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HomeMy WebLinkAboutRes 0544 - Amendment #2 Group Dental Contract (Washington Dental Service) for BenefitsATTEST: CITY OF WASHINGTON RESOLUTION NO. 544 A RESOLUTION AUTHORIZING THE MAYOR TO EXECUTE AMENDMENT NO. 2 TO GROUP DENTAL CONTRACT NO. 595 BETWEEN WASHINGTON DENTAL SERVICE AND THE CITY OF TUKWILA WHEREAS, on July 1, 1974, Washington Dental Service did issue Contract No. 595 to City of Tukwila; and WHEREAS, the Contract was previously amended by virtue of prior Amendments, and the parties wish to further amend the Contract effective July 1, 1976 by means of the document as attached herein which shall be regarded as Amendment No. 2 to the Contract; NOW, THEREFORE, the City Council of the City of Tukwila, Washington, does resolve as follows: The Mayor is authorized to execute Amendment No. 2 to Group Dental Contract No. 595 between Washington Dental Service and the City of Tukwila. PASSED BY THE CITY COUNCIL OF THE CITY OF TUKWILA, WASHINGTON, at a regular meeting thereof this 21 day of June 1976. Edgar D. Bauch Mayor Maxine Anderson City Clerk AMENDMENT NO. 2 TO GROUP DENTAL CONTRACT NO. 595 BETWEEN WASHINGTON DENTAL SERVICE AND CITY OF TUKWILA WHEREAS, on July 1 1974, Washington Dental Service did issue Contract No. 595 to City of Tukwila, hereafter referred to as the Contract, and WHEREAS, the Contract was previously amended by virtue of prior Amendments, and the parties wish to further amend the Contract effective July 1, 1976 by means of this document which shall be regarded as Amendment No. 2 to the Contract, NOW THEREFORE, it is mutually agreed as follows: (1) Article I of said Contract entitled "Definitions paragraphs 1.50 and 1.51 are amended in their entirety to read as follows: "1.50 "Basic Benefits" wherever used in this Contract shall be inter changeable with "Class Benefits" and means those dental services which are listed under the heading "Class I Covered Dental Benefits" on the attached Exhibit "A" entitled "Covered Dental Benefits, Limitations and Exclusions 1.51 "Prosthodontic Benefits" wherever used in this Contract shall be interchangeable with "Class II Benefits" and means those dental services which are listed under the heading "Class II Covered Dental Benefits" on the attached Exhibit "A" entitled "Covered Dental Benefits, Limitations and Exclusions (2) Article IV of said Contract entitled "Benefits Provided, Limitations and Services Not Covered paragraph 4.026 is amended in its entirety to read as follows: "4.026 The maximum amount payable by WDS for all Covered Dental Benefits provided to any Eligible Person per each twelve -month period from July 1 through June 30 of the next year shall be One Thousand Dollars ($1,000.00)." (3) Appendix "A" of said.Contract is amended as follows: From and after the effective date of this Amendment and notwithstanding any other language contained in the Contract, the Covered Dental Benefits, Limitations and Exclusions are as set forth on the attached Exhibit "A" entitled "Wash- ington Dental Service Covered Dental Benefits, Limitations and Exclusions" and said Exhibit "A" is substituted for and supersedes the language of Appendix "A -Page One of Two Pages AMENDMENT NO. 2 CONTRACT NO. 595 (4) Appendix "B" of said Contract is amended as follows: From and after the effective date of this Amendment and notwithstanding any other language contained in the Contract; the Schedule of Allowances for Non Participating Dentists is as set forth on the attached Exhibit "B" entitled "Schedule of Allowances for Non Participating Dentists, WDS Schedule C" and said Exhibit "B" is substituted for and supersedes the language of Appendix (5) Appendix "E" of said Contract entitled "Applicant's Financial Obligations the first paragraph is amended in its entirety to read as follows: The following shall be the monthly dues payable by Applicant under this Contract: Employee only Employee one dependent Employee two or more dependents 8.65 15.20 24.95" The term of said Contract No. 595 as amended hereby is extended through June 30, 1977. Except to the extent that said Contract and prior Amendments are modified by this Amendment, they shall remain in full force and effect and be the Contract between the parties hereto. Executed and agreed to on this day of 19 by: WASHINGTON DENTAL SERVICE By Title Executed and agreed to on this 22 day of June 19 76 by: CITY OF (1-5062,-z G �GC Cpl 2 Title Mayor -Page Two of Two Pages • CLASS I COVERED DENTAL BENEFITS CLASS II COVERED DENTAL BENEFITS EXHIBIT "A" COVERED DENTAL BENEFITS, LIMITATIONS EXCLUSIONS The following are Class