9523ZY20R0001_Amend 0001_final.pdf

(x)

9523ZY20R0001

x x

1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted ; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE

RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR

OFFER. If by virtue of this amendment you desire to change an offer already submitted , such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

x

CFTC-FMB

WASHINGTON DC 20581

1155 21ST STREET NW

THREE LAFAYETTE CENTER

COMMODITY FUTURES TRADING COMM

05/20/20200001

13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

12. ACCOUNTING AND APPROPRIATION DATA (If required) is not extended.is extended, Items 8 and 15, and returning

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended , by one of the following methods: (a) By completing

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

FACILITY CODE CODE

10B. DATED (SEE ITEM 13)

10A. MODIFICATION OF CONTRACT/ORDER NO.

9B. DATED (SEE ITEM 11)

9A. AMENDMENT OF SOLICITATION NO.

CODE

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code)

7. ADMINISTERED BY (If other than Item 6)CODE 6. ISSUED BY

PAGE OF PAGES

4. REQUISITION/PURCHASE REQ. NO.3. EFFECTIVE DATE2. AMENDMENT/MODIFICATION NO. 5. PROJECT NO. (If applicable)

1. CONTRACT ID CODE

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

04/30/2020

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority) appropriation data, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

E. IMPORTANT: Contractor is not is required to sign this document and return __________________ copies to the issuing office.

ORDER NO. IN ITEM 10A.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

"Dental Insurance Plan for the Commodity Futures Trading Commission"

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)15A. NAME AND TITLE OF SIGNER (Type or print)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA 15B. CONTRACTOR/OFFEROR 16C. DATE SIGNED

(Signature of person authorized to sign) (Signature of Contracting Officer)

KATHRYN RISON

STANDARD FORM 30 (REV. 11/2016)

Prescribed by GSA FAR (48 CFR) 53.243

Previous edition unusable

Except as provided herein, all terms and conditions of the document referenced in Item 9 A or 10A, as heretofore changed, remains unchanged and in full force and effect .

N/A

See Block 6

To All Offerors

(See Continuation Pages)

5/20/2020

9523ZY-20-R-0001 / Amendment 0001 Page 2

CONTINUATION PAGES

The purpose of this amendment is to answer questions posed by potential offerors and incorporate changes to the terms and conditions of the solicitation.

1. QUESTION: Are we supposed to provide proposals for the current and proposed plans?

ANSWER: Offerors are to propose based on the requirements contained in Part I - Statement of Work of the solicitation. The Statement of Work is consistent with the Plan Design – Proposed Tab under Attachment A - Dental Plan Proposed Package.

2. QUESTION: Confirm the deductible requested and what the group has currently. Are you requesting $50 individual, $100 individual +1 and $150 family?

ANSWER: Yes, the deductibles required are $50 individual, $100 individual plus one and $150 for individual plus family per Part I – Statement of Work of the solicitation. The deductibles CFTC currently has can be found in Tab Plan Design-Current of Attachment A - Dental Plan Proposed Package of the solicitation.

3. QUESTION: Appendix A - Dental Insurance Plan Design and the Plan Design - Proposed tab of MS Excel file. Attachment A - Dental Plan Proposal Package Final both seem to add coverage for implants to the current plan design and also identify implants in the general exclusions section (#8) of each. Please confirm CFTC’s intent to add dental implants to the plan design.

ANSWER: It is not CFTC’s intent to enhance coverage of implants. CFTC’s intent is to duplicate the current coverage of implants as described in Attachment 1 – Certificate of Insurance dated January 2016, which is included in this amendment.

4. QUESTION: The RFP states 626 employees have elected dental but your census shows

680. Can you provide the participant enrollment for the past three (3) years.

ANSWER: The number of employees enrolled fluctuates. Offerors shall use the census number of 680. Historical enrollment information can be found in Tab Enroll_Claims of Attachment A - Dental Plan Proposed Package of the solicitation.

5. QUESTION: Is the effective date of 1/3/2021 or 1/1/21?

ANSWER: CFTC’s current plan coverage expires on January 2, 2021. Therefore, the effective date of the benefit coverage for the new contract, which begins after implementation and training, is January 3, 2021.

9523ZY-20-R-0001 / Amendment 0001 Page 3

6. QUESTION: Clause II.18 IT Systems and Support Services Contract Requirements. Will the insurers system for enrolling participants and managing claims be subject to the IT Security and Privacy requirements (e.g., FISMA, NIST) contained in the clause?

ANSWER: Yes, the system must be compliant with the requirements.

7. QUESTION: Page 49 #4 of the Solicitation document mentions HubZone and a 10% adjustment. Does this apply to us at all, or only for small businesses?

