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HomeMy WebLinkAboutparagonHome office: Fort Lauderdale, Florida Address, 8781 west Broward Blvd., Butte 380 Fort Lauderdale, Florida 33324 PARAGON GROUP DENTAL BENEFIT CONTRACT PARAGON DENTAL SERVICES, INC, a network administrator (herein known as 'the Company" or "PARAGON") certifies that it covers certain employees for the benefits provided by the following contract(s): GROUP/CONTRACT HOLDER: City of Miami. Group Contract(s)- COM 1000 Contract Number- 001000 Contract Effective Date: January 1, 2005 Contract Anniversary/Term of Contract: January 1st/ 36 months Premium Due Dates: First of each month beginning January 1, 2005 Notice: Any dental benefits in this certificate will apply to an employee only if: (a) he/she has elected that benefit; and (b) he/she has a confirmation letter and/or a Paragon Identification card, which shows his/her election of that benefit. This contract is issued In consideration of the Application of the contract holder, a copy of which is attached hereto, and payment of the required premiums when such premiums are due. The first premium is due on the Contract Effective Data. Subsequent premiums will be due on the dates stated above at the office of the Company. All periods of time under this contract will begin and end at 12:01 AM local time at the Contract Holder's address. Signature_--_--_ Leonard A. Weiss, DMD President Kim Nolan, SPHR Secretary ORPONTCONNON 1I05FL 1 Int. PART A — GENERAL PROVISIONS THE CONTRACT The entire contract consists of: Part A - General Contract Provisions Part B - Member Certificate/Benefit Provisions Handbook Part C- Schedule of Benefits Part D- All Applications including, but not limited to, the attached copy of the Contract Holder's Application Part E- Any endorsements, amendments and/or riders to the above All statements made by Contract Holder are deemed to be representations and not warranties. Only a duly authorized officer of the Company may change or waive any provision of this Contract. Any change or waiver must be done in writing. The Company will not be bound by any promise or representation made by any other person. No agent, broker or Company representative other than a Company officer, has any authority to change this Contract, extend the time for payment, or waive any provision of this Contract. INITIAL TERM This Group contract shall be in effect commencing at 12:01 a.m. on the Effective Date set forth in the Group Dental Contract cover page and shall extend for an initial term of three (3) years, thereafter (Initial Term). RENEWAL TERM(S) This Group Contract is renewable at the option of the Group and the Company at the end of the initial term for two additional terms of two (2) years each (renewal term), and each subsequent renewal term may be renewed at the Group's/Company's discretion subject to PARAGON'S right to modify, change, or amend the coverage and/or the premium rates applicable for the renewal term or on an annual basis. Any such changes/amendments (annual or biannual) shall be subject to the Group's acceptance and shall be made part of the Group Contract. PARAGON will offer renewal terms a minimum of 90 days In advance of the Group's anniversary date for signature by an authorized officer of the Company. The Group must notice Paragon at least 60 days prior to the Group's anniversary date as to its intent not to renew. The Renewal Agreement shall be deemed accepted and approved with the Group's signature or without the Group's signature If the first premium due for the new Contract year is paid to PARAGON on or before the tenth day of the first month of the new Contract year. Such payment of premium without the signature of an officer of the Group will obligate the group to all terms of this Policy/Group Contract for the renewal year inclusive of the Contracts termination clauses. Should the Group elect not to renew and fail to notify Paragon within 60 days prior to the Group's anniversary date, the Group would be liable for premium of two months of benefit (60 days) less the pro rata share commensurate with the date of notice (If any) plus any existing unpaid premium of the present Contract year (ex. 30 days notice of intent not renew would obligate the Group to one month's additional premium plus any existing unpaid premium of the present Contract year). PREMIUM The premium is the amount the Company charges for dental benefits under this Contract. The rates for the particular dental benefits are as follows: Dental Benefit: COM 1000 Group Size: 50 to 10,000 Employee $12.18 Family $30.52 Premium Is payable on the date shown on the cover page of this Contract. Each monthly payment will pay for the dental benefit then in force under this contract for a period of one month. If the Company receives any premium that was not due, the Company will refund it to the Contract Holder. The Contract Holder must send the Company proof within 3 months of the payment in question that the payment was not due. Premiums not due include, but are not limited to, premiums paid for a period of time a member's coverage was not In force. Reauired Notice of Enrollment Chances PARAGON, on a monthly basis will forward to the Group an invoice for premium towards the following month's dental plan coverage, complete with a current list of Group enrollees as reflected in PARAGON'S records. The Group shall be obligated to make every effort to Immediately report any changes in enrollment to PARAGON at the time of remittance of the Invoiced premium. Should the group become aware of changes in enrollment beyond remittance of premium, the Group shall have ninety (90) days from the effective date of the change to report to PARAGON such a change. Providing there has not been any benefit paid on behalf of the member(s) requesting GRPDNTCONNON 1I06FL 2 Int. a change in enrollment status, adjustment in the premium amount as a result of such a change shalt be reflected in PARAGON'S next monthly invoice statement to the Group. Group agrees that it may receive a credit for premiums paid, or relief from liability for unpaid but accrued premiums, for an ineligible member if Group notifies PARAGON within ninety (90) days of the date eligibility ceased. Group further agrees that such credit shall be limited to no more than ninety (90) days prior to PARAGON'S receipt of such notice. GRACE PERIOD A grace period of 31 days following the first unpaid month of benefits provided will be allowed for the payment of arty premium, except the first premium. This Policy stays in force during a grace period. Full payment must be received by the 31" day of the grace period. TERMINATION OF CONTRACT Either party may terminate this contract, with or without cause, by noticing the other party 60 days prior to the requested termination date. All notices of termination are to be considered 60-day termination notices regardless of other referenced notice periods or a lack of a notice period. Should either