I and Class II Covered Dental Benefits under this Con- tract which are subject to the limitations and exclusions in this Contract. Such benefits only are available when rendered by a licensed dentist and when necessary and customary as determined by the standards of generally accepted dental practice. Note: The Payment Level for CLASS I benefits (70 80 90% or 100 is described elsewhere in this Contract. A. Diagnostic: Examination and recall services including necessary dental x -rays. B. Preventive: Prophylaxis (cleaning) and topical application of stannous flu- oride. Space maintainers only when used to maintain space. C. Restorative: All carious (decayed) teeth should be restored to a state of functional acceptability utilizing filling materials such as amalgam, silicate or plastic. Refer to CLASS II benefits, paragraph A. for payment if teeth are restored with other filling materials. D. Oral Surgery: Removal of teeth, as well as minor surgical preparation of the mouth for insertion of dentures. Services covered include surgical and non- surgical extractions and general anesthesia when administerd by a dentist in connection with oral surgery. E. Periodontics: Necessary non surgical procedures for treatment of the tissues supporting the teeth. Services covered include root planing, subgingival curettage and adjustments to occlusion such as smoothing of teeth or reducing cusps. F. Endodontics: Necessary procedures for pulpal and root canal therapy. Services covered include pulp exposure treatment and pulpotomy. Note: The Payment Level for CLASS II benefits (constant 50 is described else- where in this Contract. A. Restorative: Crowns, inlays or onlays, whether they be of gold, porcelain, plastic, gold substitute castings or combinations thereof may be covered when verification of need is provided to WDS that the teeth cannot be reasonably restored with other filling material. B. Prosthodontics: Services covered include dentures, bridges, partials and related items and the adjustment or repair of an existing prosthetic device. Fixed bridgework only will be covered when the use of a partial denture is clearly unsatisfactory. CLASS I LIMITATIONS COVERED DENTAL BENEFITS, LIMITATIONS EXCLUSIONS -2- A. Diagnostic: Examination will be covered once in a six (6) month period. Charges for the review of a proposed treatment plan or case presentation by the attending dentist are not covered. Complete mouth or panorex x -rays will be covered once in a three (3) year period, unless special need is shown. Supplementary bitewing x -rays will be covered upon request, but not more than once in a six (6) month period. Study or diagnostic models are not covered. B.. Preventive: Prophylaxis will be covered once in a six (6) month period. Topical application .of stannous fluoride will be cove eI once in a six (6) month period when performed in conjunction with prophylaxis, up to the patient's 19th birthday. Plaque control, oral hygiene or dietary instructions are not covered. C. Restorative: Restorations on the same surface of the same tooth are covered once in a two (2) year period, unless verification of need is supplied to WDS and approved by the Dental Director. Sealants are not covered. Refer to CLASS II limitations, paragraph A. for limitations on crowns, inlays and onlays. 1. Restorations: If.a tooth can be restored with a material such as amalgam, silicate or plastic, an allowance will be made for such procedure toward the cost of any other type of restoration that may be provided. 2. Occlusion: Cost of necessary procedures to eliminate oral disease and to replace missing teeth may be covered. Appliances or restorations necessary to increase vertical dimension or restore the occlusion are not covered; such procedures include restoration of tooth structure lost from attri- tion and restorations for malalignment of the teeth. D. Oral Surgery: Major oral surgery is covered only in conjunction with treat- ment rendered by a dentist because of an accident. Ridge extension for inser- tion of dentures is not covered. General anesthesia is covered only when ad- ministered by a dentist in connection with oral surgery. Transplants and implants are not covered. E. Periodontics: Non surgical procedures only are covered. Surgical treatment of periodontitis and periodontal splinting and /or crown and bridgework -used in conjunction with periodontal splinting are not covered. Root planing and sub gingival curettage will 'be covered o"ce in a teele enth period. F. Endodontics: Apicoectomies (surgical correction for elimination of infection or pathology) may be covered when root canal therapy has been completed and a root end pathology subsequently develops; it is not a covered benefit if done at the same time as root canal therapy. -3- COVERED DENTAL BENEFITS, LIMITATIONS EXCLUSIONS CLASS II LIMITATIONS A. Restorative: Crowns, inlays or onlays on the same tooth are covered once in a five (5) year period, unless verification of need is supplied to WDS and approved by the Dental Director. 