220000000382.pdf

STATE OF MICHIGAN PROCUREMENT

Department Technology, Management and Budget Central Procurement Services 320 S Walnut Street Lansing, MI 48933 P.O. Box 30026, Lansing, MI 48909

CONTRACT CHANGE NOTICE

CONTRACT SUMMARY

Dental Benefits Administration Services

INITIAL EFFECTIVE DATE INITIAL EXPIRATION DATE INITIAL AVAILABLE OPTIONS EXPIRATION DATE

BEFORE

April 1, 2022 March 31, 2025 7 - 1 Year March 31, 2029

PAYMENT TERMS DELIVERY TIMEFRAME

ALTERNATE PAYMENT OPTIONS EXTENDED PURCHASING

MINIMUM DELIVERY REQUIREMENTS

N/A

P-Card Direct Voucher (PRC) Other Yes No

4100 Okemos Road

Okemos MI 48864

Lisa Eggert

517-347-5709 leggert@deltadentalmi.com

CV0021332

DELTA DENTAL PLAN OF MICHIGAN

INC

C O

N

TR

A C

TO

R

517-335-2323 guyskir@michigan.gov

Mary Ostrowski

(517) 249-0438

DTMB

Rebecca Guyski MCSC

OstrowskiM@michigan.gov

C ontract

A dm inistrator Program M anagerSTA

TE

N/ANET 45

Change Notice Number 5 to

Contract Number 220000000382

DESCRIPTION OF CHANGE NOTICE

OPTION EXTENSIONLENGTH OF OPTION LENGTH OF EXTENSION REVISED EXP. DATE

CURRENT VALUE VALUE OF CHANGE NOTICE ESTIMATED AGGREGATE CONTRACT VALUE

$782,600,000.00 $0.00 $782,600,000.00

CHANGE NOTICE NO. 5 TO CONTRACT NO. 220000000382

FOR THE CONTRACTOR:

DELTA DENTAL PLAN OF MICHIGAN INC

Company Name

Authorized Agent Signature

Authorized Agent (Print or Type)

Date

DESCRIPTION

Effective September 15, 2025, this Contract is amended to reflect updated accessibility standards. All prior references to ADA, Accessibility, and/or WCAG 2.0 are replaced and superseded with the following language:

Accessibility Requirements.

The State is required to comply with the Americans with Disabilities Act of 1990 (ADA) and has adopted standards and procedures regarding accessibility requirements for websites, applications, content, and electronic documents. Due to a change in the law, the State is required to comply with specific accessibility standards for websites, applications, content and documents. Starting 4/24/2026, throughout the Term, all websites, applications, software, content, and electronic documents, including but not limited to mobile applications, text, images, sounds, videos, controls, animations, links, and documents (including files in the following formats: PDF, word processing, presentation, and spreadsheet), created, provided, or made available by the Contractor under this Contract, must comply with WCAG 2.1 Level

AA.

All other terms, conditions, specifications and pricing remain the same. Per contractor and agency agreement, and DTMB Central Procurement approval.

STATE OF MICHIGAN

ENTERPRISE PROCUREMENT

Department of Technology, Management, and Budget 320 S. Walnut Street 2nd Floor Lansing, MI 48933

P.O. BOX 30026 LANSING, MICHIGAN 48909

CONTRACT CHANGE NOTICE

CONTRACT SUMMARY

Dental Benefits Administration Services

INITIAL EFFECTIVE DATE INITIAL EXPIRATION DATE INITIAL AVAILABLE OPTIONS EXPIRATION DATE

BEFORE

April 1, 2022 March 31, 2025 7 - 1 Year March 31, 2025

PAYMENT TERMS DELIVERY TIMEFRAME

ALTERNATE PAYMENT OPTIONS EXTENDED PURCHASING

MINIMUM DELIVERY REQUIREMENTS

N/A

P-Card Direct Voucher (PRC) Other Yes No

4100 Okemos Road

Okemos MI 48864

Lisa Eggert

517-347-5709 leggert@deltadentalmi.com

CV0021332

DELTA DENTAL PLAN OF MICHIGAN

INC

C O

N

TR

A C

TO

R

517-335-2323 guyskir@michigan.gov

Mary Ostrowski

(517) 249-0438

DTMB

Rebecca Guyski MCSC

OstrowskiM@michigan.gov

C ontract

A dm inistrator Program M anagerSTA

TE

N/ANET 45

Change Notice Number 4 to

Contract Number 220000000382

DESCRIPTION OF CHANGE NOTICE

OPTION EXTENSIONLENGTH OF OPTION LENGTH OF EXTENSION REVISED EXP. DATE

CURRENT VALUE VALUE OF CHANGE NOTICE ESTIMATED AGGREGATE CONTRACT VALUE

4 Years March 31, 2029

$303,700,000.00 $478,900,000.00 $782,600,000.00

DESCRIPTION

Effective April 1, 2025, this Contract is exercising four option years and is increased by $478,900,000.00.

The revised Contract expiration date is March 31, 2029. In addition, Schedule B, Pricing is updated and replaced with the attached which incorporates Administrative pricing through March 31, 2029.

All other terms, conditions, specifications, and pricing remain the same. Per contractor and agency agreement, DTMB Central Procurement Services approval, and State Administrative Board approval on February 25, 2025.

Mich igan .gov/MiProcure ment

Contrac t No . 220000000382

SCHEDULE B – PRICING

Dental Benefits Administration Services

1. Reserved.

2. Reserved.

3. Pricing includes all costs, including but not limited to, any one-time or set-up charges, fees, and potential costs that Contractor may charge the State (e.g., shipping and handling, per piece pricing, and palletizing).

4. The Contractor must provide pass-through pricing to Plan Sponsor for all claims reimbursements. The Contractor must not charge Plan Sponsor or any Member any claims payment amount above that which is paid or payable to the provider under the terms of the Contract between the Contractor and the provider.

