83-051 California Dental Service Agreement 0 -0S'
® �=-; -7I 51' STEPHEN •CHELBAY COMPANY
II[a;
' 9 EMPLOYEE BENEFIT PLAN CONSULTANTS
MAILING ADDRESS: P.O. BOX 5057. ZIP 95150.5057 • 1120 S. BASCOM AVE.. ZIP 95128-3590
SAN JOSE, CA • PHONE (4081 279.3131
December 5, 1988
Ms. Mary E. Reasoner
Personnel Technician
City of Cupertino
P. 0. Box 580
Cupertino, CA 95015
RE: COUNTY DELTA DENTAL PLAN
GROUP NO. 1766-0014
Dear Mary:
Here is a copy of the Delta Dental Master Document. It outlines
the dental benefits currently in force for employees and
dependents of your group.
Please call me if you should have any questions.
Sincerely,
ce
David K. Andresen
Executive Vice President
DKA/pmp 0)-0
Enclosure T ' tel
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HOSPITAL MEDICAL AND DENTAL PLANS • SALARY CONTINUATION PLANS
PENSION AND PROFIT SHARING PLANS • GROUP LIFE INSURANCE PLANS
I
AMENDMENT TO AGREEMENT
(RENEWAL)
GROUP #1766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY and
DELTA DENTAL PLAN OF CALIFORNIA "Delta", is hereby further amended, effective July
1, 1988, as follows:
. Number I. of page 1 is amended to read:
I. Applicant agrees to pay to Delta within ten (10) days after receiving each
monthly accounting, the amount shown thereof as the full amount of Dentists'
statements paid or otherwise discharged by Delta, plus $3.16 for each Eligible
Employee per month, to compensate Delta for its administration of the Program.
Paragraph 1.06 is amended to read:
1.06 "Contract Term" means the period commencing on the Effective Date hereof
and terminating on June 30, 1989, and each yearly period thereafter during
which this Contract remains in effect.
Paragraph 3.01 is amended to read:
3.01 The amount payable under this Contract, to be paid by Applicant to Delta,
at the address shown on the cover page of this Contract, shall be as
follows:
Applicant agrees to pay to Delta, within ten (10) days after receiving
each monthly accounting, the amount shown thereof as the full amount of
Dentists' statements paid, plus $3. 16 for each Eligible Employee per month
to compensate Delta for its administration of the dental program provided
hereby.
The amounts payable for each person who elects continued coverage as
provided in Section 2.04 for himself or herself only shall be the same as
for a single Eligible Employee. The amounts payable for a person who also
elects continued coverage for his or her dependents shall be the same as
for an Eligible Employee with the same number of dependents.
Applicant agrees to bear the expense of such amounts payable without
withholding or otherwise charging Eligible Employees for coverage of
themselves or their dependents. However, Applicant may charge persons
- electing continued coverage pursuant to Section 2.04 such amounts as are
permitted. by Title X of P.L. 99-272.
Paragraph 9.04 is-amended to read:
9.04 In the event of termination by Delta under paragraph 9.Ola) , all Benefits
•
shall terminate and Delta shall be released from all further obligations
of this Contract, effective on the last day of the month in which written
notice oftermination is given; provided, however, that Delta shall make
payment to Dentists for dental services authorized by Delta prior to
termination and performed in reliance on such authorization, if any. Delta
may retain funds on hand after termination until all such claims have been
discharged and Applicant shall remain liable to Delta for the full amount
of all Attending Dentists' Statements paid or otherwise discharged by
Delta pursuant to this Contract, including claims discharged pursuant to
this paragraph, plus $3.16 for each Eligible Employee per month as
provided in paragraph 3.01, less amounts actually paid by Applicant to
Delta.
DATED: July 20, 1988
SANTA CLARA COUNTY: DELTA DENTAL PLAN OF CALIFORNIA:
By: By:
By: By:
1
•
AMENDMENT TO AGREEMENT
GROUP #1766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY and
DELTA DENTAL PLAN OF CALIFORNIA "Delta", is hereby further amended, effectivf June
• 1, 1988, as follows:
Paragraph 2.02 is amended to include:
Sub-location 0002 shall hereinafter be known and referred to as West
Valley Sanitation District of Santa Clara County.
DATED: July 21, 1988
SANTA CLARA COUNTY: DELTA DENTAL PLAN OF CALIFORNIA:
By: By:
By: By:
•
• AMENDMENT TO AGREEMENT
GROUP #1766
•
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY and DELTA
DENTAL PLAN OF CALIFORNIA "Delta", is hereby further amended, effective March 1,
1987, as follows:
COBRA employees are eligible under this Contract.
Paragraph 1.02 is amended to read:
1.02 "Eligible Person" means an employee or a dependent who meets the
conditions of eligibility outlined in Article II of this Contract, or a
person no longer meeting such conditions who has elected continued
coverage as provided in said Article II, and for whom the appropriate
monthly payment specified in Article III is received by 'Delta.
Paragraph 2.01 is amended to read:
2:01 Applicant shall compile and furnish to Delta on or prior to the first day
of every month, . commencing on the Effective Date, a list of all Eligible
Employees, showing their federally assigned Social Security Numbers, the
dates of hire, and if applicable, the location code. Applicant shall also
include in the list, all persons electing continued coverage pursuant to
Section 2.04, showing their federally assigned Social Security Numbers and
dates of election.
Sub-paragraph 4 of paragraph 2.02 is amended to include:
Sub-location 1001 - COBRA employees
Paragraph 2.04 is amended to read:
2.04 Eligibility of an employee shall terminate on the last day of the month in
which full-time employment terminates, unless the Eligible Employee elects
to continue coverage under the Continued Coverage Option Rider (attached
hereto as Appendix "F") . Eligibility of dependents shall terminate along
with the Eligible Employee's,- or sooner upon loss of dependent status,
- unless continued coverage is ,elected by or on behalf of the dependents
under the Continued Coverage Option Rider. Eligibility for such continued
• . coverage shall continue for the period required. by the Rider. Eligibility
shall , in any event, terminate immediately upon termination of this
Contract. _
Paragraph 3.01 is amended to: include:
The amounts payable ; for each personwho elects continued coverage as
provided in Section 2.04 for himself or herself only shall be the same as
for a single Eligible Employee. The amounts payable for a person Who also
elects ' continued coverage for his or her dependents shall be the same as
for an Eligible Employee with the same number of dependents:.
• Applicant agrees to bear the expense of such amounts payable without
withholding or otherwise charging Eligible Employees for coverage of
themselves or their dependents. However, Applicant may charge persons
electing continued coverage pursuant to Section 2.04 such amounts as are
permitted by Title X of P.L. 99-272.
ARTICLE X - ATTACHMENTS is amended to include:
Appendix "F" Continued Coverage Option Rider
Appendix "F", Continued Coverage Option Rider, attached hereto, is hereby made a
part of this Agreement.
DATED: March 4., 1988
SANTA CLARA COUNTY: DELTA DENTAL PLAN OF CALIFORNIA:
By: By:
By: By:
•
•
•
-
•
APPENDIX "F"
• CONTINUED COVERAGE OPTION RIDER
EFFECTIVE: March 1, 1987
•
In consideration of the payments specified in paragraph 3.01 of the attached
Contract, and subject to all of the terms and conditions thereof, Delta agrees to
provide Benefits to persons who elect continued coverage pursuant to this Rider.
1. For purposes of this Rider, each of the following shall constitute a
"Qualifying Event":
(a) Termination of an Eligible Employee's employment With Applicant
(other than for gross misconduct), or a reduction in the number of
hours worked by the Eligible Employee to less than the minimum number
of hours required under Section 2.02 of the attached Contract.
(b) Death of an Eligible Employee.
' (c) Divorce or legal separation from an Eligible Employee.
(d) An Eligible Employee becoming entitled to Medicare benefits.
(e) A dependent child ceasing to meet the description of dependent child
contained in Section 2.02 of the attached Contract.
2. Eligible Employees whose coverage under this program is terminated by
reason of a Qualifying Event described in Section 1 (a) of this Rider may
elect to continue coverage for eighteen (18) months following the month in
which the Qualifying Event occurs.
3. Eligible Dependents whose coverage udder this program is terminated by
reason of any of the Qualifying Events described in Section 1 (b) through
(e) of this Rider may elect to continue their coverage for thirty-six (36)
months following the month in which the Qualifying Event occurs. However,
persons who elect to continue their coverage based on a Qualifying Event
described In Section 1 (a) of this Rider, . and whose coverage is terminated
within the next eighteen (18) months by reason of a Qualifying Event
described In Sections 1 (b) through (e) of this Rider, may elect to
continue their coverage for a maximum of thirty-six (36) months following
the month in which the first Qualifying -Event occurred. -
4. Continued coverage can be elected only by notice to Applicant, which must
be ' given no later than sixty (60) days after a termination of coverage by
reason of a Qualifying Event, or within sixty (60) days after the Eligible
Person receives from Applicant a notice about his. or her rights to
continued coverage because of the particular Qualifying Event, whichever
is later. Persons for whom a Qualifying Event described in Section 1 (c) ..
6—(e) occurs must report it to Applicant within sixty (60) days, or lose
their right to elect continued coverage.
5. Continued coverage elected by a person under this Rider shall be effective
as of the first day of the month following the applicable Qualifying Event
described in paragraph 1 above. However, Benefits shall not be available
to .a person electing continuing coverage until Delta receives the data
about such, person required in Section 2.01 of the Contract, along with all
amounts payable then currently payable for such person as stated in
Section 3.01. Delta shall not, in any event, make Benefits available under
this Rider with respect to any person for whom such information and
amounts payable are not received by Delta within sixty (60) days after the
date such person is required by Section 4 of this Rider to notify
Applicant of his or her election.
6. Continued coverage for persons under this Rider shall be the same as the
coverage for similarly situated Eligible Persons under the attached
Contract, and if coverage is modified for such Eligible Persons it shall
also be modified in the same manner for persons having continued coverage
under this Rider.
7. A person's continued coverage elected under Sections 2 or ,3 of this Rider
shall terminate on the last day of the month in which any of the following
events first occurs:
' (a) The period of continued coverage specified in Section 2 or 3 expires.
(b) This Contract terminates.
(c) Applicant fails to pay amounts payable for the person as specified in
Section 3.01 of the Contract.
(d) The person with continued coverage becomes covered for dental
benefits under another group health plan (as an employee or
otherwise) .
(e) The person becomes eligible for Medicare benefits.
8. Once continued coverage under this Rider is terminated, it cannot be
reinstated.
DATED: March 4, 1988
DELTA DENTAL PLAN OF CALIFORNIA:
By:
•
AMENDMENT TO AGREEMENT
GROUP #1766 •
•
AGREEMENT dated July .1, 1978, as amended, between SANTA CLARA COUNTY and DELTA
DENTAL PLAN OF CALIFORNIA "Delta", is hereby further amended, effective -July 1 ,
1987, as follows:
COBRA employees are eligible under this Contract.
Paragraph 1 .02 is amended to read:
1.02 "Eligible Person" means an employee or a dependent who meets the
conditions of eligibility outlined in Article II of this Contract, or a
person no longer meeting such conditions who has elected continued
coverage as provided in said Article II, and for whom . the appropriate
monthly payment specified in Article III is .received by Delta.
Paragraph 2.01 is amended to read:
2.01 Applicant shall compile and furnish to Delta on or prior to the first day
of every month, commencing on the Effective Date, a list of all Eligible
Employees, showing their federally assigned Social Security Numbers, the
dates of hire, and if applicable, the location code. Applicant shall also
include in the list, all persons electing continued coverage pursuant to
Section 2.04, showing their federally assigned Social Security Numbers and
dates of election.
Sub-paragraph 4 of paragraph 2.02 is amended to include:
Sub-location 1001 - COBRA employees
Paragraph 2.04 is amended to read:
2.04 Eligibility .of an employee shall terminate on the last day of the month in
which full -time employment terminates, unless the Eligible Employee elects
to continue coverage under the Continued Coverage Option Rider (attached _
hereto as Appendix "F") . Eligibility of dependents shall terminate along
with the Eligible Employee's, . or sooner upon loss of dependent status,
• unless continued coverage is elected by or on behalf of the dependents
under the Continued Coverage Option Rider. Eligibility for such continued
coverage shall continue for the period required by the Rider. Eligibility
shall , in any event, terminate immediately upon termination of this
Contract.
Paragraph 3.01 is amended to include:
•
The amounts payable for each person who elects continued coverage as
provided in Section 2.04 for himself or herself only shall be the same as
for a single Eligible Employee. The amounts payable for a person who also
elects continued coverage for his or her dependents shall be the same as
for an Eligible Employeewith the same number of dependents. ..
Applicant agrees to bear the expense of such amounts payable without
withholding or otherwise charging Eligible Employees for coverage of
themselves or their dependents. However, Applicant may charge persons
electing continued coverage pursuant to Section 2.04 such amounts as are
permitted by Title X of P.L. 99-272.
ARTICLE X - ATTACHMENTS is amended to include:
Appendix "F" Continued Coverage Option Rider
Appendix "F", Continued Coverage Option Rider, attached hereto, is hereby made a
part of this Agreement.
DATED: December 17, 1987
SANTA CLARA COUNTY: DELTA DENTAL PLAN OF CALIFORNIA:
if
By: By: '
Z'3 •FGR r FEB 2 3 1988 `AIRM ' N OF ' 'E BOA'S
Boa i of Supervisors
By: By: �,C,�,� •
VHtSIDt;�i/Or MATIONS
AP OVED AS TO -ORM:
•
' A 1
/ Deputy County Counsel
AT ST: Donald M..R s. Clerk
Board of Supe isors
APPENDIX "F"
CONTINUED COVERAGE OPTION RIDER
EFFECTIVE: July 1, 1987
In consideration of the payments specified in paragraph 3.01 of the attached
Contract, and subject to all of the terms and conditions thereof, Delta agrees to
provide Benefits to persons who elect continued coverage pursuant to this Rider.
1 . For purposes of this Rider, each of the following shall constitute a
"Qualifying Event":
(a) Termination of an Eligible Employee's employment with Applicant
(other than for gross misconduct) , or a reduction in the number of
hours worked by the Eligible Employee to less than the minimum number
of hours required under Section 2.02 of the attached Contract.
(b) Death of an Eligible Employee.
(c) Divorce or legal separation from an Eligible Employee.
(d) An Eligible Employee becoming entitled to Medicare benefits.
(e) A dependent child ceasing to meet the description of dependent child
contained in Section 2.02 of the attached Contract.
2. Eligible Employees whose coverage under this program is terminated by
reason of a Qualifying Event described in Section 1 (a) of this Rider may
eledt to continue coverage for eighteen (18) months following the month in
which the Qualifying Event occurs.
3. Eligible Dependents whose coverage under this program is terminated by
reason of any of the Qualifying Events described in Section 1 (b) through
(e) of this Rider may elect to continue their coverage for thirty-six (36)
months following the month in which the Qualifying Event occurs. However,
persons who elect to continue their coverage based on a Qualifying Event
described in Section 1 (a) of this Rider, and whose coverage is terminated
within the next eighteen (18) months by reason of a Qualifying Event
described in Sections '1 (b) through (e) of this Rider, may elect to
continue their coverage for a maximum of thirty-six (36) months following
the month in which the first Qualifying Event occurred.
