dFFental ,service.
l�iVw L'rs`(' .i ,°'+
n ,
* According; to the Schedule, of..Maximum .covered charges
included in this .proposal.,; c
r
i1*�J v r i 1 y
-
' � ,Plan -II -Newnort' Pre=paid Plan 300
. � }�,. State license-d Plana }�d
x '>" ?, x'X t '°' f �.tit`- d •t `
...�
TMs. �h The employee ;selects a 'CDHP. pfeferred-,panel dentist from tithe � r3 s t
flµ list of over :,1 O .,contracted :dental i o ffices th oughoutT �t��
,a "`'California. These are` not 'clinics but""privately owned y . -
t- neighborhood, offaicesr,;with dentistsho =have, agreed;;toy give
. .-_ _.
the -same,-guality ,;care' and ;service_ toy wour .members: aq,,, ly
give their ;own :pr,ivate.cpatients.={,.!-`
�!�C° :� "-G.'1 iqq t A 1, .t ..>t :�. 1-� � .^'! ^^''rrN. f)TW 'Y,.. '•f. r � 1
. i;t�ir J" ..t'-�nr^i.ft....� � :•:... ✓� �-.. .. wi 'J.S... �..4 y �` .. of �•: ,�
This,,Pl.an„has �no,;•deductibles,_ no,,,claim -:;forms: and a.,�,on'
$2,000 per person annual maximum.
653 South"B” Street, Tustin, California 92680 (714) 731-6133 ,." " ti
Page two
Preventive and Diagnostic care is covered 100% and
includes the following:
Office visits
Clinical exams
X-rays i
Teeth cleaning
Routine Dental Care is covered 100% and includes the
following:
- Restorative Dentistry '.(fillings).
**Periodontics
**Endodontics
Oral Surgery (extractions)
**See miscellaneous _._. �.': ::._.-..._ _. ,.:_..•.. +: _.. ._,•. .
alor Dental, Care' '(with no. waiting period)'
+ This plan covers Major Dental Care at 100% except for two
co-payment's•
.' Crowns':and Bridges .per.:.unitr:x:550
�= Dentures/Partials per unit 470 - - - •
:'2 _
` Miscellaneous Co-paynierits
, � . '?•a.t:tzt t:�?�, '+! !,: �� ati -+� ;J`�3lid.:.°ta:�'7�
*Sub in ival curetta 'e - r- �ua'drant` $-I.40':00` -
Osseous or ,Muco-gingival surgery
per quadrant ' 200.00
*Roots=canal� tYier'a ' per-�canalii � �ij 35.00
treatment ,to rel ieve' �q.z_�� s`i i ,i ph
,Emergency,.,,
}} , ; t' gtl •..) I _ , F iii -
t. P .. -z p...n 3•... - - ��'♦ r Y' 1 £ {" „
alliative 15 .00z
p j.•e k .r... ? F _ ` , � v � i. � t 1•
i
Failure Ito :cancel appointment ��� „� �r;
t 1
,.,fi �rJk.i i•Jt`,,/•ir,^. ��, t<*ti''SSf�ltti 'if r �f ,fl...'����'.:".i
71 4 y�r,.�1,/•�,,y(i'�.X1(.7, ,.At:X y:l i 5*,?+ 11i'r�' ifS� ,S •.,j f, c•.ti{ t . a l qr'r my,it,t'(24 hours r Prio ., '!r5It r C�3.�•:.k.y k.44 'u-.�}k,7^'v,'20 .00.�d A +,. - r:' �k,r�.{+f i...tK l 5 >. ,f"..�l
I .s;.t +�u eJl 4rl r;v.«:•• w r!. : .; �.•. S t
CS + !�. x ;),I e� , }�. +� ,a 'a !•,8 t i, e � r ,• 1
+'rl�?,.r`Y.,'¢ +,,,,.,ft a)`�^t. L 1,..w.,,�' .y i 4^ �y i r,a• a 4 a�t+t s,y t4,Ru�, t t!a i �S r'.a'r r •''�x
w
''trt'tP.S,.,S Y•t �.k; zti a'�yy+4+i,?;1.3t . s{�`T•' �.� � , 7� � .J t >7..�_' � 2`y r' ,P,:, � '3 s'' ,F�,�-ri'�ct$i:•'rs °�13'rJ"Etr�.Kr' . ie 4
` .}
1tWf'1 .YNY( ; i .. •Yf�d MF v4 \ R,..T _ CA.1f '1R f`!'e !�•Vi' .1 d4 1
./�� • •-f 'Y �' �}✓i M Y'.'fi v" V� '.�� F'
l t ai'' !, ,tr -,1.,cas _'" •.• t. �:.,M,i•R 9, %1,.:9,ti- pty -4I,� 1 r, ry ai, u
MSyra 'L4♦ t't:v'i � ,i}t14�;F' a 'y
-� ti ,�l t , S Orthodontic Care tin,! ,s �e5il w� .lari ,S wl � , .tip, i . + -vbm.t .Jyra
i? ; : .!• I,'tit "q ,f ..rf '1Y..`1 iT�.'.�t3N 1�'y+' iY•:Y ltt S . r s.:4''" r $' f k+��, krJry.+ �F•'�f -;:'�..r.1.•T 3if�_3� piN;✓.f r
A„
J Plan '=berfefits'`cover us'ualJ�'and cu'stomary� "orthodontic
treatmeritf-?(CT'ass' I{cteeth' st'raighteri ng)':+,The ••maximum':fee":
charged_ the , patient will 'be the $ i 5`ico=payment not
including x-rays and case studies for a 24-month treatment
i plan:`.t:Orthodontic treatment :must be ;provided by'"a member Hof
'°the iCDHP orthodontic panel.
