HomeMy WebLinkAboutDocumentation_Regular_Tab 12DE_4/10/1997 tlemorandunt
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To : Village Council .
From: Thomas G. Bradford, Village Manager
Date : March 25 , 1997
Subject: Health, Life, and Dental Insurance Changes; Agenda
Item
At the Finance and Administration Committee Meeting held on March
14, 1997 , the Committee Members were presented with alternatives
relative to health, life, and dental insurance for Tequesta
employees . Tequesta was recently- provided notice from Anthem
Health Services that its Network would no longer be applicable to
Tequesta effective May 1, 1997 . Tequesta is a participant in the
Florida Municipal Health Trust Insurance Program for its current
insurance package . With the loss of the Anthem Health Network,
the cost to the Village and its employees who choose dependent
coverage will rise. Accordingly, Village staff has been seeking
new proposals for health, life, and dental insurance services .
'Based upon the review undertaken by Tequesta ' s insurance agent,
Acordia, the following is recommended by Village staff and has
been recommended by the Finance & Administration Committee:
• , ' Health Insurance - United Health Care of Florida
• Life Insurance - Standard Life Insurance Company
• Dental Insurance - Florida Municipal Trust Fund
The cost of the health insurance package and life insurance
package shall result in a savings . The cost of dental insurance
will-rise but is more than offset by the savings in health and
life.
Based upon the foregoing, it is recommended that the Village
Council approve the aforementioned insurance underwriters for the
applicable coverages referenced. If you concur, a Resolution
authorizing the same has been prepared for each of the applicable
insurance packages for your consideration.
TGB/krb
=:unci'_, :3:5: -_.sa-,
RESOLUTION NO. 11 - 96/97 •
A RESOLUTION OF THE VILLAGE COUNCIL OF THE
VILLAGE OF TEQUESTA, PALM BEACH COUNTY,
FLORIDA, APPROVING UNITED HEALTH CARE OF
FLORIDA AS THE HEALTH INSURANCE UNDERWRITER
FOR THE TEQUESTA EMPLOYEE HEALTH INSURANCE
PROGRAM AND AUTHORIZING THE VILLAGE MANAGER
TO DO ALL THINGS NECESSARY TO EFFECTUATE
THIS APPROVAL.
NOW, THEREFORE, BE IT RESOLVED BY THE VILLAGE COUNCIL OF THE
VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA, AS FOLLOWS:
Section 1. United Health Care of Florida is hereby approved
as the health insurance benefit underwriter for the
employees health insurance program of the Village of
Tequesta effective May 1, 1997 .
Section 2 . The Village Manager is authorized to do all
things necessary to effectuate the terms of this approval,
including, but not limited to, execution of necessary
service agreements .
THE FOREGOING RESOLUTION WAS OFFERED by Councilmember
, who moved its adoption. The motion was
seconded by Councilmember , and upon being
put to a vote, the vote was as follows:
FOR ADOPTION AGAINST ADOPTION
The Mayor thereupon declared the Resolution duly passed and
adopted this 10th day of April, A.D. , 1997 .
MAYOR OF TEQUESTA
Elizabeth A. Schauer
ATTEST:
•
Joann Manganiello
Village Clerk
wp60\res\11-97
is
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VILLAGE OF TEOUESTA
EMPLOYEE GROUP HEALTH INSURANCE
,Curnnt Plan(Florida Municipal Insurance Trust)
MONTHLY MONTHLY 1 MONTHLY BI-WEEKLY
VILLAGE EMPLOYEE COST i VILLAGE DEPENDENT COST ' EMPLOYEE DEPENDENT COST EMPLOYEE DEPENDENT COST
Village Pays 100%
;BENEFIT
Health Insurance' $245 00 $376.88 $94 22 $43 48
,Life Insurance($5.000 DI) $4.55 I $0 00 $0 00 $0 00
!Dental Insurance" • $17.00. $25.00 $25 00 S 11 54
PPO Network(Anthem) $4.54; $0.00 $4.54 I $0 00
TOTAL S271.09; S401.88 $119.22 i $55.02
EMPLOYEE&DEPENDENT COMBINED TOTAL $872.97 $119.22 i 155.02
Proposed Plans
. MONTHLY MONTHLY MONTHLY I 81-WEEKLY
VILLAGE EMPLOYEE COST VILLAGE DEPENDENT COST EMPLOYEE DEPENDENT COST EMPLOYEE DEPENDENT COST
Village Pays 100% ,
BENEFIT
'Health Insurance(United)* $180.87 I $278.24 $69.56 $32 10
' . ' ILlfe Insurance(Standard) $1.80 i $0.00 $0.00' $0 00
- 'Dental Insurance(FMIT)" ' $19.00 I $28,00 $28.00 i $12.92
TOTAL $201.57 I 5305.24 597.58' $45.02
EMPLOYEE&DEPENDENT COMBINED TOTAL • I - 5807.91 597.58 I $45.02
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; VILLAGE EMPLOYEE COST SAVINGS . $89.42
VILLAGE DEPENDENT COST SAVINGS 595.64
VILLAGE EMPLOYEE&DEPENDENT COST SAVINGS $165.08
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EMPLOYEE COST SAVINGS 821.86 I $10.00•
•Employee Pays 25%Dependent
I••Employee Pays 100%DepnMent
I
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April 3, 1997
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VILLAGE OF TEQUESTA
FLA. MUNICIPAL UNITED HEALTHCARE
COMPANY HEALTH TRUST
— — . u Current Plan
PLANS --- -----PPO t POS Plan 210
Benefits In Network Out of Network In Network 1 hit of Network
Lifetime Maalmum SI.000,000 $1,000,000 unlimited $2.000,000
('AStI DEDII(TIBLE
$100/$200 S100/$200 none $500 $1,011)
(Indlvldual/Frmlly) .