party terminate for cause, such notice should include a description of the facts underlying the claim that supports that the other party is in breach of this Contract. Remedy of such a breach, in a manner satisfactory to the party giving notice within twenty (20) days of the receipt of such notice, shall revive this Contract in effect for the remainder of the term. TERMINATION OF CONTRACT/NON PAYMENT OF PREMIUM T121sPolicy terminates accorsing to the followinq table: Then this Fojicy terminates: The Company receives, provided all premiums are paid, 60 days written notice from the Contract holder to terminate this Contract At the end of the notice period after the Company receives written notice. The Group has no further obligation. The Company receives, during a grace period, 80 days written notice from the Contract holder to terminate this Contract At the end of the grace period. The Group is obligated to premium for the grace period and one month's additional premium. Premium is not paid by the end of the grace period and no notice has been given. At the end of such grace period. The Group is obligated to premium for the grace period plus two months additional premium. The number of insured's falls below 50. At the end of a 60-day period following notification of termination by the Company and the group has not cured the default. Under State law, the Company ceases, bankrupts, becomes insolvent, is adjudicated, or a receiver is appointed, thus unable to continue to provide benefits If any of these events occur, no interest In this Contract shall be deemed an asset of creditors. No interest in this agreement shall be deemed an asset or liability of the Group. At the end of a 90-day advance written notice period given by the Company. REINSTATEMENT OF CONTRACT If this Policy terminates because the Policyholder has not paid the required premium by the end of its grace period, the Policyholder may apply for reinstatement of this Policy at the sole discretion of PARAGON. The Policyholder must request reinstatement from the Company in writing on Policyholder letterhead. The Policyholder must submit this request with all past due premiums, the grace period's premium, the current month's premium, and a reinstatement fee of $100.00, to PARAGON within 30 days of the request. If PARAGON, at its sole discretion, accepts any partial payment of past due premium, shall apply it to the account for the most overdue premium on the account. If the Company chooses to reinstate this Policy, the coverage provided hereunder will resume as of the date this Contract terminated. If the Company chooses not to reinstate this Contract, the Company will notify the Contract Holder of such decision in writing. The Company will refund any uneamed premium submitted with the request for reinstatement. GRPDNTCONNON 1/06FL 3 Int. EMPLOYEE ENROLLMENT AND SUPPORT In addition to all areas outlined in the member certificate of coverage, Paragon will affect enrollment through the processing of all enrollment forms submitted by the Group, enrolled "on-line" or via the "Paragon Call Center". Paragon is only responsible for providing benefits to employees who have been appropriately enrolled, and which the required premium payment has been received, it Is understood that Paragon will need to rely on the Group to provide all enrollment forms submitted by their members and to further assure the completeness of appropriate and necessary Information to effectuate the administration of member services. It is further understood that the Group will be responsible for the internal administration of it's benefit program, which they will communicate to it's employees via Group publications, marketing collateral, promotion at time of enrollment, website and ongoing support to Group employees/members throughout the initial enrollment and remainder of the Contract period. Paragon agrees to maintain adequate information so that the Group or any of its employeeslmembers may contact Paragon to ascertain; 1. whether a particular employee/member is enrolled in the appropriate benefit plan; 2. whether a particular employee/member is current with regard to premium; and 3. Paragon agrees to be responsible for items pertaining to the service of the dental benefit plan including; Member Services, Provider Relations, Accounting and Administration, specifically by: ▪ Maintaining appropriate staffing to ensure prompt and efficient responses to member inquiries during business hours. • Producing and distributing member ID cards and schedules of benefits at enrollment and upon request. • Maintaining Provider standards to ensure benefit delivery throughout the Paragon Network and support any member grievances that may occur. • Completing monthly billing and reconciliation in accordance with the Group's data communication. • Providing reporting on a regular basis and as requested by the Group • Quarterly service meetings with key persons of the Group to review service levels, Provider Relations and Administration. CONFIDENTIALTY OF INFORMATION Paragon and the Group agree to the following: Ail confidential and proprietary information of either party to this Contract, including but not limited to information regarding this contract, computer software, business procedures and manuals, data, review criteria, and Contract rates shall not be disclosed without the expressed written approval of the other party. Such information outlined shall only be disclosed to those persons and/or entities that are instrumental in implementing the terms of this Contract. For the purposes of this Contract, confidential Information shall not indude: • Information generally available or known to the Public or obtained from third parties; • Information independently developed by the other party subsequent to the completion of this Contract; and • Information provided to the other party with the intention that it be published, disseminated, released or distributed by such other party. The Parties to this Contract agree that no remedy of law may be adequate to compensate either party for breach of the provisions of the prior paragraph. Therefore both parties agree that either party shall be entitled to temporary and permanent injunctive relief against each other, in addition to all other remedies, which either party shall be otherwise entitled to, and this paragraph shall in no way limit, such other remedies of the parties. Such temporary or permanent injunctive relief may be granted along with any other remedies provided by Florida Law. Paragon and the Group agree to abide by all applicable laws of the State of Florida, governing the confidentiality of medical information as required by I-IIPAA. INCONTESTABILITY This Contract may not be contested after it has been in force for 2 years after the Contract effective date. This Contract may be contested at any time for nonpayment of premium or fraudulent misrepresentation. ORPDNTCONNON 1/05FL 4 Int MISSTATEMENT OF FACTS If any