ANSWER: If a proposal is received from a company that meets all the requirements of the solicitation as well as the definition of HubZone and the company has not waived the preference, the Federal Acquisition Regulation (FAR) clause 52.219-4 Notice of Price Evaluation Preference for HUBZone Small Business Concerns requires that the government evaluate proposals be evaluated by adding a factor of 10 percent to the price to each offer.

The adjustment does not apply to HubZone or small businesses.

8. QUESTION: Part III - Section 2.2(a) of the Solicitation states proposals are due no later than 12:00PM local (Washington DC) time on June 1, 2020. Section 2.4(b) outlines the number of original copies needed when sending hard copy only and when sending electronically. We plan on submitting our proposal electronically by e-mail by no later than 12PM EST on June 1st, can we follow up with our hard copy of "(1} full set of all proposal volumes, and two {2} original-signed copies of Standard Form 1449" after June 1st given the added challenges COVID-19 has added to assembling and mailing hard copy material?

ANSWER: Part III – Section 2.4(b) contemplates that if offerors submit proposals via email, they would be “followed-up” in hard-copy. Considering the challenges of COVID-19, Part III Sections 2.2(b) Time, Date and Place Proposals are Due and 2.4(b) Proposal Form and Content are revised in their entirety as reflected below. (Note: Changes to the original provisions are reflected in grey.)

Section 2.2(b):

(b) Proposals shall be submitted by e-mail to: krison@cftc.gov. Please note that CFTC quarantines all emails that exceed 100MB in size. The e-mail submission shall be followed by three (3) full sets of all proposal volumes, and one (1) original-signed copy of the Standard Form 1449. The full set of proposal volumes shall be delivered to CFTC not later than June 5, 2020, and may be hand delivered to the building lobby, sent by special delivery service or regular mail. However, be advised that U.S. Postal Service deliveries are being significantly delayed due to security related irradiation procedures. Offerors assume full responsibility for assuring that proposals are received in a timely manner. Email submissions that require CFTC to retrieve the proposal volumes (e.g., through the use of a file transfer website or a personal network storage and backup website) will not be accepted.

9523ZY-20-R-0001 / Amendment 0001 Page 4

When the hard-copies of the proposal are hand-delivered, sent by special delivery service or regular mail and to assure that your package arrives at the proper place on time and to prevent opening by unauthorized individuals, your proposal must be identified on the envelope or wrapper as follows:

Commodity Futures Trading Commission Attn: Kathryn (Kay) Rison, Contracting Officer 1155 21st Street, NW

Washington, DC 20581

Proposal submitted in response to RFP No. 9523ZY-20-R-0001 Email Submisssion Due Date: 12:00 p.m. local time on June 1, 2020

Hard Copies Due Date: June 5, 2020

Section 2.4(b)

(b) Number of Copies: Offerors shall submit three (3) full sets of all proposal volumes, and one (1) original-signed copy of the Standard Form 1449 copy of their proposal in accordance with the provision entitled “Time, Date and Place Proposals are Due.”

NOTE: Contractor delivery personnel will only be admitted with appropriate personal protective equipment.

9. QUESTION: Please advise regarding Attachment C – Past Performance. Does this apply to insurance companies that have previously had contract with CFTC for the same benefits?

ANSWER: Yes, Attachment C - Past Performance applies to all offerors.

10. QUESTION: Please provide the name of the current insurance carrier and current plan

Summary of Benefit/Table of Benefit.

ANSWER: The name of CFTC’s current dental insurance carrier is MetLife. Please see Attachment D – Certificate of Insurance dated January 2016 which provides the information in a Summary of Benefit/Table of Benefit.

11. QUESTION: Can CFTC please provide a copy of the full dental booklet?

ANSWER: A full dental booklet will not be provided. Please see Attachment D – Certificate of Insurance dated January 2016 which provides the information in the full dental booklet.

9523ZY-20-R-0001 / Amendment 0001 Page 5

12. QUESTION: Can you send us the complete Metlife certificate?

ANSWER: Please see Attachment D – Certificate of Insurance dated January 2016 included in this amendment.

13. QUESTION: Can CFTC provide the current/renewal rates (Any prior rates would be helpful also)?

ANSWER: The CFTC cannot provide this information as it consists of competitive information and is proprietary.

14. QUESTION: Can CFTC provide a complete utilization report so that offerors can do a full disruption on 100% of your claims? This is very helpful to show any network wholes or claims cost differences when changing carriers.

ANSWER: Attachment A - Dental Plan Proposed Package included the listing of top providers for 2019 (see Tab-Provider List) and claim information (see Tab-Enroll_Claims).

No additional utilization information will be provided.

15. QUESTION: What’s the current and past 2-year Premium Expenditure?

ANSWER: The Premium Expenditure for the last three (3) calendar years is included in Tab Enroll_Claims of Attachment A - Dental Plan Proposed Package of the solicitation.

16. QUESTION: Can you advise why the premium paid for some months much was much higher than other months?

ANSWER: The CFTC currently pays premiums every two weeks. The higher paid premium is a result of those months where three (3) payments were made based on the calendar.