OUT-OF-POCKET MAXIMUM S350/S700 S8501$1,700 $1,500/$3,000 $1,000 $6.000
(Indlvldu,d/Fanrily)
90°oafter 70°palter 70°°alter
HOSPITAL SERVICES 1004.
annual deductible annual deductible annual deductible
90%after 70%alter 100°°atter Ill°°after
EMERGENCY ROOM SERVICES annual deductible annual deductible S50 co-pay annual deductible
PHYSICIAN SERVI('ES I'1o°o after
90%after 70•o alter 70°°otter
Of11ce Visite CO-PAY-PRIMARY $5 co-pay
annual deductible annual deductible annual deductible
•
Office Visits CO-PAY-SI'l('IALIST ' $5 co-pay
ROUTINE ADULT PIIYSIt'ALS not included not included I00°o not included
MATERNITY same assame
any as any same as any same as any
rillnoaa illness illness illness
PRESCRIPTION DRUG BENEFITS 100%after 100%after
Generic SIO co-pay N/A S5 co-pay NIA
Hrand S10co-pay $5 co-pay
MONTHLY PREMIUM RATES CURRENT r PROPOSED *
Employee (28) $244.99 $180.87
Employee and Family (38) $621.87 $459:1 1
• MONTHLY TOTAL •
$30,490.78 $22,510.54
ANNUAL TOTAL S365,889.36 $270,126.48
* Proposed rates quoted assume a 5/1/97 effective date of coverage
•
This summary is not intended to be a complete explanation of henefits'of the proposed insurance policies. Actual premiums and benefits will he determined by the final em ollment and.o c,uhtcct to under..i nuig
approval.
l 1/ 4011.(
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• Plans of Florida
Insurance Products provided by United Health and L'fe!new-am Company
GROUP INFORMATION Actual Group Effective Date
i,catnpiny Name
2,Federal Identification Number • ;3.Contact Name 4.Title
5.Address ti CIty
7.Canty I S.State 9.Zip Code 10.Work Plane
11,last business owners/partners to be excluded from Worker's Compensation 12.Lot any employee elves conceded from coverage
C Part-time ❑Other -
E Temporary ❑Seasonal
13.Application for(check all that apply)
Medial E Dental D Life J Major Medical(ant-of-area) E Short-term Disability
14.Dumber of years Company in hrssine,s 15.Nature of business 16.Standard Industry Code
1 T.1p the past 36 months,has the Coinparry or any affiliated entity filed for protection or operated under federal/state laws
barsloaptr7 (Chapter Ll or 7)?
Yee ❑No
ACV past 36 months,has any creditor Ned or threatened to file a petition requesting the Company or any affiliated entity be placed voluntarily into bankruptcy!
Clin ❑Nn
IL'1btal number of employees 19.Total number at eligible employees 20.'btal bed 21.Number of employes terminated
, ®
(including those In uniting period) employees applying in lea 12 mouths
\SUB-time hrtthvk) Part-time .I
.