relevant facts about a covered member were not accurate, the Company, at Its discretion, may adjust premiums due under this Contract. The facts wilt decide whether and in what amount Insurance is valid under this Contract. INFORMATION The Contract Holder shall maintain its own records of transactions relating to this Policy, including but not limited to: 1. the names of all covered members; 2. the date upon which each member became covered under thls Contract; and 3. the effective date of any change in a covered member's benefit under this Contract. The Contract Holder shall furnish the Company with a copy of such records upon request. The Contract Holder shall immediately report any change to such records to the Company. The Company has the right to inspect any records of the Contract Holder that the Company deems relevant to the administration of its benefits. Employees and/or their dependents shall be enrolled on forms approved by the Company. Errors of the Contract Holder in furnishing information will not invalidate benefits that should have become effective. Contract Holder reporting errors will not continue, extend, or otherwise create benefits which should have terminated or for which an employee/dependent was not eligible under this Contract. Premiums shall be paid, credited or offset as appropriate when such errors are detected. GOVERNING LAW The laws of the State of Florida and Miami -Dade County shall govem this Contract. Any provision of this contract, which conflicts with the laws of the State of Florida, is amended to conform to the minimum requirements of such laws. SEVERABIUTY If any of the provisions of this Contract are declared to be invalid, such provisions shall be severed from this Contract and the other provisions hereof shall remain in full force and effect. LITIGATION In the event that litigation arises as a result of this Contract between the parties, each party shall bear its own costs and attorney's fees, pre -suit, suit, and on appeal. NOTICE Any notice given by PARAGON under this Contract shall be sufficient and effective for all purposes If and when mailed: (a) to the Group at Its last known address, or (b) to a Member, at either his or her address as appearing In the records of PARAGON or in care of the Group at its last known address. The Group shall act as agent for all Members to receive all notices to them hereunder and shall promptly notify Members. Each Member shall also serve as an agent of each of his or her dependents to forward all notices to them. It shall be the responsibility of the Group to promptly notify all members of the termination of this contract. In case of changes in the contract, specifically the certificate. Any notice to the Group by PARAGON will constitute notice to all members and PARAGON need give no further notice to any member in order to effectuate such a change. Should it be deemed appropriate, PARAGON reserves the right to notify/contact any and ail members regarding its dental benefits and changes to them without liability to the Group. Any notice required to be given, whether pursuant to the terms and provisions hereof or otherwise, shall be in writing and shall be either personally delivered or sent by certified or registered mail, retum receipt requested, addressed to the party to receive the notice at the pertinent address set forth below. ff sent by registered or certified mail/return receipt requested, such notice shall have been deemed to have been delivered to the party to whom it was addressed on the third (3'd) business day after the day on which it was mailed to such party or as designated on any receipt card by a postai clerk. Paragon Kim Nolan, SPHR Executive Vice President Paragon Dental Services, Inc. 8751 West Broward Blvd Suite 300 Fort Lauderdale, Florida 33324 GRPDNTCONNON 1/66K The City of Miami Ramona Flumara, CEBS Assistant Director, Risk Management City of Miami 444 SW 2nd Ave Miami, Florida 33130 g Int IN WITNESS WHEREOF, the parties hereto have caused this instrument to be executed by their respective officials thereunto duly authorized, this the day and year above written. "Provider" ATTEST: Corporate Secretary (affix corporate seal) "City, ATTEST: Priscilla A. Thompson, City Clerk APPROVED AS TO FORM AND CORRECTNESS: Paragon Dental Services, Inc. A State of Florida Corporation By: Leonard A. Weiss, DMD President CITY OF MIAMI, a municipal corporation By: Joe Arriola, City Manager APPROVED AS TO INSURANCE REQUIREMENTS: ,Jorge I. Fernandez Dania Carrillo, City Attorney Risk Management Administrator GRPDNTCONNON 1/06FL 6 Int. pLirr"✓ Dn Home cfflae: Fort Lauderdale, Florida Address: 8751 west Brossard Blvd., Suite 300 Fort Lauderdale, Florida 33324 PARAGON MEMBER CERTIFICATE OF COVERAGE Group Dental PARAGON SERVICES, INC, a network administrator certifies that It covers certain employees for the benefits provided by the following contract(s): GROUP CONTRACT HOLDER: City of Miami GROUP NUMBER: 00000 CERTIFICATE HOLDER: CERTIFICATE NUMBER: CERTIFICATE EFFECTIVE DATE: January 1, 2005 Notice: Any benefits in this certificate will apply to an employee only if: (a) he has elected that benefit; and (b) he has a confirmation fetter and/or a Paragon identification card, which shows his election of that benefit. Paragon certifies that under the terms and conditions of the Contract referenced above and Issued to the Contract Holder named above, the Certificate holder became covered as of the Certificate Effective Date Indicated above. The Certificate is not a contract for insurance. This Certificate summarizes the provisions, limitations, and exclusions of the Contract Issued to the Contract Holder, and are subject to the terms of the Contract. All periods of time under this Contract will begin and end at 12:01 AM local time at the Contract Holder's address. Leonard A. Weiss, DMD Kim Nolan, SPHR President Secretary GR PDNT POLO4 A —4 1 /04FL 1 ____Int. For a dependent child 19 years of age or older who is a fulltime student at an educational institution, coverage will be provided for an entire academic term during which the child begins as a full time student and remains enrolled, regardless of whether the number of hours of instruction for which the child Is enrolled is reduced to a level that changes the child's academic status to less than that of a full-time student. For a child who falls into category (2) or (3) above, you will need to furnish PARAGON evidence of his or her reliance upon you, in the form requested, within 31 days after the Dependent reaches the age of 19 and once a year thereafter during his or her term of coverage. Coverage for Dependents living outside of PARAGON service area is subject to the availability of an approved network where the Dependent resides. This definition of "Dependent" applies unless your Group Contract modifies it. Employee —an employee of the Group who meets eligibility rules of PARAGON as set out In the group contract, as prescribed by the group (specifically