5. Reserved.

6. Quick payment terms: None.

7. Contractor’s Implementation Credit to be used for implementation services, communications or to fund third-party audits within the first 2-Years of the Contract:

$100,000.00

8. Contractor’s Additional Savings Guarantee:

The Contractor is confident in its ability to continue to increase savings to the State of Michigan and its members and is willing to guarantee the Contractor’s performance. The Contractor guarantees that the gap between net submitted charges1 per employee per month and allowed charges per employee per month will grow by at least $0.50 in each of the first three years of the contract compared to the 01/2019-12/2019 baseline contract year.2 This equates to almost $3.7 million in additional savings in the first three years of the contract3.

If the gap does not grow by this amount, The Contractor will refund $0.01 per employee per month for each $0.01 by which the Contractor misses the goal.

These savings will be delivered while maintaining the most robust package of networks in the industry. If, under the standard reimbursement methodology, the percentage of procedures paid to out-of-network providers relative to the total number of procedures increases during the Contract by more than 3% over the 01/2019-12/2019 baseline of 5%, that is, the percent of procedures paid to out-of-network providers will not exceed a total of 8%, the Contractor will refund $250,000 of collected administrative fees.

Additional Savings Guarantee Example:

Net Submitted Allowed Charges Difference Baseline 01/01/2019 – 12/31/2019 $133.82 $96.84 $36.98

Mich igan .gov/MiProcure ment

Contrac t No . 220000000382 Guaranteed Gap and Increase Additional savings Total New Savings* Difference First Year $0.50 $615,000 $37.48 Guaranteed Second Year Gap $1.00 $1,230,000 $37.98 Example if Increase is Missed First Year $0.40 $492,000 $37.38 First Year Penalty ($0.10) ($123,000) Second Year $0.75 $922,500 $37.73 Second Year Penalty ($0.25) ($307,500) *Based on a projected enrollment of 102,500

1 Net submitted charges = Gross submitted charges – Invalid claims – Eligibility denials 2 The gap for 01/2022-12/2022 is guaranteed to be greater than or equal to the gap for 01/2019-12/2019 plus $0.50. The gap for 01/2023-12/2023 is guaranteed to be greater than or equal to the gap for 01/2019-12/2019 plus $1.00. The gap for 01/2024-12/2024 is guaranteed to be greater than or equal to the gap for 01/2019-12/2019 plus $1.50.

3 Projections are based on an average monthly enrollment of 102,500 employees each year.

Pricing Table:

Self- Insured Pricing*

Year Fixed Annual Rate (Per Subscriber Per Month Administration Fee)

Plan Year 1 (4/1/22 – 3/31/23) $2.54

Plan Year 2 (4/1/23 – 3/31/24) $2.54

Plan Year 3 (4/1/24 – 3/31/25) $2.54

Plan Year 4 (4/1/25 – 3/31/26) $2.54

Plan Year 5 (4/1/26 – 3/31/27) $2.63

Plan Year 6 (4/1/27 – 3/31/28) $2.73

Plan Year 7 (4/1/28 – 3/31/29) $2.83

*The State of Michigan does not guarantee a minimum or maximum volume of services, claims and conversions.

ENTERPRISE PROCUREMENT

Department of Technology, Management, and Budget 320 S. Walnut Street 2nd Floor Lansing, MI 48933

P.O. BOX 30026 LANSING, MICHIGAN 48909

CONTRACT CHANGE NOTICE

CONTRACT SUMMARY

Dental Benefits Administration Services

INITIAL EFFECTIVE DATE INITIAL EXPIRATION DATE INITIAL AVAILABLE OPTIONS EXPIRATION DATE

BEFORE

April 1, 2022 March 31, 2025 7 - 1 Year March 31, 2025

PAYMENT TERMS DELIVERY TIMEFRAME

ALTERNATE PAYMENT OPTIONS EXTENDED PURCHASING

MINIMUM DELIVERY REQUIREMENTS

N/A

P-Card Direct Voucher (PRC) Other Yes No

4100 Okemos Road

Okemos MI 48864

Lisa Eggert

517-347-5709 leggert@deltadentalmi.com

CV0021332

DELTA DENTAL PLAN OF MICHIGAN

INC

C O

N

TR

A C

TO

R

517-335-2323 guyskir@michigan.gov

Mary Ostrowski

(517) 249-0438

DTMB

Rebecca Guyski MCSC

OstrowskiM@michigan.gov

C ontract

A dm inistrator Program M anagerSTA

TE

N/ANET 45

Change Notice Number 3 to

Contract Number 220000000382

DESCRIPTION OF CHANGE NOTICE

OPTION EXTENSIONLENGTH OF OPTION LENGTH OF EXTENSION REVISED EXP. DATE

CURRENT VALUE VALUE OF CHANGE NOTICE ESTIMATED AGGREGATE CONTRACT VALUE

$303,700,000.00 $0.00 $303,700,000.00

DESCRIPTION

Effective January 1, 2025, Schedule J, Plan Design is updated and replaced with the attached, to accommodate the following changes for State of Michigan retirees, with the exception of persons retiring from the state police troopers and sergeants unit on or after October 1, 1987 (as these benefits are already in effect for that population):

• $2,000 per person total per benefit year (January – December) on Diagnostic & Preventive Services, Basic Services, and Major Services

• Orthodontic Services will not exceed a lifetime maximum of $1,750 per eligible person

• Sealants are covered 100% for dependents under age 14

All other terms, conditions, specifications, and pricing remain the same. Per Contractor and Agency agreement, and DTMB Central Procurement approval.

