2022 Delta Dental Renewal

June 30, 2021 REVISED

Unified Government of Athens-Clarke County 375 Satula Avenue Athens, GA 30601

RE: Contract Renewal for Unified Government of Athens-Clarke County Delta Dental PPO℠ Group# 17763

The following is the renewal information for your Delta Dental PPO℠ dental plan:

Effective Date

Contract Term

Current Rates Renewal Rates

1/1/2022 - 12/31/2023

% change 6.00%

Enrollee Only $28.45 $30.16

Enrollee + Spouse $54.92 $58.22

Enrollee + Children $66.49 $70.48

Family $92.91 $98.48

Division #00001, 00002, 09001

We appreciate your business and thank you for choosing Delta Dental Insurance Company. Your employees are among the millions nationwide who trust their smiles to Delta Dental.

We are pleased to present you with your dental plan contract renewal information. We are committed to providing you with quality plan designs combined with excellent customer service.

When reviewing your dental plan, we considered cost factors related to your group's dental service utilization and claims experience. We have made every attempt to provide the most competitive renewal possible.

We have calculated your rates based on the employer/employee contribution levels in your contract remaining the same. If the contribution levels and/or enrollment guidelines have changed or will change, please notify us immediately, as such a change may affect your renewal rate.

January 01, 2022

January 01, 2022 - December 31, 2023

Current Rates Renewal Rates

1/1/2022 - 12/31/2023

% change 6.00%

Enrollee Only $28.45 $30.16

Enrollee + Spouse $54.92 $58.22

Enrollee + Children $66.49 $70.48

Family $92.91 $98.48

Sincerely, Delta Dental Insurance Company

MohammadReza Navid Group Vice President, Sales & Marketing

If you have any questions about your renewal, your Account Manager will be happy to help. We appreciate your continued confidence in Delta Dental. We are proud of our association with you and look forward to a long and mutually successful relationship.

The American Dental Association (ADA) annually updates its standard dental procedure coding system, which is a component of its Code on Dental Procedures and Nomenclature (CDT Code) reference manual. When the ADA changes the codes, carriers must adopt the changes. We process claims according to the current CDT reference manual. Changes made to comply with the CDT Code do not constitute a material change to your dental plan design.

Division #08001

As part of our continued commitment to you and your dental program, Delta Dental maintains a high level of service. Delta Dental continues to assure you of our dedication through ongoing review of our performance standards. Please refer to the attached guarantee exhibit for further details.

To renew your dental plan contract, please follow these steps:

1) Review this letter for changes to your dental plan for January 01, 2022

2) Begin paying the rates outlined in this letter with your new contract term.

OTHER INFORMATION

Provider reimbursement. As a reminder, Delta Dental's policy is to reimburse contracted dentists based on the network payment provisions for the geographic area in which the services are provided.

Summary of Contract Amendments to

Unified Government of Athens-Clarke County

Delta Dental PPO℠

Delta Dental's retro-termination policy for enrollees. As a reminder, Delta Dental's policy is that enrollment may be adjusted retroactively to the immediately preceding three months plus the current month billed if no claims have been processed after the requested termination date for the enrollee.

OHCA Notification

Please be informed that consistent with the group application and group contract terms, Delta Dental considers its relationship with fully insured group health plans as subject to HIPAA’s "Organized Health Care Arrangement" (OHCA) privacy rules as defined in 45 Code of Federal Regulations (C.F.R.) §164.501. Functionally, the exchange of enrollment information between Delta Dental and your group remains the same.

While a Business Associate Agreement is not required between Delta Dental and your fully insured group health plan within an OHCA, any Protected Health Information (PHI) exchanged or shared between the entities remains subject to HIPAA’s minimum necessary rule and other privacy rules in addition to any applicable state laws and regulations governing the disclosure of individually identifiable health information.

Additionally, confidentiality requirements remain applicable to the exchange of information within an

OHCA.