17. QUESTION: Please provide the last 3-year Claim Report and Loss Ratio.

ANSWER: The total claims and premiums paid are included in Tab Enroll_Claims of Attachment A - Dental Plan Proposed Package of the solicitation. Offerors can use the information reflected in Tab Enroll_Claims to calculate the loss ratio per month

9523ZY-20-R-0001 / Amendment 0001 Page 6

18. QUESTION: Can CFTC please provide a census with the occupations?

ANSWER: The CFTC will not provide detailed census information by occupation. CFTC employees work in an office setting and include occupations such as administrative staff, lawyers, analysts, information technology experts.

19. QUESTION: Please provide enrollee census data including nationality, date of birth / age, sex, smoker status, enrollee dependency/relationship.

ANSWER: In accordance with Part III, Provision 2.4(d) of the solicitation, census data will be provided to offerors that certify they meet the minimum financial rating or premium size standard specified in clause II.16 “Minimum Insurer Financial Rating/Premium Size” and provide a completed copy of the Nondisclosure Agreement (NDA) signed by an officer of the offeror authorized to contractually bind the firm. As stated in the NDA, the census information includes the sex, birth year, city of duty location, personal zip code, and plan coverage of each participant as of March 2020. No other census data is available.

20. QUESTION: Does the plan include any lifetime cap limitations?

ANSWER: Lifetime cap limitations are reflected in Part I – Statement of Work of the solicitation and Attachment A - Dental Plan Proposed Package and Attachment 1- Certificate of Insurance dated January 2016 of this amendment.

21. QUESTION: Does CFTC have Tax Exempt Status? If so, current Tax Exemption

Certificate.

ANSWER: CFTC is a U.S. federal entity, thus tax exempt. The tax exempt certificate is attached.

22. Part III of the solicitation is hereby amended to require all offerors, other than small business, to submit a subcontracting plan. Accordingly, Section 2.4 and Section 4 are hereby amended as follows:

Section 2.4(d)(2) VOLUME II – TECHNICAL is amended to incorporate paragraph (iv):

(iv) Subcontracting Plan – In accordance with FAR 52.219-9 Alt II, all offerors whose size status is “other than small” shall submit a Small Business Subcontracting Plan with their proposal. In determining the size of the offeror, CFTC will utilize the small business standards defined by the Small Business Administration (SBA) for the North American Industry Classification System (NAICS). The NAICS Code for this

9523ZY-20-R-0001 / Amendment 0001 Page 7 acquisition is 524114, Direct Health and Medical Insurance Carriers, with an applicable size standard of $41.5m.

Offerors shall describe the precise scope of work to be performed by subcontractors, consults or teaming partners. Additionally, the proposal shall identify the work to be performed by small business, including the role small businesses will have in the overall performance of the Statement of Work.

The CFTC’s small business goals are as follows:

• 23% for Small Business (SB)

• 5% for Small Disadvantaged Business (SDB)

• 3% for Service Disabled Veteran-Owned Small Business (SDVOSB)

• 5% for Women-Owned Small Business (WOSB)

• 3% for a certified HUBZone Small Business (HUBZone)

Section 4 – EVALUATION CRITERIA revises paragraph (a) to add Subcontracting Plan and incorporates paragraph (b)(6) as follows:

(a) CFTC intends to award a single contract to the offeror whose offer, conforming to the solicitation, represents the best value to the Government. In considering which offer represents the best value, CFTC will consider the following technical criteria:

(1) Corporate Experience and Past Performance

(2) Quality of Network

(3) Administrative Services

(4) Capability, Compliance & Risk Management

(5) Communication Materials

(6) Subcontracting Plan

(b)(6) Subcontracting Plan - The offeror’s subcontracting plan, where practicable, demonstrates a reasonable approach to assisting, promoting and utilizing Small Businesses (SB), Small Disadvantaged Business (SDB), Service Disabled Veteran-Owned Small Business (SDVOSB), Women-Owned Small Business (WOSB) and HUBZone Small Business (HUBZone).

{End of Amendment}

YOUR BENEFIT PLAN

Commodity Futures Trading Commission (CFTC)

All Employees

Dental Insurance for You and Your Dependents

Certificate Date: January 1, 2016

Solicitation 9523ZY-20-R-0001 Amendment 0001 Attachment 1

1155 21st Street, N.W.

Washington, DC 20581

TO OUR EMPLOYEES:

All of us appreciate the protection and security insurance provides.

This certificate describes the benefits that are available to you. We urge you to read it carefully.

GCERT2000

fp 1

Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166

CERTIFICATE OF INSURANCE

Metropolitan Life Insurance Company (“MetLife”), a stock company, certifies that You and Your Dependents are insured for the benefits described in this certificate, subject to the provisions of this certificate. This certificate is issued to You under the Group Policy and it includes the terms and provisions of the Group Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY.

