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HomeMy WebLinkAboutDelta Dental-Alternate Rate Proposal-06.22.2009 oitia.d,fr..,a) .. 6. v; -o, City of Waterloo L DELTA DENTAL Group#92088&92089 Alternate Rate Proposal Financial Exhibit Plan Design Delta Dental Delta Dental PPO Premier® Non Par Individual Maximum $1,800 $1,800 $1,800 Deductible Individual $0 $25 $50 Family $0 $75 $150 Diagnostic and Preventive Services Exams,cleanings,x-ray,fluoride treatments 100% 100% 70% Sealants,Space Maintainers 100% 100% 70% Deductible applies No No No Basic Restorative Services 85% 80% 60% Fillings,Emergency treatment for pain 85% 80% 60% Extractions and Impacted Teeth 85% 80% 60% Deductible applies Yes Yes Yes Endodontics Endodontics-nonsurgical 50% 50% 40% Endodontics-surgical 50% 50% 40% Deductible applies Yes Yes Yes Periodontics Periodontics-nonsurgical 50% 50% 40% Periodontics-surgical 50% 50% 40% Deductible applies Yes Yes Yes Major Restorative Services Crowns,inlays,onlays 50% 50% 40% Bridges and dentures 50% 50% 40% Repairs and adjustments to bridges and dentures 50% 50°%0 40% Deductible applies Yes Yes Yes Orthodontic Services Coverage coinsurance 50% 50% 50% Individual lifetime maximum $1,500 $1,500 $1,500 Dependents eligible to age 19 19 19 Full-time students eligible to age 19 19 19 Adult orthodontics No No No Deductible applies Yes Yes Yes Dependent Eligibility Dependents eligible to age 19 19 19 Full-time students eligible to age 25 25 25 Matching current frequencies and limitations Employer Contribution Complete this Section Participation ER Contribution* Single Number of benefit Eligible Employees* Family Plan Costs Contract Period 07/01/2009 through 06/30/2010 Single Family Annual Expense Contracts 147 499 Self-insured incurred claim estimates $21.67 $64.56 $424,791 Self-insured Administrative Fees-Weekly Settlement PEPM 7/1/2010 7/1/2011 Administrative Fee $3.15 $3.25 $3.35 Network Fee $0.25 $0.25 $0.25 Broker Fee $0.00 $0.00 $0.00 Total Administrative Fee $3.40 $3.50 $3.60 Recommended Rates(Includes Admin) $23.01 $68.56 $451,147 * Please update employer contribution and number of benefit eligible employees above and sign below. Return to Delta Dent Iowa t fax#515-261-5573 / Signature 4, Date CO - 342 - D / 7 1/13/2009 �J