GROUP NUMBER: 17763

DELTA DENTAL INSURANCE COMPANY

January 1, 2022 Renewal

Group Name: Unified Government of Athens-Clarke County

Group Number: 17763

Address: 375 Satula Avenue

Athens, GA 30601

Original Effective Date: July 01, 2015

Current Contract Effective Date: July 01, 2019

Renewal Date: January 01, 2022

Current Enrollment: 1,617 primary enrollees (May-2021)

Prior Enrollment: 1,616 primary enrollees (May-2020)

Dual Choice?: No

Contract Type: Risk - Non-Retention

Current Commission: 0.00%

Broker: EDGEWOOD PARTNERS INSURANCE CENTER

Broker Address: 2405 SATELLITE BLVD STE 125

DULUTH, GA 30601

Account Manager: Untilare Spencer

Summary of Group Information

DELTA DENTAL INSURANCE COMPANY

Rate History Report

Tier Proposed Rate Change Enrollment % Enrolled

Enrollee Only $30.16 525 43.5%

Enrollee + Spouse $58.22 201 16.6%

Enrollee + Children $70.48 175 14.5%

Family $98.48 307 25.4%

Total 1,208 100.0%

Tier Rates Rate Change Enrollment % Enrolled

Enrollee Only $28.45 521 42.5%

Enrollee + Spouse $54.92 213 17.3%

Enrollee + Children $66.49 174 14.2%

Family $92.91 318 25.9%

Total 1,226 100.0%

Tier Rates Rate Change Enrollment % Enrolled

Enrollee Only $28.45 510 40.9%

Enrollee + Spouse $54.92 233 18.6%

Enrollee + Children $66.49 168 13.5%

Family $92.91 337 27.0%

Total 1,248 100.0%

Tier Rates Rate Change Enrollment % Enrolled

Enrollee Only $25.00 511 39.6%

Enrollee + Spouse $48.26 249 19.3%

Enrollee + 1 Child $58.46 82 6.3%

Enrollee + Children $58.43 93 7.2%

Family $81.64 354 27.5%

Total 1,289 100.0%

Tier Rates Rate Change Enrollment % Enrolled

Enrollee Only $24.27 514 39.9%

Enrollee + Spouse $46.85 245 19.0%

Enrollee + Children $56.73 171 13.3%

Family $79.26 359 27.8%

Total 1,289 100.0%

July 1, 2017 - June 30, 2018

July 1, 2015 - June 30, 2017

Division #00001,00002,09001

January 1, 2022 - December 31, 2023

6.00%

July 1, 2019 - December 31, 2021

0.00%

July 1, 2018 - June 30, 2019

DELTA DENTAL INSURANCE COMPANY

Rate History Report

Tier Proposed Rate Change Enrollment % Enrolled

Enrollee Only $30.16 227 55.5%

Enrollee + Spouse $58.22 155 37.9%

Enrollee + Children $70.48 4 1.0%

Family $98.48 23 5.6%

Total 409 100.0%

Tier Rates Rate Change Enrollment % Enrolled

Enrollee Only $28.45 209 55.4%

Enrollee + Spouse $54.92 142 37.5%

Enrollee + Children $66.49 5 1.3%

Family $92.91 22 5.8%

Total 378 100.0%

Tier Rates Rate Change Enrollment % Enrolled

Enrollee Only $28.45 180 55.8%

Enrollee + Spouse $54.92 119 36.9%

Enrollee + Children $66.49 6 1.7%

Family $92.91 18 5.6%

Total 322 100.0%

Tier Rates Rate Change Enrollment % Enrolled

Enrollee Only $25.00 171 59.3%

Enrollee + Spouse $48.26 95 33.0%

Enrollee + 1 Child $58.46 5 1.6%

Enrollee + Children $58.43 0 0.0%

Family $81.64 18 6.1%

Total 288 100.0%

Tier Rates Rate Change Enrollment % Enrolled

Enrollee Only $24.27 149 59.9%

Enrollee + Spouse $46.85 81 32.5%

Enrollee + Children $56.73 4 1.4%

Family $79.26 16 6.3%

Total 248 100.0%

July 1, 2017 - June 30, 2018

July 1, 2015 - June 30, 2017

Division #08001

January 1, 2022 - December 31, 2023

6.00%

July 1, 2019 - December 31, 2021

0.00%

July 1, 2018 - June 30, 2019