This certificate is part of the Group Policy. The Group Policy is a legal contract between MetLife and the Policyholder and may be changed or ended without Your consent or notice to You.

Policyholder: Commodity Futures Trading Commission (CFTC)

Group Policy Number:

Type of Insurance: Dental Insurance

MetLife Toll Free Number(s):

For Claim Information FOR DENTAL CLAIMS: 1-800-942-0854

THIS CERTIFICATE ONLY DESCRIBES DENTAL INSURANCE.

THE BENEFITS OF THE POLICY PROVIDING YOUR COVERAGE ARE GOVERNED PRIMARILY BY THE

LAWS OF A STATE OTHER THAN FLORIDA.

THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED

IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS

REQUIRED BY MARYLAND LAW.

WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE

AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S)

CAREFULLY.

GCERT2000 For Texas Residents notice/tx 11/14 2

IMPORTANT NOTICE

To obtain information or make a complaint:

You may call MetLife’s toll free telephone number for information or to make a complaint at:

1-800-942-0854

You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights, or complaints at:

1-800-252-3439

You may write the Texas Department of Insurance:

P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 490-1007 Web: www.tdi.texas.gov

Email: ConsumerProtection@tdi.texas.gov

PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact MetLife first. If the dispute is not resolved, you may contact the Texas Department of Insurance.

ATTACH THIS NOTICE TO YOUR CERTIFICATE:

This notice is for information only and does not become a part or condition of the attached document.

AVISO IMPORTANTE

Para obtener información o para presentar una queja:

Usted puede llamar al número de teléfono gratuito de MetLife para obtener información o para presentar una queja al:

1-800-942-0854

Usted puede comunicarse con el Departamento de Seguros de Texas para obtener información sobre compañías, coberturas, derechos, o quejas al:

1-800-252-3439

Usted puede escribir al Departamento de Seguros de Texas a:

P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 490-1007 Sitio Web: www.tdi.texas.gov

Email: ConsumerProtection@tdi.texas.gov

DISPUTAS POR PRIMAS DE SEGURAS O

RECLAMACIONES: Si tiene una disputa relacionada con su prima de seguro o con una reclamación, usted debe comunicarse con MetLife primero. Si la disputa no es resuelta, usted puede comunicarse con el Departamento de Seguros de Texas.

ADJUNTE ESTE AVISO A SU CERTIFICADO:

Este aviso es solamente para propósitos informativos y no se convierte en parte o en condición del documento adjunto.

NOTICE FOR RESIDENTS OF ALASKA, LOUISIANA, MINNESOTA, MONTANA, NEW

HAMPSHIRE, NEW MEXICO, TEXAS, UTAH AND WASHINGTON

GCERT2000 3

notice/childdef

The Definition Of Child Is Modified For The Coverages Listed Below:

For Alaska Residents (Dental Insurance):

The term also includes newborns.

For Louisiana Residents (Dental Insurance):

The term also includes Your grandchildren residing with You. The age limit for children and grandchildren will not be less than 21, regardless of the child’s or grandchild’s student status or full-time employment status. In addition, the age limit for students will not be less than 24. Your natural child, adopted child, stepchild or grandchild under age 21 will not need to be supported by You to qualify as a Child under this insurance.

For Minnesota Residents (Dental Insurance):

The term also includes:

Your grandchildren who are financially dependent upon You and reside with You continuously from birth;

children for whom You or Your Spouse is the legally appointed guardian; and children for whom You have initiated an application for adoption.

The age limit for children and grandchildren will not be less than 25 regardless of the child’s or grandchild’s student status or full-time employment status. Your natural child, adopted child stepchild or children for whom You or Your Spouse is the legally appointed guardian under age 25 will not need to be supported by You to qualify as a Child under this insurance.

For Montana Residents (Dental Insurance):

The term also includes newborn infants of any person insured under this certificate. The age limit for children will not be less than 25, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a child under this insurance.

For New Hampshire Residents (Dental Insurance):

The age limit for children will not be less than 26, regardless of the child’s marital status, student status, or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported by You to qualify as a Child under this insurance.

For New Mexico Residents (Dental Insurance):

The age limit for children will not be less than 25, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild will not be denied dental insurance coverage under this certificate because:

• that child was born out of wedlock;

• that child is not claimed as Your dependent on Your federal income tax return; or

• that child does not reside with You.

For Texas Residents (Dental Insurance):

The term also includes Your grandchildren. The age limit for children and grandchildren will not be less than 25, regardless of the child’s or grandchild’s student status, full-time employment status or military service status.

Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a Child under this insurance. A child will be considered Your adopted child during the period You are party to a suit in which You are seeking the adoption of the child. In addition, grandchildren must be able to be claimed by You as a dependent for Federal Income Tax purposes at the time You applied for Insurance.