T iI A'• 114 Yry�'��• � � '
.. .�'.��',al� + ' _.......w_._.-«.�._...w......._._.«�w.r.._........._ ...-.-...-,.._�_....-.+,.u......_.«.w..u......•.. .........way....... �._.r_._....-_.......-......w.._...r
Page three
Your employees may choose the plan that suits his needs
best. The employee may change from one plan to the other
once a year during open enrollment. Open enrollment will be
held on the anniversary date of your original enrollment
into the plan.
A dental provider listing and a sample of some of the groups
covered by CDHP, along with several business references have
been included for your information.
If you have any questions regarding this proposal , please
give us a call at (714) 730-0145 .
tits i Ir swh h i r .N -.i
r
r r 2
Y t 7
1 4
in
PLAN I
AMERICAN BUSINESS DENTAL TRUST
( USE DENTIST OF YOUR CHOICE)
THIS PLAN IS FULLY INSURED BY:
FEDERAL. HOME LIFE INSURANCE COMPANY
l i,. t =F!• r c-4 I '. r 1 y L' •k y
-Yp.�E.'r1j`• 1. )� S � Y a t 1 �: w st s Si k .,.
PL AN I
PrincipI Benefits And Coverages
Annual Maximum per person $1000
Deductible per person $50
(max. of $125
per family
Part I Preventive Procedures 1008
(No Deductible)
Part II Routine Procedures 808
Part III Major Procedures 508
Part IV Orthodontia 508
(Dependent 'children under age 19)
$1000. lifetime maximum Tt : .
*Schedule of -maximum covered ;charges 4 ;I � f}r ;rd.
included in .this proposals; ', " a... + ' ;t ` .l
Zf
DENTAL PROGRAM
Covered Dental Services
Part I - Preventive Procedures:
1. Oral Prophylaxis, to include scaling of teeth and
routine oral examination, and will be authorized only
once during any 6 month period.
2 . Topical applications of fluoride for children.
3 . Space Maintainers to replace primary teeth up to age 19.
Part II - Routine Procedures:
1 . Full Mouth X-Ray Series (or Panographic X-Ray) , will be
authorized not more than once during any 24 consecutive
month period. Bitewing and single film X-Rays as
professionally required.
-2. Restorations, fillings (amalgam, composites, etc. ) other
than gold or cast restorations, to restore diseased or
accidentally broken teeth.
3 . Emergency Treatment, palliative.
4 . Oral Surgery, as follows.: Extraction of teeth,
alveolectomies, frenectomies, removal ,of .tori, cysts, ..
tumors and other lesions,',.root recovery (sinus) , and
biopsies.
5 General anesthetics, Ywhen medically necessary and
i J administered in conjunction with oral surgery
procedures.
!1 �+' �•F y �, ,. i t. -..i „ -.a x -f - d* s'`r t ..•C ;.,' / ., t>.... ,r-4 i - _ '
6 : "Endodontic Treatment, =root canal treatment.
t 7 . Periodontal Treatment: n ',
7 .
Recementing ,crowns, inlays' or -bridges.
9. Injection of `Antibiotic Drug by the"attending Dentist
10 . Adjustments and repairs ' to full and partial dentures and .: ..:. . -
fixed bridgework. ;
11 . Relines and rebases - not more often than once every 2
years. ;
C' '
Part III - Major Procedures:
1 . Jackets, Full cast or Veneer Crowns, and all gold and
cast restorations. These restorations will be
authorized only when the tooth, because of extreme
caries or fracture, cannot be restored with amalgam,
composite or other restoration.
2. Initial Fixed Bridgework, splints and full or partial
dentures for the replacement of permanent teeth:
a. which were extracted on or after the effective date
of this insurance.
b. which were extracted or missing prior to the
effective date of this insurance.
3 . Replacement of fixed bridgework, splints, or full or
partial dentures if the appliance is at least 5 years
old and cannot be made serviceable.
Part IV - Orthodontia:
Appliances and treatment for dependent children under 19 when
such treatment begins one year after a dependent' s effective date
of dental insurance.
�' fr� r - F- •,..� � t' t ir_� a .*i, c .t
Excluded Dental Charges
Covered Dental Charges do not include and no benefits are
payable for :
1 . Loss as a result of any occupational accident or
sickness covered by Worker ' s Compensation or as a
result of war or act of war, declared or
undeclared, or participation in a riot.
2. Services or supplies which may be payable under
other provisions of any Group Health Policy.
3 . Charges which the insured person in the absence of
this insurance is not legally obligated to pay.