4. Continued coverage can be elected only by notice to Applicant, which must
be given no later than sixty (60) days after a termination of coverage by
reason of a Qualifying Event, or within sixty (60) days after the Eligible
Person receives from Applicant a notice about his or her rights to
continued coverage because of the particular Qualifying Event, whichever -
is later. Persons for whom a Qualifying Event described in. Section 1 (c)
or (e) occurs must report it to Applicant within sixty (60) days, or lose
their right to elect continued coverage.
5. Continued coverage elected by a person under this Rider shall be effective
as of the first day of the month following the applicable Qualifying Event
described in paragraph 1 above. However, Benefits shall not be available
to a person electing continuing coverage until Delta receives the data
about such person required in Section 2.01 of the Contract, along with all
contributions then currently payable for such person as stated in Section
3.01. Delta shall not, in any event, make Benefits available under this
Rider with respect to any person for whom such information and
contributions are not received by Delta within sixty (60) days after the
date such person• is required by Section 4 of this Rider to notify
Applicant of his or her election.
6. Continued coverage for persons under this Rider shall be the same as the
coverage for similarly situated Eligible Persons under the attached
Contract, and if coverage is modified for such Eligible Persons it shall
also be modified in the same manner for persons having continued coverage
under this Rider.
•
•
7. A person's continued coverage elected under Sections 2 or 3 -of this Rider
shall terminate on the last day of the month in which any of the following
events first occurs:
(a) The period of continued coverage specified in Section 2 or 3 expires.
(b) This Contract terminates.
(c) Applicant fails to pay contributions for the person as specified in
Section 3.01 of the Contract.
(d) The person with continued coverage becomes covered for dental
' benefits under another group health plan (as an employee or
otherwise) .
(e) The person becomes eligible for Medicare.benefits.
8. Once continued coverage under this Rider is terminated, it cannot be
reinstated.
DATED: December 17, 1987
DELTA DENTAL PLAN OF CALIFORNIA:
By: 4C: 51-4.CI
Vjcsedad
VICE PRESIDENT1OPERATIONS
. r (.
•
' l
AMENDMENT TO AGREEMENT
GROUP #1766
AJuly 1,GTY and
REEMENT amis nded,hereby furtheramended, effecetween SANTA CLARA ctiive July
1, 1987, as follows:
Number I. of page 1, is amended to read:
I. Applicant agrees to pay to Delta within ten (10) days after receiving each.
monthly accounting, the amount shown thereof as the full amount of
• Dentists' statements paid or otherwise discharge by Delta, plus 52.88 for
each . Eligible Employee per month, to compensate Delta for its
administration of the Program.
Paragraph 1.08 is amended to read:
1 .08 "Contract Term" means the period commencing on the Effective Date hereof
and terminating on June 30, 1988, and each yearly period thereafter during
which this Contract remains in effect.
Paragraph 3.01 is amended to read:
3.01 The amount payable under this Contract, to be paid by Applicant to Delta,
at the address shown on the cover page of this Contract, shall be as
follows:
Applicant agrees to pay Delta within ten (10) days after receiving each
monthly accounting, the amount shown thereof 'as the full amount of
Dentists' statements paid, plus $2.88 for each Eligible Employee per
month, to compensate Delta for its administration of the program provided
hereby.
Delta will not charge Applicant for Dentists' statements incurred and paid
and administration in excess of 559.05 multiplied by the number of
• employees eligible during the Contract Year. A 150% stop-loss is provided
at no additional charge.
• Applicant agrees to bear the expenses of such payments without withholding
or otherwise charging the Eligible Employees for coverage of themselves or
their Dependents .
AMENDMENT TO AGREEMENT
(Renewal)
GROUP #1766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY and DELTA
DENTAL PLAN OF CALIFORNIA, "Delta", is hereby further amended, effective July 1,
1986, as follows:
Number I. of page 1, is amended to read:
I. Applicant agrees to pay to Delta within ten (10) days after receiving each
monthly accounting, the amount shown thereof as the full amount of Dentists'
statements paid or otherwise discharged by Delta, plus $2.62 for each Eligible
Employee per month, to compensate Delta for its administration of the Program.
Paragraph 1 .06 is amended to read:
1.06 "Contract Term" means the period commencing on the Effective Date hereof
and terminating on June 30, 1987, and each yearly period thereafter during
which this Contract remains in effect.
Paragraph 3.01 is amended to read:
3.01 The amount payable under this Contract, to be paid by Applicant to Delta,
at the address shown on the cover page of this Contract, shall be as
follows:
Applicant agrees to pay Delta within ten (10) days after receiving each
monthly accounting, the amount shown thereof as the full amount of
Dentists' statements paid, plus $2.62 for each Eligible Employee per
month, to compensate Delta for its administration of the program provided
hereby.
Delta will "not charge Applicant for Dentists' statements incurred and paid
and administration in excess of $56.14 multiplied by the number of
employees eligible during the Contract Year. A 150% stop-loss is provided
at no additional charge.
Applicant agrees to bear the expenses of such paymentswithoutwithholding
or otherwise charging the Eligible Employees for coverage of themselves or
their Dependents.
Paragraph 9.04 is amended to read:
9.04 In the event of termination by Delta under paragraph 9.01 a) , all Benefits
shall terminate and Delta shall be released from all further obligations
of the Contract, effective on the last day of the month in which written
notice of termination is given; provided, however, that Delta shall make
payment to Dentists for dental services authorized by Delta prior to
termination and performed in reliance on such authorization, if any.
Delta may retain funds on hand after termination until all such claims
have been discharged and Applicant shall remain liable to Delta for the
full amount of all Attending Dentists' Statements paid or otherwise
discharged by Delta pursuant to this Contract, including claims discharged
pursuant to this paragraph, plus $2.62 for each Eligible Employee per
month, as provided in paragraph 3.01, less amounts actually paid by
Applicant to Delta.
Appendix "C", Orthodontic Benefit Rider, attached hereto and made a part of this
Agreement, is hereby amended.
DATED: July 1, 1986
SANTA CLARA COUNTY: DELTA DENTAL PLAN OF CALIFORNIA:
By: By:
By: By:
APPENDIX "C"
ORTHODONTIC BENEFIT RIDER
In consideration of the payments specified in paragraph 3.01 of the attached
Contract, and subject to all of the terms and conditions thereof, except as herein
otherwise specified, Delta agrees to provide Orthodontic Benefits to Eligible
Persons, as follows:
•
1. Orthodontics are defined as the procedures performed by a licensed
Dentist, involving surgical repositioning of the jaws in whole or in part
and/or the use of an active orthodontic appliance and post-treatment
retentive appliances for treatment of malalignment of teeth and/or jaws
which significantly interferes with their function.
2. Delta will pay or otherwise discharge 60% of the lesser of the Usual ,
Customary and Reasonable fees or of the fees actually charged for
Orthodontics, provided that the amount payable to a Dentist who is not a
Participating Dentist shall not exceed 60% of the amounts for the
corresponding services set forth in the Orthodontic Table of Allowances, a
copy of which is attached hereto, marked Exhibit I and incorporated herein
by reference. All payments shall be on a monthly or periodic basis, in
accordance with the Dentist's normal billing practice.
3. The maximum amount payable by Delta for all Orthodontics rendered to each
Eligible Person shall be $1,500.00, and the limitations on maximum amounts
payable during a calendar year, if any, specified in the attached
Agreement, shall not apply to Orthodontics.
4. EXCLUSIONS AND LIMITATIONS: In addition to the Exclusions and Limitations
stated in Article IV to the attached Contract, the following exclusions
and limitations shall apply to Orthodontic Benefits:
(a) The obligation of Delta to make monthly or other periodic payments
for an Orthodontic treatment plan begun prior to the eligibility date
of the patient shall commence with the first payment due following
the patient's eligibility date. The above-mentioned maximum amount
payable will apply fully to this and subsequent payments.
(b) The obligation of Delta to make monthly or other periodic payments
for Orthodontics shall terminate on the payment due date next
following the date the dependent loses eligibility or the employee
loses eligibility, or upon termination of treatment for any reason
prior to completion of the case, or upon termination of the Contract,
whichever shall occur first.
•
- (c). Delta will not make any payment for repair or replacement . of an
Orthodontic appliance furnished, in whole or in part, under this
Program.
(d) X-rays and extraction procedures incident to Orthodontics are not
covered by Orthodontic Benefits, but may be covered under the
provisions of the attached Contract, subject to all of the terms and
provisions thereof.
DATED: July 1, 1986 DELTA DENTAL PLAN OF CALIFORNIA:
By:
EXHIBIT I
•
TABLE OF ALLOWANCES FOR ORTHODONTICS
(To be used for cases submitted by non-participating* dentists)
PROCEDURES
Orthodontic Treatment -
Appliances for Minor Tooth Guidance
Procedure Number
840/08110 Removable $ 120.00
843/08120 Fixed or cemented 150.00
Appliances to Control Harmful Habits
Procedure Number
844/08210 Removable 120.00
845/08220 Fixed or cemented 150.00
Interceptive Orthodontic Treatment Appliances
Procedure Number
846/08360 Removable 150.00
847/08370 Fixed or cemented 150.00
Permanent Dentition
Procedure Number
850/08560 Class I, involving extraction 1,950.00 •
•
851/08561 _ Class I, non-extraction 1,950.00
852/08562 Class I, limited treatment 900.00
855/08570 Class II, involving extraction 1,950.00
856/08571 Class II, non-extraction 1,950.00
857/08572 Class II, limited treatment 900.00
860/08580 Class III, involving extraction 1,950.00
861/08581 Class III, non-extraction ' 1,950.00
862/08582 Class III, limited treatment 900.00 .
Transitional Dentition -
Procedure Number
870/08460 Class I 1,050.00
871/08470 Class II 1,050.00
872/08480 Class III 1,050.00
Post-Treatment Stabilization (Retention)
Procedure Number
878/08750 Removable 150.00
879/08751 Fixed or cemented 150.00
*Non-participating Dentist--Dentist who does not agree to abide by the conditions
governing dentist participation in Delta Dental Plan of California group dental
program.
•
• AMENDMENT TO AGREEMENT
(ANNUAL RENEWAL) •
CDS GROUP #1766
•
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY and CALIFORNIA
DENTAL SERVICE, is hereby further amended, effective July I, 1985, as follows:
Number I. of page 1 is amended to read:
I. • Applicant agrees to pay to CDS within ten (10) days after receiving each monthly
accounting, the amount shown thereof as the full amount of Dentists' statements paid or
otherwise discharged by CDS, plus $2.35 for each Eligible Employee per month, to
compensate CDS for its administration of the Program.
Paragraph 1.06 is amended to read:
1.06 "Contract Term" means the period commencing on the Effective Date hereof and
terminating on June 30, 1986, and each yearly period thereafter during which this
Contract remains in effect.
Paragraph 3.01 is amended to read:
3.01 The amount payable under this Contract, to be paid by Applicant to CAS, at the
address shown on the cover page of this Contract, shall be as follows:
Applicant agrees to pay ('n4 within ten (10) days after receiving each monthly
accounting, the amount shown thereof as the full amount of Dentists' statements
paid, plus $2.35 for each Eligible Employee per month, to compensate CDS for its
administration of the dental program provided hereby.
CDS will not charge Applicant for Dentists' statements incurred and paid and
administration in excess of $47.68 multiplied by the number of employees eligible
during the Contract Year. A 150% stop-loss is provided at no additional charge.
Applicant agrees to bear the expenses of such payments without withholding or
otherwise charging the Eligible Employees for coverage of themselves or their
dependents.
Paragraph 9.04 is amended to read:
9.04 In theevent of termination by CDS under paragraph 9.01 a) , all Benefits shall
terminate and CDS shall be released from all further obligations of this Contract,
effective on the last day of the month in which written notice of termination is
given; provided, however, that CDS shall make payment to Dentists for dental
services authorized by CDS prior to termination and performed in reliance on such
authorization, if any. CDS may retain funds on hand after termination until all
such claims have been discharged and Applicant shall remain liable to CDS for the
full amount of all Attending Dentists' Statements paid or otherwise discharged by
CDS pursuant to this Contract, including claims discharged pursuant to this
paragraph, plus $2.35 for each Eligible Employee per month, as provided in
paragraph 3.01, less amounts actually paid by Applicant to CDS.
DATED: July 1, 1985
SANTA CLARA COUNTY: CALIFORNIA DENTAL SERVICE:
By: By:
By: By:
AMENDMENT TO AGREEMENT '
CDS GROUP #1766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY,
and CALIFORNIA DENTAL SERVICE is hereby-further amended, effective July 15,
1984, as follows: _
Paragraph 2.02 is amended to include:
All employees in sub-location 0004 shall be transferred into sub-location
0001.
DATED: July 15, 1984
SANTA CLARA COUNTY: CALIFORNIA DENTAL SERVICE:
,42-c4
d
CHAIRibinii 0FS �
THrE
By: By: ��
`, 6
TICE PHLSIDEIT/OP13►TION1
AMENDMENT ID AGREEMENT
cc GROUP #1766 -
AGREEMENT dated July 1 , 1978, as amended, between SANTA CLARA COUNTY and CALIFORNIA
DENTAL SERVICE is hereby further amended, effective July 1 , 1983, as follows:
Paragraph 3.01 is amended to read:
3.01 The amount payable under this Contract by Applicant to CDS, at the address shown on
the cover page of this Contract, shall be as follows:
Applicant agrees to pay CDS a bi-weekly Prefunding Amount of $15.07 for each
Eligible Employee in sub-locations 0001 , 0005 & 0020, and a monthly Prefunding
Amount of $32.65 for each other Eligible Employee. Within 10 days after receiving
each monthly accounting, Applicant shall pay to CDS the amount, if any, by which
the Prefunding Amount is less than the amount shown on such accounting as the full
amount of Dentists' statements paid or otherwise discharged irrespective of when
the dates of services were incurred, and $2.08 per Eligible Employee to compensate
CDS for its administration of the Dental Program provided hereby.
Applicant agrees to bear the expenses of such payments without withholding or
otherwise charging the Eligible Employees for coverage of themselves or their
dependents.
Paragraph 9.04 is amended to read:
9.04 In the event of termination, Applicant shall remain liable to CDS for the full
amount of all Dentists' statements paid or otherwise discharged irrespective of
when the dates of services were incurred, and $2.08 per Eligible Employee for each
month, (to compensate CDS for its administration of' the dental program), less
amounts actually paid by Applicant to CDS.
DATED: July 1 , 1983
SANTA CLARA COUNTY: CALIFtNIA DE/ g.E 'aT:By e
,J 4 611 /
Assistant Director of Personnel CHAlRMtiP1OFTH :0!7
By: - By: (St. >144)
ISN'T. VICE PRESIDENT/OPERLTIOJ5
ail,
AMENDMENT TO AGREEMENT
•
; CDS GROUP #1766 •
•
AGREEMENT dated July 1 , .1978 , as amended between SANTA CLARA COUNTY and
CALIFORNIA DENTAL SERVICE is hereby further amended , effective July 1 ,
1982 , as follows : •
Item I of page • 1 is amended to read :
I . Applicant agrees to pay to CDS within 10 days after receiving each
monthly accounting the amount shown thereof as the full amount of
Dentists ' statements paid or otherwise discharged irrespective of
when the dates of services were incurred , and $1 . 81 per Eligible
Employee per month , to compensate CDS for its administration of the
Dental Program.
Paragraph 1 . 06 is amended to read:
1 . 06 "Contract Term•" means the period commencing on the Effective Date
hereof and terminating on June 30 , 1983 , and each yearly period
thereafter during which this Contract remains in effect .