NOTICE FOR RESIDENTS OF ALASKA, LOUISIANA, MINNESOTA, MONTANA, NEW

HAMPSHIRE, NEW MEXICO, TEXAS, UTAH AND WASHINGTON (continued)

GCERT2000 4

notice/childdef

For Utah Residents (Dental Insurance):

WARNING: IF THE DEFINITION OF CHILD COVERS A CHILD REGARDLESS OF

MARITAL STATUS, PLEASE OMIT "AN UNMARRIED" IN THE MENTAL OR PHYSICAL

HANDICAP CHILD AND THE SENTENCE WILL REFLECT "A CHILD"

The age limit for children will not be less than 26, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported by You to qualify as a Child under this insurance. The term includes an unmarried child who is incapable of self-sustaining employment because of a mental or physical handicap as defined by applicable law and who has been continuously covered under a Dental plan since reaching age 26, with no break in coverage of more than 63 days, and who otherwise qualifies as a Child except for the age limit. Proof of such handicap must be sent to Us within 31 days after:

the date the Child attains the limiting age in order to continue coverage; or You enroll a Child to be covered under this provision;

and at reasonable intervals after such date, but no more often than annually after the two-year period immediately following the date the Child qualifies for coverage under this provision.

For Washington Residents (Dental Insurance):

The age limit for children will not be less than 26, regardless of the child’s marital status, student status, or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported by You to qualify as a Child under this insurance.

NOTICE FOR RESIDENTS OF ALL STATES WHO ARE INSURED FOR DENTAL

INSURANCE

GCERT2000 5

notice/denrights

Notice Regarding Your Rights and Responsibilities

Rights:

We will treat communications, financial records and records pertaining to Your care in accordance with all applicable laws relating to privacy.

Decisions with respect to dental treatment are the responsibility of You and the Dentist. We neither require nor prohibit any specified treatment. However, only certain specified services are covered for benefits. Please see the Dental Insurance sections of this certificate for more details.

You may request a pre-treatment estimate of benefits for the dental services to be provided. However, actual benefits will be determined after treatment has been performed.

You may request a written response from MetLife to any written concern or complaint.

You have the right to receive an explanation of benefits which describes the benefit determinations for Your dental insurance.

Responsibilities:

You are responsible for the prompt payment of any charges for services performed by the Dentist. If the dentist agrees to accept part of the payment directly from MetLife, You are responsible for prompt payment of the remaining part of the dentist’s charge.

You should consult with the Dentist about treatment options, proposed and potential procedures, anticipated outcomes, potential risks, anticipated benefits and alternatives. You should share with the Dentist the most current, complete and accurate information about Your medical and dental history and current conditions and medications.

You should follow the treatment plans and health care recommendations agreed upon by You and the Dentist.

notice/ak 6

NOTICE FOR RESIDENTS OF ALASKA

Reasonable and Customary Charges

Reasonable and Customary Charges for Out-of-Network services will not be based less than an 80th percentile of the dental charges.

Reasonable Access to an In-Network Dentist

If You do not have an In-Network Dentist within 50 miles of Your legal residence, We will reimburse You for the cost of Covered Services and materials provided by an Out-of-Network Dentist at the same benefit level as an In-Network Dentist.

Exclusions

The exclusion of services which are primarily cosmetic will not apply to the treatment or correction of a congenital defect of a newborn child.

Coordination of Benefits or Non-Duplication of Benefits with a Secondary Plan:

If This Plan is Secondary, This Plan will determine benefits as if the services were obtained from This Plan’s In-Network provider under the following circumstances:

the Primary Plan does not provide benefits through a provider network;

both the Primary Plan and This Plan provide benefits through provider networks but the covered person obtains services through a provider in the Primary plan’s network who is not in This Plan’s network; or both the Primary Plan and This Plan provide benefits through provider networks but the covered person obtains services from a provider that is not part of the provider network of the Primary Plan or This Plan because no provider in the Primary Plan’s provider network or This Plan’s network is able to meet the particular health need of the covered person.

Procedures For Dental Claims

Procedures for Presenting Claims for Dental Insurance Benefits

All claim forms needed to file for Dental Insurance benefits under the group insurance program can be obtained from the Employer who can also answer questions about the insurance benefits and to assist You or, if applicable, Your beneficiary in filing claims. Dental claim forms can also be downloaded from www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim. Be sure all questions are answered fully.

Routine Questions on Dental Insurance Claims

If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1-800-942-0854.

Claim Submission

For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit the required proof as described in the FILING A CLAIM section of the certificate.

Claim forms must be submitted in accordance with the instructions on the claim form.

notice/ak 7

Procedures For Dental Claims (Continued)

Initial Determination

After You submit a claim for Dental Insurance benefits to MetLife, MetLife will review Your claim and notify You of its decision to approve or deny Your claim.