1. Restorations: If a tooth can be restored with a material such as amalgam, silicate or plastic, an allowance will be made for such procedure toward the cost of any other type of restoration that may be provided. B. Prosthodontics: Replacement of an existing prosthetic device may be covered only if it is unsatisfactory and cannot be made satisfactory. Services which are necessary to make such a device satisfactory may be covered. In any event, prosthetic devices will be covered only after five (5) years have elapsed fol- lowing any prior provision of such a device under any WDS Dental Program. 1. Full, immediate and overdentures: If in the provision of denture services, personalized restorations or specialized techniques as opposed to standard procedures are used, WDS will allow the appropriate amount for the standard procedure toward such treatment. Root canal therapy performed in conjunc- tion with overdentures is limited to two (2) teeth per arch. Temporary dentures are not covered. 2. Partial Dentures: If a cast chrome or acrylic partial denture will restore the case, WDS will allow the appropriate amount of the cost of such pro- cedure toward a more elaborate or precision device that may be provided. 3. Denture adjustments and relines: Denture adjustments made more than six (6) months after the initial placement are covered. Relines done more than six (6) months after initial placement are covered; however, subse- quent relines will be covered once in a twelve (12) month period. 4. Implants: WDS will allow the appropriate amount for a standard full or partial denture toward the cost of implants and appliances constructed thereon. Surgical placement or removal of implants is not covered. Attach- ments to implants, either movable or removable, are not covered. EXCLUSIONS COVERED DENTAL BENEFITS, LIMIATIONS EXCLUSIONS -4- A. Services for injuries or conditions which are compensable under Workmen's Com- pensation or Employer's Liability Laws; services which are provided by'any Federal or State or Provincial government agency, or are provided, without cost to the Eligible Person by any municipality, county or other political subdivision or community agency, except to the extent that such payments are insufficient to pay for the applicable Covered Dental Benefits outlined in this Contract. B. Surgical procedures to correct congenital malformations or developmental mal- formations; procedures, appliances or restorations primarily for cosmetic pur- poses; nightguards or orthodontic services or supplies. C. Dental services started prior to the date the person became eligible for such services under this Contract. D. Analgesics (such as nitrous oxide), or any other euphoric drugs or prescrip- tion drugs. E. Hospitalization charges. F. Broken appointments. G. All other services not specifically included as CLASS I or CLASS II Covered Dental Benefits. EXHIBIT "B" SCHEDULE OF ALLOWANCES FOR NON- PARTICIPATING DENTISTS WDS SCHEDULE "C" The following procedures when covered are payable at the appropriate Payment Level based on the Eligible Person's Incentive Period. PROCEDURES GENERAL MAXIMUM VALUE Examination (payable for initial episode of treatment only) 5.00 Prophylaxis treatment to include scaling and polishing 10.00 Topical application of Sodium Fluoride (four treatments including prophylaxis under age 4) 20.00 Topical application of Stannous Fluoride (one treatment including prophylaxis payment limited to'once each year 16.00 Emergency treatment palliative per visit 5.00 ROENTGENOLOGY MAXIMUM VALUE Single film Additional films (up to 13 films each) Entire denture series consisting of at least 14 films (including Bitewings if indicated) Bitewings (two large or four small) films Amalgam Restorations Permanent Teeth: Cavities involving one tooth surface Cavities involving two tooth surfaces Cavities involving three or more tooth surfaces 3.00 2.00 16.00 5.00 RESTORATIVE DENTISTRY MAXIMUM VALUE Amalgam Restorations Primary Teeth: Cavities involving one tooth surface 6.00 Cavities involving two tooth surfaces 9.00 Cavities involving three or more tooth surfaces 13.00 7.00 11.00 16.00 RESTORATIVE DENTISTRY (CON'T) Silicate, Acrylic, Plastic