Paragraph 3. 01 is amended to read :
3 . 01 The amount payable under this Contract by Applicant to CDS , at the
address shown on the cover page of this Contract , shall be as
follows :
Applicant •agrees to pay CDS a bi—weekly Prefunding Amount of
• $11 . 82 for each Eligible Employee in sub—locations 0001 , 0005 &
0020 , and a monthly Prefunding Amount of $25. 61 for each other
Eligible Employee. Within 10 days after receiving each monthly
accounting , Applicant shall pay to CDS the amount , if any, by which
the Prefunding Amount is less than the amount shown on such
accounting as the full amount of Dentists ' statements paid or
otherwise discharged irrespective of when the dates of services
were incurred , and $1 . 81 per Eligible Employee to compensate CDS
for its administration of the Dental Program provided hereby.
Applicant agrees to bear the expenses of such payments without
withholding or otherwise charging the Eligible Employees for
coverage of themselves or their' dependents .
The quarterly Dues payable to Applicant by each enrolled Retiree
for coverage of themselves and their dependents shall be as
follows :
The sum of $30. 00 for each enrolled Retiree with no enrolled
dependents ; the sum of $60 . 00 for each enrolled Retiree with one
- enrolled dependent ; or , the sum of $90 . 00 for each enrolled Retiree
with two or more enrolled dependents.
Paragraph 9. 04 is amended to read :
9 . 04 In the event of termination , applicant shall remain liable to CDS
for the full amount of all Dentists ' statements paid or otherwise
discharged irrespective of when the dates of services were
incurred , and $1 . 81 per Eligible Employee for each month , (to
compensate CDS for its administration of the dental program) , less
amounts actually paid by Applicant to CDS.
DATED: July 1 , 1982
• SANTA CLARA COUNTY: CALIFORNIA DENTAL SERVICE:
By: iV
j/41— By: 74tC 4 AV
CHAIRMAN OF THE BO
By: By : •
Ass - 4L
ssi st+T PLRATIONE1E
AMENDMENT TO AGREEMENT
CDS GROUP 41766
•
•
•
: GREL: TEi;T datedJuly 1 , 1-976 , as amended , between SANTA CLARA COUNTY
• and CALIFORNIA DENTAL SERVICE is hereby further amended , effective October •
1 , 19 : 1 , as follows : _
•
Paragraph 2. 03 is amended to 'include :
•
f.etircd Employees of Santa Clara County shall be included in Sub-
location 0060
Pcr_araph 3 . 01 is amended to include :
L J
J1 _ 'he quarterly Dues payable to Applicant by each enrolled Retiree for
coverage of themselves and their dependents shall be as follows :
The sum cf 530 . 00 for each enrolled Retiree with no dependents ; the
sum of . 63 . G0 for each enrolled Retiree with one enrolled dependent ;
or , the sum of $90 . 00 for each enrolled Retiree with two or more -
enrolled depenJents .
Paragraph 4 . 09 is amended to include :
Retirees in Sub-location 0060 are not eligible for Orthodontic
Benefits .
DATED : October 1 , 1981
•
SANTA CLARA COUNTY : CALIFORNIA DENTAL SERVICE :
:.y :_ By :e-�J �D-s
�- !f{MA OF fHt HUAKU
y : by :
ASS PEZSID ICRAEO
AMENDMENT TO AGREEMENT •
CDS GROUP #1766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY, and
CALIFORNIA DENTAL SERVICE Is hereby further amended, effective October 1, 1981, as follows:
Paragraph 2.03 is amended to include:
Retired Employees of Santa Clara County shall be included in Sub-location 0060.
Paragraph 3.01 is amended to Include:
The dues payable to Applicant by each enrolled Retiree for coverage of•
themselves and their dependents shall be 1.
DATED: October 1, 1981 •
SANTA CLARA COUNTY: CALIFORNIA DENTAL SERVICE;
By: By:
By: By:
AMENDMENT TO AGREEMENT
• CDS GROUP 51766
•
•
AGREEMENT dated July 1 , 1973 , as amended , between SANTA CLARA COUNTY
and CALIFORNIA DENTAL SERVICE is hereby further amended , effective October
1 , 981 , as follows :
•
Paragraph 2 . 03 is amended to include :
Retired Employees of Santa Clara County s:-iall be included in Sub-
location 0060
Paragraph 3. 01 is amended to include :
3. 01 • The quarterly Dues payable to Applicant by each enrolled Retiree for
coverage of themselves and their dependents shall be as follows :
The sum of $30 . 00 for each enrolled Retiree with no dependents ; the
sum of $60 . 00 for each enrolled Retiree with one enrolled dependent ;
or , the sum of $90 . 00 for each enrolled Retiree with two or more
enrolled dependents .
Paragraph 11 . 09 is amended to include :
Retirees in Sub-location 0060 are not eligible for Orthodontic
Benefits .
•
DATED : October 1 , 1951
SANTA CLARA COUNTY: CALIFORNIA DENTAL SERVICE:
•
By : By :
•
•
By : By : •
•
•
AMENDMENT TO AGREEMENT
CDS GROUP #1766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY, and
CALIFORNIA DENTAL SERVICE is hereby further amended, effective July 1, 1981, as follows:
Paragraph 3.01 is amended to reads
3.01 The amount payable under this Contract by Applicant to CDS, at the address shown on
the cover page of this Contract, shall be as follows:
Applicant agrees to pay CDS a bl-weekly Prefunding Amount of $10.94 for each
eligible employee in sub-locations 0001 and 000, and a monthly Prefunding Amount of
$23.71 for each other eligible employee. Within 10 days after receiving each monthly
accounting, Applicant shall pay to CDS the amount, if any, by which the Prefunding
Amount Is less than the amount shown on such accounting as the full amount of
dentists'statements paid or otherwise discharged irrespective of the date the services •
were Incurred, and $1.51 per eligible employee to compensate CDS for its
administration of the Dental Care Program provided hereby.
DATED: July 1, 1981
SANTA CLARA COUNTY: CALI RNIA s NTAL SERVICE:
•
; fair
By:� ( C 1 w By: sae
cgrirrry OF THE BOARD
•
By: By: ti
• ASS'1., ICE PRESID L'T/OPERATIONIS
•
•
•
AMENDMENT TO AGREEMENT
•
•
CDS GROUP 01766
AGREEMENT dated July 1, 19711, as amended, between SANTA CLARA COUNTY, and
CALIFORNIA DENTAL SERVICE Is hereby further amended,effective Apr11 1, 19111, as follows:
Paragraph 3.01 Is amended to includes
Applicable to Sub-location 00171
If an employee becomes eligible between the first (1st) and fiftenth (15th) of the
month, the Applicant agrees to pay CDS a full months premium for that employee. If
an employee becomes eligible after the fiftenth (15th) of the month, the Applicant
shall not pay a premium for that employee.
DATED* April i, 1981
SANTA CLARA COUNTY: CALIFORNIA DENTAL SERVICE:
By: By;
By: By:
•
•
•
AMENDMENT TO AGREEMENT
CDS GROUP t
AGREEMENT dated July 1, 1978, as araended, between SANTA CLARA COUNTY and
CALIFORNIA DENTAL SERVICE is hereby further amended, effective Febnary 1, I9$11, as .
follows'
Parat,rapti 2.02 Is amended to Include'
Employees of the CITY OF MONTE SERENO shall bo included in Stab-location 0022.
•
OATES): February i, Int
•
SANTA tr OUNTY1 LIF%.,0RNIA44ENTAL SERVICE;
. • cy,TP.IR:i.ri rriE BOA1.-0
•
•
3)-1 ail
ASS'T. 71C: P2.T.C:D-1-271/0=1-LITIO115
• -
•
_ .
_ - _
•
•
•
•
AMENDMENT TO AGREEMENT
CDS GROUP *1766
AGREEMENT dated July 1, 197$, as amended, between SANTA CLARA COUNTY ad
CALUPOItNIA DENTAL SERVICE is hereby further amended, effective 2eutuary 1, 1411, as tallness
Paragraph 2.02 is amended to Includes
Employees and their eligible dependents of 6ut2-location 3613 "SANTA CLARA
COUNTY PAIR" shell be eligible fat this Dental Care Program the first dsy al the
month coincident with et next followln` thirty (30)days of tuU•tlme employment.
°ATabt January 1, 1911
SANTA C $A COUNTYt CAWORNIA DENTAL SERVICE.
By;
- _=
•
•
:Syr7�F£�TIONS
• tu' _. ._. ..._._
AMENDMENT TO AGREEMENT
CDS GROUP #1766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY and
CALIFORNIA DENTAL SERVICE is hereby further amended, effective October 1, 1980, as follows:
Paragraph 2.02 is amended to include:
Former employees of CDS Group #2584-0005 shall now be eligible under this Dental
Care Service Contract and shall become eligible immediately.
DATED: October 1, 1980
SANT • -• RA COUNTY: 1 CALIFORNIA DENTAL SERVICE:
: .
By: By: %t•
cS/%
10/'
�a " �"`"
By: By: -,
US'T. VICE PRESIDENNT PY?ERATI08S
AMENDMENT TO AGREEMENT
(ANNUAL RENEWAL)
CDS GROUP #1766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY, and
CALIFORNIA DENTAL SERVICE Is hereby further amended, effective July 1, 1980, as follows:
Paragraph 1.06 Is amended to read:
1.06 "Contract Term" means the period commencing on the Effective Date hereof and
terminating on June 30, 1981, and each yearly period thereafter during which this
Contract remains in effect.
Paragraph 7.02 is amended to read:
7.02 CDS shall authorize such ADS for Benefits when satisfied from the ADS and other data
that (a) the patient Is an Eligible Person hereunder, provided, however, that CDS may
determine such eligibility on the basis of the latest list of Eligible Employees received
by CDS (b) the services proposed are Benefits under this Contract; and (c) that the
total fees to be charged for such services to both CDS end the Eligible Person do not
exceed the Participating Dentist's Usual, Customary and Reasonable fees. Such
authorization shall be for a reasonable period up to a maximum of sixty (60) days, but
shall not be required to extend beyond termination of the patient's eligibility, and may
be revokes upon notice of such termination. In no event shall an authorization period
extend beyond the termination date of this Contract.
DATED: July 1, 1980
SANT: RA COUNTY: CAL ORNIA ENTAL SERVICE:
By: •
a _i , !" By: 4
ael•IRM• OFTH AR
By: By: ezee'Afe.P/
ASST. VICE P •SIDENT/OPERATIONS
•
AMENDMENT TO AGREEMENT
CDS GROUP ('1766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY and
CALIFORNIA DENTAL SERVICE is hereby further amended, effective July 1, 1980,as follows:
Paragraph 3.01 is amended to includes
Applicable to sub-location 0017:
If an employee becomes eligible between the first (1st) and flftenth (15th) of the
month, the Applicant agrees to pay CDS a full months premium for that employee. U
an employee becomes eligible after the fiftentt: (15th) of the month, the Applicant
shall not pay a premium for that employee.
DATED: July 1, 1980
SANTA CLARA COUNTY: CALIFORNIA DENTAL SERVICE:
By: By:
By: By:
•
AMENDMENT TO AGREEMENT
CDS GROUP #1766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY and
CALIFORNIA DENTAL SERVICE is hereby further amended, effective May 1, 1980, as follows:
Paragraph 2.02 is amended to include:
Employees of Gilroy Rural Fire Protection District - Morgan Hill Rural Flre Protection
District shall be included in sub-location 0021.
DATED: May 1, 1980
SANTA CLARA COUNTY: CALI RNIA ' 'NTAL SERVICE:
By: ; c.\, - By: 4.
������
CHATHErARD
By: By: AL
•
•
AMCNDMENT TO AGREEMENT
•
CDS GROUP 41766 ..
AGREEMENT dated July 1, 1973, u amended, etween SANTA CLARA COUNTY, and
CALIFORNIA DENTAL SERVICE is hereby further amended, effective drecernber !, IQ7?, as
follows;
Paragraph 2.02 Is amended to includes
Employees of Youth Science Institute shall be Included in sub-location 0020.
•
DATED; December 1, 1979
SANTA -:, COUP ,V; CALIF NI4J ?NTAl. SERVICE:,
r
�� �AIRhTAN C�Ff[yE> 6R!?�x
0y; fly;A99 TICS PI bENTT/4P�EpAATTI0113
•
• AMENDMENT TO AGREEMENT
•
• CD5 GROUP #1766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY, and
CALIFORNIA DENTAL SERVICE is hereby further amended, effective December 1, 1979, as
follows
Paragraph 2.02 is amended to Include:
Employees of Youth Science Institute shall be included In sub-location 0020.
DATED: December 1, 1979
SANTA CLARA COUNTY: CALIFORNIA DENTAL SERVICE:
By: • By:
9y: 3y:
AMENDMENT TO AGREEMENT '
CDS GROUP 01766
AGREEMENT dated July 1, 1978, as amended, between SANTA CLARA COUNTY, and
CALIFORNIA DENTAL SERVICE is hereby further amended, effective July 1, 1979,as follows*
Paragraph 1.06 is amended to reads
1.06 "Contract Term" means the period commencing on the Effective Date hereof and
terminating on June 30, 1980, and each yearly period thereafter during which this
Contract remains in effect.
Paragraph 1.11 is amended to reads
1.11 Each of the words in the term "Usual, Customary and Reasonable" as used herein shall
have the following meanings
USUAL - A usual fee is the fee regularly charged and
received for a given service by an individual dentist, i.e.,
his own usual fee. If more than one fee is charged for a
•
given service,the fee determined to be the usual fee shall
not exceed the lowest fee which is regularly charged or
which is offered to patients.
CUSTOMARY - A fee is customary when it is within the
range of usual fees charged and received by dentists of
similar training for the same service within the
geographic area determined by CDS to be statistically
relevant.
REASONABLE - A fee is reasonable If It is "usual" and
"customary" or if it falls above "customary" and is
justifiable due to a level of treatment superior to that
customarily provided in the dentist's geographic area.
Additionally, a specific fee to a specific patient is
reasonable if It is justifiable considering special
circumstances or extraordinary difficulty, of the case In
question.
•
•
•
Paragraph 4.03 is amended to reach •
4.03 LIMITATIONS ON DIAGNOSTIC AND PREVENTIVE BENEFITS* The following
limitations apply to Diagnostic and Preventive Benefits
•
a) Routine oral examinations and prophylaxis treatment shall not be provided
more than twice each In any twelve:month.period while the patient Is an
Eligible Person under any CDS program.
b) Unless special need Is shown, full mouth x-rays are provided only after
three years have elapsed following any prior provision of full mouth se-rays
under any CDS program. Supplementary bite-wing (individual) x-rays are
provided on request by the Dentist, but not more than once every six (6)
months while the patient is an Eligible Person under any CDS program.
Paragraph 4.05 Is amended to reads
4.05 CDS shall pay or otherwise discharge 75% of the Dentist? Usual, Customary and
Reasonable fees or the fees actually charged, whichever is less, for the following
Crowns, Jackets and Gold or Cast Restorations Benefits
• Crowns, Jackets and Gold or Cast Restorations for treatment of carious lesions
(visible destruction of hard tooth structure resulting from the process of dental
decay) which cannot be restored with amalgam, synthetic porcelain or plastic
restorations.