Such notification will be provided to You within a 30 day period from the date You submitted Your claim; except for situations requiring an extension of time of up to 15 days because of matters beyond the control of MetLife. If MetLife needs such an extension, MetLife will notify You prior to the expiration of the initial 30 day period, state the reason why the extension is needed, and state when it will make its determination. If an extension is needed because You did not provide sufficient information or filed an incomplete claim, the time from the date of MetLife’s notice requesting further information and an extension until MetLife receives the requested information does not count toward the time period MetLife is allowed to notify You as to its claim decision. You will have 45 days to provide the requested information from the date You receive the notice requesting further information from MetLife.

If MetLife denies Your claim in whole or in part, the notification of the claims decision will state the reason why Your claim was denied and reference the specific Plan provision(s) on which the denial is based. If the claim is denied because MetLife did not receive sufficient information, the claims decision will describe the additional information needed and explain why such information is needed. Further, if an internal rule, protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Within 30 days after We receive Proof of Your claim, We will approve and pay the claim or We will deny the claim. If We deny the claim, We will provide You with the basis of Our denial or the specific additional information that We need to adjudicate Your claim. If We request additional information, We will approve and pay the claim or We will deny the claim within 15 days after We receive the additional information. If the claim is approved and not paid within the time period provided, the claim will accrue at an interest rate of 15 percent per year until the claim is paid.

Appealing the Initial Determination

If MetLife denies Your claim, You may appeal the denial. Upon Your written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim. You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife’s decision, or as soon as reasonably possible for situations in which You cannot reasonably meet the deadline. Appeals must be in writing and must include at least the following information:

Name of Employee Name of the Plan Reference to the initial decision Whether the appeal is the first or second appeal of the initial determination An explanation why You are appealing the initial determination.

As part of each appeal, You may submit any written comments, documents, records, or other information relating to Your claim.

After MetLife receives Your written request, MetLife will conduct a full and fair review of Your claim. Deference will not be given to initial denials, and MetLife’s review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that You submit relating to Your claim without regard to whether such information was submitted or considered in the initial determination. Your appeal will be reviewed by a person holding the same professional license as the treating Dental provider. The person who will review Your appeal will not be the same person as the person who made the initial decision to deny Your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim.

notice/ak 8

Procedures For Dental Claims (Continued)

MetLife will notify You in writing of its final decision within 18 days after MetLife’s receipt of Your written request for review.

If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s) why the claim You appealed is being denied and references any specific Plan provision(s) on which the denial is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge. Upon written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim.

Second Level Appeal

If You disagree with the response to the initial appeal of the denied claim, You have the right to a second level appeal.

We shall communicate Our final determination to You within 18 calendar days from receipt of the request, or as required by any applicable state or federal laws or regulations. Our communication to You shall include the specific reasons for the determination.

External Appeal

If You disagree with the response to the second appeal of the denied claim, You have the right to an external appeal.

We will communicate the decision of the external appear agency in Writing. The decision will be made in accordance with the medical exigencies of the case involved, but in no event later than 21 working days after the appeal is filed, or, in the case of an expedited appeal, 72 hours after the time of requesting an external appeal of the health care insurer’s decision. Decisions made by an external appeal agency are binding on Us and You unless the aggrieved party files suit in superior court within 6 months from the decision of the external appeal agency. All costs of the external appeal process, except those incurred by You or the treating professional in support of the appeal, will be paid by Us.

Overpayments

Recovery of Overpayments

We have the right to recover any amount that is determined to be an overpayment, within 180 days from the date of service, whether for services received by You or Your Dependents.

An overpayment occurs if it is determined that:

the total amount paid by Us on a claim for Dental Insurance benefits is more than the total of the benefits due to

You under this certificate; or payment We made should have been made by another group plan.

If such overpayment occurs, You have an obligation to reimburse Us.

notice/ak 9

Overpayments (Continued)

How We Recover Overpayments

We may recover the overpayment, within 180 days from the date of service, from You by:

stopping or reducing any future benefits payable for Dental Insurance;

demanding an immediate refund of the overpayment from You; and taking legal action.

If the overpayment results from Our having made a payment to You that should have been made under another group plan, We may recover such overpayment within 180 days from the date of service, from one or more of the following:

any other insurance company;

any other organization; or any person to or for whom payment was made.

notice/ar 10

NOTICE FOR RESIDENTS OF ARKANSAS

If You have a question concerning Your coverage or a claim, first contact the Policyholder or group account administrator. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.

If You are still concerned after contacting both the Policyholder and MetLife, You should feel free to contact:

Arkansas Insurance Department Consumer Services Division

1200 West Third Street Little Rock, Arkansas 72201

(501) 371-2640 or (800) 852-5494

GCERT2000 11

notice/ca

NOTICE FOR RESIDENTS OF CALIFORNIA

IMPORTANT NOTICE

TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE

POLICYHOLDER OR THE METLIFE CLAIM OFFICE SHOWN ON THE EXPLANATION OF BENEFITS

YOU RECEIVE AFTER FILING A CLAIM.

