2004/06/08 City Council Resolution (3)RESOLUTION NO. 2004 - 139
A RESOLUTION OF THE CITY OF ROHNERT PARK APPROVING AN INSURANCE
COVERAGE AGREEMENT WITH DELTA DENTAL
WHEREAS, the City of Rohnert Park has met and conferred with its bargaining
units regarding the change in coverage for health benefits;
WHEREAS, the dental health plan offered to the City's employees and retirees
will be provided by Delta Dental;
WHEREAS, attached as EXHIBIT A to this resolution are the benefit highlights
for the Delta Preferred Option Plan that the City will be offering its employees and
retirees;
NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of Rohnert
Park approves an insurance coverage agreement with Delta Dental and authorizes the
City Manager to finalize negotiations and execute the agreement.
DULY AND REGULARLY ADOPTED this 8t" day of June 2004.
CITY OF ROHNERT PARK
ATTCC-T-
FLORES: AYE MACKENZIE: AYE SPRADLIN: AYE VIDAK MARTINEZ: AYE NORDIN- AYE
AYES: (5) NOES: (0) ABSENT: (0) ABSTAIN: (0)
BENEFIT HIGHLIGHTS
& DELTAPREFERRED OPTION
Preferred Provider Program
AsoUT DPO
The DeltaPreferred Option (DPO) plan allows you to:
♦ Save on out -of- pocket expense when you visit a DPO network dental office
Visit any licensed dentist of your choice — select a different dentist for each
member of your family
• Change dentists at any time
• Go to a dental specialist of your choice
Receive dental care anywhere in the world
EXHIBIT A for Resolution No. 2004 -139
SAMPLE ONLY FOR THE CITY OF ROHNERT PARK
Under the DPO plan, you may visit any licensed dentist you wish. However,
you receive the maximum benefits available under the program when you
choose one of the more than 10,000 in- network dental offices throughout
California.
If you choose an out -of- network dentist, you will benefit by selecting a Delta
dentist. More than 18,000 dentists in California are Delta dentists, including
DPO dentists. Delta dentists agree to abide by Delta's fee and quality
guidelines.
IN- NETWORK
OUT -OF- NETWORK
NON -DPO
NON -DELTA
DPO DENTISTS
DELTA DENTISTS
DENTISTS
Your out -of- pocket expense
You will be charged no
You will be responsible
will probably be less because
more than the fees
for the difference if
DPO dentists have agreed to
approved by Delta.
your dentist charges
charge DPO patients reduced
more than Delta's
fees.
approved fees.
Claim forms will be completed
Claim forms will be
You may have to
and submitted for you at no
completed and
complete and submit
charge.
submitted for you at no
your own claim forms
charge.
or pay a service fee.
You may be charged only the
You may be charged
You may have to pay
patient share" at the time of
only the patient share"
the entire amount in
treatment, not Delta's portion.
at the time of treatment,
advance and wait for
not Delta's portion.
reimbursement.
"Patient share" is the copayment, applicable deductible and any amount over the annual maximum.
Some services may not be covered; please refer to your Evidence of Coverage. Some examples of
services not covered are cosmetic dentistry, experimental procedures and services to correct congenital
malformations.
DPO is EASY To USE
DPO is Delta's preferred provider plan, The plan provides the maximum benefit
when you visit a DPO dentist. DPO dentists are Delta dentists who have agreed
to charge DPO patients reduced fees. Delta endodontists, oral surgeons and
periodontists are not DPO dentists, but you also receive in- network benefits
when visiting one of these Delta specialists.
To use your DPO plan, just call the dental office of your choice and make an
appointment. During your first appointment, give your dentist your group
number, which is at the top of this page, and the primary enrollee's social
security number. When you call a DPO dentist for an appointment, please
confirm that the dentist participates in the DPO network.
For a list of DPO or Delta dentists in your area, search the dentist directory on
our web site at www.deltadentaica.org or call our toll -free automated telephone
service at (800) 4- AREA -DR (800- 427 - 3237). You can also check with your
benefits administrator, who has a complete list of DPO and Delta dentists.
You can also view your eligibility and benefits information on our web site,
including remaining deductible and maximum amounts for you and your family.
Or, you can have the information faxed to you by calling toll -free (888) DELTA -
CS (888- 335 - 8227).
Delta Dental Plan of California offers you what no other dental plan can — The
Delta Difference°. Here's what makes us unique:
We prenegotiate dentists' fees. Delta dentists agree to charge you the
lowest fees usually charged in their office,
Copayments are guaranteed. Delta dentists may charge you only what
Delta determines to be your share of the treatment cost.