including any minimum number of hours worked during a week and waiting period) and as set out in the Group Enrollment Application. Employee Waiting Period- The time period in which an employee must wait before being eligible for benefits Group — An Employer, labor union or other organization that has entered into a Group Contract with PARAGON for managed/discounted dental services on your behalf. Group Contract — The entire group contract consists of the following: Part A- General Contract Provisions Part B- Member Certificate/Benefit Provisions Handbook Part C- Schedule of Benefits Part D- All Applications including, but not limited to, the attached copy of the Contract Holder's Application Part E- any endorsements, amendments and/or riders to any or all of the above. Member/Subscriber/You- means an Employee or Employee's Dependent enrolled in a dental plan in accordance with this Contract. Network Dentist — A licensed Dentist who has signed an agreement with PARAGON to provide general dentistry or specialty care services to you. The term includes both Network General Dentists and Network Specialty Dentists. Network General Dentist — A licensed Dentist who has signed an agreement with PARAGON under which he or she agrees to provide general dental care services to you. Network Specialty Dentist — A licensed Dentist who has signed an agreement with PARAGON under which he or she agrees to provide specialized dental care services, as outlined in Section H, upon payment authorization by PARAGON. Patient Co -Payment — The amount you owe your Network Dentist for any dental procedure listed on your Patient Schedule of Benefits. Contract Holder -Your group/employer that has elected to sponsor this dental coverage and administrate it. Schedule of Benefits — List of services covered under your dental Plan and how much they cost you. Premiums/Prepayment Fees — Fees that your Group remits to PARAGON, on your behalf, during the term of your Group Contract. Dental Service Area — The geographical area designated by PARAGON within which it shall provide benefits and arrange for dental care services. Usual and Customary Fee — The customary fee that an individual Dentist most frequently charges for a given dental service. INTRODUCTION TO YOUR PARAGON DENTAL PLAN Welcome to the PARAGON Dental Plan. We encourage you to use your dental benefits. Please note that enrollment in the Dental Plan allows the release of patient records to PARAGON or its designee for 3 Int. administrative purposes and is to be considered in full satisfaction of all HIPAA requirements and pertinent Florida Statutes. ELIGIBILITY -WHEN COVERGAGE BEGINS To enroll in the dental Plan, you and your Dependents must make written application for the dental plan on an approved PARAGON application form and be able to seek treatment for Covered Services within a PARAGON Dental Service Area. Your Group as set forth in your Group Application/Contract may determine other. eligibility requirements. There will be at least one open enrollment period of not less than 30 days every 18 months unless PARAGON and your group mutually agree to a period of time shorter than 18 months. You the Employee if you enrolled in the Dental Plan before the effective date of your Group Contract, you will be covered on the first day the Group Contract is effective. If you enrolled in the Dental Plan after the effective date of the Group Contract, you will be covered on the first day of the month following processing of your enrollment (unless effective dates other than the first day of the month are provided for in your Group Contract). If you are aubject to an Employee Waiting Period, then this must be completed prior to eligibility, which would commence on the first of the month following such completion. Your Dependents may be enrolled in the Dental Plan at the time you enroll, during an open enrollment, or within 31 days of becoming eligible due to a life status change such as marriage, birth, adoption, placement, or court or administrative order. All enrollments must be done through approved PARAGON forms. You may drop coverage for your Dependents only during the open enrollment periods for your Group, unless there is a change in status such as divorce, Newborn/Adonted Children Coveraoe If you have family coverage, a newbom child and/or an adopted child are automatically covered during the first 31 days of life/ placement in the home or date of entry of an order granting you custody. If you wish to continue coverage beyond the first 31 days, your baby/child needs to be enrolled In the Dental Plan by submitting an approved application and you need to begin to pay Premiums/Prepayment Fees, if any additional are due, during that period. Family and Medical Leave Act of ijjjN IFMLA) Under the Family and Medical Leave Act of 1993, you may be eligible to continue coverage during certain leaves of absence from work. During such leaves, you will be responsible for payment to your Group the portion of the Premium/Prepayment Fees, if any, which you would have paid If you had not taken the leave. You may be entitled to FMLA for any of the following reasons: • The birth of a child, and to care for such child; • The placement of a child with you for adoption or foster care; • To care for your seriously III spouse, child, or parent; or • A serious health condition which makes You unable to perform your job functions The Contract Holder shall be responsible for the determination of your eligibility, rights, or length of leave period for FMLA. Initial Terra This Group Contract shall be in effect commencing at 12.01am on the effective date set forth in the certificate of coverage and shall extend for a minimum initial term of thirty six (36) months thereafter. Renewal Terrors) The Group Contract Is renewable at the option of the Group and the Company at the end of the initial term for two additional terms of two (2) years each (Renewal Term) and each subsequent Renewal Term may be renewed at the Group's option subject to PARAGON'S right to modify/change, or amend the coverage and/or the premium rates/prepayment fees applicable for the Renewal Term. Any such changes/amendments shall be subject to the Group's acceptance and shall be made part of the Group Contract. PARAGON will offer renewal terms a minimum of ninety (90) days in advance of the Group's anniversary date for signature by an authorized officer of the company. The Renewal Agreement shall deem accepted and approved without the Group's signature if the first premium due for the new contract year is pald to PARAGON on or before the first day of the month of the new contract year. 4 Int. Member/Dependent Dlsenrollment from the Dental Plan -Termination of Benefits Except as otherwise provided In the Sections titled "Extension/Continuation of Benefits", or in your Group Contract, disenroliment from the Dental Plan/Temvination of Benefits and coverage will be as follows: Member • The day the contract terminates; • The