4 . The replacement of lost, stolen, or missing
prosthetic devices.
5 . Services which are furnished, paid for, or
otherwise provided for by reason of past or present
service of any person in the armed services of a
government.
.6 . Treatment which is cosmetic in nature.
7. Services, Appliances, or Restorations, which:
a., increase vertical dimension
b. restore occlusion
c. replace tooth structure lost by attrition . ,
d. correct congenital or .developmental .malformation
. e. : are employed 'in Implantology Techniques
f. Myofunctional treatment'.or .therapy
8 . Completion .of insurance or� other .forms, or broken .- _
dental appointments.,
Examinations * are..made durin ,the same ^` i
9 . Exa in g '
a intment,�for°whichchargest re mad or other E5
„ ;rx PPo b FL s, a e� f, t
ser• i{res• .f
,, h, _ w a `� r�sL 't �v. �,i.d q. '.i� s �. i ;�r r� r "C”'� r•, >a
Temporary,prosthesis.
Training , n, '1or} Supplies used {;for ;dietar
,,:;oral hygieneot'plaque control
f counseling ;
r � t t� :d N{
12. ''Specialized techniques .:involving gold, precision
attachments,`-personalization 'o r_.characterization:
:. Allowance will - be made -.for conventional . procedure.
Procedures which are considered experimental in
nature, 'such as sealants.'
13. Veneers or similar materials "of crowns and pontics
placed on or replacing teeth, other -than the ten
upper -and lower anteror ,teeth.
14. Services or supplies related to periodontal
L splinting.
Charges exceeding the amount shown are not covered:
Maximum
Covered
Charge
part I - Preventive - Covered immediately
Oral Prophylaxis - to include examination and scaling
of teeth (only once each 6 months)
Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 25.00
Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.00
Topical Fluoride Application (for children only) . . . . . 17.00
Space Maintainers for missing primary teeth, up to
age 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.00
Part II - Routine:
Diagnostic Study Models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 20.00
Radiographs (only once each 24 months)
Full mouth series (including examination
and bitewings) Minimum 14 films. . . . . . . . . . . . . . . . . . 39.00
Bitewing X-rays (including examinations) . . . . . . . . . . . 11.00
Single Films - First Film. . . . . . . . . . . . . . . . . . • • . • . . . . 6 .00
Each Additional Film. . . . . . . . . . . • . • . . 4 .00
Amalgam Restorations
Deciduous Teeth:
1. One Surface• • . • . . . . • . . . . . . . . . . . . . . . . . . . • . • • . . • . . 17.00
2. Two Surfaces— . . . . . . . . . . . . . . . . oo . . 25.00
3 . Three or more Surfaces• • • • . . . . . • . . . • . . . . . . . . . . • . 34.00
Permanent Teeth:
1. One Surface. 20.00
2. Two . Sur faces. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.00
3 . ' Three or more Surfaces. . . . . . . . . . . . . . . . . : . . . : . . . . 39.00
Silicate, plastic or - composite restorations. 22.00
Silicate, plastic :or ' composite restorations
r involving :incisal angle: : . . :. . . . . . . : .. : .':: . . . . : .. 36.00,, v
Recementing
crown,, ,facing and bridge (per abutment
J
aooth) : :: : . : . . . :.. . . . . . . . . . 17.00 . E
Emergency-.Treatment,'- Palliative 17.00
fi. Oral ,ESurgery _ . :. x, ,;_,.,��
i A Simple;ext`ractions •;:(including ,local ,anesthesia and ' ,via
:post=operative-,care?
'First .Tooth . . . . .`. . . . . . : . . 0 : . '. . 0 0 0 0 0 . . 0 8.00
_.
Each Additional . Tooth:. . . • . : : :. . • . . . .0 . . . :': • : .': • • • • 22.00 . ._ 's
-Impactions (including local anesthesia and t
post-operative ,care) ;
Soft Tissue• . . . . • • . • • . . .-. . : •-• • • • • • • • • • • • • • • • • • . • • . . 77.00
Partial (bone) . : . . • • . . • . . . . . . • • • • • • • • • • : • . • • • : . • . . . 119.00 • '
Complete (bone) . . . . . . . • . . . . . . . : • . • . . .: • . • : • • • • • • • . . ,168.00 .-
Alveolectomies ' (per quadrant) • . . • . • . . . • • • • • • : . . • : : • . . 77.00
Frenectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 .00
Removal of tori, cysts, tumors and other lesions. . . . . 119.00
Root recovery (sinus only) . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 .00
Biopsy of Oral Tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63.00
Endodontic Treatment and Root Canal Filling
Single Rooted Tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 .00
Bi-rooted Tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238.00
Tri-rooted Tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266.00
Apicoectomy
In conjunction with endodontic therapy. . . . . . . . . . . . . 63.00
Independent Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84.00
Periodontia
Periodontic treatment (non-surgical) ,
scaling and root planing, per quadrant. . . . . . . . . . . . 56.00
Periodontic treatment (surgical)
per quadrant, hard tissue. . . . . . . . . . . . . . . . . . . . . . . 252.00
Periodontic treatment (surgical)
per quadrant, soft tissue . . . . . . . . . . . . . . . . . . . . . . . . . 133 .00
Occlusal Equilibration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 .00
Denture Repairs
Broken Dentures
WithNo Teeth Involved. . . . . . . . . . . . . . . . . . . . . . . . . . . 49.00 .