Restorations: Silicate cement filling Acrylic or plastic milling Pulp Treatment: Vital pulpotomy Pulp exposure treatment END0D0NTICS Single rooted canal therapy* 8i- rooted canal therapy* Tri- rooted canal therapy* Apicoectomy (separate from Endodontia) *Fees do not include final restoration, necessary roentgenograms in addition to the above allowance, or apicoectomy. PERIODONTICS Prophylaxis (includes scaling and polishing) Emergency treatment (periodontal) abscess, acute periodontitis, etc. ORAL. SURGERY Extractions: -2- NOTE: All hospital costs are the responsibility of the Eligible Person. WDS will allow fees per the pro- cedures listed in this Schedule. Additional fees charged by the dentist for performing procedures in the hospital are the responsibility of the Eligible Person. MAXIMUM VALUE 9.00 10. 12.00 6.00 MAXIMUM VALUE 62.00 83.00 109.00 36.00 MAXIMUM VALUE 10.00 10.00 MAXIMUM VALUE Uncomplicated (single fee includes routine postoperative visits) 8.00 Each additional tooth (fee includes routine postoperative. visits) 7.00 Surgical removal of erupted teeth 15.00 Root recovery B/R Impacted Teeth (enclose film): Removal of tooth (soft tissue) 20.00 Removal of tooth (partially bony) 35.00 Removal of tooth (completely bony) 50.00 ORAL SURGERY (C0N'T) Alveolar or Gingival Reconstruction: Alveolectomy (without removal of teeth) per quadrant 20.00 Surgical removal of torus from mandible or maxilla 30.00 Excision of hyperplastic tissue per arch B/R Cysts and Neoplasms: Intraoral incision and drainage of abscess 6.00 Excision periocornal gingiva B/R Removal of foreign body from bone (independent procedure) B/R Maxillary sinusotomy for removal of tooth fragment or foreign body B/R Closure of oral fistula or maxillary sinus B/R Excision of cyst,. large (2.5 cm or larger) B/R Miscellaneous: Incision and removal of foreign body from soft tissue B/R Frenectomy 20.00 Anesthesia: -3- MAXIMUM VALUE General anesthesia: First 15 minutes, $20; each additional 15 minutes, $5; not to exceed $50. Any further charges for anesthetics, anesthetists, or anesthesiologists are the responsibility of the Eligible Person. SPACE MAINTAINERS MAXIMUM VALUE Fee includes all adjustments within six months following installation Space maintainer, acrylic: 35.00 Space maintainer, metal 45.00 The following procedures when covered are payable at the constant 50% Payment Level regardless of the Eligible Person's Payment Level according to his /her Incentive Period. RESTORATIVE DENTISTRY MAXIMUM VALUE Gold Restorations: One tooth surface. 36.00 Two tooth surfaces 52.00 Three or more tooth surfaces 61.00 CROWNS AND BRIDGES MAXIMUM VALUE Crowns: Cured acrylic jacket crown Acrylic with metal Porcelain Porcelain with metal (Ceramco) Gold (full) 3/4 Gold Pontics: Cast gold, sanitary Tru- pontic Porcelain baked to gold Plastic processed to gold Recementatioo: -4- 60.00 77.00 78.00 94.00 73.00 69.00 59.00 65.00 89.00 75.00 Inlay 6.00 Crown 6.00 Bridge 9.00 Replacing bridge pontic 17.00 Repairs, Bridges: Repairs fee based on time and laboratory charges B/R PROSTHETICS MAXIMUM VALUE Dentures, partial dentures and relines (fees include adjustment for six month period following installation) Complete maxillary denture $163.00 Complete mandibular denture 163.00 NOTE: Fees for specialized techniques involving precision dentures, personalization or characterization are to be borne by the Eligible Person. Full fee for entire treatment plan must be listed on Treatment Form. Temporary type partial denture, no clasps 74.00 Partial acrylic upper or lower with gold or chrome cobalt alloy clasps with metal clasps 149.00 Partial lower or upper with chrome cobalt alloy lingual or palatal bar and cast metal skeleton 188.00 Denture adjustment unrelated to new dentures 5.00 Denture reline 48.00 Denture duplication (jump) per denture 65.00 -5- Repairs, Dentures, Acrylic: Broken denture, repairing (no teeth involved) Replacing missing or broken teeth Each additional tooth Partial denture repairs other than above based on time and laboratory charges PROSTHETICS (CON'T) MAXIMUM VALUE 13.00 18.00 6.00 B/R "B /R on the Schedule means "By Report The allowance for such procedure will be determined by the WDS Dental Director based upon the report and the treating dentist's usual, customary and reasonable fee for such procedure. If a covered procedure is not listed above, the allowance will be determined at an amount consistent with those listed taking into account the nature and com- plexity of the procedure involved. All allowances whether listed or not are subject to the limitations and provisions of this Contract.