day Your employment terminates; • The last day of the grace period which was enacted due to tack of premium paid in the month prior; • The last day of the month in which eligibility requirements are no longer met; • The day You enter the armed forces of any country or international authority on a full time basis; • Upon 60 days notice from PARAGON due to permanent breakdown of the Dentist -Patient relationship as determined by PARAGON after at least three opportunities to utilize Dental offices have failed; • Upon 60 days notice by PARAGON due to fraud of misuse of dental services and/or dental offices; ▪ Upon 30 days notice by PARAGON due to continued lack of a Dental Office in your Service Area; • The last day of the month after voluntary disenrollment; and • Upon any condition cited in the Group Contract. Dependent • The day the contract terminates; • The date on which the Contract is changed to end Dependent Insurance • The date on which a Dependent ceases to be a Dependent as defined in the Contract • The last day of a period for which the required premium payment for the cost of the Dependent is remitted; • The day You request that the coverage for the Dependent be terminated; • The day the Dependent enters the armed forces of any country or international authority on a full time basis; • Upon all notices available by PARAGON to the Member as stated in the Member termination provisions above; and • When one of your Dependents Is disenrolled, you and your other dependents may continue to be enrolled. When you are disenrolled, your Dependents will be disenrolled as well. Extension of Benefit Coverage for a specific dental procedure (other than orthodontics) which was started before your dlsenrollment/your group's termination from the Dental Plan, will be extended for a maximum of ninety (90) days from the disenrollment/termination date. Your Provider, by Contract, Is obligated to complete any/all procedures begun during such dental plan coverage period at the original Contracted fees. Should this treatment be considered "complex dentistry"(ex. full mouth rehabilitation involving 6 or more crowns to be fabricated at the same time, periodontal therapy, etc...) as determined by the PARAGON dental director, a decision will be rendered as to the additional time period that the provider needs to complete the original dental treatment plan. Coverage for orthodontic treatment, which was started before member disenrollment/group termination will be extended to the end of the quarter or for 60 days after member dieenrollmentlgroup termination whichever is later, unless such action was prompted due to nonpayment of premiums, in which case coverage ceases Immediately. 8ubroaatton When benefits have been paid under the Contract for any loss caused by a third party, PARAGON has the right to be reimbursed from any recovery the member obtains as a result of the alleged negligence. PARAGON is entitled to any recovery even if such recovery does not fully satisfy the judgment, settlement, or underlying claim for damages or fully compensate the member. If the member is not fully compensated, PARAGON shall be reimbursed on a pro-rata basis. PARAGON may take whatever legal action it sees fit against a third party to recover the benefits paid under this Contract. This will not affect the member's right to pursue other forms of recovery, unless the member or his/her legal representative consent otherwise. The member shall advise PARAGON of a claim or suit against a third party or insurance carrier within 60 days of the action. PARAGON has the right to the member's full cooperation. All procedures and provisions relating 5 _ Int, to the right of subrogation shall not be in conflict with any applicable Florida Statute or the decisions of courts of competent jurisdiction, which eliminate or restrict such rights. Contlnuation of Benefits (COBRA) For groups with 20 or more employees, federal law requires the employer to offer continuation of benefits coverage for an employee or dependent after termination of employment or reduction of work hours, for any reason other than gross misconduct. Such reasons (qualifying event) include the following: • The Employee's death; • Termination of the Employee's employment (except for gross misconduct) or a reduction of hours below the minimum for eligibility; • The Employee's divorce or legal separation; • The Employee becoming eligible for benefits under Medicare; or • A Dependent Child ceasing to be eligible under the terms of the Policy. The maximum period of continued coverage for the Employee and his/her Dependents as a result of termination/reduction of hours is 18 months from the date of such event. The maximum period of continued coverage as a result of any qualifying event other than Termination/reduction is 38 months from the date of the event. It is the responsibility of the Employee or Dependent to notify the Contract Holder of a qualifying event other than Termination/reduction within 60 days of such event and make known his/her right for extension of benefits. ft Is the responsibility of the Employer to provide continued coverage however it is the responsibility of the Employee/Dependent to remit the premium for such coverage within 45 days after such election. Subsequent payments must be made to the Employer within 10 days of the group's premium due date. Termination of the extended coverage will end at the earliest of the following dates: • The end of the maximum period of continued coverage set forth; • The date on which the Employer ceases to provide any group plan; • If an Employee/Dependent fails to make a premium payment when due, the last day of the period of coverage for which premiums have been paid; or • The date on which the Employee/Dependent becomes covered under any other group dental plan or becomes eligible for benefits under Medicare. Coordination of Benefits If you or your dependents have other coverage, indemnity or otherwise, through your spouse's employer or other sources, applicable coordination of benefits rules will determine which coverage is primary or secondary. In most cases: • The plan covering you as an employee is primary for you; • The plan covering your spouse as an employee is primary for him/her; • Your children are covered as primary by the plan of the parent whose birthday occurs earlier in the year, or • Utilizing two dental benefits cannot result in reimbursement for more than 100% of the charge of the service rendered. Grace Period A grace period of 31 days will be allowed for the payment of any premium except the first premium due to enact the Contract. This Contract stays in force during a grace period. Full payment must be received by the 31" day of such a grace period. The policy terminates at the end of the grace period with no further coverage. USING YOUR PARAGON DENTAL PLAN The information below outlines the utilization of your coverage and will help you to better understand how to make the beat