Paragraph 4.08 (c) Is amended to reads
(c) CDS will pay the applicable percentage of the Dentist's fee for a standard
cast chrome or acrylic partial denture or a standard complete denture, up
to a maximum fee allowance which Is at least the Prevailing Fee for a
standard denture. (A "standard' complete or partial denture is defined as a
removable prosthetic appliance provided to replace missing natural,
permanent teeth and which is constructed using accepted and conventional
procedures and materials.) The maximum allowance is revised periodically
as dental fees change. Any denture and/or related service for which a
charge Is made which exceeds. this allowance is considered an optional
service, and the patient is responsible for the portion of the Dentist's fee in
excess of the CDS allowance.
•
•
•
•
Paragraph 441 IS amended to reams •
4.11 GENERAL LIMITATIONS.- OPTIONAL SERVICES
If an Eligible Person selects a more-expensive plan of treatment than is customarily
provided, or specialized techniques rather than standard procedures. CDS will pay the
applicable percentage of the lesser tee and the,patient is responsible for the remainder
of the Dentist's fee._ For example: a gold crown where a silver filling would restore the
tooth,a precision denture where a standard denture would suffice.
Paragraph 5.02 (II) Is amended to read: •
(ii) If the other coverage is by a dental insurance policy or prepaid dental
care program, the policy or program covering the patient as an
employee shall be primary over the policy or program covering the
patient as a dependent, and the policy or program covering the
patient as a dependent child of a male person shall be primary over
the policy or program covering the patient as a dependent of a female
person (provided, however, that In the case of a dependent child of
legally separated or divorced parents,if the mother has legal custody,
then the policy or program covering the patient as a dependent of the
mother, or as a dependent of her spouse if she has re-married, shall
be primary over the policy or program covering the patient as a
dependent of the natural father).
DATED: July 1, 1979
SANTA CL/jR COUNTY: CAL NI kS T{4L ; VICEt
/
By: �. P By:
P2ESIOEpy
By: • By: - _Qa 1CG�c/!�i/
ASS'T. TICE PRE EnT/OPERATIONS
A.
AMENDMENT TO AGREEMENT
CDS GROUP #1784
•
AGREEMENT dated May I, 1978, as amended, between SANTA CLARA COUNTY, and
CALIFORNIA DENTAL SERVICE is hereby further amended, effective May 1, 1978, as follows,
•
Paragraph 2.02 is amended to ready •
Sub-location 0019 - Employment and Training Board Employees hired on or after May 1,
197E and their oliglbto dependents will be eligible ninety (90) days after date of hire.
DATED, May 1, 1978
SANArCO ,• Y,
T 4ALI O?NI e "„ L _ VICE, —
flys By:
fIeslo er
�� �'
CALIFORNIA DENTAL SERVICE
•
(A Non-for-profit Corporation)
P. O. Box 7736, San Francisco, California 94120
Group #1766
APPLICATION FOR DENTAL CARE PROGRAM ADMINISTRATION CONTRACT
SANTA CLARA COUNTY
herein sometimes called Applicant, hereby applies for a DENTAL CARE PROGRAM
ADMINISTRATION CONTRACT with CALIFORNIA DENTAL SERVICE, herein called "CDS" on the
following termss
I. Applicant agrees to pay to CDS within ten days after receiving each monthly accounting the
amount shown thereof as the full amount of dentists' statements paid or otherwise discharged by
CDS plus $1.31 per eligible employee for each month, to compensate CDS for its administration of
the program.
IL Upon acceptance of this Application by CDS and payment by the Applicant of the Prefunding
amount, specified in Section 3.01 of the Contract, the Effective Date of the Contract shall be
12.01 a.m., on the first day of July 1978, and the Contract shall continue until terminated in
accordance with the provisions therein.
Date ,a T 7 )
By Nt
Author zeds gnature
(Ti -)J
' 3y
(Authorized Signature)
(Title)
•
CALIFORNIA DENTAL SERVICE
(A Not-for-profit Corporation Incorporated In California
and a Member of the Delta Dental Plans Association)
Home Offices -P.O. Box 7736, San Francisco, California 94120
•
(Herein Called "CDS")
Group #1766
IN CONSIDERATION of the application made by SANTA CLARA COUNTY, herein called
APPLICANT, a copy of which Is attached hereto and made a part of this Contract, and IN
CONSIDERATION of payment by the APPLICANT of amounts payable as herein provided, CDS
hereby agrees to perform the administrative services described herein for a period of one year
beginning at 12s01 a.m., Standard Time, on July 1, 1978, (herein called the Effective Date) and
from year to year thereafter, unless this Contract is terminated as provided herein. This Contract
is issued and delivered in the State of California, is governed by the laws thereof and is subject to
the terms and conditions recited on the subsequent pages hereof, which are a part of this Contract
as fully as If recited over the signatures hereto affixed.
IN WITNESS HEREOF, MS has caul n this Contract to be signed this (Pin day of
( Ahe , 197 .
C$ .IFORA�TA ERVICE
By
PictaiWc
and `
By / -47-le l
LSS'T. VICE P u.S• _.12/0= ?.uTIQ
APPLICANTS
• Santa Clara County
70 W. Redding - East Wing
Department of Personnel
San Jose, California 95110
DESIGNATED AGENT OR REPRESENTATIVE:
Robert Gustafson
Stateco Employment Benefit Div.
39I1 Stevens Creek Blvd.
Santa Clara, California 95050
-2- - - -
ARTICLE I- DEFINITIONS
For the purpose of this Contract, the following definitions shall applys
1.01 "Applicant" means the Group or Employer for whose members or employees dental
benefits are being provided.
1.02 "Eligible Employee" means any employee who meets the conditions of eligibility
outlined in this Contract.
1.02 "Eligible Dependent" means any of the dependents of an Employee who are eligible
for benefits in accordance with the conditions of eligibility outlined In this Contract.
1.02 "Eligible Person" means an employee or a dependent who meets the conditions of
eligibility outlined in Article 11 of this Contract.
1.03 "Eligibility Date" means the date an Employee's eligibility for Benefits becomes
effective under the terms of this Contract.
• 1.04 "Contract"' means this agreement between CDS and Applicant inducting the
Application of the Applicant for this Contract and the attached appendices,
endorsements and riders, if any. This Contract constitutes the entire Contract
between the parties.
1.05 "Effective Date" means the date stated in the acceptance of Application for this
Contract as made a part hereof.
1.06 "Contract Term" means the period commencing on the Effective Date hereof and
terminating on June 30, 1979, and each yearly period thereafter during which this
Contract remains in effect.
1.07 "Contract Year" means the twelve-month period commenting on the Effective Date
and each yearly period thereafter.
1.08 "Dentist" means a duly licensed dentist legally entitled to practice dentistry at the
time and In the place services are performed.
1.09 "Participating Dentist" means a licensed dentistwho is a member of CDS and has
agreed to-provide services In accordance with terms and conditions established by
CDS.
1.10 "Procedure Numbers" means the "Procedure Numbers", which is attached to and made
a part of this Contract as Appendix "B". -
1.11 Each of the words in the term "Usual, Customary and Reasonable" as used herein shall
have the following meanings.
USUAL - A usual fee is the fee regularly charged and
received for a given service by an individual dentist, i.e.
his own usual fee. If more than one fee is charged for a
given service, the fee determined to be the usual fee
shall not exceed the fee charged members of any group •
dental care program, other than a governmentally funded
program.
CUSTOMARY - A fee is customary when It is within the
range of usual fees charged and received by dentists of
similar training for the same service within the
geographic area as determined by CDS, or the review
committee, to be statistically relevant.
REASONABLE - A fee is reasonable if It is "usual" and
"customary", or if it falls above "customary" and is
justifiable due to a level of treatment superior to that
customarily provided In the dentist's geographic area.
Additionally, a specific fee to a specific patient is
reasonable if it Is justifiable considering special &cum-
stances, or extraordinary difficulty, of the case in
question.
1.12 "Benefits" means those dental services which are available under the terms of this
Contract as specified in Article IV.
1.13 "Single Procedure" means a dental procedure listed on the Procedure Numbers
(attached hereto as Appendix "6") to which a separate procedure number is assigned,
e.g., a three-surface amalgam restoration of a single permanent tooth (procedure 613)
or a complete maxillary denture, Including adjustments for a six-month period
following installation (procedure 700).
1.19 "Prevailing Fee" is the fee which satisfies the majority of dentists in California, as
determined by CDS based upon confidential fee listings accepted by CDS from
participating dentists.
-4-
ARTICLE H- ELIGIBILITY
2.01 Applicant shall compile and furnish to CDS on or prior to the first day of every
month, commencing on the Effective Date, a list of all Eligible Employees, showing
their Social Security Numbers, the dates of hire, and, if applicable, the location code.
2.02 Every employee and dependent who meets the followingconditions of eligibility shall
be considered an "Eligible Person".
Effective July 1, 1978, all present management supervisory and confidential personnel
and all employees covered by negotiated agreement, who have signed up for County
sponsored Health Plan Coverage, are eligible for CDS Dental Care Program Benefits
as described herein. New employees who do not qualify on July 1, 1978 will become
eligible on the same day their Health Plan Coverage takes effect.
Employees and their eligible dependents of Sub-location 0017 Santa Clara County
Transit District shall be eligible for this Dental Care Program after ninety (90) days
of full-time employment.
Eligible Employees shall be defined as follows:
Sub-location 0001 - Santa Clara County
Sub-location 0002 - County Sanitation District #4
Sub-location 0003 - County Supervisors Association of California of Santa Clara
County
Sub-location 0004 - Santa Clara County - Judges Department of Finance
Sub-location 0005 - GIlroyRural Fire District
Sub-location 0006 - Midpeninsuia Regional Open Space District
Sub-location 0007 - Central Fire Protection District
Sub-location 0008 - Housing Authority of the County of Santa Clara
Sub-location 0009 - Service Employees International Local #715
Sub-location 0010 - South Santa Clara Valley Water Conservation District
Sub-location 0011 - CETA VI
Sub-location 0013 - Santa Clara County Fair
Sub-location 0014 - City of Cupertino •
Sub-location 0015 - Rubicon Centers, Inc.
Sub-location 0016 - California Library Authority for Systems & Services
Sub-location 0017 - Santa Clara County Transit District
Sub-location 0018 - ACT for Mental Health
The dependents of Eligible Employees are eligible coincident with the employee or,
thereafter Immediately upon attainment of dependent status. Dependents are lawful
spouse and unmarried dependent children from birth to age 19 or to 23 if enrolled as
full-time students In an accredited school, college or university. Children include
step-children, adopted children and foster children, provided such children are
dependent upon the employee for support and maintenance.
•
•
-5- -
An unmarried child 19 years or over may continue to be eligible as a dependent if he
is incapable of self-support because of physical or mental incapacity that commenced
prior to reaching age 19 and if he Is chiefly dependent on the Eligible Employee for
support and maintenance, provided proof of such Incapacity and dependency is
submitted within thirty-one (31) days after a request therefor:by either CDS or
Applicants and subsequently as may be required by either CDS or Applicant, but not
more frequently than annually after the incapacitated and dependent child has
attained age 21.
No one may be a dependent if eligible as an employee, and no one may be a dependent
of more than one eligible employee.
Dependents in military service are not eligible.
2.03 Employees who have been absent from work due to strike or lay-off, and who return
• to work will become eligible on the first day of the month following the return to
work, provided that the absence does not exceed six (6) months. Such employees shall
be considered as newly-hired employees with respect to the application of
deductibles, maximum and waiting periods. If an absence exceeds six(6) months,then
such employees shall be considered newly-hired employees in every respect and must
fulfill the eligibility requirements. Services provided during the period such
employees were not eligible due to strike or lay-off shall not be covered by this
Contract.
During a leave of absence because of Illness, coverage will continue for 13 pay
periods. During a maternity leave of absence coverage will continue for 6 pay
periods.
ARTICLE III-PAYMENTS BY APPLICANT
3.01 The amount payable under this Contract by Applicant to CDS, at the address shown
on the cover page of this Contract, shall be as 1ollowsi
Applicant agrees to pay CDS a monthly Prefunding Amount of $22.38 for each eligible
employee In sub-locations 0002-0004 and 0006-0013, and a bi-weekly Prefunding
Amount of $10.42 for each eligible employee In sub-location 000I and 0005. Within
10 days'after receiving each monthly accounting, Applicant shall pay to CDS the
amount shown thereon as the full amount of dentists' statements paid or otherwise
discharged irrespective of the date the services were incurred, plus $1.31 per eligible
employee for each month, to compensate CDS for its administration of the Dental
Care Program provided hereby.
3.02 In the event that any governmental unit shall Impose any new tax or assessment not
now in effect, which is measured directly by the payments made to CDS by Applicant
pursuant to.the within Contract and similar payments by others, or in the event that
- the rate of any such tax or assessment now,in effect should hereafter be Increased,
the amount which CDS is authorized to deduct pursuant to .paragraph 3.01 shall be
increased by the amount of such new tax or assessment which is directly applicable to
such payment by Applicant under this Contract and by the additional amounts directly
applicable to such payments by Applicant which result from any such increase in an
existing tax or assessment. _ '
-6-
3.03 The funds existing as of bene 30, 1977, totaling $618,033.18, pursuant to the Contract
between Applicant and CDS dated October 1, 1972 shall be retained by CDS. CDS
shall credit Interest annually at the rate of 63% on such amount. Claims received by
CDS on or after July 1, 1978 shall be paid pursuant to this contract, thereby
terminating all CDS obligations under the aforementioned Contract.
ARTICLE IV- BENEFITS PROVIDED, LIMITATIONS AND EXCLUSIONS
4.01 Subject to the limitations and exclusions hereinafter set forth, the following services
are Benefits when provided by a Dentist and when necessary and customary as
determined by the standards of generally accepted dental practice. The specific
procedure code numbers are listed In Appendix "3".
4.02 CDS shall pay or otherwise discharge 75% of the Dentists' Usual. Customary and
Reasonable fees or of the fees actually charged, whichever Is less, for the following
Diagnostic and Preventive Benefits:
Diagnostic - procedures to assist the Dentist in determining required
dental treatment.
Preventive - prophylaxis (cleaning), not more often than twice in any
twelve-month period. Topical application of fluoride
solutions. Space Maintainers.
4.03 LIMITATION ON DIAGNOSTIC AND PREVENTIVE BENEFITS: The following
limitation applies to Diagnostic and Preventive Benefits:
Complete mouth x-rays (at least 14 films) are provided only once in a three-
year period, unless special need is shown. Supplementary bite-wing (individual)
x-rays are provided on request by the Dentist, but not more than once every six
months.
4.04 CDS shall pay or otherwise discharge 7596 of the Dentists' Usual, Customary and
Reasonable fees or of the fees actually charged, whichever is less, for the following
Basic Benefits:
Oral Surgery - extractions and certain other surgical procedures, including
pre- and post-operative care.
Restorative - synthetic porcelain and plastic restorations for treatment of
carious lesions (visible destruction of hard tooth structure
' resulting from the process of dental decay).
Endodontic - treatment of the tooth pulp.
Periodontic - treatment of gums and bones supporting teeth. -
- -7-
4.05 CDS shall pay or otherwise discharge 75% of the Dentists' Usual, Customary and
Reasonable fees or of the fees actually charged, whichever is less, for the following
, Crowns, Jackets and Gold or Cast Restorations Benefits:
Crowns, Jackets and Gold or Cast Restorations will be provided when teeth
cannot be restored with amalgam, synthetic porcelain or plastic restorations.
4.06 LI.MITATION ON CROWNS, JACKETS AND GOLD OR CAST RESTORATIONS: The
following limitation applies to Crowns, Jackets and Gold or Cast Restorations:
Crowns, Jackets and Gold or Cast Restorations will be replaced only after five
years have elapsed following any prior provision under any CDS program.