2 -llequested effective date 23-List entployeddependents an Continuation at Coverage/COBRA. ,
24. active due for new hiree: 25.Previous carriers in past free years
Rot r¢the month following the completion of day waiting period
21,1QNmum number of boars worked per week to be eligible 21.>inplayer Medical % ^6h' %
Dependents
%Rim=of 20 hours/week) Conlabution
Dental %Single 2 Depended
Life % Side %Dependents
Short-term Disability %Single
HEALTH INFORMATION
Male answer the live Questions. &plain say yes"answers on the second page of this fora
14 Ups bent of your knowledge: YES NO
1.tyg any employee/dependent been treated for a serious Ulnas(physicallmental),had more than 15,000 of medical expenses,been ❑ ❑
hespidtised or had stage y in the paid twelve months
2.is my employee/dependent apt to have a mntinnmg claim from any existing mental or ptpsic l disorder, pregsuocy? ❑ ❑
N AY any employee/dependent been advised to have surgery in the last six months or anticipate hospitalization for any other reason? ❑ []
4.Aip there empltryeerldependente who are incapacitated or confined In a hospital or treatment facI iV' 0 ❑
6.Arc there employees/dependents who arc not actively performing their duties fill-time doe to a disrahling illness or y! ❑ 0
•
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APPLICATION INSTRUCTIONS
iv avoid processing delays,please metre sure you:
I.Answer all questions completely and accurate'''. •
2,OD NOT CANCEL YOUR EXISTING COVY.RAGE UNTIL YOU RECEIVE WRITTEN NOTIFICATION OF APPRO%L.
IMPORTANT- PLEASE READ CAREFULLY
7�re company certifies that the information provided above is complete and accurate.Computy shall notify the insurer promptly of any changes in this
Zb arson that mg affect the eligibility of employe or their dependents,including the addition of any newly eligible employees or dependents Insurer
e entitled to rely on the most current information in its possession regarding' eligibility of employees and their dependents in providing coverage
updsr thin Policy.
DON and after termination of the Policy,Company grants Innaer permission to me and/or transfer to third pieties,for research and analysis purposes,
the alias:and related medical data in Insure's possession.The parties shall maintain the confidentiality of up cdornution relating to Covered Persons in
accordance with any applicable laws.Neither party shall disclose arp confidential business information at the other party without the prior written consent
oil paw
It is pndestoud and agreed Vail:(1)renewal rates will be based on several factors which will include,but will not be limited to,the projected future claims
experience of your group,except where prohibited by law,(2)insurance will be effective only on the date speedied by the Insurer after the application has
approved by the leaner and after the fan fun premium bag been paid.
Bandrper sig?aataue X
Done
Thin
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BROKER/SALES REP INFORMATION
sill Rep Name • Seto Rep Number Bales Name Broker Number
Agency Name Prone No.( )
Fast No.( )
Cig State rlp
('TORS Payable lb Tax II SR
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131olepr Signature X Data
TOTAL P.03
RESOLUTION NO. 12 - 96/97
A RESOLUTION OF THE VILLAGE COUNCIL OF THE
VILLAGE OF TEQUESTA, PALM BEACH COUNTY,
FLORIDA, APPROVING STANDARD LIFE INSURANCE
COMPANY AS THE LIFE INSURANCE UNDERWRITER
FOR THE TEQUESTA EMPLOYEES LIFE INSURANCE
PROGRAM AND AUTHORIZING THE VILLAGE MANAGER
TO DO ALL THINGS NECESSARY TO EFFECTUATE
THIS APPROVAL.
NOW, THEREFORE, BE IT RESOLVED BY THE VILLAGE COUNCIL OF THE
VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA, AS FOLLOWS:
Section 1 . Standard Life Insurance Company is hereby
approved as the life insurance service provider for the
Tequesta employees life insurance benefit program, in
addition to that life insurance coverage currently provided
by Unum effective May 1, 1997 .
Section 2 . The Village Manager is authorized to do all
things necessary to effectuate the terms of this approval,
including, but not limited to, the execution of necessary
service agreements .
L THE FOREGOING RESOLUTION WAS OFFERED by Councilmember
who moved its adoption. The motion was
seconded by Councilmember , and upon being
put to a vote, the vote was as follows:
FOR ADOPTION AGAINST ADOPTION
•
The Mayor thereupon declared the Resolution duly passed and
adopted this 10th day of April, A.D. , 1997 ..
MAYOR OF TEQUESTA
•
Elizabeth A. Schauer
•
ATTEST:
Joann Manganiello
Village Clerk
wp60\res\11-97
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' VILLAGE OF TEQOESTA
Presented by
ACORDIA OF FLORIDA, INC.