Updated December 3, 2024 Effective January 1, 2025

State of Michigan Current Plan Design for the State Dental Plan

Summary of Benefits Group No. 8700 & 8800

State Dental Plan

Delta Dental

PPO

Dentist**

Delta Dental Premier Dentist

Nonparticipating Dentist*

Covered Services Plan Pays

You Pay

Plan Pays

You Pay

Plan Pays

You Pay

Diagnostic & Preventive Services

Diagnostic and Preventive Services - Used to diagnose and/or prevent dental abnormalities or disease (includes exams, cleanings and fluoride treatments)

100% 0% 100% 0% 100% 0%

Palliative Treatment - Used to temporarily relieve pain 90% 10% 90% 10% 90% 10%

Radiographs - X-rays 100% 0% 90% 10% 90% 10%

Basic Services

Sealants - Dental sealants to prevent decay of first and second permanent molars for people under age 14 100% 0% 100% 0% 100% 0%

Minor Restorative Services - Used to repair teeth damaged by disease or injury (for example, fillings) 100% 0% 90% 10% 90% 10%

Extractions - Simple and surgical extractions, including preoperative and postoperative care 100% 0% 90% 10% 90% 10%

Oral Surgery Services - Dental surgery, including preoperative and postoperative care, but not including extractions

90% 10% 90% 10% 90% 10%

Endodontic Services - Used to treat teeth with diseased or damaged nerves (for example, root canals) 100% 0% 90% 10% 90% 10%

Periodontic Services - Used to treat diseases of the gums and supporting structures of the teeth 100% 0% 90% 10% 90% 10%

Major Restorative Services - Used when teeth can’t be restored with another filling material (for example, crowns)

90% 10% 90% 10% 90% 10%

Veneers (cosmetic bonding) - For people age 8 through 19 for the eight anterior teeth if damaged by specific conditions.

100% 0% 90% 10% 90% 10%

Major Services

Prosthodontic Services - Used to replace missing natural teeth (for example, bridges, implants, and dentures) 70% 30% 50% 50% 50% 50%

Relines - Relines and rebase to dentures 70% 30% 50% 50% 50% 50%

Prosthodontic Repairs - Repairs to bridges, implants, and dentures 100% 0% 50% 50% 50% 50%

Orthodontic Services – No Age Limit

Orthodontic Services - Used to correct malposed teeth (for example, braces) 75% 25% 60% 40% 60% 40%

Maximum Payment

$2,000 per person total per benefit year (January – December) on Diagnostic & Preventive Services, Basic Services, and Major Services.

Delta Dental's payment for Orthodontic Services will not exceed a lifetime maximum of $1,750 per eligible person.

*In the event that you seek treatment from a nonparticipating dentist, you may be responsible for more than the percentage indicated above.

**If you seek services from a Delta Dental PPO dentist, your benefit coverage levels are enhanced.

Oral exams are payable twice per benefit year. Additional oral exams by a specialist are also payable twice per benefit year.

Three prophylaxes (cleanings) are payable per benefit year.

Fluoride treatments are payable twice per benefit year for people up to age 19.

Bitewing X-rays are payable once per Benefit Year and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period. Additional bitewing X-rays by a specialist are also payable once in the same benefit year. Additional full mouth X-rays by a specialist are also payable once in any five-year period.

Sealants are payable once per tooth per three-year period for the occlusal surface of first and second permanent molars up to age 14. The surface must be free from decay and restorations.

Veneers are payable on incisors, cuspids, and first bicuspids once per tooth per three-year period for children ages 8 through 19, if required because of severe tetracycline staining, severe fluorosis, hereditary opalescent dentin or ameleo-genesis imperfecta.

Composite resin (white) restorations are Covered Services on posterior teeth.

Porcelain and resin facings on crowns are Covered Services on posterior teeth.

Provisional splinting is a Covered Service once per lifetime.

Frenulectomy and frenuloplasty are Covered Services.

Fixed bridge abutment crowns may be paid at the Major Restorative benefit level if payment for a (single) crown could be made due to the condition of the tooth being restored.

Implants and implant related services are payable once per tooth in any five-year period.

Occlusal guards are payable once in any five-year period.

X-rays taken for the purpose of Orthodontic evaluation will be paid at the Orthodontic benefit level.

Diagnostic casts and photographs taken for the purpose of Orthodontic evaluation will be paid at the

Orthodontic benefit level.

The following procedures are exempt from the annual maximum and are covered at 100%.

Apicoectomy/Periradicular Services

D3410 – Apicoectomy – anterior D3421 – Apicoectomy –premolar, first root D3425 – Apicoectomy – molar, first root D3426 – Apicoectomy - premolar (each additional root) D3430 – Retrograde filling – per root D3450 – Root amputation (per root) D3471 – Surgical repair of root resorption - anterior D3472 - Surgical repair of root resorption - premolar D3473 - Surgical repair of root resorption - molar D3501 – Surgical exposure of root surface without apicoectomy or repair of root resorption - anterior D3502 - Surgical exposure of root surface without apicoectomy or repair of root resorption - premolar D3503 - Surgical exposure of root surface without apicoectomy or repair of root resorption - molar

Periodontics – Surgical Services D4210 – Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces, per quadrant D4211 – Gingivectomy or gingivoplasty – one to three teeth, per quadrant D4240 – Gingival flap procedure, including root planning – four or more contiguous teeth or bounded teeth spaces, per quadrant D4241 – Gingival flap procedure, including root planning – one to three teeth, per quadrant D4245 – Apically positioned flap D4249 – Clinical crown lengthening – hard tissue D4260 – Osseous surgery (including flap entry and closure) – four or more contiguous teeth or bounded teeth spaces, per quadrant D4261 – Osseous surgery (including flap entry and closure) – one to three teeth, per quadrant D4263 – Bone replacement graft – first site in quadrant D4264 – Bone replacement graft – each additional site in quadrant D4265 – Biologic materials to aid in soft and osseous tissue regeneration, per site D4266 – Guided tissue regeneration, natural teeth – resorbable barrier, per site D4267 – Guided tissue regeneration, natural teeth – nonresorbable barrier, per site D4268 – Surgical revision procedure, per tooth D4270 – Pedicle soft tissue graft procedure