4.07 CDS shall pay or otherwise discharge 75% of the Dentists' Usual, Customary and
Reasonable fees or of the fees actually charged, whichever Is less, for the following
Prosthodontic Benefits:
Procedures for construction or repair of fixed bridges, partial or complete
dentures.
4.08 LIMITATIONS ON PROSTHODONTIC BENEFITS: The following limitations apply to
Prosthodontic Benefits:
a) Prosthodontic appliances, Including but not limited to fixed bridges and
partial or complete dentures, will be replaced only after five years have
elapsed following any prior provision of such appliances under any CDS
Contract, except when CDS determines that there is such extensive loss
of remaining teeth or change in supporting tissues that the existing
appliance cannot be made satisfactory. Replacement will be made of a
prosthodontic appliance not provided under a CDS Contract only if it is
unsatisfactory and cannot be made satisfactory.
b) Implants or the surgical removal of implants are not benefits under this
Contract. However, if Implants are provided, CDS will allow the cost of a
standard complete or partial denture toward the cost of implants and
appliances constructed in association therewith. If CDS makes an
allowance toward the cost of implants, CDS will not pay for any
replacement appliance placed within five years thereafter.
c) CDS will pay the applicable percentage of the Dentist's fee for a standard
.cast chrome or acrylic partial denture or a standard complete denture, up
to a maximum fee allowance which is at least the Prevailing Fee for a
standard denture. The. maximum allowance is revised periodically -as
dental fees change. Any denture for which a charges is made which
exceeds this allowance is considered an optional service, and the patient Is
responsible for the portion of the Dentist's fee in excess of the CDS
allowance.
_8_
4.09 CDS shall provide Orthodontic Benefits in accordance with Orthodontic Benefit Rider •
attached hereto as Appendix"C".
4.10 GENERAL LIMITATIONS - OPTIONAL SERVICES
• U an Eligible Person selects a more expensive plan of treatment than is customarily
provided, CDS. will pay the applicable percentage of the lesser fee and the patient is
responsible for the remainder of the Dentist's fee. For example: gold crown where a
silver filling could restore the tooth, a precision denture where a standard denture
would suffice.
•
4.11 EXCLUSIONS: The following services are not benefits:
a) Services for injuries or conditions which are compensable under Worker's
Compensation or Employer's Liability Laws; services which are provided
to the Eligible Person by any Federal or State Government Agency or are
provided without cost to the Eligible Person by any municipality, county
or other political subdivision, except as provided in Section 12532.5 of the
California Government Code.
b) Services with respect to congenital (hereditary) or developmental
(following birth) malformations or cosmetic surgery or dentistry for purely
cosmetic reasons, Including but not limited to cleft palate, maxillary and
mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack
of development), fluorosis (a type discoloration of the teeth), and
anodontia (congenitally missing teeth).
•
c) Services for restoring tooth structure lost from wear, for rebuilding or
maintaining chewing surfaces due to teeth out of alignment or occlusion,
or for stabilizing the teeth. Such services include but are not limited to
equilibration and periodontal splinting.
d) Prosthodontic Services or any single procedure started prior to the date
the person became eligible for such services under this Contract.
e) Prescribed Drugs, premedication or analgesia.
f) Experimental Procedures.
g) Prophylaxis, If the eligible patient has received two prophylaxes covered
by the program in the Immediately preceding eleven months.
h) All hospital costs and any additional Ices charged by the dentist for
hospital treatment.
i) Charges for anesthesia, other than general anesthesia administered by a
licensed dentist in connection with covered oral surgery services.
_9_
j) Extra oral grafts (grafting of tissues from outside the mouth to oral
tissues). -
k) Services with respect to any disturbances of the temporomandibular joint
(jaw joints).
ARTICLE V -MAXIMUM AMOUNT 8 COORDINATION OF BENEFITS
5.01 The maximu-n amount payable for Diagnostic and Preventive, Basic, Crowns, Jackets
and Gold or Cast Restorations, and Prosthodontic Benefits provided by any Eligible
Person in any calendar year shall be $1,000.00.
5.02 If an Eligible Person is entitled to coverage under one or more group insurance
policies or group prepaid health care programs, Including a CDS Program, then the
Benefits of this Contract shall be provided as followsi
(i) If the other policy or program(s) primarily cover services or expenses
other than dental care, then this program shall be primary.
(ii) If the other coverage is by a dental insurance policy or prepaid dental care
program, the policy or program covering the patient as an employee shall
be primary over the policy or program covering the patient as a
dependent, and the policy or program covering the patient as a dependent
child of a male person shall be primary over the policy or program
covering the patient as a dependent of a female person.
(iii) When primary coverage cannot be determined according to (1) and Ui)
above, the program which has covered the eligible patient for the longer
period of time shall be primary.
U the program provided by this Contract is "primary", as provided above, this
program shall provide Benefits without regard to any policy or program, and if the
program provided by this Contract is not "primary", this program shall provide
Benefits only to the extent that the Benefits obtained from such other insurance or
program are inadequate to provide full payment for the services which are Benefits
provided by this Contract.
ARTICLE VI-CONDITIONS UNDER WHICH BENEFITS SHALL BE PROVIDED
6.01 Benefits, except as otherwise provided In Article IV hereof, are available from the
Eligibility Date of an Eligible Person.
6.02 While an Eligible Person may elect the. service of any licensed Dentist, neither CDS
nor Applicant undertakes to guarantee the availability of any particular Dentist.
-10- -
•
•
6.03 As a condition precedent to the approval of claims hereunder, CDS shall be entitled
to receive, to such extent as may be lawful,from any attending or examining Dentist,
• or from hospitals in which a Dentist's care Is provided, such information and records
• relating to attendance to or examination of or treatment provided to an Eligible
Person as may be required in the administration of such claims, or that an Eligible
Person be examined by a dental consultant retained by CDS in or near his community
or residence; provided, however, that CDS shall in every case hold such information
and records as confidential.
. 6.04 The amounts payable by CDS with respect to services provided by a California
Dentist who is not a Participating Dentist shall not exceed the applicable percentage
herein specified of the fees charged,or of the Prevailing Fee, whichever shall be less.
6.05 Payment for services performed by a non-participating Dentist may be made to an
Eligible Person and shall not be assignable. CONTRACTS BETWEEN CDS AND ITS
PARTICIPATING DENTISTS PROVIDE THAT IN THE EVENT CDS FAILS TO PAY
THE DENTIST, THE ELIGIBLE PERSON SHALL NOT BE LIABLE TO THE DENTIST
FOR ANY SUMS OWLI) 13Y CDS. IN THE EVENT CDS FAILS TO PAY A DENTIST,
OTHER THAN A PARTICIPATING DENTIST, THE ELIGIBLE PERSON MAY BE
LIABLE TO THE DENTIST FOR THE COST OF SERVICES.
6.06 The amounts payable by COS with respect to services provided by a Dentist In
another state or country who cooperates with CDS in the administration of the
program shall be the fees charged up to the Customary fee In California.
6.07 CDS shall not be obligated to pay claims submitted more than six months after the
date of providing the service. If a claim Is denied due to a Participating Dentist's
failure to make timely submission, the Eligible Person shall not be liable to such
dentist for theamount which would have been payable by CDS.
6.08 CDS shall prepare and furnish to each Participating Dentist and to any other Dentist
or Eligible Person on request a standard form to make a claim for payment for
services covered by this Contract. In order to make a claim for payment, such form,
duly completed in accordance with the terms thereof and signed by the Dentist who
performed the services and by the Eligible Person (or the patient's parent or guardian
if such patient is a minor), shall be submitted to CDS at the address shown thereon.
6.09 CDS shall notify each claimant who submits a claim In accordance with Paragraph
6.08 above if such claim Is denied, in whole or in part, stating the reason or reasons
for the denial. WIthin 60 days after receipt of such notice, a claimant may make a
. written request for review of such denial, by addressing such request to CDS, P.O.
Box 7736, San Francisco, California 94120, Telephone (415) 864-9800, Attentions
Benefit Services Department, stating the reasonsthe claimant believes that the
denial of the claim was In error and any pertinent documents which the claimant
wishes to review. The Benefit Services Department of CDS will review the claim. If
the review involves a determination as to the quality of services provided or the
appropriateness of fees charged, and the matter cannot be resolved by CDS to the
satisfaction of the claimant, it will be referred to a peer review committee of the
appropriate dental society or association which will accept jurisdiction,-and CDS
agrees to be bound by the determination of such peer review committee. Unless
-ll- - -
reference to a peer review committee is required or other unusual circumstances.
arise, a decision on a request for review shall be provided and communicated to the
• claimant In writing within 120 days after receipt of a request for review.
•
• ARTICLE VII-OTHER CDS OBLIGATIONS
•
7.01 CDS shall advise Participating Dentists as follows:
A. To complete and submit a standardized Attending Dentist's Statement,
(ADS), prior to providing service, showing 'the Eligible Person's dental
needs and the treatment necessary in the professional Judgment of the
Dentist.
B. To notify the patient of all actions taken by COS with respect to such
Attending Dentist's Statements, and
C. That such ADS need not be submitted prior to providing of service In the
case of emergency services or in the case of brief,routine procedures.
7.02 CDS shall authorize such ADS for Benefits when satisfied from the ADS and other
data submitted by the Dentist that (a) the patient is an Eligible Person hereunder, (b)
the services proposed are Benefits under this Contract, and (c) that the total fees to
be charged for such services to both COS and the Eligible Person do not exceed the
• Participating Dentist's Usual, Customary and Reasonable fees. Such authorization
shall be for a maximum period of sixty (60) days, but no longer than the term of this
Contract.
7.03 CDS shall make no payment for any services rendered to a patient who is not an
Eligible Person hereunder at the time of providing the service, except to the extent
of services performed during a period of authorization issued by CDS pursuant to
Paragraph 7.02 of this Article, and except for completion of Single Procedures which
are commenced at the time a patient was entitled to Benefits by reason of such
authorization.
7.04 CDS shall furnish Applicant monthly accountings showing the amount of dentists'
statements paid or discharged during the preceding month and the amount payable for
administration (pursuant to Section 3.01 of this Contract). CDS may render interim
accountings at any time, if It has insufficient funds on hand to pay dentists'
statements arid may suspend payment of such statements until funds are received.
CDS shall in no event be obligated to pay for or provide.l3enefits except out of funds
paid by Applicant.
7.03 CDS shall return to Applicant after the end of the Conttact.Term monies remaining,
• - if any, after payment or other discharge of current bills for services. For purposes of.
computation of amounts payable hereunder, amounts, if any, withheld from payments
to participating dentists by CDS for Its reserves, research or other purposes deemed
• proper by the governing board of CDS shall be deemed to have been paid by CDS in
discharge of the claim of such dentists.
•
•
- - -12-
7.06 CDS. shall provide professional review of the adequacy of services provided by
Participating Dentists.
7.07 CDS shall furnish to the Applicant on the Effective Date of this Contract and at
reasonable times thereafter a directory of Participating Dentists who have agreed to
provide the services described In this Contract. It is understood that the composition
of such directory may be subject to change from time to time, and CDS reserves the
right to change the directory without prior notice to the Applicant, but shall give
notice within a reasonable time of any change which will materially and adversely
affect Applicant. Current information concerning the Participating Dentist status of
any Dentist may be obtained by telephoning the CDS Membership and Fee Listing
Department at (413) 864-9800. The dentists performing or contracting to perform
dental services under their Contract shall be solely responsible therefor, and In no
case shall CDS or Applicant be liable for any act or omission by such dentin, their
agents or employees.
7.08 CDS will prepare and furnish to the Applicant an evidence of coverage and summary
of contract provisions,summarizing the benefits to which the employee is entitled. If
any amendment to this Contract shall materially affect any benefits described in such
evidence of coverage, a corrected evidence of coverageriders, or inserts showing the
change shall be prepared and provided. CDS shall furnish such evidence of Overage
and summary of contract provisions to Applicant in sufficient quanities to permit
distribution to all eligible employees. Distribution shall be the responsibility of
Applicant.
ARTICLE VIII-GENERAL PROVISIONS
8.01 No agent has authority to change this Contract or waive any of its provisions. No
change in this Contract shall be valid unless approved by an executive officer of CDS
and evidenced by endorsement hereon.
8.02 Any controversy or claim.arising out of or relating to this Contract or the breach
thereof, by or among any two or more parties to this Contract, Dentists, Eligible
Persons or any of them, shall be settled by arbitration by a single arbitrator to be
selected by the parties, and judgment upon the award rendered by the arbitrator may
be entered in any court having jirisdiction thereof.
8.03 If any portion of this Contract or any Amendment thereof shall be determined by any
arbitrator, court or other competent authority to be illegal, void or unenforceable,
such determination shall not abrogate this Contract or any portion thereof other than
such portion determined to be Illegal, void or unenforceable, and all other portions of
this Contract shall remain in full force and effect.
•
8.04 The parties agree that all questions regarding the interpretation or enforcement of
this Contract shall be governed by the laws of the State of California, where the
Contract was entered into and is to be performed. -
- • -13=
8.05 Both parties to this Contract agree to consult to the extent reasonably "practical
concerning all material published or distributed relating to this Contract. No such
material shall be published or distributed which Is contrary to the terms of this
Contract.
8.06 Both parties to this Contract agree to permit and encourage the professional
relationship between Dentist and patient to be maintained without interference. .;.
8.07 Any notice wider this Contract shall be sufficient if given by either the Applicant or
CDS to the other addressed to the office stated in the attached Application, and shall
be effective 48 hours after deposit In the United States mall with postage fully
prepaid thereon.
8.08 For purposes of the Employee Retirement Income Security Act of 1974, CDS shall be
considered to be a "named fiduciary" with respect to the employee welfare benefit
plan dascribed In this Contract. The fiduciary duties and responsibilities delegated
to CDS shall be limited to those specified in this Contract. Applicant will designate a
Plan Administrator who will be responsible for all duties Imposed by law upon Plan
Administrators. CDS shall provide the Plan Administrator at least thirty (30) days
prior to filing dates ail necessary information which has available to it and which
need by the Plan Administrator for completing and filing reports under the Employee
Retirement Income Security Act.
ARTICLE IX - TERMINATION AND RENEWAL
9.01 This Contract may be terminated only for the following causes; •
(a) By CDS, upon Applicant's failure to pay Amounts Payable provided in
Article III, but only after the Applicant has been duly notified and billed
and at least 15 days have elapsed since the date of notification.
(b) By either Applicant or COS, upon expiration of a Contract Term.
9.02 In the event of termination for failure to pay Amounts Payable, all Benefits shall
terminate and CDS shall be released from all further obligations of this Contract,
effective on the last day of the month In which written notice of termination is given;
provided, however, that CDS shall make payment to Dentists for dental services
authorized by CDS prior to termination and for dental services which are provided
without prior authorization by a Dentist prior to receipt by him at notice of such
termination of Benefits, in reliance upon this Contract.
9.03 Termination at the end of a Contract Term shall be by at least sixty (60) days' written
notice of termination given by the party desiring to terminate to the other party. In
the event that OS shall desire to change the administrative fee or Benefits effective
at the end of any Contract Term, advice of such changes may be given to Applicant In
writing within such 60 days'. period, and shall have the effect of a notice of
termination as of the end of the Contract Term, unless an amendment to this
Contract is mutually agreed upon between Applicant and CDS.