We require professional treatment standards. Delta dentists must meet
professional standards for hygiene, radiation safety and other areas related
to quality care.
These are just a few of the reasons that one in three Californians count on
Delta for dental care benefits.
H : \CityOps &Admin \HumanResout'Ces \Dental Highlight Sheet - DPO Plan.doc
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BENEFIT HIGHLIGHTS SAMPLE ONLY FOR G11 UI- KUNNr-KI rAKIIN EAHIM-1 a 1(7L
Resolution No. 2004 -139
,� The following are not covered by the plan:
PRINCIPAL BENEFITS AND COVERED SERVICES ♦ Services for injuries or conditions covered under Workers'
WHEN TREATMENT IS
A DPO IN- NETWORK
AN OUT -OF- NETWORK
PROVIDED BY...
DENTIST **
DENTIST
WHO'S COVERED
Primary enrollee and
Primary enrollee and spouse
spouse as well as
as well as dependent
dependent children to age ?
children to age ?
DEDUCTIBLES AND
$0 per person, per calendar
$10 per person, per
BENEFITS MAXIMUM
year. The maximum benefit
calendar year($30 max. per
paid per calendar year is
family.) The maximum
$2000 per person.
benefit paid per calendar
year is $2000 per person.
DIAGNOSTIC AND
100% of DPO approved fee
100% of Delta approved
PREVENTIVE BENEFITS*
(no deductible applies for
fee(no deductible applies for
—oral examinations,
these services)
these services)
cleanings, x -rays,
examinations of tissue
biopsy, fluoride treatment,
soace maintainers. specialist
BASIC BENEFITS* — oral
85% of DPO approved fee
85% of Delta approved fee
surgery (extractions), fillings,
root canals, periodontic
(gum) treatment, tissue
removal (biopsy), sealants
CROWNS, JACKETS AND
85% of DPO approved fee
85% of Delta approved fee
OTHER CAST
RESTORATIONS*
PROSTHODONTIC
50% of DPO approved fee
50% of Delta approved fee
BENEFITS *t — bridges,
(denture subject to a
(denture subject to a
partial dentures, full dentures
maximum allowance)
maximum allowance)
ORTHODONTIC BENEFITS*
50% of DPO approved fee
50% of Delta approved fee
— for adults and eligible
(subject to a $3500 lifetime
(subject to a $3500 lifetime
dependent children
maximum per person)
maximum per person)
*Please refer to your Evidence of Coverage for limitations on these benefits.
Some examples of limitations on services are the number of cleanings and oral exams
covered in a calendar year, and time limitations on filling and crown replacements.
* *Delta endodontists, oral surgeons and periodontists are not DPO dentists, but you
receive in- network benefits when visiting one of these specialists.
tYou must be enrolled in this dental plan for 12 continuous months before receiving
these benefits.
SERVICES THAT ARE NOT COVERED
Although your plan covers many of the most commonly needed services,
some services are not covered. If you are unsure whether a particular
procedure is covered, or how much of it is paid for by your plan, check
with Delta before proceeding.
H: \CityOps &Admin \HumanResources \Dental Highlight Sheet - DPO Plan.doc
Compensation or Employer's Liability Laws
Cosmetic surgery or dentistry or services to correct congenital
malformation
Experimental procedures
♦ Therapeutic drugs, premedication or pain relievers
Hospital costs or extra charges for hospital treatment
Anesthesia (except for general anesthesia for oral surgery)
♦ Extra -oral grafts, implants and implant removal
s Treatment related to the temporomandibular joint (TMJ)
The preceding information is not intended for use as a summary plan
description, nor is it designed to serve as an Evidence of Coverage
for the plan.
This DeltaPreferred Option plan is administered by Delta Dental Plan
of California. If you have specific questions regarding benefit
structure, limitations or exclusions, consult the Evidence of
Coverage or contact Delta's Customer and Member Service
department.
d DELTA DENTAL®
Delta Dental Plan of California
P.O. Box 7736
San Francisco, California 94120
For customer service:
(800) 765 -6003 or cros @delta.org
For automated or faxed eligibility /benefits information:
(888) DELTA -CS (888- 335 -8227)
For online eligibility /benefits information:
www.deltadentalca.org
For a list of Delta dentists:
(800) 4- AREA -DR (800- 427 -3237) or
www.deltadentalca.org
Group 31 12 -0006 cg 702) (Master Rev. S 01)
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