D4273 – Autogenous connective tissue graft procedures D4274 – Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) D4275 – Non-autogenous connective tissue graft procedure D4276 – Combined connective tissue and double pedicle graft D4277 – Free soft tissue graft, first tooth implant, or edentulous tooth position in graft D4278 – Free soft tissue graft, each contiguous tooth, implant, or edentulous tooth position in graft D4283 – Autogenous connection tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site D4285 – Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site

Oral Surgery D7220 – Removal of impacted tooth – soft tissue D7230 – Removal of impacted tooth – partially bony D7240 – Removal of impacted tooth – completely bony D7241 – Removal of impacted tooth – completely bony, with unusual surgical complications D7250 – Surgical removal of residual tooth roots (cutting procedure) D7280 – Surgical access of an unerupted tooth D7283 – Placement of device to facilitate eruption of impacted tooth D7284 – Excisional biopsy of minor salivary glands D7310 – Alveoloplasty in conjunction with extractions, four or more teeth or tooth spaces, per quadrant D7311 – Alveoloplasty in conjunction with extractions – one to three or tooth spaces, per quadrant D7320 – Alveoloplasty not in conjunction with extractions, four or more teeth or tooth spaces, per quadrant D7321 – Alveoloplasty not in conjunction with extraction – one to three teeth or tooth spaces, per quadrant D7956 – Guided tissue regeneration, edentulous area – resorbable barrier, per site D7957 – Guided tissue regeneration, edentulous area – non-resorbable barrier, per site D7961 – Buccal/labial frenectomy (frenulectomy) D7962 – Lingual frenectomy (frenulectomy) D7963 – Frenuloplasty D7970 – Excision of hyperplastic tissue – per arch D7971 – Excision of pericoronal gingival D7922 – Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site

Anesthesia D9222 - Deep sedation/general anesthesia – first 15 minutes D9223 - Deep sedation/general anesthesia – each subsequent 15-minute increment D9239 - Intravenous moderate (conscious) sedation/analgesia – first 15 minutes D9243 - Intravenous moderate (conscious) sedation/analgesia – each subsequent 15-minute increment

Deductible – None

Current Plan Design for the State Preventive Dental Plan

Summary of Benefits Delta Dental PPO Dentist**

Delta Dental Premier Dentist or Nonparticipating

Dentist*

Covered Services Plan Pays

You Pay

Plan Pays

You Pay

Diagnostic & Preventive

Diagnostic and Preventive Services – Used to diagnose and/or prevent dental abnormalities or disease (includes exams, cleanings and fluoride treatments)

100% 0% 100% 0%

Brush Biopsy – to detect oral cancer 100% 0% 100% 0%

Radiographs – X-rays 100% 0% 100% 0%

Periodontal Maintenance – cleanings following periodontal therapy 100% 0% 100% 0%

*In the event that you seek treatment from a nonparticipating dentist, you may be responsible for more than the percentage indicated above.

**If you seek services from a Delta Dental PPO dentist, your benefit coverage levels are enhanced.

Oral exams are payable twice per benefit year. Additional oral exams by a specialist are also payable twice per benefit year.

Three prophylaxes (cleanings) are payable per benefit year.

Fluoride treatments are payable twice per benefit year for people up to age 19.

Bitewing X-rays are payable once per Benefit Year and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period. Additional bitewing X-rays by a specialist are also payable once in the same benefit year. Additional full mouth X-rays by a specialist are also payable once in any five-year period.

Maximum Payment – None.

Deductible – None.

Current Plan Design for the State Retiree Dental Plan

Summary of Benefits Group No. 8600 & 8601

State Retiree Dental Plan

Delta Dental

PPO

Dentist**

Delta Dental Premier Dentist

Nonparticipating Dentist*

Covered Services Plan Pays

You Pay

Plan Pays

You Pay

Plan Pays

You Pay

Diagnostic & Preventive Services

Diagnostic and Preventive Services - Used to diagnose and/or prevent dental abnormalities or disease (includes exams, cleanings and fluoride treatments)

100% 0% 100% 0% 100% 0%

Palliative Treatment - Used to temporarily relieve pain 90% 10% 90% 10% 90% 10%

Radiographs - X-rays 100% 0% 90% 10% 90% 10%

Basic Services

Sealants - Dental sealants to prevent decay of first and second permanent molars for people under age 14 100% 0% 100% 0% 100% 0%

Minor Restorative Services - Used to repair teeth damaged by disease or injury (for example, fillings) 100% 0% 90% 10% 90% 10%

Extractions* - Simple and surgical extractions, including preoperative and postoperative care 100% 0% 90% 10% 90% 10%

Oral Surgery Services- Dental surgery, including preoperative and postoperative care, but not including extractions

90% 10% 90% 10% 90% 10%

Endodontic Services - Used to treat teeth with diseased or damaged nerves (for example, root canals) 100% 0% 90% 10% 90% 10%

Periodontic Services - Used to treat diseases of the gums and supporting structures of the teeth 100% 0% 90% 10% 90% 10%

Major Restorative Services - Used when teeth can’t be restored with another filling material (for example, crowns)

90% 10% 90% 10% 90% 10%

Veneers (cosmetic bonding) - For people age 8 through 19 for the eight anterior teeth if damaged by specific conditions.

100% 0% 90% 10% 90% 10%

Major Services

Prosthodontic Services - Used to replace missing natural teeth (for example, bridges, implants, and dentures) 70% 30% 50% 50% 50% 50%

Relines - Relines and rebase to dentures 70% 30% 50% 50% 50% 50%

Prosthodontic Repairs - Repairs to bridges, implants, and dentures 100% 0% 50% 50% 50% 50%

Orthodontic Services – No Age Limit

Orthodontic Services - Used to correct malposed teeth (for example, braces) 75% 25% 60% 40% 60% 40%

Maximum Payment

$2,000 per person total per benefit year (January – December) on Diagnostic & Preventive Services, Basic

Delta Dental's payment for Orthodontic Services will not exceed a lifetime maximum of $1,750 per eligible person.