_14. -
9.04 In the event of termination, Applicant shall remain liable to CDS for the full amount
of all Dentists' statements paid or otherwise discharged by CDS during the full term
• of this Contract, plus $1.31 per eligible employee for each month, (to compensate
CDS for Its administration of the dental program), less amounts actually paid by
Applicant to CDS.
9.05 My person who believes that this Contract, or coverage hereunder, has been
terminated or not renewed because of any Eligible Person's health status or
requirements for health care services may request a review by the California
Commissioner of Corporations, In accordance with Section 1365 (b) of the California
Health and Safety Code.
9.06 In the event of termination of this Contract for any cause, CDS shall not be required
to authorize services beyond the termination date or to pay for services performed
beyond such termination date, except for the completion of Single Procedures
commenced while this Contract was in effect, which are otherwise Benefits under the
terms of this Contract.
9.07 All Benefits shall terminate for any Eligible Person In the event that this Contract is
terminated or such person ceases to be eligible under terms of this Contract, and
neither CDS nor Applicant shall be obligated to provide continuation of Benefits to
any such person In such event.
9.08 Dental Statements received by CDS on or after July 1, 1978, shall be paid pursuant to
this Contract thereby terminating all CDS obligation under the Contract dated July 1,
1977.
•
ARTICLE X - ATTACHMENTS •
The following documents are attached to this Contract and made a part hereof.
Appendix "3" - Procedure Numbers
Appendix "C" - Orthodontic Benefit Rider
•
•
•
-1% .
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a3E ' +,�irs�•.
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s'e
,r M 'z, t - PROCEDURE, NUMBERWr : ., � Cv-, APPENDNCag
Proc. Proc. _. - -
No. Procedures. No. Procedures -
VISITS (020-099) - -7-v.- ,:s;::—..i.. . 265 Closure.of salivary fistula
•
• 020 Office visit; to include observation and/or treatment of 266 Dilation of salivary duct '
injuries and observation of patient when no other services 269 Resection of benign tumor,to 1.25 cm
are provided (regulac.pffice hours):- 270 Resection of benign tumor,larger than 1.25 cm
030 Professional visit; after hours; in addition to service 271 Resection of a malignant tumor
provided 273 Reimplantation and/or stabilization of accidentally
040 Special consultation (by specialist only—when patient evulsed or displaced teeth and/or alveolus
not treated by consultant) . 275 Transplant of tooth or tooth bud '
049 Prophylaxis—children to age 14 276 Removal of foreign body from bone (independent pro-
050 Prophylaxis—treatment to include scaling of unattached - cedure)
tooth surfaces,and polishing—adult 277 Radicalresection of bone for tumor with bone graft
061 Topical application of fluoride including prophylaxis— 278 Maxillary sinusotomy for removal of tooth fragment or
to age 14 • foreign body
062 Topical application of fluoride including prophylaxis— 279. Closure of oral fistula of maxillary sinus
adult 280 Excision of cyst;to 1.25 cm
080 Emergency treatment—palliative,per visit 281 Excision of cyst,larger than 1.25 cm
282 Sequestrectomy for osteomyelitis or abscess,superficial
DIAGNOSTIC (100-199) 285 Condylectomy of temporomandibular joint
Film procedures include exam and diagnosis. 289 Meniscectomy of temporomandibular joint
110 Single film 290 Incision and removal of foreign body from soft tissue
111 Additional,up to 12 films 291 Frenectomy
112 Entire denture series consisting of at least 14 films 292 Suture of soft tissue wound or injury.
(including bite-wings,if necessary) 293 Crown exposure with attachment placed for orthodontic
113 Intra-oral,occlusal view,maxillary or mandibular,each traction
114 Lateral jaw,lateral or P/A Head,one film 294 Injection of temporomandibular joint
115 Lateral jaw,lateral or P/A Head,two films 295 Treatment trigeminal neuralgia by injection_into second
116 Bite-wing films,2 films and third divisions
117 Bite-wing films,4 films: 296 Crown exposure to aid eruption ``-
it
125 Panographic-type film only
126 Cephalometric film only DRUGS (300-399)
127 Cephalometric film,each additional 300 Drugs administered bydentist—injectable therapeutic
128 Temporomandibular articulation x-ray survey (includes •
all necessary films) 'ANESTHESIA (400-449)
129 Orthodontic x-ray survey (entire denture series and all 400 Anesthesia,general,one-half hour(office administration)
other films,including cephalometric and photos) - 401 Anesthesia, general, each additional 15 minutes (office
150 Biopsy of oral tissue,incisional administration)
160 Microscopic examination of biopsied material
PERIODONTICS (450-499)
ORAL SURGERY (200-299) 450 Recall following active surgical periodontal treatment
Genera/Anesthesia—See Procedure#400. after four months (includes any prophylaxis, root plan-
EXTRACTIONS ing,and curettage as necessary)
Includes local anesthesia and routine post-operative visits. 451 Emergency treatment (periodontal abscess, acute perio-
200 Uncomplicated—single dontitis,etc.)
201 Each additional uncomplicated tooth (same date of 452 Subgingival curettage and root planing per quadrant(not
service) prophylaxis and scaling—see Procedure#050)
202 Surgical removal of an erupted tooth 453 Correction of occlusion—per quadrant(minor spot grind-
n)
203 Removal of residual root totally covered by bone ing, not to
472 Gingivectomymy per per quadrant
drant (including post-surgical visits)
220 Post-operative visit—complications(i.e.osteitis) 473 Gingivectomy, osseous or muco-gingival surgery per
230 Removal of impacted tooth (soft tissue) quadrant (includes post-surgical visits)
231 Removal of impacted tooth (partially bony) 474 Gingivectomy,treatment per tooth (fewer than six teeth)
232 Removal of impacted tooth (completely bony)
ALVEOLAR AND GINGIVAL RECONSTRUCTION ENDODONTICS (500-599)
250 Alveolectomy(edentulous),per quadrant 500 Direct pulp capping
252 Alveolectomy (in addition to removal of teeth), per 501 Therapeutic pulpotomy (in addition to restoration) per
quadrant • treatment
' 253 Reduction of tuberosity,unilateral 502 Vital Pulpotomyv. .
255 Vestibuloplasty, submucosal resection (does not include 503 Indirect pulp capping (recalcification) including tempo-
skin,bone or mucosal grafts) - rary restoration
256 Atveoplasty with ridge extension (secondary epitheliali- ROOT CANAL THERAPY
zation)
257 Removal of palatal torus - 510 Culture canal-
258 Removal of mandibular tori,per quadrant - 511 Single canal
259 Excision of hyper-plastic tissue,per.arch 512 Two canals
513 ' Three canals -
CYSTS,NEOPLASMS,MISCELLANEOUS 514 Four canals
260 Intra-oral incision and drainage of abscess(soft tissue) • 530 Apical Surgery
- including filling of root canal and/or
261 Extra-oral incision and drainage of abscess retrograde therapy—single operation
262 Excision pericoronal gingiva - - 531 - Apicoectomy (separate procedure)
263 Sialolithotomy: removal of salivary calculus,intra-orally _ 532 Hemisection,root amputation — -
264 Sialolithotomy: removal of salivary calculus,extra-orally 534 Apexification,per visit -
CDS 1006 8/77- -- — - -
CALIFORNIA DENTAL SERVICE
A Nonprofit Corporation
CDS GROUP #1949
APPLICATION FOR DENTAL CARE SERVICE AGREEMENT
CITY OP CUPERTINO
herein called "EMPLOYER," hereby applies for a DENTAL CARE SERVICE AGREEMENT with CALIFORNIA DENTAL
SERVICE, herein called "CDS,"on the following terms:
•
I. Definitions:
A. Monthly Payment the sum of $8.69 for each eligible single employee,
the sum of $15.31 for each eligible employee with one eligible depend-
ent, the sum of $24.69 for each eligible employee with two or more
eligible dependents.
B. Applicable Percentages: -t ri
Basic Benefits (as defined in Appendix,l'C")Csh't ll!be-710% during the first calendar year of an eligible patient's
eligibility. Provided the eligible patient has utilized available Basic Benefits'during the calendar year in which the Applicable
Percentage was 70%, the Applicable Percentage,for• Basic Benefits shall be'indeased to 80% for care rendered during the next
succeeding calendar year of eligibility;and the Applicable:Percentage forBasic Benefits shall increase to 90% in the calendar year
succeeding a period in which the Applicable Percentage]was 80%and the Appl ci able Percentage for Basic Benefits shall increase
to 100% in the calendar year succeeding a period in which the 'A, Percentage'was 90%. If during a calendar year of
eligibility an eligible patient does not utilize-avilablei;Basic1Benefits, th'e Applicable Percentage for Basic Benefits rendered
during the next succeeding calendar year shall.be reduced-by'ten' percentage points, but in no event to less than 70%. (For
example, if during a period in which the Applicable Percentage wa's,90% the eligible patient fails to utilize available Basic
Benefits the Applicable Percentage for the succeeding cal'erfdar year'shall Ibe 80%). CDS shall waive the consequences of failure
of an eligible patient to utilize available Basic!Benefits during:any-calendariyear,if-it finds, in its sole discretion,that such failure
was due to extenuating circumstances and that the subsequenrconditibrPrequiring dental care was not caused by such failure.
T
] Prosthodontics (as defined in Appendix(,7C7-) 50%
] Dental Accident (as defined in Appendix'!CL!)100%./ C, (\J
II. Benefits provided and limitations:
A. Subject to the terms and conditions herein specified, CDS shall pay or otherwise discharge the applicable percent-
age of the lesser of the usual, customary and reasonable fees or the fees actually charged for services rendered to an eligible
patient during the term hereof and covered by this Agreement set forth in Appendix "C" attached hereto.
] B. The amounts payable by CDS for covered Basic and Prosthodontic services rendered by a participating dentist in
California who is not a member of CDS shall not exceed the applicable percentage of the amounts shown for corresponding
services in the Table of Allowances, attached hereto as Appendix "B"; and the amounts payable by CDS for covered services
rendered by a participating dentist outside of California shall not exceed the applicable percentage of the customary fees in
California.
C. The amounts payable to a dentist who is not a participating dentist shall not exceed the amount which CDS would
pay to such a dentist on account of such services if he were a participating dentist, but not a member of CDS.Such payment
shall be made only upon receipt by CDS of evidence which it deems satisfactory showing the rendition of covered services during
a period in which the patient was eligible for care under the provisions of this Agreement and the amount which the patient has
paid or become obligated to pay therefor. Such payment may, in the discretion of CDS,be made to the eligible patient,to the
dentist,or jointly to both of them.
D. The maximum amount payable by CDS for Basic, Prosthodontic and Dental Accident Benefits rendered to an
eligible patient in any calendar year or portion thereof shall be$1,000.00.
111 E. CDS shall not be obligated'to pay for, or otherwise discharge, in whole or in part, the first $50.00 of fees for
covered services rendered to each eligible patient during the term of this Agreement which fees shall be computed on the basis of
the dentist's usual, customary and reasonable fees or fees actually charged or the Table of Allowances,whichever is applicable
under the provisions of Sections I I-A and I I-B of this Application.
❑ F. The deductible specified in Section II-E above shall not apply to services rendered to eligible dependent children as
defined in Appendix "A"attached hereto.
SECTIONS II-E AND II-F ARE APPLICABLE ONLY WHERE A CHECK MARK HAS BEEN PLACED IN THE BOX
PRECEDING SUCH SECTION.
3-74-Nu-ng N -1-
III. In the event that the number of eligiblegrpployees reported by EMPLOYER to CDS pursuant to paragraph 1(a) of
General Agreements shall be less than UU in each of any three consecutive months,CDS shall,at
its option, terminate this Agreement upon written notice to EMPLOYER given not more than fifteen (15) days after receipt of
the List of Eligible Employees which indicates that such ground for termination exists.Such termination shall be effective as of
the last day of the month in which notice of termination is given, and CDS shall make payment to dentists for dental services
authorized prior to termination and dental services which were rendered without prior authorization by the dentist prior to
receipt by him of notice of such termination of benefits.
IV. Any notice which is required or permitted to be given under the terms of this Agreement may be given by registered or
certified mail addressed to the parties at the addresses which are indicated below and shall be deemed to have been'given 48
hours after deposit in the mail with postage fully prepaid at any post office located in the continental United States. The
addresses of the parties are as follows subject to change by written request:
(a) EMPLOYER
CITY OF CUPERTINO
10300 Torre Avenue
Cupertino, California 95014
(b) DESIGNATED AGENT OR REPRESENTATIVE
I n
(c) CALIFORNIA DENTAL SERVICE) r
Director of Marketing �Y • .;"
P.O. Box 7736 � _ �• n -—"-- =pi
San Francisco,California 941207
ri
V. The term of this Agreement shall beIJtlly 1, 1974'.', lihrough=June 30, 1976 and shall
continue thereafter from year to year until ;terminated Tris Agreement may be terminated on any
anniversary date by at least sixty (60) days' written notice-of_termination giver-OK-the party desiring to terminate to the other
party. In the event that CDS shall desire to change the ;rates or other terms an i:conditions of this Agreement effective on an
anniversary date, advice of such proposed changes maybe given with7p notice of termination,and such notice of termination
shall be effective only in the event that agreement_is not reached as to such changes. In the event that this Agreement is
terminated pursuant to this pacayy[[aapph, DS 'Ls efggby'empowered not to authorize reaatmeut plans beyond such termination.An
anniversary date shall mean `�ujY 1, 1910 sy 11�->)`r1 , ;'� and/ �uly 1
of each subsequent year. JJt w J
The attached Definitions, Recitals, General Agreements and Appendices A, B, C, (and ) are each a part of
this Application and, upon acceptance hereof by CDS, this Application and the aforesaid documents shall constitute the entire
Agreement between EMPLOYER and CDS. All prior negotiations,representations and understandings are intended to be merged
herein. No modification of this Agreement shall be effective for any purpose unless in writing and signed by both parties or their
duly authorized representatives.
ACCEPTED: DATED: July 1, 1974
CALIFOR IA DEN SE E: • CITY OFPERTI' e :
By By 0�%�
�[ (Title)
PRESIDENT
ByBy
�G� • (Title)
ASSISTAN VICE PRE S ENT/CONTRTROTISI
3-74-N U-I N -2
RECITALS
CDS is a nonprofit corporation, organized and existing under Section 9201 of the Corporations Code of the State of
California, composed of members licensed to practice dentistry under the provisions of the Dental Practice Act. It is the
purpose of CDS to provide dental care under programs with responsible entities so as to maintain the prime requisites of an
independent and responsible profession, i.e., fee for services, free choice of dentists and preservation of dentist-patient
relationship without lay control, interference,promotion or commercialization.
GENERAL AGREEMENTS
1. EMPLOYER agrees:
(a) To compile, certify and furnish to CDS on or prior to the first of every month commencing on the
commencement date of the term of this Agreement, a LIST OF ALL ELIGIBLE EMPLOYEES AND THEIR SOCIAL
SECURITY NUMBERS entitled to receive dental benefits hereunder. Eligible employees shall be determined according to
the Eligibility Rules—Appendix "A",attached hereto.
(b) To pay CDS monthly, commencing on tfie ffec vL4ate of the term of this Agreement, and on or before the
first day of each succeeding month, the mont ly`payment specified in/Section 1-A of the Application for Dental Care
Service Agreement and to bear the expense7o�fsuch payments withou withholding or otherwise charging the Eligible
Employees for coverage of themselves or theird?pendents. 'Cr
� 9
(c) To provide information to all eligible erpployee�al\to the existence.a id terms of this Agreement and the right
of eligible patients to receive care as providgd-hdrein from a dentist'.of each patient choice,as such choice may be exercised
from time to time by a patient during the continued eligibility/of the patient. h 1
< IIL±\ I1
(d) To advise eligible employees torno'tjfy their dentist at the time ofjeir first appointment that they are covered
by this Agreement and to provide their dentist:with group identification=and socral•security number.