•
STANDARD INSURANCE COMPANY
Tampa
April 01, 1997
VILLAGE OF TEQOESTA
LIFE AND AD&D INSURANCE
SCHEDULE OF INSURANCE
Class : All Eligible
•
Benefit Amount $5, 000
•
COST:
No. of Benefit Rate Monthly
•
Lives Volume Per $1,000 Premium
LIFE 66 $326, 498 $0. 31 $101
AD&D 66 $326,498 $0. 05 $16
Total Premium $117
PLAN FEATURES:
* Rates assume all eligible Members work at leapt 30 hours
each week.
* Rates assume Employer pays .100% of each Member ' s premium.
* Final rates will be guaranteed for 3 years.
* Proposal assumes all known health risks have been disclosed
to Standard's field personnel.
* Benefits reduce to 65% at age 65, to 50% at age 70, and to
35% at age 75. No termination of benefits due to age.
* Waiver of Premium if disabled prior to age 60 : waiver
terminates at age 65.
* An Accelerated Benefit, which allows a portion of a Member 's
Life Insurance benefit to be paid while still living, is
available to Members with a Qualifying Medical Condition.
Certain minimums and maximums apply, subject to state
statute.
Plan continued on next page. . .
STANDARD niSURANCE COMPANY 0000091438/1 04/O1/97
•
P.A`:
* AD&D provides 24 hour coverage .
* AC6,D provides coverage for private flying .
* AD&D includes an additional Seat Belt Benefit equal to the
lesser of $10 , 000 and the amount of AD&D payable for loss of
life .
* All benefits are Guarantee Issue .
* If Members contribute to the cost 'of insurance, increase the
rate by 12% . 75% participation is required, and at least 10
Members must be insured .
* Proposal valid for 90 days .
•
•
•
•
• STANDA*O INSURANCE OOMPH 0000091439/1 04/01/97
•
VILLAGE OF TEQUESTA
•
/ FLORIDA
COMPANY / MUNICIPAL STANDARD
TRUST FUND
EMPLOYEE COVERAGES Current Proposed
Life Amount $5,000 $$OC,0
Total Volume $330,000 $330,000..
MONTHLY RATE PER$1000 OF •
BENEFIT •
Life Insurance .$0.31
Accidental Death & $4.55 •
$0.05
Dismemberment combined
MONTHLY COST $300.30 $118.80
ANNUAL COST $3,603.60 $1,425.60
•
This summary is not intended to be a complete explanation of benefits of the proposed insurance policies. Actual premiums and benefits will be detcrnuned by the final enrollment and arc subject to widely.0 ling
approval.
cmc.ic n ha
RESOLUTION NO. 13 - 96/97
A RESOLUTION OF THE VILLAGE COUNCIL OF THE
VILLAGE• OF TEQUESTA, PALM BEACH COUNTY,
FLORIDA, APPROVING THE FLORIDA MUNICIPAL
HEALTH TRUST AS THE DENTAL INSURANCE SERVICE
. UNDERWRITER FOR TEQUESTA EMPLOYEES DENTAL
INSURANCE PROGRAM AND AUTHORIZING THE
VILLAGE MANAGER TO DO ALL THINGS NECESSARY
TO EFFECTUATE THIS APPROVAL.
! NOW, THEREFORE, BE IT RESOLVED BY THE VILLAGE COUNCIL OF• THE
VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA, AS FOLLOWS:
Section 1 . The Florida Municipal Health Trust Fund is
hereby approved as the Tequesta employees dental insurance
benefit underwriter effective May 1, 1997 .
Section 2 . The Village Manager is authorized to do all
.things necessary to effectuate the terms of this approval,
including, but not limited to, the execution of an
applicable service agreement.
THE FOREGOING RESOLUTION WAS OFFERED by Councilmember
, who moved its adoption. The motion was
seconded by Councilmember , and upon being
put to a vote, the vote was as follows:
FOR ADOPTION AGAINST ADOPTION
•
The Mayor thereupon declared the Resolution duly passed and
adopted this 10th day of April, A.D. , 1997 .
MAYOR OF TEQUESTA •
•
Elizabeth A. Schauer
ATTEST:
•
is Joann Manganiello
Village Clerk
1. wp60\res\13-97
201 West Park Avenue wea • Publ•ic •Risk •
Services
Pgbt Office Box 1757 135 East Colonial Drive
Tallahassee, FL 32302-1757 Post Office Box 530065
Telephone (904) 222 9684 Orlando, FL 32R43-0065
Suncom 278-5331 �LEAGUE � Telephone (407)425-9142
FAX (904) 222-3806 T— Suncom 344-6767
- -__—_—
D Reply to =Y =_ - ® Reply to
•
March 20, 1997
Mr. Bill Kascavelis
Village of Tequesta
357 Tequesta Drive
Tequesta, FL 33469-0273
Re: RFP - Group Health Insurance .