*In the event that you seek treatment from a nonparticipating dentist, you may be responsible for more than the percentage indicated above.

**If you seek services from a Delta Dental PPO dentist, your benefit coverage levels are enhanced.

Routine oral exams are payable twice per calendar year. Evaluations by specialists are also payable twice in the same calendar year.

Three prophylaxes (cleanings) are payable per calendar year.

Fluoride treatments are payable twice per calendar year for people up to age 19.

Bitewing X-rays are payable once per calendar year and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period. Additional bitewing X-rays by a specialist are also payable once in the same calendar year. Additional full mouth X-rays by a specialist are also payable once in any five-year period.

Sealants are payable once per tooth per three-year period for the occlusal surface of first and second permanent molars up to age 14. The surface must be free from decay and restorations.

Veneers are payable on incisors, cuspids, and first bicuspids once per tooth per three-year period for children ages 8 through 19, if required because of severe tetracycline staining, severe fluorosis, hereditary opalescent dentin or ameleo-genesis imperfecta.

Composite resin (white) restorations are Covered Services on posterior teeth.

Porcelain and resin facings on crowns are Covered Services on posterior teeth.

Provisional splinting is a Covered Service once per lifetime.

Frenulectomy and frenuloplasty are Covered Services.

Fixed bridge abutment crowns may be paid at the Major Restorative benefit level if payment for a (single) crown could be made due to the condition of the tooth being restored.

Implants and implant related services are payable once per tooth in any five-year period.

Occlusal guards are payable once in any five-year period.

X-rays taken for the purpose of Orthodontic evaluation will be paid at the Orthodontic benefit level.

Diagnostic casts and photographs taken for the purpose of Orthodontic evaluation will be paid at the

Orthodontic benefit level.

The following procedures are exempt from the annual maximum and are covered at 100%.

Apicoectomy/Periradicular Services D3410 – Apicoectomy – anterior D3421 – Apicoectomy –premolar, first root D3425 – Apicoectomy – molar, first root D3426 – Apicoectomy - premolar (each additional root) D3430 – Retrograde filling – per root D3450 – Root amputation (per root) D3471 – Surgical repair of root resorption - anterior D3472 - Surgical repair of root resorption - premolar D3473 - Surgical repair of root resorption - molar D3501 – Surgical exposure of root surface without apicoectomy or repair of root resorption - anterior D3502 - Surgical exposure of root surface without apicoectomy or repair of root resorption - premolar D3503 - Surgical exposure of root surface without apicoectomy or repair of root resorption - molar

Periodontics – Surgical Services D4210 – Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces, per quadrant D4211 – Gingivectomy or gingivoplasty – one to three teeth, per quadrant D4240 – Gingival flap procedure, including root planning – four or more contiguous teeth or bounded teeth spaces, per quadrant D4241 – Gingival flap procedure, including root planning – one to three teeth, per quadrant D4245 – Apically positioned flap D4249 – Clinical crown lengthening – hard tissue D4260 – Osseous surgery (including flap entry and closure) – four or more contiguous teeth or bounded teeth spaces, per quadrant D4261 – Osseous surgery (including flap entry and closure) – one to three teeth, per quadrant D4263 – Bone replacement graft – first site in quadrant D4264 – Bone replacement graft – each additional site in quadrant D4265 – Biologic materials to aid in soft and osseous tissue regeneration, per site D4266 – Guided tissue regeneration, natural teeth – resorbable barrier, per site D4267 – Guided tissue regeneration, natural teeth – nonresorbable barrier, per site D4268 – Surgical revision procedure, per tooth D4270 – Pedicle soft tissue graft procedure

D4273 – Autogenous connective tissue graft procedures D4274 – Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) D4275 – Non-autogenous connective tissue graft procedure D4276 – Combined connective tissue and double pedicle graft D4277 – Free soft tissue graft, first tooth implant, or edentulous tooth position in graft D4278 – Free soft tissue graft, each contiguous tooth, implant, or edentulous tooth position in graft D4283 – Autogenous connection tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site D4285 – Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site

Oral Surgery D7220 – Removal of impacted tooth – soft tissue D7230 – Removal of impacted tooth – partially bony D7240 – Removal of impacted tooth – completely bony D7241 – Removal of impacted tooth – completely bony, with unusual surgical complications D7250 – Surgical removal of residual tooth roots (cutting procedure) D7280 – Surgical access of an unerupted tooth D7283 – Placement of device to facilitate eruption of impacted tooth D7284 – Excisional biopsy of minor salivary glands D7310 – Alveoloplasty in conjunction with extractions, four or more teeth or tooth spaces, per quadrant D7311 – Alveoloplasty in conjunction with extractions – one to three or tooth spaces, per quadrant D7320 – Alveoloplasty not in conjunction with extractions, four or more teeth or tooth spaces, per quadrant D7321 – Alveoloplasty not in conjunction with extraction – one to three teeth or tooth spaces, per quadrant D7956 – Guided tissue regeneration, edentulous area – resorbable barrier, per site D7957 – Guided tissue regeneration, edentulous area – non-resorbable barrier, per site D7961 – Buccal/labial frenectomy (frenulectomy) D7962 – Lingual frenectomy (frenulectomy) D7963 – Frenuloplasty D7970 – Excision of hyperplastic tissue – per arch D7971 – Excision of pericoronal gingival D7922 - Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site

Anesthesia D9222 - Deep sedation/general anesthesia – first 15 minutes D9223 - Deep sedation/general anesthesia – each subsequent 15-minute increment D9239 - Intravenous moderate (conscious) sedation/analgesia – first 15 minutes D9243 - Intravenous moderate (conscious) sedation/analgesia – each subsequent 15-minute increment