use of your Dental Plan. The COM 1000 Schedule of Benefits is attached to velar certificatelmember oapdbook. which outlingp each specific procedure covered. malleable patient co payments to these fefvicea. and excluslont and limitations. Plow refer to this document each and avery tlm. tat you use your dental :gap, g Int. Member Services If you have any questions or concerns about the Dental Plan, our Member Services representatives are just a toll -free phone call away. They can give you information on Dental Offices in your area; explain certain dental services and their co payments, second opinion or consultation; act as your liaison with your Dental Office, or explain your benefits. To contact Member Services from any location, call 1-877-760-2247, Premiums Your Group remits a monthly fee to PARAGON for members participating in the Dental Plan. The amount and term of thls fee is set forth in your Group Contract. You may contact your Benefits Representative for information regarding any part of this fee to be withheld from your salary to be paid by you to the Group or the amount that the Group is paying on your behalf. Other Charges — Patient Charues Your Patient Benefit Schedule lists the dental procedures covered under your Dental Plan. Some dental procedures are covered at no charge to you while others require a patient copayment that is your responsibility to be paid at the time that the service is rendered, There is no deductible in your plan. There is a specific annual dollar limit with regard to Preventive services covered by your Dental Plan. Your Dentist receives supplemental payments from PARAGON and/or its Reinsurers towards some "No Charge" services as wall as some services requiring patient co payments. Your Network General Dentist should tell you about Patient Charges for Covered Services, the amount you must pay for non -Covered Services and the Dental Offfce's payment policies. It Is possible that the Dental Office may add late charges to overdue balances or charges for broken appointments. Your Patient Benefit Schedule is subject to annual change in accordance with your Group Contract. PARAGON will provide written notice to your Group of any change in Patient Charges at least 90 days prior to such change. You will be responsible for the Patient Charges listed on the Patient Charge Schedule that is in effect on the date a procedure is started. Choice of Network Dentist You and your Dependents can select a Dental Office once enrolled in the Dental Plan. The benefits of the Dental Plan are available only at a Network Dental Office within the Dental Service Area, except in the cases of an emergency. Should you wish to change your Network Dentist or your Network Dentist elect to terminate their contract with PARAGON, you have several help options: • Contact Member Services at 1-877-760-2247; • Request and/or review our printed Network Dentist Directory and make your choice; or • Visit us at Paragondentel.com and utilize our Network Dentist Search Feature to make your choice. It Is you/your dependent's responsibility to review the Network Dentist Directory to ascertain whether there is sufficient/any Network Dentists in your service area. PARAGON will make every effort to establish and maintain an adequate choice of Network Dentists throughout the state however claims no responsibility should Network representation be diminished or eliminated through attrition of Network Dentists from the Paragon Network. Should all Network Dentists In a given Service Area elect to terminate after having been active at the time of your enrollment in the dental plan, PARAGON may tell you if you may obtain Covered Services at a particular non -network Dentist on a temporary/ emergency basis. in this situation, PARAGON may pay the non -network Dentist the difference, if any, between his or her usual fee and the applicable patient charge. You may receive a description of the process used to analyze the qualifications and credentials of Network Dentists upon request. Emergency Denial Care Reimbursement An emergency is a dental condition of recent onset and seventy, which would lead a prudent layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental procedures necessary to control excessive bleeding, relieve severe pain, or eliminate acute infection. Please contact your Network General Dentist if you have an emergency in your Service Area. Emeroencv Care Away From Home If you have an emergency while you are out of your Service Area, you may receive emergency Covered Services as defined above from any General Dentist. Typical routine emergency services may be emergency examination, x-rays, extraction, prescription, or other palliative care to relieve immediate pain, infection and 7 Int. bleeding. Routine restorative procedures or definitive treatment (e.g. root canal) which might be the final therapy necessary to correct the clinical situation creating the patient symptoms are not considered emergency care. You should return to your Network General Dentist for these procedures. For emergency Covered Services you will be responsible for the Patient Charges listed on your Patient Benefits Schedule. PARAGON will reimburse you the difference; if any, between the Dentists's usual fee for emergency Covered Services and your copayment as listed In your particular Benefit Schedule, PARAGON will typically reimburse up to $100,00 In differences of fees. Emergency Care After Hours There Is a Patient Charge listed on your Patient Benefit Schedule for the emergency care rendered after regularly scheduled office hours. This charge will be In addition to other applicable Patient Charges. BENEFIT LIMITATIONS, EXCLUSIONS AND EXCEPTIONS Limitations on Covered Services Listed below are limitations on services covered by your Dental Plan: Frequency/Age- The frequency of certain covered services, specifically preventive and diagnostic procedures such as cleanings, x-rays, are limited. Your patient Schedule of Benefits lists these limitations on frequency and age. Specialty Care All members of Dental Plans may seek treatment from a contracted PARAGON Dental Specialist without a referral from PARAGON and/or your General Dentist (we encourage the involvement of your General Dentist so that proper coordination of treatment be considered In your dental therapy). The PARAGON Dental Specialist is obligated to provide a 25% discount off of his usual and customary fee. It is the member's responsibility to determine and confirm that the Dental Specialist that Is consulted and utilized for any/all treatment is an active provider of the PARAGON Dental %moiellst's Network The COM 1000 also allows your election to obtain prior written authorization from PARAGON to receive an evaluation as to whether Paragon would approve specialty treatment by an approved PARAGON Specialist (which may or may not be on the list of PARAGON Dental Specialists) at the listed copayments on your Schedule of Benefits should they appear