IF, AFTER CONTACTING THE POLICYHOLDER AND/OR METLIFE, YOU FEEL THAT A SATISFACTORY

SOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA

INSURANCE DEPARTMENT AT:

DEPARTMENT OF INSURANCE

300 SOUTH SPRING STREET

LOS ANGELES, CA 90013

1 (800) 927-4357

GCERT2000 12

notice/dp/ca

NOTICE FOR RESIDENTS OF THE STATE OF CALIFORNIA

California law provides that for dental insurance, domestic partners of California’s residents must be treated the same as spouses. If the certificate does not already have a definition of domestic partner, then the following definition applies:

"Domestic Partner means each of two people, one of whom is an employee of the Policyholder, a resident of California and who have registered as domestic partners or members of a civil union with the California government or another government recognized by California as having similar requirements."

If the certificate already has a definition of domestic partner, that definition will apply to California residents, as long as it recognizes as a domestic partner any person registered as the employee’s domestic partner with the California government or another government recognized by California as having similar requirements.

Wherever the term "Spouse" appears in this certificate it shall, unless otherwise specified, be read to include Your Domestic Partner.

Wherever the term step-child appears, it is replaced by step-child or child of Your Domestic Partner.

notice/ga 13

NOTICE FOR RESIDENTS OF GEORGIA

The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family violence.

notice/id 14

NOTICE FOR RESIDENTS OF IDAHO

If You have a question concerning Your coverage or a claim, first contact the Policyholder. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.

If You are still concerned after contacting both the Policyholder and MetLife, You should feel free to contact:

Idaho Department of Insurance Consumer Affairs

700 West State Street, 3rd Floor PO Box 83720

Boise, Idaho 83720-0043 1-800-721-3272 (for calls placed within Idaho) or 208-334-4250 or www.DOI.Idaho.gov notice/il 15

NOTICE FOR RESIDENTS OF ILLINOIS

To make a complaint to MetLife, You may write to:

MetLife

200 Park Avenue New York, New York 10166

The address of the Illinois Department of Insurance is:

Illinois Department of Insurance

Public Services Division Springfield, Illinois 62767 notice/in 16

NOTICE FOR RESIDENTS OF INDIANA

Questions regarding your policy or coverage should be directed to:

Metropolitan Life Insurance Company

1-800-438-6388

If you (a) need the assistance of the government agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email:

State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, Indiana 46204

Consumer Hotline: (800) 622-4461; (317) 232-2395

Complaint can be filed electronically at www.in.gov/idoi notice/me 17

NOTICE FOR RESIDENTS OF MAINE

You have the right to designate a third party to receive notice if Your insurance is in danger of lapsing due to a default on Your part, such as for nonpayment of a contribution that is due. The intent is to allow reinstatements where the default is due to the insured person’s suffering from cognitive impairment or functional incapacity. You may make this designation by completing a “Third-Party Notice Request Form” and sending it to MetLife. Once You have made a designation, You may cancel or change it by filling out a new Third-Party Notice Request Form and sending it to MetLife. The designation will be effective as of the date MetLife receives the form. Call MetLife at the toll-free telephone number shown on the face page of this certificate to obtain a Third-Party Notice Request Form. Within 90 days after cancellation of coverage for nonpayment of premium, You, any person authorized to act on Your behalf, or any covered Dependent may request reinstatement of the certificate on the basis that You suffered from cognitive impairment or functional incapacity at the time of cancellation.

notice/ma 18

NOTICE FOR MASSACHUSETTS RESIDENTS

CONTINUATION OF DENTAL INSURANCE

1. If Your Dental Insurance ends due to a Plant Closing or Covered Partial Closing, such insurance will be continued for 90 days after the date it ends.

2. If Your Dental Insurance ends because:

You cease to be in an Eligible Class; or Your employment terminates;

for any reason other than a Plant Closing or Covered Partial Closing, such insurance will continue for 31 days after the date it ends.

Continuation of Your Dental Insurance under the CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT subsection will end before the end of continuation periods shown above if You become covered for similar benefits under another plan.

Plant Closing and Covered Partial Closing have the meaning set forth in Massachusetts Annotated Laws, Chapter 151A, Section 71A.

CONTINUATION OF DENTAL INSURANCE FOR YOUR FORMER SPOUSE

If the judgment of divorce dissolving Your marriage provides for continuation of insurance for Your former Spouse when You remarry, Dental Insurance for Your former Spouse that would otherwise end may be continued.

To continue Dental insurance under this provision:

1. You must make a written request to the employer to continue such insurance;

2. You must make any required premium to the employer for the cost of such insurance.

The request form will be furnished by the Employer.