• Dear Mr. Kascavetis:
We appreciate the opportunity to provide you with this proposal of insurance for employee benefits. Coverage
has been proposed through the Honda Municipal Insurance Trust, a non-profit, non-accessible, group pooled
program.
•
The Trust provides medical, dental and short term disability benefits'sand a prescription drug card plan. Other
traditional insured coverages include life insurance through Maccabees Life Insurance Company and vision care
through Vision Service Plan.
Effective October 1, 1995,the Trust has contracted with Sun Health Plans of Florida and Dimension Health Inc.
to provide a statewide managed care network for its participants. This comprehensive neterork of doctors and
hospitals is available_in most regions.
All rates quoted are guaranteed for sixty (60) days from the date of the proposal. The rates include costs of
administration,reinsurance and estimated claims costs. Monthly,quarterly and annual loss reports are provided
at no additional charge.
We welcome the opportunity to further discuss our proposal and should you have any questions,please contact
me at 1-800-445-6248.
•
Si rely,
Ott
Vim'
Sandy Osbor
Health Operations Manager •
SOO.
Enclosure
•
Florida Municipal Self Florida Municipal Health \Florida Municipal Pension Florida Municipal Insurance
Insurers Fund(Workers' Trust Fund Trust Fund I Trust(Liability and
Compensation) Property)
Zu1 west rarK Avenue ruviic BUSK aernccs
Pest Office Box 1757 135 East Colonial Drive
Tallahassee, FL 32302 1757 Post Office Box 530065
Telephone (904) 222-9684 Orlando, FL 32E53.0065
Suncom 278-5331 Telephone (407) 425-9142
Of
FAX (904) 222-3806 � 5 Suncom 344-6767
p Reply to -- _ — =- = Q Reply to
PROPOSAL OF INSURANCE
FOR
•
VILLAGE OF TEOUESTA
Effective Date. 05/01/97
•
Provided by .
Florida Municipal Insurance Trust
Administered by: •
The Florida League of Cities,Inc.
PUBLIC RISK SERVICES
• P.0 Box 530065
Orlando, FL 32853-0065.
• 407-425-9142 or TO Free 1-800- 45-6248
March 20. 1997
•
Florida Municipal Self Florida Municipal Health Florida Municipal Pension Florida Municipal insurance
Insurers Fund (Workers' Trust Fund Trust Fund Trust(Liability and
Compensation) Property)
STATEMENT OF OBJECTIVES
Florida Municipal Insurance Trust
The Florida League of Cities, In response to the interest expressed among its' members, has proposed a
program of self-insurance for employee health,and accident coverage.
The concept of pooled self-insurance was endorsed by the League Board of Directors primarily because of the
increased control this program provides to local governments over their employee benefits plans. Our
experience with self-insurance pools for workers'compensation and general liability/auto liability has shown that
this method of providing coverage is less expensive and more effective than the traditional forms of risk
management.
The advantages of this type of program are that the employer can control costs through closer management
of losses. The advantages of pooling over Individually self-insuring relate to the problems of proper claims han-
dling, lack of funds to cover the catastrophic or shock losses either through retention or reinsurance, and the
• concentration of risk in a small geographic area.
The Fund is required to secure the services of a professional administrator which supplies the expertise
necessary to handle claims, reserves, and excess insurance. Their fee is part of the total operating costs or
overhead of the Fund. The Administrator and Trustees have carefully selected the service company end excess
insurance provider to significantly lower total administrative costs to the employer and employees. Any premium
surplus that is generated can be used to offset costs,of additional benefits,or reduce costs of the sedating plan.
The exact combination of these alternatives is determined by the Board of Trustees.
The minimum operating costs, the expertise of the Administrator and claims service company combined with
the flexibility and responsiveness of the program results in low cost effective health benefit coverages for
employees.
•
WHY FMIT?
WHY FLORIDA MUNICIPAL INSURANCE TRUST'?
The Florida Municipal Insurance Trust helps put you in control of your health program. Members of the Fund
are currently enjoying benefits seldom provided by other health Insurance carriers
• Monthly, quarterly and annual loss reports provide a management tool to evaluate
your claims experience.