there. It Is at Paragon's sole discretion to determine whether a particular dental specialty procedure Is approved or whether the patient/member even presents as a likely candidate for the procedure to be performed. Though it Is the intent to provide easy access for PARAGON members to its Specialty Dental Specialists, PARAGON is not obligated to provide the required Dental Specialist within a specific radius or geographic area, The following general limitations apply: a. Pediatric Dentistry — Coverage for referral to a pediatric Dentist ends on your child's 8'h birthday, however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist may provide care after your child's 8s' birthday. b. Oral Surgery — The surgical removal of an impacted/partially impacted wisdom tooth Is not covered If the tooth is not diseased or If the removal Is only for orthodontic reasons. C. There are certain procedure codes listed in your Schedule of Benefits that are not eligible under S-Plan reimbursement. These services are noted by an "iron cross". Please refer to the section "Specialty Care Protocol" for a review of the authorization procedure. ORTHODONTICS The following definitions apply: • Orthodontic Treatment Plan and Records- The preparation of orthodontic records and a treatment plan by the orthodontist (models, x-rays, etc) • Interceptive/Transitional Orthodontic Treatment- Treatment prior to full eruption of the permanent teeth, frequently a first phase prior to comprehensive therapy. • Comprehensive Orthodontic Treatment- Treatment after eruption of most permanent teeth (I.e. braces). • Retention (Post Treatment Stabilization)- The period following comprehensive treatment where you may wear an appliance to maintain and stabilize the new position of the teeth 8 ant. The PARAGON Orthodontic benefit allows for a total of 24 months of Orthodontic treatment whether It be entirely "comprehensive" or 12 months of "interceptive" and 12 months of Comprehensive, etc... The patient charge for your entire orthodontic case, including retention, will be based upon the appropriate Schedule of Benefits In effect on the date of your visit for Treatment Plan and Records. The Paragon orthodontic benefit Is handled In a similar manner as specialty care in that written authorization from Paragon is required and a referral to a Paragon designated orthodontist is necessary. Factors that could alter the total charge might be the type of brackets utilized (ceramic, clear, lingual vs. metal), required surgery, appliances to guide minor tooth movement, harmful habit appliances, as well as the evaluation of the difficulty or case type of the orthodontic treatment and/or the degree to which the treatment plan deviates from a "typical' or normal case difficulty as discerned entirely by the Orthodontist. pARAGQN bears no liability towards the assessment bv the treating orthodontist regardina total fee or treatment unable to be comoiejed due to a terminated status or a treatment planned case. originally thought to be completed within 24 months. at the end of which more therapy is evident to achieve a satisfactory result as discerned bv the Orthodontist. If you/ your dependent is in the middle of orthodontia treatment of any type at the time of initial enrollment, you must contact PARAGON to see if you are eligible for reimbursement under the orthodontia benefit. )EXCLUSIONS OF YOUR DENTAL PLAN Listed below are the services or expenses which are NOT covered under your Dental Plan and which are your responsibility. Services not listed on the Patient Schedule of Benefits are charge to you the member/dependent at a 25% discount of the Provider's usual and customary fee. a. Services provided by a non -network General Dentist or Dental Specialist without PARAGON'S prior approval (except emergencies, as described in Section. b. Services related to an injury or illness paid under worker's compensation, occupational disease or similar laws. c. Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a public program, other than Medicaid, d. Services relating to injuries, which are Intentionally self-inflicted. e. Services required while serving in the armed forces of any country or international authority or relating to a declared or undeclared war or acts of war. f. General anesthesia, sedation and nitrous oxide, unless specifically listed on your Patient Benefit Schedule to be administered at the General Dentist facility under the direction of a General Dentist. General anesthesia and IV sedation are not covered when under the direction of a Dental Specialist. g. Prescription drugs. h. Procedures, appliances or restorations If the main purpose is to: (1) change vertical dimension (degree of separation of the Jaw when teeth are In contact) or (2) diagnose or treat abnormal conditions of the temporomandibular joint ("TMJ") unless TMJ therapy is specifically listed on your Patient Charge Schedule or specified as an orthodontic benefit. i. Dental procedures initiated prior to the member's eligibility under this Dental Plan or initiated after the member's termination from the Dental Plan. j. Replacement of fixed and/or removable Prosthodontics or orthodontic appliances that have been lost, stolen, or damaged due to patient abuse, misuse or neglect. k. Services associated with the placement or Prosthodontics restoration of a dental implant, I. Services considered being unnecessary or experimental In nature. m. Any inpatient/outpatient hospitalization, including any associated incremental charges for dental services/medical services performed in a Hospital. n. Treatment of malignancies, cysts or neoplasms. o. Services to the extent you or your enrolled Dependent is compensated under any group any group medical plan, no-fault auto insurance policy, or an insured motorist policy. p. Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the member Including, but not 9 - _Int. limited to physical or emotional resistance, inability to visit the dental office, or allergy to commonly utilized local and or general anesthetics. Fxceot as set forth 'Ova. oreexistina conditions are not excluded, EXCEPTIONS Within each particular Schedule of Benefits, there may be additional copayments, fees, surcharges that apply to services that present with a patient co -payment (ex. precious metal co -payment when undergoing crown restoration therapy, complex rehabilitation/multiple crowns-6 or more requiring a 30.00 surcharge). Please review your entire Schedule of Benefits to determine whether such additional charges apply. GENETIC. HANDICAPPED. AND COMMUNICABLE DISEASE CONDITIONS PARAGON, in compliance with Florida Statutes and Florida Administrative Code, does not consider members with the following conditions sub}ect to limited, altered, or denied coverage, by virtue of these specific conditions alone: • HIV • Handicapped Children • Genetic Information absent of a condition requiring diagnosis PARAGON, in the course of its business, complies with the following Florida Statues/Administrative Codes 636.016, 4-203.025, 636.0201 636.022. GRIEVANCE PROCEDURES -WHAT TO DO IF THERE I8 A PRQBlEN( Moat problems can be resolved between you and your Dentist. We suggest that you discuss your questions and/or concerns with your Dentist first in the hopes of continuing to maintain an easy working relationship. However, we want you to be completely satisfied with the Dental Plan. That's why we've established a process for addressing your concerns and complaints. The complaint procedure Is voluntary and will be used only upon your request. 