CENTRAL PROCUREMENT SERVICES

Department of Technology, Management, and Budget

320 S. WALNUT ST., LANSING, MICHIGAN 48933

P.O. BOX 30026 LANSING, MICHIGAN 48909

CONTRACT CHANGE NOTICE

Change Notice Number 2 to 220000000382Contract Number guyskir@michigan.gov

Rebecca Guyski

Mary Ostrowski leggert@deltadentalmi.com

Lisa Eggert

Okemos, MI 48864

DELTA DENTAL PLAN OF MICHIGAN INC

CV0021332

517-347-5709

4100 Okemos Road

(517) 249-0438 S

T A

T E

P ro g ra m

M a n a g e r

C o n tra ct

A d m in istra to r

C O

N T R A C T O

R

517-335-2323

DTMB

ostrowskim@michigan.gov

$303,700,000.00

April 1, 2022 March 31, 2025

DENTAL BENEFITS ADMINISTRATION SERVICES

March 31, 2025

INITIAL AVAILABLE OPTIONS EXPIRATION DATE

BEFORE

7 - 1 Year

PAYMENT TERMS DELIVERY TIMEFRAME

NET 45

ALTERNATE PAYMENT OPTIONS EXTENDED PURCHASING

☐ P-Card ☐ PRC ☐ Other ☐ Yes ☒ No

MINIMUM DELIVERY REQUIREMENTS

DESCRIPTION OF CHANGE NOTICE

OPTION LENGTH OF OPTION EXTENSION LENGTH OF EXTENSION REVISED EXP. DATE

☐ ☐ March 31, 2025

CURRENT VALUE VALUE OF CHANGE NOTICE ESTIMATED AGGREGATE CONTRACT VALUE

N/A

$0.00 $303,700,000.00

Effective March 22, 2023, the updates in Change Notice 2, Attachment 1 are incorporated.

All other terms, conditions, specifications, and pricing remain the same. Per Contractor and Agency agreement, and DTMB Central Procurement approval.

INITIAL EXPIRATION DATEINITIAL EFFECTIVE DATE

N/A

DESCRIPTION

CONTRACT SUMMARY

MCSC

Change Notice 2, Attachment 1 Contract No. 220000000382

1.) Schedule A, Statement of Work, Section 4.12 Disclosure of Subcontractors is updated and replaced to add Snowflake as a subcontractor:

4.12. Disclosure of Subcontractors

If the Contractor intends to utilize subcontractors, the Contractor must disclose the following:

• The legal business name; address; telephone number; a description of subcontractor’s organization and the services it will provide; and information concerning subcontractor’s ability to provide the Contract Activities.

• The relationship of the subcontractor to the Contractor.

• Whether the Contractor has a previous working experience with the subcontractor. If yes, provide the details of that previous relationship.

• A complete description of the Contract Activities that will be performed or provided by the subcontractor.

Note: Subcontractors do not include independent contractors engaged by the Contractor solely in a staff augmentation role.

The legal business name, address, telephone number of the subcontractor(s).

Delta Dental Plans Association 1515 West 22nd Street, Suite 450 Oak Brook, Illinois 60523

A description of subcontractor’s organization and the services it will provide and information concerning subcontractor’s ability to provide the Contract Activities.

The Delta Dental Plans Association (DDPA) is a non-profit organization created to coordinate Delta Dental branded insurance companies across multiple states.

DDPA provides integrated online toolkits that allow Delta Dental members and providers to easily check eligibility and benefit information across all Delta Dental member company plans. DDPA also provides a mobile application that syncs with a Delta Dental member company in order to provide members with mobile access to their benefits and eligibility. These services are completely optional and are provided in addition to the standard online toolkits that Delta Dental of Michigan provides to its customers, members, and providers for the purposes of managing benefits and eligibility and submitting claims.

The relationship of the subcontractor to the Contractor.

☒ Used by entire Book of Business ☐ Used only for this contract ☐ Used for multiple contracts

Whether the Contractor has a previous working experience with the subcontractor. If yes, provide the details of that previous relationship.

Delta Dental of Michigan has been a member of the Delta Dental Plans Association since 1970.

Delta Dental has an on-going relationship with the Delta Dental Plans Association. Delta Dental licenses the right to use the Delta Dental trademarks and logos from the Delta Dental Plans Association. As part of its membership standards, Delta Dental is required to comply with certain uniform membership standards set by the DDPA, including provider credentialing guidelines, and quality and security standards.

A complete description of the Contract Activities that will be performed or provided by the subcontractor.

In relation to the contract activities, the Delta Dental Plans Association provides a single national toolkit so that providers and members can quickly check benefits and eligibility information on a nationwide basis and a mobile application that can be used by members to access eligibility and benefit information on a mobile device. As noted above, these services are add-ons to the standard online toolkit that Delta Dental of Michigan provides to its customers, members, and providers for the purposes of managing benefits and eligibility and submitting claims.

The legal business name, address, telephone number of the subcontractor(s).

Voiance Language Services LLC 2650 E. Elvira Rd Suite #132 Tucson, AZ 85756

A description of subcontractor’s organization and the services it will provide and information concerning subcontractor’s ability to provide the Contract Activities.

Voiance is a division of CyraCom International, Inc., the leading provider of language interpreting services.

The relationship of the subcontractor to the Contractor.

☒ Used by entire Book of Business ☐ Used only for this contract ☐ Used for multiple contracts

Whether the Contractor has a previous working experience with the subcontractor. If yes, provide the details of that previous relationship.

Delta Dental of Michigan contracts directly with Voiance to provide remote interpretation services to help bridge communication gaps between our call center agents and customers who speak languages other than English.

A complete description of the Contract Activities that will be performed or provided by the subcontractor.

Voiance provides Remote Interpretation Services for the Delta Dental of Michigan Call Center.