A DELTA DENTAL PLAN
(e) To permit CDS, by its auditors or other authorized represe tives, on reasonable advance written notice,to
inspect records of EMPLOYER in order to verifMhenccuracy oflis s of�e igible employees prepared by,EMPLOYER and
submitted to CDS. �• i�JJV \1\1
2. CDS agrees:
(a) To advise participating dentists as follows:
(i) To submit a treatment plan, prior to rendition of service, showing the patient's dental needs and the
treatment necessary in the professional judgment of the dentist;and
(ii) To notify the eligible patient of all actions taken by CDS with respect to such treatment plans;and
(iii) That such treatment plan need not be submitted prior to rendition of service in the case of emergency
services or in the case of brief routine procedures.
(b) To authorize such treatment plan for 'coverage under the dental care program provided by this Agreement
when satisfied from the treatment plan and other data submitted by the dentist (1) that the patient is eligible hereunder;
(2) that the services proposed are included in the Schedule of Services covered by this Agreement set forth in Appendix "C"
attached hereto; and (3) that the total fees to be charged to both CDS and the eligible patient do not exceed the dentist's
usual, customary and reasonable fees.Such authorization shall be for a maximum period of sixty (60)days from the date of
authorization by CDS,but not longer than the term of this Agreement.
(c) To make no payment for services rendered to a patient who is not eligible for dental care hereunder at the
time of rendition of service, except to the extent of services performed during a period of an authorization issued by CDS
pursuant to subparagraph (b) of this paragraph, and except for completion of single procedures commenced at a time the
patient was entitled to treatment by reason of such authorization.
(d) To make periodic checks as to the adequacy of care provided by dentists through local dental consultants and
committees of local dentists appointed by CDS.
5-74-N-1
3. (a)If an eligible patient is eligible for coverage under two or more CDS dental care programs,and more than one of
said programs provide coverage for a particular service, CDS will pay the aggregate sum payable under all applicable
programs, but not more than the lesser of the usual, customary and reasonable fee or the fee actually charged for such
service and will prorate the cost thereof between the applicable programs, provided, that no program shall be charged
with a greater amount than the amount for which it would be liable if such dual coverage did not exist.
(b) If an eligible patient is entitled to coverage under one or more group insurance policies or group prepaid health
care programs, other than a CDS dental care program, then the benefits of this Agreement shall be provided as follows:
(i) If the other policy or program(s) primarily cover services or expenses other than dental care,then this Agree-
ment shall be primary.
(ii) If the other coverage is by a dental insurance policy or prepaid dental care program,the policy or program
covering the patient as an employee shall be primary over the policy or program covering the patient as a dependent and
the policy or program covering the patient as a dependent child of a male person shall be primary over the policy or pro-
gram covering the patient as a dependent of a female person.
If the program provided by this Agreement is "primary", as provided above, CDS shall provide benefits without
regard to any other policy or program, and if the program provided by this Agreement is not "primary", CDS shall
provide benefits only to the extent that the benefits obtained from such other insurance or program are inadequate to
provide full payment for the services which are benefits pEs i d Fjyy this Agreement.
(c)If an eligible patient is injured throng ee act or omission of another person CDS shall provide the benefits of
this Agreement only on condition that the eligible patient,shall.agree,in l rit'`jJ1))
(I) To reimburse CDS to the extentof such'benefits4immedia ely uppn-collection of damages by him,whether
by action at law,settlement or otherwise,and, I /^\ �H
(ii) To grant CDS a lien,to the ext& of such benef�its.on_aany rich acts oT-at law,settlement or right to recovery.
ii ��.
(d)In no event shall the provisions ofthisparagraphDloperate_to increase-the liability of CDS beyond the benefits
for which it might otherwise be liable in the event this paragraph'did'not apply.
aa`ppplly.
rf-
4. Neither EMPLOYER nor CDS shall be liabl o ann Tact/.o o idn by a dentist, his employees or agents,or any
person performing dental or other professional services under tit's Agreement.
5. Participating dentists shall be obligated to schedule and render all dental treatment for eligible patients in accor-
dance with the applicable standards of the dental profession in their community and to charge no more than the usual,
customary and reasonable fee therefor. CDS is authorized to exclude from participating in the services provided by this
Agreement any dentist who persistently fails to comply with the obligations of participating dentists hereunder.
6. Any controversy or claim arising out of or relating to this Agreement or the breach thereof, by or between either
or both parties to this Agreement, dentists, eligible patients or any of them, shall be settled by arbitration by a single
arbitrator to be selected by the parties, and judgment upon the award rendered by the arbitrator may be entered in any
court having jurisdiction thereof.
7. In the event that any payment due pursuant to paragraph 1(b) of General Agreements is not paid when due, CDS
may give written notice that payment is due, and if such payment is not received within 10 days after such notice, CDS
may, at its option, terminate all further benefits and be released from all further obligations hereunder; provided,
however, that CDS shall make payment to dentists for dental services authorized by CDS prior to termination and for
dental services which are rendered without prior authorization by a dentist prior to receipt by him of notice of such
termination of benefits. In the event of termination pursuant to this paragraph, EMPLOYER shall remain liable to CDS
for the full amount of all dentists' statements paid or otherwise discharged by CDS,plus Twenty-Five Percent (25%) of
such amount (to compensate CDS for its administration of the dental program), less amounts actually paid by
EMPLOYER to CDS.
8. Both parties to this Agreement agree to consult to the extent reasonably practical concerning all material published
or distributed relating to this Agreement. No such material shall be published or distributed which is contrary to the
terms of this Agreement.
6-74-N _Z-
9. Both parties to this Agreement agree to permit and encourage the professional relationship between dentist and
patient to be maintained without interference.
10. If any portion of this Agreement or any Amendment thereof shall be determined by any arbitrator,court or other
competent authority to be illegal, void or unenforceable, such determination shall not abrogate this Agreement or any
portion thereof other than such portion determined to be illegal, void or unenforceable, and all other portions of this
Agreement shall remain in full force and effect.
11. The parties agree that all questions regarding the interpretation or enforcement of this Agreement shallbe governed
by the laws of the State of California,where the Agreement was entered into and is to be performed.
LP
A DELTA DENTAL PLAN
&Pe
RV IC
•
•
•
6-74-N
3-
DEFINITIONS
Eligible patient means an eligible employee and his eligible dependents (to be determined as provided in the Eligibility
Rules—Appendix "A").
Participating dentist means a dentist who is licensed to practice by the State of California and agrees to render dental
care to eligible patients in accordance with standard terms and conditions applicable to dentist participation in CDS
prepaid dental care programs, as established by the Board of Directors of CDS consistent with the provisions of this
Agreement. Participating dentist also means any dentist outside of the State of California who is licensed to practice
dentistry by the state or other jurisdiction in which he practices and who agrees to render dental care to eligible patients
in accordance with the terms of this Agreement.
Single procedure means a dental procedure listed on the CDS Table of Allowances(attached hereto as Appendix "B")
to which a separate procedure number is assigned, e.g., a three-surface amalgam restoration of a single permanent tooth
(procedure 613) or a complete maxillary denture, including adjustments for a six-month period following installation
(procedure 700).
Usual, Customary and Reasonable fee means a fee.which,'meets'.all of the following criteria, as determined by CDS
based upon confidential fee listings filed with CDS.by;member'dentists ancPthe findings of local dental society review
committees: - ''� -
USUAL: Usual fees are those fees usua:Ik charged for-a given service Liy anlindividual dentist to all his private
patients, i.e.,his own usual fee. i
CUSTOMARY: A fee is Customary when uit-isAwithinJthe range orusual fees charged by dentists of similar training and
experience for the same service within that same specific and-limited geographic'area.
REASONABLE: A fee is Reasonable when itT'meets the above two criteriatand-when, in the opinion of the review
committee of the responsible dental society,if is justifiable,considefingthe special circumstances of the particular case
in question.
e. T fr it ,,,?
j J
1-70-DD ' ,.'
APPENDIX "A"
ELIGIBILITY RULES
Effective July 1, 1974 ,all present,permanent employees of
CITY OF CUPERTINO
who have completed three(3)months of continuous full-time employment with a minimum of thirty-
two (32) hours per week are eligible under the Dental Care Service Agreement. Present permanent
employees not eligible on July 1, 1974 , and all future permanent employees will become
eligible on the first day of the month coincident with or next following three (3) months of
continuous full-time employment with a minimum of thirty-two (32) hours per week.
The dependents of eligible employees are eligible under the Dental Care Service Agreement. Dependents are lawful
spouse and unmarried dependent children to 19 or io 23I if enrolled as full-time student in an accredited school, college
or university. Children include step-children,adopiedichildren and foster children, provided such children are dependent
upon the employee for support and maintteennav
annncce " ✓�/!JA
An unmarried child 19 years or overmay continue-to-be-eligibleas.a dependent if he is incapable of self-support
because of physical or mental incapadiiythat commenced prior to reaching age 19, provided a physician's certificate
is submitted within six months following his 19th birth6y yy or the effectiivret]]date of this Agreement.
—1139
Dependents in military service are noveligiblel
Eligibility of employees shall terminate'on the last day of the month innwhich full time employment has terminated.
Dependents shall remain eligible until thel'ast day ofthe--g onfh-coincident with or following termination of eligibility of
the employee or loss of dependent status, whichever slisll`occc first. Eligibility shall, in any event, terminate
immediately upon termination of this Agreemmen�.
1-70-EN
Lt, o.pr. TABlE OF ALLOWANIES APPENDIX B
FLAY This is not a fee schedule. The amounts listed in this Table are allowances which are made
toward usual and customary fees. Usual and customary fees vary with individual dental practices.
Proc. Proc.
No. Procedures (B/R means By Report) No. Procedures (B/R means By Report)
VISITS AND DIAGNOSTIC(010-199) Allowance AllowanceCYSTS AND NEOPLASMS:
020 Office visit for treatment and observation of 260 Intra-oral incision and drainage of abscess 10.00
injuries to teeth and supporting structure,other 261 Extra-oral incision and drainage of abscess 15.00 or B/R
than for routine operative procedures(Regular 262 Excision pericoronal gingiva 10.00
office hours) 4.00 263 Sialolithotomy: removal of salivary calculus,intra-
030 Professional visits after hours (Dentist may elect orally 33.00
payment on basis of services rendered or visits 264 Sialolithotomy:removal of salivary calculus,extra-
whichever is greater) 10.00 orally 100.00
040 Special consultation (by specialist for case pre- 265 Closure of salivary fistula 60.00
sentation when diagnostic procedures have been 266 Dilation of salivary duct 17.00
performed by general dentist) 10.00 270 Resection of benign tumor of soft tissue (2.5 cm
049 Prophylaxis-children to age 14 6.00 or larger) - 25.00
050 Prophylaxis-to include scaling and polishing 9.00 271 Resection of malignant tumor B/R
061 Topical application of sodium fluoride (one treat- 275 Transplantation of tooth or tooth bud 70.00
ment including prophylaxis under age 4) 12.00 276 Removal of foreign body from bane(independent
062 Topical application of stannous fluoride (one procedure) B/R
treatment including prophylaxis - payment 271 Radical resection of bone for tumor with bone
limited to once each year to age 18) 14.00 graft B/R
080 Emergency treatment-palliative per visit 5.00 278 Maxillary sinusotomy for removal of tooth frag-
ment or foreign body 65.00 or B/R
Film allowances include exam and diagnosis -279 Closure of oral fistula of maxillary sinus 40.00 or B/R
9 280 Excision of cyst,small 25.00 or B/R
110 Single film 4.00 281 Excision of cyst,large(2.5 cm or larger) 75.00 or B/R
111 Additional,up to 12 films,each 1.00 282 Sequestrectomy for osteomyelitis or bone abscess
112 Entire denture series, including examination con- superficial 20.00 or B/R
silting of at least 14 films (bite wings if 285 Condylectomy of temporomandibular joint 300.00
necessary) 17.00 289 Meniscectomy of temporomandibular joint 250.00
113 Intra-oral, occlusal view, maxillary or mandib-
ular,each 4.00 MISCELLANEOUS:
114 Superior or inferior maxillary, extra oral, one 290 Incision and removal of foreign body from soft
film 10.00 tissue 10.00 or B/R
115 Superior or inferior maxillary, extra oral, two 291 Frenectomy 25.00
films 15.00 292 Suture of soft tissue wound or injury B/R
116 Bite wing films,including examination 293 Crown exposure for orthodontia 15.00
2 films 5.00 294 Injection of sclerosing agent into temporomandib-
4 films 7.00 ular joint 30.00
Additional films,each 1.00 295 Treatment trigeminal neuralgia by injection into
150 Biopsy of oral tissue 8.00 second and third divisions 34.00
160 Microscopic examination 15.00 DRUGS (300-399)
ORAL SURGERY(200-299) 300 Drugs administered by dentist-based on cost... 8/R
'All hospital casts are the responsibility of the patient. ANESTHESIA (400-049) •
CDS will allow for the procedures listed in this schedule. 400 Anesthesia: General 15.00
Additional fees charged by the dentist for performing PERIODONTICS 450-099
procedures in the hospital are the responsibility of the ( )
patient. Special consultation(by specialist for case presenta-
tion when preliminary diagnostic procedures
•••CSee Procedure#400 (films, models, etc.) have been performed by
AnesthesiaDSallowances
general dentist) see Procedure#040
Any further charges for anesthetics, anesthetists, or
anesthesiologists are the responsibility al the patient Prophylaxis(includes scaling and polishing) See Procedure#050
"'Allowances for procedures not listed in this schedule 451 Emergency treatment (periodontal abscess, acute
periodontitis,etc.) 10.00
will be paid at the rate listed in the Relative Value 452 Subgingival curretage, root planing per quadrant
Study as approved by the American Society of Oral (not prophylaxis) 12.00
Surgeons. Consultation (by specialist for case presenta- 453 Correction of occlusion per quadrant 12.00
tion when diagnostic procedures have been performed 472 Gingivectomy per quadrant(including post surgical
by general dentist) See Procedure#040 visits) 50.00
473 Gingivectomy, osseous or muco-gingival surgery
EXTRACTIONS: per quadrant(iecludes post surgical visits) 60.00
200 Uncomplicated single, including routine post aper- 474 Gingivectomy, treatment per tooth(fewer than six
ative visits 8.00 - teeth) 10.00
201 Each additional tooth,including routine post oper-
ative visits 6.00 ENDODONTICS (500-599)
202 Surgical removal of erupted teeth B/R - Special consultation(by specialist far case present&
220 Post-operative visit(sutures and complications) 3.00 tion when diagnostic procedures have been
performed by general dentist) see Procedure#040
IMPACTED TEETH(enclose film): 500 Pulp capping 6.00
230 Removal of tooth(soft tisue) 17.00 501 Therapeutic pulpotomy(in addition to restoration,
231 Removal of tooth(partially bony) 25.00 per treatment) 6.00
232 Removal of tooth(completely bony) 40.00 or B/R 502 Vital pulpotomy 12.00
503 Remineralization (Caoh, temporary restoration)
ALVEOLAR OR GINGIVAL RECONSTRUCTION: per tooth 10.00
250 Alveolectomy(edentulous)per quadrant 25.00
252 Alveolectomy (in addition to removal of teeth) ROOT CANALS:
per quadrant 10.00 510 Culturing canal 7.00
256 Alveoplasty with ridge extension,per arch 42.00 511 Single rooted canal tooth therapy 45.00
257 Removal of palatal torus 35.00 or BIR 512 Bi-rooted tooth canal therapy 60.00
258 Removal of mandibular tori per quadrant 35.00 513 Tri-rooted tooth canal therapy 75.00
259 Excision of hyper plastic tissue per arch 32.00 530 Apicoectomy(including filling of root canal).. . . 50.00
;t lik
Proc. Proc.
