9-D9 - CITY OF BURLESON ASO dental renewal.pdf
PDF 257 KB Posted
- Attached to
- RFP 2026-015 Dental & Vision Insurance Benefits
- Solicitation number
- RFP 2026-015
- Issued by
- Johnson County, Texas
About this file
This is a dental insurance renewal proposal from UnitedHealthcare for the City of Burleson, Texas, issued on October 15, 2025, for coverage effective January 1, 2026 through December 31, 2027. The City of Burleson selected UnitedHealthcare for renewal of its Administrative Services Organization (ASO) dental plan, which provides comprehensive dental coverage including diagnostic services, preventive care, basic restorations, oral surgery, periodontics, endodontics, major services such as crowns and implants, and orthodontic services. The plan covers approximately 416 employees and 934 total members, including dependent children up to age 26, with coverage available on both in-network and out-of-network bases through a Passive PPO network structure.
The renewal maintains a consistent ASO fee structure of $4.15 per employee per month (PEPM) across both plan years, with an annual ASO premium of $14,292.60 and a 12-month claims projection of $72.31 PEPM. The plan includes a $500 individual deductible with specific coverage percentages ranging from 100% for preventive and diagnostic services to 50% for major services and orthodontia, with annual maximums of $1,500 and lifetime orthodontic maximums of $2,500. The employer contribution requires 75% employee participation with no broker commissions charged. The proposal is valid for 90 days from the issue date and is subject to negotiation and execution of a written agreement. Rate guarantees are valid through December 31, 2027, with UnitedHealthcare reserving the right to adjust rates if enrollment fluctuates by more than 10%.
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Text version
Renewal Sold UAF for
CITY OF BURLESON
Issued on: October 15, 2025
Legal Entity
Diagnostic Service
Periodic Oral Evaluation
Radiographs
Lab and Other Diagnostic Tests
Preventive Services
Dental Prophylaxis (Cleaning)
Fluoride Treatment
Sealants
Space Maintainers
Emergency Treatment/General Services
General Services - Adjunctive Emergency Treatment
Basic Services
Restorations (Amalgams or Composite)*
Emergency Treatment/General Services
General Services - Adjunctive Anesthesia
General Services - Adjunctive Occlusal Guard
General Services - Adjunctive Other
Simple Extractions
Oral Surgery (incl. surgical extractions)
Periodontics
Endodontics
Major Services
Inlays/Onlays/Crowns
Dentures and Removable Prosthetics
Fixed Partial Dentures (Bridges)
TMJ
Implants
Orthodontic Services
Orthodontia
Orthodontia Eligibility
Deductible (Individual/Family)
Deductible applies to Prev. & Diag.
Annual Max
Lifetime Ortho Max
Lifetime TMJ Max
Waiting Period
Out of Network Basis
PPO Network
CMM–Annual Roll-Over
ASO Fees Current Renewal Current Renewal 1/1/2026-
12/31/2027
1/1/2026-
12/31/2027
ASO Fee PEPM 287 $4.15 $4.15 129 $4.15 $4.15
Broker Commissions $0.00 $0.00 $0.00 $0.00
Total ASO Fee PEPM $4.15 $4.15 $4.15 $4.15
ASO Annual Premium
Renewal Action (before commissions)
Renewal Action (after commissions)
12 month Claims Projection PEPM $72.31 $72.31
Daily Imprest Balance (1 Day) $1,443.99 1443,99
Employer Contribution
Participation Requirements
Dependent Children Coverage
Contract Basis
Benefit Period Basis
Exclusions and Limitations
Broker Commissions
Rate Guarantee
Expiration Date
Group Policy #
UnitedHealthcare Dental Renewal Sold UAF for CITY OF BURLESON
Effective Date: 01/01/2026 | Policy Number: 00906435
Dental Services
Custom Custom
Passive PPO
42P97
CS0
100% 100%
100% 100%
100% 100%
United HealthCare Services, Inc. (20020)
In Network Out of Network
80% 80%
In Basic In Basic
In Basic In Basic
100% 100%
100% 100%
100% 100%
100% 100%
80% 80%
80% 80%
80% 80%
80% 80%
80% 80%
80% 80%
50% 50%
50% 50%
50% 50%
80% 80%
80% 80%
00906435
Passive PPO
58P83
CS28
United HealthCare Services, Inc. (20020)
Calendar Year
Custom
$0.00 PEPM
24 Months
0.00%
Contributory
75% of Eligible Employees
To Age 26
ASO
$14,292.60 $14,292.60
0.00%
$500 $500
None
UCR 90th
Options PPO 30
No
100% 100%
100% 100%
100% 100%
In Network Out of Network
12/31/2027
$1,500 $1,500
Child Only (Up to Age 19)
$50/$150 $50/$150
No No
$2,000 $2,000
50% 50%
50% 50%
50% 50%
Split Class Split Class
100% 100%
100% 100%
100% 100%
100% 100%
Split Class Split Class
80% 80%
80% 80%
80% 80%
100% 100%
80% 80%
80% 80%
80% 80%
80% 80%
80% 80%
50% 50%
50% 50%
50% 50%
50% 50%
50% 50%
50% 50%
$2,500 $2,500
Child Only (Up to Age 19)
$50/$150 $50/$150
No No
$3,000 $3,000
$6,424.20 $6,424.20
0.00%
$500 $500
None
UCR 90th
Options PPO 30
No
12/31/2027
00906435
Calendar Year
Custom
$0.00 PEPM
24 Months
0.00%
Contributory
75% of Eligible Employees
To Age 26
ASO
General Assumptions
Dental Assumptions
- Rates assume standard administrative services including Claims & Data processing, Enrollment & Billing, Customer Service, Case Management, Provider Relations, and Reporting.