The legal business name, address, telephone number of the subcontractor(s).

Snowflake Inc.

450 Concar Drive San Mateo, CA 94402

A description of subcontractor’s organization and the services it will provide and information concerning subcontractor’s ability to provide the Contract Activities.

Snowflake is a Software-as-a-Service (SaaS) provider delivering a fully relational SQL data platform built for the cloud and deployed on infrastructure supported by Amazon AWS, Microsoft Azure and Google GCP. In four (4) of these regions, Snowflake has received FedRAMP Moderate Authorization to Operate (ATO).

There are 3-regions from Amazon AWS and 1 from Microsoft Azure. Delta Dental of Michigan will be leveraging these FedRAMP certified regions to provide additional reporting and analytics capabilities to DDMI staff.

Snowflake has been providing services to organizations like DDMI since 2012. The contract terms between Snowflake and DDMI contains Service Level Agreement (SLA) language that aligns with all other tier-1 applications that support Roosevelt and DDMI operations.

The relationship of the subcontractor to the Contractor.

☒ Used by entire Book of Business ☐ Used only for this contract ☒ Used for multiple contracts Snowflake is an external vendor to DDMI contracted to provide a SaaS platform that would allow for additional reporting and analytics capabilities that are not available from other software products used by DDMI.

Whether the Contractor has a previous working experience with the subcontractor. If yes, provide the details of that previous relationship.

DDMI entered into an initial contract agreement with Snowflake in 2021 to begin exploring use cases for internal research projects. This engagement proved valuable, and the contract was extended through 2025.

A complete description of the Contract Activities that will be performed or provided by the subcontractor.

Snowflake will be providing a SaaS data platform that DDMI will leverage to continue to expand the reporting and analytics capabilities for DDMI personnel in support of member administration for the Roosevelt platform.

2.) Schedule F, Data Security Requirements is updated and replaced with the attached

Schedule F, Data Security Requirements.

Michigan. gov/ MiProcurement C ontract No . 22000000038 2

Version 5 (10/2020)

SCHEDULE F – DATA SECURITY

REQUIREMENTS

Contract No. 220000000382

1. Definitions. For purposes of this Schedule, the following terms have the meanings set forth below. All initial capitalized terms in this Schedule that are not defined in this Schedule shall have the respective meanings given to them in the Contract.

“Contractor Security Officer” has the meaning set forth in Section 2 of this Schedule.

“Contractor Systems” has the meaning set forth in Section 8 of this Schedule.

“FedRAMP” means the Federal Risk and Authorization Management Program, which is a federally approved risk management program that provides a standardized approach for assessing and monitoring the security of cloud products and services.

“FISMA” means the Federal Information Security Modernization Act of 2014 (Pub.L. No.

113-283 (Dec. 18, 2014.).

“Hosting Provider” identifies any separate third-party subcontractor that is providing any of the hosting services including management and operation of computing hardware, ancillary equipment, networking, Software, firmware, data, other services used to provide Hosted Services; typically identified as a cloud provider.

“Hosted Services” means the hosting, management and operation of the computing hardware, ancillary equipment, Software, firmware, data, other services (including support services), and related resources for remote electronic access and use by the State and its Authorized Users, including any services and facilities related to disaster recovery obligations.

“NIST” means the National Institute of Standards and Technology.

“PCI” means the Payment Card Industry.

“Process” means to perform any operation or set of operations on any data, information, material, work, expression or other content, including to (a) collect, receive, input, upload, download, record, reproduce, store, organize, combine, log, catalog, cross-reference, manage, maintain, copy, adapt, alter, translate or make other improvements or derivative works, (b) process, retrieve, output, consult, use, disseminate, transmit, submit, post, transfer, disclose or otherwise provide or make available, or (c) block, erase or destroy. “Processing” and “Processed” have correlative meanings.

“PSP” or “PSPs” means the State’s IT Policies, Standards and Procedures

“SSAE” means Statement on Standards for Attestation Engagements.

“Security Accreditation Process” has the meaning set forth in Section 6 of this Schedule.

“State Systems” means the information technology infrastructure, including the computers, software, databases, electronic systems (including database management systems) and networks, of the State or any of its designees.

2. Security Officer. Contractor will appoint a Contractor employee to respond to the State’s inquiries regarding the security of the Hosted Services who has sufficient knowledge of the security of the Hosted Services and the authority to act on behalf of Contractor in matters pertaining thereto (“Contractor Security Officer”).

3. Contractor Responsibilities. Contractor is responsible for establishing and maintaining a data privacy and information security program, including physical, technical, administrative, and organizational safeguards, that is designed to:

(a) ensure the security and confidentiality of the State Data;

(b) protect against any anticipated threats or hazards to the security or integrity of the State Data;

(c) protect against unauthorized disclosure, access to, or use of the State Data;

(d) ensure the proper disposal of any State Data in Contractor’s or its subcontractor’s possession; and

(e) ensure that all Contractor Representatives comply with the foregoing.

The State has established Information Technology (IT) PSPs to protect IT resources under the authority outlined in the overarching State 1305.00 Enterprise IT Policy. In no case will the safeguards of Contractor’s data privacy and information security program be less stringent than the safeguards used by the State, and Contractor must at all times comply with all applicable public and non-public State IT policies and standards, of which the publicly available ones are at https://www.michigan.gov/dtmb/0,5552,7- 358- 82547_56579_56755---,00.html.

4. Acceptable Use Policy. To the extent that Contractor has access to the State’s IT environment, Contractor must comply with the State’s Acceptable Use Policy, see

1340.00.130.02 Acceptable Use of Information Technology (michigan.gov) . All Contractor Personnel will be required, in writing, to agree to the State’s Acceptable Use Policy before accessing State systems. The State reserves the right to terminate Contractor’s and/or subcontractor(s) or any Contractor Personnel’s access to State systems if the State determines a violation has occurred.