With Teeth Involved (each tooth) . . . . . . . . . . . . . . . . . 28.00
Replacement of Broken Tooth on Denture or
Facing on Bridge
First Tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . 49.00 `
Each Additional Tooth. . . . . . . . . . . .. . 00 — . . . 0 . . . . . . . . 28.00
Adding Tooth to Replace Extracted Natural Tooth _ _: n U:
t:
First Tooth. . . . . . . . . . . : 0 .•0 . .. : . . . :0 . 0 . . . . . . . . . . : . . 84 .00
Each . Additional Tooth. :'. . . . 0 . 000 . . . : . . . . . . . .
Adding Clasp to Denture. . . . a. . � .'. . . .�. x=98 '00
Q
i . r •'ti ,:t •r.- a ��S j,'cr 4,a ��wt r r e° y r ♦n' 'ac q �..�`" ry'4-i.r � ht�
3 �� ' 6 ..!• .� y n . ;? ^ 1 _ -.. 4�. ;.. , t s5}.,,urn r e ,� '� iy it n.JS k _� �3
Rebase Full ,Upper or Full �Lower4,Dent*ure ; � , t�`� atF d{ Ott, t r f ``z •o,
Office _. Cold Cure. : . . . . . :. . . . . .: . :: :.`. .: :. .` 98:00 > , t
i t C
Laboratory,- Heaue. 7 14000" ; s Y � �
� t s.. _ r .- ! t rt t. ..j xL•at 5 3�• � � . i t'Y •'.F } c Syr a .y rti� .'-.t
i
Part III Major - „r� xA� =t �•
Gold Restorations ^_ i
1. One Surface. . . . :. . . . . . . :'.. . . :': . . $133 .00-
2. Two Surfaces. . . —o . . . . . : :0 0 . . . 0 0 0000.. . :. . .. . . . . 196 .00
3 . Three or more' Surfaces. . . . : . . . . . . . . . :. : . . . . . . . . . 259.00 . :
Jackets s"
Plastic-Acrylic. . . . . . . . . . . . . . . . . . . . . .: . : . .?. 0 . . . 00 . 0 210 .00.. .
Porcelain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 .00
Veneer Crown
Plastic with Gold. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301. 00
Plastic with Non-Precious Metal . . . . . . . . . . . . . . . . . . . . 245 .00
Porcelain with Gold. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 .00
Porcelain with Non-Precious Metal . . . . . . . . . . . . . . . . . . 287 .00
Cast Crowns
Full or 3/4 Cast - Gold. . . . . . . . . . . . . . . . . . . . . . . . . . . . 294 .00
Full or 3/4 Cast - Non-Precious Metal . . . . . . . . . . . . . . 252 .00
Fixed Bridgework
Abutment Crowns (Retainers) and Pontics - same
allowance as single crowns except Pontics
Cast Gold, Trupontic, Steel ' s Facing - each. . . . . . . . 252 .00
Full Dentures - Including Adjustments
Upper. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462.00
Lower. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490 .00
Partial Dentures - Including Adjustments
Bilateral Partial upper or lower
Cast Base with 2 or more cast clasps with rests. . . 434.00
Plastic Base with 2 or. more Wrought Clasps with
rests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315.00 -
Unilateral - Removable Partial . . . . . . . . . . . . .. . . . . . . . . .. ; 217 .00
... The Schedule of. Maximum Dental .Covered Charges may not be all ',..,: -
`°. inclusive.,*For ,'any procedure which. ,is 'not ',listed .and not s; .
''Otherwise 'excluded from coverage, an allowance :consistent with .
those .`listed will be -determined by. the Company:
f ,.,,This plan. includes a .coordination of benefits 'provision. x,If.,any
family member 'is eligible .to ' receive .benefits ;under another ';group ,
or.,J'ianchise''plan , employee.:welfare 'or..bene its' plan, l;or, ;through::: :
s any., governmental - program, =,benef its :under;;;this;'plan:will b6.,
�4 fi
`coordinated with the •benefits. f rom ariy other-,;'plan so ,that%up tow i1a
f_jf .F100$
of; the ;,°allowable, expenses° :incurred ;during {a calendar :-year
w wi11 be.,paid,Jo`1ntly by.`.the ,'plans. ;Ah'-. allowable '.expense.,,. is .any
reasonable, ;,necessary . and customary' item of $,expense �co:vered in: _
:.part: or ,full°'under 'any -`one of the plans ,involved._ _
EXTENDED BENEFITS
If insurance ends other than for payment of the maximum benefit,: .
before completing a course of dental treatment which .began while .
insured, insurance for only . the . incomplete treatment will. be -
extended for the first of:
1. The date insurance begins under another group dental
policy, which pays benefits for the treatment in
progress;
2. Three months if insurance ends while not totally
disabled; or
3 . Twelve months if insurance ends while totally disabled.