UnitedHealthcare Assumptions for CITY OF BURLESON
Effective Date: 01/01/2026 | Policy Number: 00906435
- We reserve the right to change rates and/or plan provisions if the number of lives or volume of insurance change by more than 10% before, on, or after the effective date listed above or if factors used to generate this quote such as group demographics or effective date are changed, found to be incomplete or incorrect.
- Rates assume no changes in legislation or regulation that affects the benefits payable, eligibility or contract.
Quote is based on total group Average Contract Size (ACS) of 2.25
- Assumed contract situs is Texas.
- Employees must be U.S. citizens or residents regularly working and living in the U.S. Coverage for U.S. citizens working outside of the U.S. must be approved in writing by us. Approval depends on locale and length of assignment.
- Employer's assumed primary business is classified as 9111.
- Rates may increase on renewal in accordance with the terms of the policy.
Rates listed above assume the plan designs quoted. Rates may change, if plan design changes.
Our contract covers only those procedures performed in the United States.
Please contact your sales representative for more details on the network quoted in your proposal.
Run-In Claims are not Paid.
Fees include 12 months of run out claims. Additional months are available at an additional cost.
The In- and Out-of-Network Plan Deductibles, Maximums and Lifetime Ortho Maximums are combined.
* Please contact your sales representative to confirm specific plan Restorations (Amalgams or Composite) coverage.
Please note that the summary of benefits in this document provides a brief description of coverage. State mandates may preclude certain benefit plan design features. This is not a policy, certificate of insurance or coverage document. For complete details on coverage, exclusions, limitations and the terms under which coverage may continue, please contact your sales representative.
Quote is based on total group of 416 Employees and 934 Members.
United Healthcare reserves the right to adjust the above rates should enrollment or ACS fluctuate by +/- 10%.
This quote assumes UnitedHealthcare will retain claim fiduciary responsibility.
Digital ID cards will be available on-line, upon initial enrollment, for employees enrolled in PPO, INO and Indemnity plans. Plastic ID cards will be issued, upon initial enrollment, for employees enrolled in Direct Compensation, Select Managed Care and DHMO plans.
90017262-03
UnitedHealthcare Disclaimers for CITY OF BURLESON
Effective Date: 01/01/2026 | Policy Number: 00906435
This proposal is valid for 90 days from the issued date, unless otherwise noted within this document.
Brokers and agents may receive commissions, bonuses and other compensation for selling the products presented in this proposal. The cost of this compensation may be directly or indirectly reflected in the premium or fees for those products.
Contact your broker and/or agent if you have questions regarding their compensation relating to products in this proposal.
This proposal is subject to negotiation and execution of a written agreement, which will supersede the proposal contents. This proposal does not constitute an agreement, and is based on assumptions made from the written information in our possession and provided by you. We retain the right to modify our proposal if the information upon which this proposal is based is changed or is supplemented.
We consider much of the information contained in the proposal to be proprietary or otherwise confidential, and are releasing this proposal to you on the understanding that you and your representatives will only use it, and any data included in the proposal, for the specific purpose of evaluating its content. If this is not consistent with your understanding, please notify us before reviewing the proposal.
In addition, by accepting and reviewing the contents of this proposal, you and your agents or other designees agree, to the extent permitted by law, that certain information contained herein, or other information provided to you in connection with this proposal response or associated request for proposal (RFP), is proprietary and/or confidential to UnitedHealthcare and its related entities, and may not be copied, used, distributed or disclosed without prior written consent from an authorized representative of
UnitedHealthcare, other than is necessary to evaluate this proposal.
© 2021 United HealthCare Services, Inc. All Rights Reserved 0004411-05 - 10/15/2025
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