5. Protection of the State’s Confidential Information. Throughout the Term and at all times in connection with its actual or required performance of the Services, Contractor will:

5.1. If Hosted Services are provided by a Hosting Provider, ensure each Hosting https://www.michigan.gov/dtmb/0%2C5552%2C7-358-82547_56579_56755---%2C00.html https://www.michigan.gov/dtmb/0%2C5552%2C7-358-82547_56579_56755---%2C00.html https://www.michigan.gov/dtmb/0%2C5552%2C7-358-82547_56579_56755---%2C00.html https://www.michigan.gov/dtmb/-/media/Project/Websites/dtmb/Law-and-Policies/IT-Policy/13400013002-Acceptable-Use-of-Information-Technology-Standard.pdf?rev=be02ad06273b40d0b28fd1569c01435e&hash=686A1BFBA24EE0049E2757EC68567A4F

Provider maintains FedRAMP authorization for all Hosted Services environments throughout the Term, and in the event a Hosting Provider is unable to maintain FedRAMP authorization, the State, at its sole discretion, may immediately terminate this Contract for cause pursuant to Section 28 of the Contract Terms;

5.2. for Hosted Services provided by the Contractor, maintain either a FedRAMP authorization or an annual SSAE 18 SOC 2 Type II audit based on State required NIST Special Publication 800-53 MOD Controls using identified controls and minimum values as established in applicable State PSPs;

5.3. ensure that the Software and State Data is securely stored, hosted, supported, administered, accessed, developed for the State pursuant to the terms of the Contract, and backed up in the continental United States, and the data center(s) in which the data resides minimally meet Uptime Institute Tier 3 standards (www.uptimeinstitute.com), or its equivalent;

5.4. maintain and enforce an information security program including safety and physical and technical security policies and procedures with respect to its Processing of the State Data that complies with the requirements of the State’s data security policies as set forth in this Contract, and must, at a minimum, remain compliant with FISMA and NIST Special Publication 800-53 (most recent version) MOD Controls using minimum control values as established in applicable State PSPs;

5.5. provide technical and organizational safeguards against accidental, unlawful or unauthorized access to or use, destruction, loss, alteration, disclosure, encryption, transfer, commingling or processing of such information that ensure a level of security appropriate to the risks presented by the processing of State Data and the nature of such State Data, consistent with best industry practice and applicable standards (including, but not limited to, compliance with FISMA, NIST, CMS, IRS, FBI, SSA, HIPAA, FERPA and PCI requirements as applicable);

5.6. take all reasonable measures to:

(a) secure and defend all locations, equipment, systems and other materials and facilities employed in connection with the Services against “hackers” and others who may seek, without authorization, to disrupt, damage, modify, access or otherwise use Contractor Systems or the information found therein; and

(b) prevent (i) the State and its Authorized Users from having access to the data of other customers or such other customer’s users of the Services; (ii) State Data from being commingled with or contaminated by the data of other customers or their users of the Services; and (iii) unauthorized access to any of the State Data;

5.7. ensure that State Data is encrypted in transit and at rest using FIPS validated AES encryption modules with a key size of 256 bits or higher encryption;

5.8. ensure the Hosted Services support Identity Federation/Single Sign-on (SSO) capabilities using Security Assertion Markup Language (SAML), Open Authentication (OAuth) or comparable State approved mechanisms;

5.9. ensure the Hosted Services implements NIST compliant multi-factor authentication for privileged/administrative and other identified access.

6. Security Accreditation Process. Throughout the Term, Contractor will assist the State, at no additional cost, with its Security Accreditation Process, which includes the development, completion and on-going maintenance of a system security plan (SSP) using the State’s automated governance, risk and compliance (GRC) platform, which requires Contractor to submit evidence, upon request from the State, in order to validate Contractor’s security controls within two weeks of the State’s request. On an annual basis, or as otherwise required by the State such as for significant changes, re-assessment of the system’s controls will be required to receive and maintain authority to operate (ATO). All identified risks from the SSP will be remediated through a Plan of Action and Milestones (POAM) process with remediation time frames based on the risk level of the identified risk. For all findings associated with the Contractor’s solution, at no additional cost, Contractor will be required to create or assist with the creation of State approved POAMs and perform related remediation activities. The State will make any decisions on acceptable risk, Contractor may request risk acceptance, supported by compensating controls, however only the State may formally accept risk.

7. Unauthorized Access. Contractor may not access, and shall not permit any access to, State systems, in whole or in part, whether through the Hosted Services or otherwise, without the State’s express prior written authorization. Such authorization may be revoked by the State in writing at any time in its sole discretion. Any access to State systems must be solely in accordance with the Contract and this Schedule, and in no case exceed the scope of the State’s authorization pursuant to this Section. All State-authorized connectivity or attempted connectivity to State systems shall be only through the State’s security gateways and firewalls and in compliance with the State’s security policies set forth in the Contract as the same may be supplemented or amended by the State and provided to Contractor from time to time.

8. Contractor Systems. Contractor will be solely responsible for the information technology infrastructure, including all computers, software, databases, electronic systems (including database management systems) and networks used by or for Contractor in connection with the Services (“Contractor Systems”) and shall prevent unauthorized access to State systems through the Contractor Systems.

9. Security Audits.

9.1 During the Term, Contractor will maintain complete and accurate records relating to its data protection practices, IT security controls, and the security logs of any of the State’s Confidential Information, including but not limited to any backup, disaster recovery or other policies, practices or procedures relating to the State’s Confidential Information and any other information relevant to its compliance with this Contract.

9.2 Without limiting any other audit rights of the State, the State has the right to review Contractor’s data privacy and information security program prior to the commencement of Services and from time to time during the term of this Contract. The State, at its own expense, is entitled to perform, or to have performed, an on- site audit of Contractor’s data privacy and information security program.