,�� yt 1 y ,,y ti �t_d :. � f •�'i !'. r;F r .t Iz zFt .,+ HSj+y�7,tirc.��flr b
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OPTIONAL BENEFIT
GROUP SURVIVORS MONTHLY INCOME
This benefit is designed to provide a monthly income to the
family of a deceased during a two-year adjustment period after
the death of an employee prior to age 70.
Payments begin upon notification of proof of death of an employee
and are paid monthly thereafter.
If death occurs before age 65, the benefit payable is $250
monthly for 24 months. If death occurs between ages 65 and 70 the
benefit is $175 monthly for 24 months.
Benefits are paid in accordance with the following order of
qualification:
a. Surviving spouse
b. Any unmarried child of the deceased under age 21 at the
time of each monthly payment
c. Any parent of the deceased who is dependent upon the
deceased for at least 50% support in the calendar year _
preceding death
d. If no eligible survivors, payment will be made in one
lump sum .to the duly appointed executors or
administrators of the estate
If more • than one _ survivor. in Class B `or :C,` -payments will
be divided equally. ' ,
' The monthly. rate `for this .benef it is $3.15,._per.. employee.��; This
? ? r cost is 'not incl tided in the monthly .rates pr opose c, �
tys. J is ;• t. ' t tt ! ^r i . ;} a } -} �! f �SJ i j � ?F r , 5. 'i -F.
li rii1; ,u
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PLAN II
NEWPORT PRE-PAID PLAN 300
(USE A PREFERRED PANEL DENTIST)_
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California
Dental
H ealth
Plan
ABOUT_ CALIFORNIA DENTAL HEALTH PLAN
CALIFORNIA DENTAL HEATLH PLAN was formed in 1972 as -the .
United Dental Health Corporation. It is a state licensed,
pre-paid dental health care corporation under the Knox-Keene
Act of 1975. CDHP was granted its permanent license under
Knox-Keene in February 1979. The company is regulated by `
the Department of Corporations and is required to provide ,
financial reports on a regular basis.
The Plan must maintain a Public Policy Committee, a
Grievance Committee, and a system of quality review in each
dental office contracted with the Plan. All .offices are
visited on a regular basis by our field representatives for
purposes of reviewing the facilities and maintaining the
highest quality dental care available. .-,
Our 'dentists 'are all *.in their own priva te -practice ;in -your
neighborhood and have -contracted with .us'to-,provide the same =^M
quality ;service to our, members �as '.to "their ,pryivate `.practice
patients.
CALIFORNIA DENTAL HEALTH PLAN serves over 50,000 people4 �. z?T q
` under:; its dental care.,,programs._ -:Our groupiplans�allow us•�to , •i ' � -
s ''provide°.the best cover` age".at `the lowestF cost toy employers:
r a 1 r t' .j . r.•. Y H 3 'r T3 r r •.. k r !. 1 _ ,T..ql ly2 - fi % V ut� �•�
f Iii e t •. , W.rr: f..•.-r r ',,,. J ry,t r n �
This plan 1s cost effective for.. the_'employer:, because' .you.
r _ ° can "give .:your ::employees ,excellent benef its twith almost.,no i,
{ out of pocket' expense ,and the `cost Ito you `is minimal. 'Ay, ��� '" 4Y r �?'
.n
653 South"B" Street, Tustin, California 92680 (714) 731-6133 ` "`�
�NERAL �I��ORMATION
WHAT IS A PRE-PAID PLAN?
A prepaid plan is based on the concept of "preventive" dentistry.
The need for dental care on a regular basis is the backbone of
this program, and it works because dentists, themselves, see the
advantage of seeing their patients on a -regular basis. They are
willing to share the risk of dental care costs with the
administrative company in order to persuade patients not to
neglect their regular dental care. The CALIFORNIA DENTAL HEALTH
PLAN dentists have their own private practices and have
contracted to provide services to members at no cost or a low
co-payment fee.
The Co-payment Schedule and Summary of Benefits for this .Prepaid
Plan are included in this proposal .
WHERE ARE THE SERVICES RENDERED?
Services are provided through a State-wide association of dental
offices which are under contract with CALIFORNIA- DENTAL' HEALTH
PLAN.
When your employee enrolls; : he/she` selects a''dental ' office ' near
home_ or:work.- :,All dental services are performed at this office.
WHAT 'IF EMPLOYEES MOVE, OR ARE NOT HAPPY -WITH ' THE `DENTISTS?
They may . change facilities by sending written '.notice. '''•Upon ;...:.r: `i
approval by the Plan, they - will be sent a new Identification -
Card.;,.. ,Change of Statusicards will be furnished',.to•ryou�for•=your
employees' use when a change of address occurs, a dependent ' is
added .'or deleted, .nor an`remployee rwants to change'.to' another -
dental facility �,,
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APPOINTMENT' AVAILABILITY
� .j,ux�Y aj�� k:-4�,• ^..r t C. 1 t f d r '� .i.. a _ .i. 7 {� ( �)f{� ;+
t:
Most rdental 'appointments .will,�,be .during regular;�,working' hours,
Mo'nday;;`through;�Friday r : Some;^offices' have- evening and/or;jtweekend
t ' hours;available. .' Your people-..can•'.telephone:the. office "they:have'
selected to':verify .. ours .they are •open: :' Y z,L. tL'
S • _TA .TY' EFERRAL.r �� att :s`. .... ._�... „t' �xm w ;
a. c. ,
If a member ;has a .covered .dental -problem sthat ='is -outside"the " y
scope *-of wthe .dental rof fice they have selected; .we have 'a ;referral
program, !whereby they ..will-.be sent -to a ,.specialist ' and the"cost
to them is still no more than the co-payment listed •iri" their;.��
schedule of benefits. This procedure requires written .approval
of the Plan.