1. Informal Grievance Procedure Begin with the Paragon Member Services Department, which can be reached at 1-877-780-2247. We're here to listen and to help. If you have a concern about your Dental Office or the Dental plan, you may call the toll -free number and explain your concern lo one of the Member Services Representatives. Many questions/concerns are able to be addressed at the time of your first phone call by reviewing your dental plan, normal Paragon procedures as described in this member handbook, and interpreting what might appear to be complicated typical dental office procedure. if necessary, and only under your direction, we will contact your dental provider for you to gain necessary treatment Information. We will evaluate such information as It pertains to your concern and get back to you as soon as possible, usually by the end of the next business day. Should you consider this informal grievance procedure unsatisfactory, Paragon employs a two level 'Appeals" process for any disputes and/or concerns. 2. Level One Complaint -Appeal Even though It Is not necessary, it is always assumed that you have attempted to have your concern(s) addressed through our informal process prior to utilizing the "Level On& formal process. To Initiate a ▪ Level One" complaint or appeal towards the findings of an informal query, you must submit a request for review of such a complaint/appeal within one year of the occurrence, to Include the following Information: • The Letter should be labeled as a "Level One" Complaint/Appeal ▪ Patient identifying information • Dental provider identifying information • The date(e) of the experience • Description of the Intended dental service • The nature of the deviation • The patient financial obligation toward the dental provider, If any • The overall temperament/attitude of the dentist and his/her auxiliaries • A review of your attempt, if any, to clarify/correct the provider deviation • A review of the Provider's attempt, if any, to clarify/correct the deviation • A review of the Informal grievance process by you and Paragon, if one had occurred. 10 _ The above letter should be addressed to: Appeals Coordinator Paragon Dental Services, Inc, 8751 West Broward Blvd., Suite 300 Fort Lauderdale, Florida 33324 If you are unable or choose not write, you may ask Member Services/Appeals Coordinator to register your request by calling the toll -free number 1-877-760-2247 at which time the Member Services Representative will fill out a formal grievance form. Once completed, this Formal Grievance Form will be mailed to you for your signature to be returned to Paragon for action. Your "Level One" Request will be considered and the resolution made by someone not Involved In the initial decision or occurrence. Issues Involving dental necessity or clinical appropriateness will be considered by a dental professional, We will respond with a decision within 15 calendar days after we receive your request. If the review cannot be completed before 15 days, we will notify you on or before the 15th day of the reason for the delay. The review will be completed within 15 calendar days after that. If you are not satisfied with our decision, you may request a second level review. 3. Level Two Anoeal To initiate a level two appeal, you must submit your request in writing to PARAGON within 60 days after receipt of PARAGON's level one decision. Second level reviews will be conducted by PARAGON's Appeals Committee, which consists of a minimum of 3 people. Anyone involved In the prior decision may not vote on the Appears Committee. For appeals Involving dental necessity or clinical appropriateness, the Committee will Include at least one Dentist. If specialty care Is In dispute, the Committee will consult with a Dentist in the same or similar specialty as the care under consideration, as determined by PARAGON. PARAGON will acknowledge your appeal in writing within 5 business days and schedule a committee review. The acknowledgement will Include the name, address, and telephone number of the Appeals Coordinator. Additional information may be requested at that time. The review will be held within 30 calendar days. If the review cannot be completed within 30 calendar days, you will be notified in writing on or before the 15" calendar day, and the review will be completed no later than 45 after the receipt of your request. You may present your situation to the Committee in person or by conference call. Please advise PARAGON 5 days in advance if you or your representative plans to be present. The location of the review will be at the PARAGON home office address or at a location within your service area that Is mutually convenient. You will be notified in writing of the Committee decision within 5 business days after the Committee meeting. The resolution will include the specific contractual or clinical reasons for the resolution, as applicable. Exaedlte4t Appeals You may request that the complaint or appeal resolution be expedited if the tlmeframes under the above process would seriously jeopardize your life or health or would Jeopardize your ability to regain the dental functionality that existed prior to the onset of your current condition. A dental professional, in consultation with the treating Dentist, will decide if an expedited review is necessary. When a review is expedited, PARAGON will respond orally with a decision within 72 hours, followed up in writing within two business days of the decision. Appeals to the State You have the right to contact your state's Department of Insurance or Health for assistance at any time. See your State Rider for further details. Such Contact can be made at the following address: Department of Financial Services 200 East Gaines Street Tallahassee, Florida 32399 1-800-342-2672 Arbitration At the total discretion of PARAGON, any/all grievances may be placed in an arbitration process so that an agreeable resolution may be established. All arbitration processes will not preclude review pursuant to Rule 4- 191.081 of the Florida Administrative Code and shall be conducted pursuant to Chapter 682 of the Florida Statues. PARAGON will not cancel or refuse to renew coverage because you or your Dependent has filed a complaint or appealed a decision made by PARAGON. You have the right to file suit In a court of law for any claim involving the professional treatment performed by a Dentist. 11 _