No. Procedures (B/R means By Report) No. Procedures (B/R means By Report)
Allowance Allowance
531 Apicoectomy(separate procedure) 35.00
Allowances do not include final restoration 702 Partial acrylic upper or lower with gold or chrome
or necessary roentgenograms cobalt alloy clasps-base 75.00
712 Teeth and clasps-extra per unit 5.00
RESTORATIVE DENTISTRY(600-679) 703 Partial lower or upper with chrome cobalt alloy
AMALGAM RESTORATIONS PRIMARY TEETH: lingual or palatal bar and acrylic saddles-base . 150.00
600 Cavities involving one tooth surface 6.00 704 Teeth and clasps-extra per unit 5.00
601 Cavities involving two tooth surfaces 9.00 705 Simple stress breakers-extra 14.00
602 Cavities involving three or more tooth surfaces. . . 12.00 706 Stayplate-base 30.00
AMALGAM RESTORATIONS PERMANENT TEETH: 716 Teeth and clasps-extra per unit 3.00
611 Cavities involving one tooth surface 8.00 720 Denture adjustment 4.00
612 Cavities involving two tooth surfaces 11.00 721 Office reline-cold cure-acrylic• 15.00
613 Cavities involving three or mare tooth surfaces... 15.00 722 Denture reline 35.00
GOLD RESTORATIONS: 723 Special tissue conditioning, per denture, in addi-
635 One tooth surface 35.00 tion to reline-maximum 2 per denture 15.00
636 Two tooth surfaces 40.00 724 Denture duplication(jump case)per denture .... 55.00
637 Three or more tooth surfaces 50.00
. 638 Onlays extra per tooth 10.00
SILICATE,ACRYLIC,PLASTIC RESTORATIONS: REPAIRS, DENTURES,ACRYLIC:
640 Silicate cement filling 9.00 790 Broken denture,repairing(no teeth involved) 1/00
645 Acrylic or plastic filling 11.00 Replacing missing or broken teeth, each addi-
tional 3.00
RESTORATIVE DENTISTRY UNDER GENERAL ANESTHESIA Adding teeth to partial denture to replace ex-
(Special cases only) (Handicapped Patients) tracted natural teeth:
649 Long term operative cases performed under Gen- 793 First tooth 25.00
eral Anesthesia on hourly basis.' 794 First tooth with clasp 30.08
-One hour duration from beginning to end .... 75.00 795 Each additional tooth and clasp 5.00
-Two and one half hours,maximum 150.00 796 Partial denture repairs - based on time and
-Three and one half hours,maximum 175.00 laboratory charges B/R
-Four or more hours 200.00
The above includes all operative procedures, ex-
tractions, pulpotomies,necessary treatments,stan-
nous fluoride and oral prophylaxis. Fees for anes-
thesiologists
new SPACE MAINTAINERS (800$99)
thesiologists must be paid by patient.
Allowances include all adjustments within six
CROWNS: months following installation.
650 Acrylic 60.00 800 Fixed space maintainer(hand type) 35.00
651 Acrylic with metal 75.00
652 Porcelain 75.00 REMOVABLE ACRYLIC SPACE MAINTAINERS:
653 Porcelain with metal 100.00 801 With stainless steel round wire rest only 40.00
660 Gold(full) 65.00 802 Stainless steel clasps and/or activating wires, in
663 Y.Gold 60.00 addition per wire or clasp 5.00
670 Stainless Steel(primary) 17.00 803 Study models 5.00
671 Stainless Steel(permanent) 20.00 810 Removable inhibiting appliance to correct thumb-
672 Gold dowel pin 10.00 sucking 40.00
CDS does not pay for facings on crowns,posterior 832 Fixed or cemented inhibiting appliance to correct
to 2nd bicuspids (if placed, fees must be paid thumbsucking 40.00
by patient). Office visit for observation, adjustment and acti-
PROSTHETICS(680-799) (Includes Fixed Bridges) vation per visit 4.00 '
PONTICS:
680 Cast gold(sanitary) 40.00
681 Steele's facing 45.00
682 Tru-Pontic Type 55.00 FRACTURES AND DISLOCATIONS900-999
692 Porcelain baked to gold 80.00 DISLOCATIONS (900-999)
693 Plastic processed to gold 55.00 900 Treatment of simple fracture of the maxilla,open
reduction 200.00
REMOVABLE(UNILATERAL BRIDGES): 901 Treatment of simple fracture of the maxilla,closed
683 One piece casting, chrome cobalt alloy clasp at- reduction 125.00
tachment (all types) per unit - including 902 Treatment of simple fracture of the mandible,
pontics 20.00 open reduction 230.00
903 Treatment of simple fracture of the mandible,
RECEMENTATION: closed reduction 125.00
685 Inlay 5.00 904 Treatment of compound or comminuted fracture
686 Crown 5.00 of the maxilla,closed reduction 200.00
687 Bridge 10.00 905 Treatment of compound or comminuted fracture
of the maxilla,open reduction 300.00
REPAIRS,CROWN AND BRIDGES: 906 Treatment of compound or comminuted fracture
690 Repairs-based on time and laboratory charges.. 6/R of the mandible,closed reduction 200.00
907 Treatment of compound or comminuted fracture
of the mandible,open reduction 300.00
910 Treatment of luxation (dislocation) of the man-
DENTURES: dible(uncomplicated) 8.00
Dentures, partial dentures and reline allowances 911 Treatment of condylar fracture,open reduction 350.00
include adjustmentsfor six month period follow- 912 Treatment of condylar fracture,closed reduction 150.00
ing installation.Fees for specialized techniques 913 Reduction of dislocation of temporomandibular
involving precision dentures,personalization or joint 35.00
characterization must be paid by patient. 915 Treatment of malar fracture,simple,closed reduc-
tion 100.00
700 Complete maxillary denture 155.00 916 Treatment of malar fracture,simple or compound
701 Complete mandibular denture 155.00 depressed,open reduction 200.00
C D5-298 (4/70)
APPENDIX"C"
SCHEDULE OF SERVICES
Subject to the exclusions and limitations hereinafter set forth, the following is the Schedule of Services covered by the
within Agreement when rendered by a licensed dentist and when necessary and customary,as determined by the standards
of generally accepted dental practice.
I. BASIC BENEFITS
Diagnostic
Procedures to assist the dentist in evaluating the existing conditions to determine the required dental treatment.
Preventive
Prophylaxis once every six months
Topical application of fluoride solutions 1 Tr
Space maintainers ,c)\ .\4 7-
Oral Surgery `
C>)
Procedures for extractions and other oral surgery including:pre_and-post-operative care.
I
li `✓i
General Anesthesia 'r
When administered for a covered oral surgery procedure performed by.a dentist.1
Restorative L �� II l>�
Provides amalgam, synthetic porcelain and,plastic restorations-for,;treatment of carious lesions. Gold restorations,
crowns and jackets will be provided when teeth cannot.berestored_with the above materials.
A➢rLYA Orr.rAL PLA'4
Endodontic
Procedures for pulpal therapy and root canal filling'(treatment of non-vital teeth).
Pt � , �
Periodontic " -.i‘;, /
Procedures for treatment of the tissues supporting the teeth.
II. PROSTHODONTIC BENEFITS:
Procedures for construction of bridges,partial and complete dentures.
III. DENTAL ACCIDENT BENEFITS:
Procedures for dental treatment and diagnosis rendered within 180 days following the date of an accident for
conditions caused, directly and independently of all other causes,by external,violent and accidental means;provided,that
any charges for which benefits or services are provided for an eligible patient under any group,franchise, Blue Cross, Blue
Shield or other insurance or prepayment plan arranged through an employer, union, trustee or association shall not be
covered by this section.
IV. EXCLUSIONS:
(a) Services for injuries or conditions which are compensable under Workmen's Compensation or Employer's Liability
Laws; services which are provided the eligible patient by any Federal or State Government Agency or are provided without
cost to the eligible patient by any municipality,county or other political subdivision,except as provided in Section 12532.5
of the California Government Code.
(b) Services with respect to congenital or developmental malformations or cosmetic surgery or dentistry for purely
cosmetic reasons; including but not limited to: cleft palate, maxillary and mandibular malformations, enamel hypoplasia,
fluorosis,and anodontia.
--3-74-5"A"
•
(c) Prosthodontic Services or Devices (including crowns and bridges) or any single procedure started prior to the date
the patient became eligible for such services under this Agreement.
(d) Prescribed drugs.
(e) Orthodontic Services.
(f) Experimental Procedures.
V. LIMITATIONS:
The benefits as outlined are subject to the following limitations:
(a) X-rays:
Complete mouth x-rays are provided only once in a three (3) year period, unless special need is shown.
Supplementary bite-wing x-rays are provided upon request but not more than once every six (6) months.
(b) Crowns,Jackets and Gold Restorations: 1:-;'
' u IA
)11
Replacement will be made only after five (5) years have elapsed following any prior provision of crowns,jackets or
gold restorations under any CDS program. --3'�f - - - _— _- ;
(c) Prosthodontics: I '%. J Vii`
Prosthodontic appliances (including but not(limited ,to partial and complete dentures and fixed bridges) will be
replaced only after five (5) years have elapsed`following.any prior_provision of,s ch appliances under any CDS program,
except when CDS determines that there is such-extensiv`e loss of-remaining teeth or change in supporting tissues that the
existing appliance cannot be made satisfactory._Replacement-wilLbe;made of a,prosthodontic appliance not provided under
a CDS program only if it is unsatisfactory and cannot be made satisfactory:
(d) Optional: rn^
c - ` / :-•
In all cases in which the patient selects a more expensive plan of treatment than is customarily provided,CDS will
pay the applicable percentage of the lesser fee.The patient is responsible for the remainder of the dentist's fee.
(1) Partial Dentures. CDS will provide a standard cast chrome or acrylic partial denture or will allow the cost of
such procedure toward a more complicated or precision appliance that patient and dentist may choose to use.Any denture
for which a charge is made which exceeds the customary fee shall be considered an optional service.
(2) Complete Dentures. If in the construction of a denture the patient and dentist decide on personalized
restorations or employ specialized techniques as opposed to standard procedures,CDS will allow an appropriate amount for
the standard denture toward such treatment and the patient must bear the difference in cost. Any denture for which a
charge is made which exceeds the customary fee shall be considered an optional service.
I ,
(3) Occlusion. CDS will allow the cost of restorations required to replace missing teeth. Procedures,appliances or
restorations necessary to increase vertical dimension and/or restore or maintain the occlusion are considered optional,and
the cost is the responsibility of the patient. Such procedures include, but are not limited to, equilibration, periodontal
splinting,restoration of tooth structure lost from attrition,and restoration for malalignment of the teeth.
(4) Implants. If implants are utilized,CDS will allow the cost of a standard complete or partial denture toward the
cost of implants and appliances constructed in associated therewith. CDS will not provide surgical removal of implants.
'2-
APPENDIX"D"
ORTHODONTIC BENEFIT RIDER
In consideration of the payments specified in paragraph 1 of the attached Agreement, and subject to all of the terms
and conditions thereof, except as herein otherwise specified, CDS agrees to provide Orthodontic Benefits to eligible
patients,as follows:
1. Orthodontics are defined as procedures of treatment by a licensed dentist for correction of malposed teeth of an
eligible dependent child.
2. CDS will pay or otherwise discharge 50 %of the lesser of the usual, customary and reasonable fees or the fees
actually charged for Orthodontics,provided that the amount payable to a dentist who is not a participating dentist shall not
exceed SO %of the amounts for the corresponding services set forth in the Orthodontic Table of Allowances, a
copy of which is attached hereto, marked Exhibit 1 and incorporated herein by reference.
3. The maximum amount payable by CDS for Orthodontics rendered to an eligible patient shall be $500 and
the limitations on maximum amounts payable duri g'a calendartyear, as;specified in the attached Agreement, shall not
apply to Orthodontics. ®� `/C//J�
•
4. Exclusions. In addition to the Exclusions andrtimitations;stated in dix C to the attached Agreement, the
following exclusions shall apply to Orthodontics //��
(a) The obligation of CDS to make=rrjonthly or othe" /perjodicpaymect_e_lor an orthodontic treatment plan will
cease upon termination of treatment for anyreason prior�/comp�nn of the case.
(b) The obligation of CDS to make•monthly or other periodic payments for an orthodontic treatment plan begun
prior to the eligibility date of the patient'will be calculated=on=the.balance of the dentist's normal payment pattern
remaining at the patient's initial eligibility date.The abb3ehiientioiin i Tnafiimum will apply fully to this amount.
P. �I
(c) CDS will not make any payment fomep orreplacerpe fyan orthodontic appliance furnished under this
program. uu/IJJ,,JJ�U1J ``111111
(d) CDS's obligation to make monthly or other periodic payments for Orthodontics shall terminate on the
termination date of this Agreement or on the date the eligible dependent child reaches age 19 or age 23,if a full-time
student.
S . A patient shall be eligible for Orthodontics only following such
patient's continuous enrollment in the dental program provided hereby
for a period of 12 months.
6. The period during which an eligible patient was enrolled in the
dental caro program provided by the Agreemiii dated-July 1, 1973,
between EMPLOYER and CDS shall be included in computing the 12-month,
period specified in paragraph 5 .
Dated: July 1, 1974 CALIFORNIA DENT L 5E VICE:
By: / •
PRESI DENT
ASSI ANT VIC SI /CONTROLLIR
CTA 3-74
EXHIBIT 1
TABLE OF ALLOWANCES FOR ORTHODONTICS
(To be used for cases submitted by non-participating' dentists)
A percentage of the amounts listed in this table of allowances will be paid toward the charges of the dentist providing
orthodontic services in accordance with the terms and conditions of the applicable group dental care contract. Such
amounts will be paid periodically when dentist has completed services and upon proper presentation of statement for
services rendered.
PROCEDURESS
13 Diagnostic 11���1 1L<Q111
129 Orthodontic Survey nccludding_entire.denture_series�
and all other films'.incfuuding cephalometrics and photo $ 25.00
125 Panagraphic 12.00
Extraoral Head Film-4
126 One Film"1 8.00
127 Each Additional 4.00
•DELTA DENTAL PLAN
Comprehensive Orthodontic Traatment
Permanent Dentition
850 Class n 700.00
855 Class I I 700.00
860 Class III 700.00
Mixed Dentition
870 Class I 400.00
871 Class II 400.00
872 Class III 400.00
Primary Dentition •
875 Class I 200.00
876 Class II 200.00
877 Class III 200.00
Appliances for Tooth Guidance
840 Removable 40.00
843 Fixed or cemented 50.00
Appliances to Control Harmful Habits
845 Removable 40.00
847 Fixed or cemented 50.00
'Non-participating Dentist — Dentist who does not agree to abide by the conditions governing dentist participation in
California Dental Service group dental care program.