WHAT ARE THE ADVANTAGES OF THE PLAN
$2,000 .00 Maximum Benefits each year (Most Indemnity plans have a
$1,000.00 maximum)
No Deductibles
No Claim Forms
No Pre-existing conditions restricted
All of the covered services are performed by a CALIFORNIA DENTAL
HEALTH PLAN Dentist as he sees necessary and according to a
careful treatment plan prepared on the initial visit.
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NEWPORT PLAN 300
,SCHEDULE OF BENEFITS
DESCRIPTION MEMBER PAYS
Visits & Diagnostic
oral examination and diagnosis. . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Office visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Prophylaxis (children and adults, one every
six months) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Topical fluoride (children under age 14) . . : . . . . . . . . . . . .NO CHARGE
Bite-wing X-rays (no more than one series of
four films in any six month period) . . . . . . . . . . . . . . . . . .NO CHARGE
Each additional film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Full mouth X-rays (every two years) . . . . . . . . . . . . . . . . . . . .NO CHARGE
Restorative Dentistry
Amalgam fillings, primary and permanent teeth. . . . . . . . . .NO CHARGE
Sedative base. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Crowns and Brides
Crowns, per unit*. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50 .00
Bridges, per unit*. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ , , 50 .00 : .: a
. . Stainless Steel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . : : . . . . . . . . .NO CHARGE ; , .. . i
Y *Plus actual lab cost of gold (member.,responsible)
s4+ ' Periodontics
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!! \�.Cp 6A;1 Tf y � •y ` ? F'1 3
.Emergency; treatment °(periodontal abscess,
.acute
.,.,.; ; periodontitis, etc: )_:' : . . : :. . .�. . . . . :NO, CHARGE,;;
Gingivectoiny r
per ,quadrant, including ;'post
' + surgical visit. . .'.`.'. :`. :'. :: . : ... . . . :. : : . . . .tNO ;CHARGE `„d .
..�e t F .. .c,. }. H, 13} .. h� \ ' ��f�{ei c•+{ � tS'�}I tk�� .Clyp .3l �}}) JF 1 M 9 :I
Endodo
. � .i; >r 'tom t � {z rs "t''f "t Y >• ;�
Pulp capping. . . . . ... : : :: ... ... . . . . . . . . . .. .. . .�:. .: . : . . . :NO,.CHARGE
Therapeutic. pulpotomy, per treatment, An addition nY F
to restoration. . . . ... . . . . . . . . . . . :: . : . . : . ... . . . . . .NO CHARGE . .
Vital pulpotomy. . . . . : . . . . . . . . . . . . . . . . . . . . . . . . : : . . .NO CHARGE .,
Temporary restoration with CaOH; per tooth.. . . . .
: . . . . . . . . . . .NO CHARGE
Culturing canal. . . . . . . . . . . . . . . . . . . . . . . . ::: . . . : . . . . . . . . .NO CHARGE
SCHEDULE OF BENEFITS CONT' D
DESCRIPTION MEMBER PAYS
Prosthetics
Complete upper or lower denture, per denture. . . . . . . . . . . $ 70.00
Partial upper or lower denture, per denture. . . . . . . . . . . . $ 70 .00
Simple stress breakers. . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . .NO CHARGE
Stayplate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Denture adjustments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Denture reline (office) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Denture repairs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Oral Suraery
Specialist consultation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Biopsy or oral tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Local anesthetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
?: Extractions (uncomplicated) , local anesthesia. . . . . . . . . .NO CHARGE
Post-operative visits, sutures. . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
Partially bony impactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE - .
Completely bony impactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . .NO CHARGE
• Orthodontics
Excluding start-up fees. . : . . . . . . . . . . . . . . . . . . . .•.. : . . . . . : $1 ,395 .00
Miscellaneous ,
® ••� iii F� 1. x t §. - .� � , �{ + - .. - - r_C
° Emergency treatment,: palliative. . . . . . . . . . .. . ..too . . . . . $ ., t . 5 .00 w. . _..
Failure to cancel 'appointment (24 '.hours prior)
r = Subgingival' curettage, per quadrant. • : . . . ..`. . . .': ::'. : $:..a.4 40:•00
Root canal•'•,ther`a er . canal . . . . . . . . : . .`.
py;, p •. :$ � 35:00 i �� • : s'
Osseous ..or° muco-gingival surgery, .per quadrants. . {.200 :00
' i
NEWPORT PLAN 300
PRINCIPAL LIMITATIONS AND EXCLUSTONs
LIMITATIONS•
Prophylaxis once every six months.
