Delta Dental Pricing

REVISED

Effective Date

Contract Term

Current Rates Renewal Rates

7/1/2019 - 12/31/2021

% change 0.00%

Enrollee Only $28.45 $28.45

Enrollee + Spouse $54.92 $54.92

Enrollee + Children $66.49 $66.49

Family $92.91 $92.91

May 21, 2019

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

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

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

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

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

When reviewing your dental plan, we considered cost factors related to your group's dental service utilization and claims experience. Our analysis indicates that no increase in your current rate is necessary.

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

July 1, 2019 July 1, 2019 - December 31, 2022

Division # 00001, 00002, 09001

Current Rates Renewal Rates

7/1/2019 - 12/31/2021 % change 0.00%

Enrollee Only $28.45 $28.45

Enrollee + Spouse $54.92 $54.92

Enrollee + Children $66.49 $66.49

Family $92.91 $92.91

% change

Enrollee Only

Enrollee + Spouse

Enrollee + Children

Family

% change

Enrollee Only

Enrollee + Spouse

Enrollee + Children

Family

$30.16

$58.22

$70.48

$98.49

Division # 00001, 00002, 09001 NTE Rates*

1/1/2022 -12/31/2022

6.00%

Division # 08001

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

$30.16

$58.22

$70.48

$98.49

Division # 08001

* Rates indicated as NTE are not-to-exceed renewal rates for the corresponding date range.

NTE Rates*

1/1/2022 - 12/31/2022

6.00%

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

1) Review this letter for changes to your dental plan for July 1, 2019

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

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

Sincerely, Delta Dental Insurance Company

MohammadReza Navid Group Vice President, Sales

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

Summary of Contract Amendments to

Unified Government of Athens-Clarke County

Delta Dental PPO℠

OTHER INFORMATION

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

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

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

OHCA.

OHCA Notification

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

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