Such insurance may be continued from the date Your marriage is dissolved until the earliest of the following:

the date Your former Spouse remarries;

the date of expiration of the period of time specified in the divorce judgment during which You are required to provide Dental Insurance for Your former Spouse;

the date coverage is provided under any other group health plan;

the date Your former Spouse becomes entitled to Medicare;

the date Dental Insurance under the policy ends for all active employees, or for the class of active employees to which You belonged before Your employment terminated;

the date of expiration of the last period for which the required premium payment was made; or the date such insurance would otherwise terminate under the policy.

If Your former Spouse is eligible to continue Dental Insurance under this provision and any other provision of this Policy, all such continuation periods will be deemed to run concurrently with each other and shall not be deemed to run consecutively.

NOTICE FOR RESIDENTS OF MISSISSIPPI

notice/ms

DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS

Procedures for Presenting Claims for Dental Insurance Benefits

All claim forms needed to file for Dental Insurance benefits under the group insurance program can be obtained from the Employer who can also answer questions about the insurance benefits and to assist You or, if applicable, Your beneficiary in filing claims. Dental claim forms can also be downloaded from www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim. Be sure all questions are answered fully.

Routine Questions on Dental Insurance Claims

If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1-800-942-0854.

Claim Submission

For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit the required proof as described in the FILING A CLAIM section of the certificate.

Claim forms must be submitted in accordance with the instructions on the claim form.

Initial Determination

After You submit a claim for Dental Insurance benefits to MetLife, MetLife will review Your claim and notify You of its decision to approve or deny Your claim.

If Your claim is a Clean Claim and it is approved by MetLife, benefits will be paid within 25 days after MetLife receives due written proof in electronic form of a covered loss, or within 35 days after receipt of due written proof in paper form of a covered loss. Due written proof includes, but is not limited to, information essential for Us to administer coordination of benefits.

"Clean Claim" means a claim that:

does not require further information, adjustment or alteration by You or the provider of the services in order for MetLife to process and pay it;

does not have any defects;

does not have any impropriety, including any lack of supporting documentation; and does not involve a particular circumstance required special treatment that substantially prevents timely payments from being made on the claim.

A Clean Claim does not include a claim submitted by a provider more than 30 days after the date of service, or if the provider does not submit the claim on Your behalf, a claim submitted more than 30 days after the date the provider bills You.

If MetLife is unable to pay a claim for Dental Insurance benefits because MetLife needs additional information or documentation, or there is a particular circumstance requiring special treatment, within 25 days after the date MetLife receives the claim if it is submitted in electronic form, or within 35 days after the date MetLife receives the claim if it is submitted in paper form, MetLife will send You notice of what supporting documentation or information MetLife needs. Any claim or portion of a claim for Dental Insurance benefits that is resubmitted with all of the supporting documentation requested in Our notice and becomes payable will be paid to You within 20 days after MetLife receives it.

NOTICE FOR RESIDENTS OF MISSISSIPPI (continued) notice/ms

Clean Claim (Continued)

If MetLife does not deny payment of such benefits to You by the end of the 25 day period for clean claims submitted in electronic form, or 35 day period for clean claims submitted in paper form, and such benefits remain due and payable to You, interest will accrue on the amount of such benefits at the rate of 1½ percent per month until such benefits are finally settled. If MetLife does not pay benefits to You when due and payable, You may bring action to recover such benefits, any interest which has accrued with respect to such benefits and any other damages which may be allowed by law. MetLife will pay benefits when MetLife receives satisfactory Written proof of Your claim.

Proof must be given to MetLife not later than 90 days after the end of the Dental Expense Period in which the Covered Dental Expenses were incurred. If proof is not given on time, the delay will not cause a claim to be denied or reduced as long as the proof is given as soon as possible.

Appealing the Initial Determination

If MetLife denies Your claim, You may take two appeals of the initial determination. Upon Your written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim. You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife’s decision. Appeals must be in writing and must include at least the following information:

Name of Employee Name of the Plan Reference to the initial decision Whether the appeal is the first or second appeal of the initial determination An explanation why You are appealing the initial determination.

As part of each appeal, You may submit any written comments, documents, records, or other information relating to Your claim.

After MetLife receives Your written request appealing the initial determination or determination on the first appeal, MetLife will conduct a full and fair review of Your claim. Deference will not be given to initial denials, and MetLife’s review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that You submit relating to Your claim without regard to whether such information was submitted or considered in the initial determination. The person who will review Your appeal will not be the same person as the person who made the initial decision to deny Your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife will consult with a health care professional with appropriate training and experience in the field of dentistry involved in the judgment. This health care professional will not have consulted on the initial determination, and will not be a subordinate of any person who was consulted on the initial determination.

MetLife will notify You in writing of its final decision within 30 days after MetLife’s receipt of Your written request for review, except that under special circumstances MetLife may have up to an additional 30…