Bite-wing X-rays limited to one series of 4 films
every six months.
Full mouth X-rays limited to once every 24 months.
Fluoride application to age 14 only and only once
per year.
EXCLUSIONS•
Cosmetic, elective or aesthetic dentistry.
Hospital and/or medical charges.
General Anesthesia, except when medically necessary.
Replacement due to loss or theft of dentures or
bridgework.
Cysts and malignancies. _ .. : ..._ _ .. .:. .;
a• Dispensing of drugs. , ''
Procedures; i'appliances or restorations :to correct
`'• congenital or developmental malformations.
:..
t '
Services for injuries..or .conditions whi.chf*,are;.
covered under Workers Compensation or Employers'.=r �: '� `•4•_ :rt
r ;Liability. `laws; or services :
PLAN COMPARISON & RATES
CHOOSE YOUR DENTAL PLAN
_PRINCIPAL BENEFITS AND COVERAGE PLAN I PLAN II
Use your dentist Use panel dentist
Annual maximum per calendar year $1,000 .00 $2,000 .00
Deductible $50 none
Part I - Preventive procedures 100%* NO CHARGE
no deductible
Part II - Routine procedures 80$* NO CHARGE
Part III - Major procedures
crowns & bridges 50%* $50 per unit
co-payment
dentures 50$* $70 per unit
(upper or lower ) co-payment
Part IV Orthodontic benefits 50%* $1,395 .00
( $1,000 max. ) co-payment
*According to Schedule of Maximum covered charges included in
'.'..'. ..*According
proposal. .
MONTHLY DUAL PLAN RATES
} , $ 50 Deductible
t` Employee Only $ 14.03 ,f r
+q �' r Employee .plus one ",dependent _ $,30 r12
r ,Employee plus 'two or more dependents x °$ 41 12
!°f11 t' A •ff l.t �(
,t!'.t t i [ r ,t: <.e r it.t3 o r•.5 } , 'i ( ,Z
. Orthodontic Benefit 'per 'employee
i _
ir t"t. Y-r- ,3ti # , r •'t ri
Survivor •Monthly. :Income ..Benefit
;:There will be a one-time enrollment fee of $10 per person to a
maximum of $70.
There will be a $10 monthly group administration fee.
;' This proposal is valid for 60 days and the rates are guaranteed
.:,:for one year.
GROUPS COVERED BY CALIFORNIA DENTAL HEALTH PLAN
Following is a sample of some of the groups covered by CDHP.
C.M. T. Federal Credit Union National Treasury Employees Union
1200 Missouri Street 209 Post Street, Suite 1112
Fairfield, CA 94533 San Francisco, CA 94108
(7 07) 422-9828 ( 415) - `'?q— bC,lto
Ruth Brateng, Operations Officer Carol Perkins, Assistant Counsel
City of Compton Oil , Chemical, Atomic Workers (OCAW)
205 S. Willowbrook Avenue 3605 Long Beach Blvd, Room 304
Compton, CA 90220 Long Beach, CA 90807
(213) 537-8000 ( 213) 426-6961
Ethel Davis, Personnel Analyst Tom Lind
Compton Unified School District ROLM Corporation
604 S. Tamarind Avenue 4900 Old Ironsides Drive
Compton, CA 90220 San Jose, CA 95050
(213) 639-4321 (408) 988-2900
R. Vincent Sangui net: , Employee Benef it Mgr .
" Coordinator of Risk Management
Environmental .Industries Sacramento Postal Employees
24121 Ventura Blvd Credit Union
Calabasas, CA 91302 : 106 "L" Street, 4201<�•:
(213) 992-5900 :° Sacramento, CA 9581415°S f
Carmen E. Reder (916) 44a 9
"
El rknz 3 ng Tech.
Hydro-Rain Company _ •- _ T ,!..`�
?: :27671 La Paz ' Avenue
7; .Laguna Niguel ," CA 92677
ti �t (714) 831-6000
«• "Ann Pastor , Administrative Mgr
' r
BUSINESS REFERENCES
i
Better Business Bureau of O.C. Tustin Chamber of Commerce
17662 Irvine Blvd. , Suite 15 399 E1 Camino Real
Tustin, CA 92680 Tustin, CA 92680
(714) 544-9181 (714) 546-2022
Ms. Sherrie Mahurin Todd Nicholson
Trade Practice Consultant Executive Director
(714) 544-5341
Maury Ross
C
FINANCIAL REFERENCES
Garden Grove Community Bank (714) 638-1200
11050 Garden Grove Blvd Perry Carter P
Garden Grove, CA 92642
Union Bank (213) 480-6636 .
3806 Wilshire Blvd Michael Brunson
Los Angeles,:. CA Senior Marketing Officer
LEGAL REFERENCES _
Bartlett & Larsen ::s: (714) 953-6222 r' G
Law Offices: 4 Howard M. Larsen ,a... .. .
Santa Ana, CA'"._ .. ;:.