• Participants nominate the Board of Trustees controlling the program.
The Trust provides specific reinsurance for large losses.
▪ A program may be designed specifically for your needs.
• Florida League of Cities State League Representatives are assigned geographic
territories throughout the state and are available for representation and general
service Information.
• Administered by-the Florida League of Cities,Tallahassee/Orlando
•
• The Tryst works along with PPO's to provide services on a discounted basis.
GROUP DENTAL
SCHEDULEOF BENEFITS
FLORIDA MUNICIPAL INSURANCE TRUST •
GENERAL DENTAL CARE BENEFIT ORTHODONTIC CARE BENEFIT
Lifetime Maximum Benefit - Unlimited Lifetime Maximum Benefit - 51,000 per
IndlvIduai.
Calendar Year Maximum Benefit-
$1,000 per Individual
SUMMARY OF GENERAL CARE SERVICES SUMMARY OF ORTHODONTIC CARE
1. Examinations.and recall services, check-ups and 1. Diagnostic procedures
cleaning of teeth 2.Appiances for tooth guidance and control of
2. Palliative treatment harmful habits
3. Endodontic treatment 3. Retention appliances
4. Space maintainer 4. Comprehensive treatment with fixed and
5. X-rays removable appliances for correction of
6. Oral surgery malocclusion in permanent, primary and
7. Periodontal treatment mixed dentition
8. Normal extraction of teeth 5. Orthodontic treatment must be completed
9. Silver and synthetic permanent fillings, crowns prior to attainment of age 19.
and jackets
10. Fixed bridges consisting of crowns or jackets •
11. Dentures and removable bridges
DEDUCTIBLE LIFETIME DEDUCTIBLE
$50 per individual per calendar year. S50 per Individual.
Maximum $100 per family.
COINSURANCE COINSURANCE
Plan pays 80%of first $1,250 of eligible Plan pays 50%of first$2.000 of eligible
expenses per calendar year. expenses per inxfivldual In their lifetime.
DENTAL RATES(PER MONTH STANDALONE- (Without Health)
Employee Dental $17.00 Employee Dental $19.00
Dependent Dental $25.00 Dependent Dental $28.00
Family Dental $42.00 Family Dental $47.00
Dental coverage written in the Florida Municipal Insurance Trust is subject to a 25% participation of those
employees quoted.
"• This summary was designed only to give you a brief description of benefits provided and does
not Include all of the provisions, limitations or exclusions In the policies. In an actual claim
situation,the policy provisions,limitations,exclusions will apply. If this outline disagrees with
the Plan Document In any way,the Plan Document will govern.
DENTAL BENEFIT PLAN SUMMARY
•
Reasonable and customary limits will apply to all covered eligible expenses.
GENERAL DENTAL CARE
Calendar Year Max'mum $1,000
Deductible $50 calendar year ($100 family)
After the deductible has been met, unless otherwise stated, the following coinsurance will apply:
This plan will pay 100% preventative services, not subject to the calendar year deductible, as follows:
�. Oral examinations
!• Dental X-rays
3. Fluoride application (for dependents under age 15)
4. Prophylaxis
This plan will pay 80% for basic dental services as follows:
�. Emergency treatment for pain
3. Space maintainers •
3. Biopsies of oral tissue
4. Pulp vitality tests
6. Fillings
Extractions
7. Oral Surgery
/. Endodontics
/. Periodontics
This plan will pay 60%for dental restorations and specialty services as follows:
•
1. Inlays,onlays •
!. Crowns •
I. Bridges. dentures
•CHEDULE OF ORTHODONTIC BENEFIT(applies only to eligible dependents under age 19). •
lifetime maximum (per person) $1,000
Lifetime deductible $50 per person
Covered eligible expenses are payable after the deductible at 50%. .
1. Diagnostic procedures.
_. Appgances for tooth guidance and control of harmful habits.
X. Retention Appliances.
A. Comprehensive treatment with fixed and removable appliances for correction of
malocclusion in permanent, primary and mixed dentition.
Those Summaries are designed only to pa you a brief description of the benefits provided and does not Include all
pf the provisions,limitations or exclusions in the policies. In an actual claim situation,the policy provisions,limitations,
exclusions will apply. If this outline disagrees with the Plan Document In any way, the Plan Document will govern.
pLAIM ADMINISTRATOR:
•
Florida League of Cities,Inc. Claims Center (407)245.0725 •
p.o. Box 025457 (600) 758-3042
Orlando, FL 32853-8135