Schur & •Domph (714) 730-1123
Law Offices ' Robert Schur I
.17291 Irvine Blvd #252
Tustin, .CA 92680
f ACCOUNTING_ REFERENCES
t v
William .& 'Magdaleno (714) 752-9283 . :{ :,
Certified Public Accountants Lou Magdaleno +. s ,
1300 Quail Avenue, Suite 100 -
Newport Beach, CA 92660
RESOLUTION NO. - 84
A RESOLUTION OF THE CITY COUNCIL
OF THE CITY OF DUBLIN
--------------------------------------
AUTHORIZING PARTICIPATION IN
AMERICAN BUSINESS DENTAL TRUST
WHEREAS, the Dublin City Council is desirous of
providing Dental Insurance to full-time employees who are not
employed on a temporary basis ; and
WHEREAS, the City Council intends to have these benefits
provided in the most cost effective manner which will meet the
needs of the employees ; and
WHEREAS, the City Council has allocated sufficient funds
in the City ' s budget for this benefit.
NOW, THEREFORE, BE IT RESOLVED that the City Council of
the City of Dublin authorizes the City Manager to execute the
American Business Dental Trust Employer Agreement and Application
( Exhibit A) .
PASSED, APPROVED AND ADOPTED this 26th day of March,
1984 . _
AYES:
NOES :
ABSENT:
Mayor
ATTEST:
City Clerk
Group Number G.E.D.
AMERICAN BUSINESS DENTAL ThvST
EMPLOYER AGREEMENT AND APPLICATION
— SHADED AREAS FOR OFFICE USE ONLY —
Employer Employer tax ID. number
CITY OF DUBLIN CALIFORNIA
City County State Zip
Address
6500 DUBLIN BLVD. , P. 0. BOX 2340 DUBLIN CA 94568
Name and Title of Person to Whom Billing is Directed
m
Phone Number Nature of Business No, of Years in same Loc. Requested Effective Date (effective
upon approval by ABDT) .
415 829-4600 ITY GOVERNMENT 5-1-84
Contribution of Premium by employer for: Type of Business Engaged in (Please check one):
100% ❑ Agriculture ❑ Manufacturing
Employee
❑ Commerce ❑ Retail/Wholesale
❑ Construction ❑ Service
Dependents 100% [R Government ❑ Transportation
❑ 5100 Deductible f$S50 Deductible ❑ 525 Deductible RATE N ENROLLED TOTAL
Employee onl y............... ................................ $14 .03
X S
Employee + 1 ................:................................. $30 .12 X
S
Employee+ 2 or more......................................... $41.12 X S
10.00
Monthly Administration Fee .................................................
......................5
Monthly Premium ......................................................
.:*0*0 ...................S
Enrollment fee S 10 per app./S70 max. (norrrefundable one time charge) 10.00 X S 70 . 00
First Months Remittance ...........................................................................5
Make check payable to American Business Dental Trust
Agent :i:e`: - ir'i?.=s s;';::�� ' %
If yes give name of carrier(include copy of billing& policy and Date of termination of previous plan
Will this replace any existing date your firm first provided a dental plan for your employees)
Insurance Plan YesYS,No
Number of eligible employees. Number of employees applying Number of dependent Number dependent units
for coverage. 8 Units Eligible. I applying for coverage.
1. The undersigned employer hereby adopts and enrolls in the group insurance plan of the American Business Dental Trust and subscribes to the
terms of the Trust agreement which established such Trust.It is understood that no coverage is in force until notice of approval has been furnished
by the Trust Administrator and premium has been received by the Trust Administrator. ;
_ 2. 1 further acknowledge and agree that no one other than Trustees or a person designated in writing by the Trustees may accept this application on
behalf of American Business Dental Trust.
3. 1 understand that only permanent, full time,active employees, partners and proprietors,working a minimum of 30 hours per week and their
eligible dependents are eligible for coverage. I understand the pre-existing conditions limitations of the insurance plan,and understand that
coverage is renewable at the option of the Underwriting Company.All eligible persons have been given an opportunity to enroll,and future
employees will be given the same opportunity when eligible. New empir yees are eligible for coverage on the first month following one full
calendar month of employment in a eligible class.
4. 1 understand the underwriting and participation requirements,and understand that the initial participation(if applicable)must be maintained or
exceeded in order for coverage to remain in force.
5. All employers will be billed monthly.Employer Agreement and Application,checkand employee information must be postmarked by the 20th of
the month prior to requested effective date.Enrollment fees are non-refundable,if less than$70.00 per group is paid,anynew employees will be
charged the enrollment fee, until a maximum of 570.00 has been paid by each group.
6. Insurance coverage shall become effective on the first premium due date coinciding with,or next following,satisfaction of anywaiting period and
receipt of proper enrollment material. Rates may be changed each year based upon those insured.
7. A 31-day grace period is allowed for premium payment. Upon termination of the plan,all unpaid premiums for insurance up to the date of
termination, including any part of the grace period during which the insurance was in force, is due and payable.
Signature of Authorized person, Official Title
Date signed
I hereby certify that all of the information contained in the agreement and application is correct to the best of my
knowledge, I have complied with underwritng rules and have explained in detail coverages. any exceptions are
detailed here or on an additional sheet.
Broker or General Agent Signature DATE