RFP_5800_SLW3030_ATT_2_v1.pdf

Dental Benefits Current Dental Terminology American Dental Association City of Austin BlueCare Dental PPO Account #246681 Group #299988 Active January 1, 2026 Group #300189 Retirees

Your Dental Care Benefits Program

Administered by:

+. ' BlueCross BlueShield of Texas

Blue Cross and Blue Shield ofTexas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Table of Contents

Section 1 Plan Provisions Section 2 Eligibility

Section 3 How the Plan Works Section 4 Dental Benefits

Section 5 Claims Filing and Appeal Procedures Section 6 General Provisions Section 7 Plan Administration Information

Section 8 Dental Plan Document Definitions

Out-of-Network Table of Allowances Notices …………………………………

Helpful Resources Blue Cross and Blue Shield of Texas (BCBSTX) Claims Administrator Phone number: 888-907-7880 Office hours: 8:00 a.m. to 6:00 p.m., Monday – Friday

Call for: Dental coverage and claims information

Website: www.bcbstx.com/coa 24 hours a day, 7 days a week

City of Austin Human Resources Department Employee Benefits Division 505 Barton Springs Road, Suite 600 Austin, Texas 78704

Phone number: 512-974-3284 TTY number: 512-974-2445; Relay Texas: 800-735-2989 Fax number: 512-974-3420

Office hours: 8:00 a.m. to 5:00 p.m., Monday – Friday Call for: Enrollment and adding/dropping dependents

2025 Dental Plan Document

Section 1 Plan Provisions This document constitutes the entire 2025 BlueCare Dental PPO (the Plan) for eligible City retirees and their eligible dependents. The Plan does not constitute a contract of employment. Defined terms are capitalized in this document. See DEFINITIONS section of this Benefit Booklet.

Section 2 Eligibility The City will determine eligibility for covered persons enrolled in the Plan. Eligibility guidelines are outlined in the 2025 Retiree Benefits Guide.

If Coverage terminates, benefits will be extended, without premium, for 31 days after Coverage has terminated or coverage goes into effect for another dental plan, for the following services:

1. Dentures, if the final impressions were taken before Coverage ended.

2. A crown, bridge, or gold filling, if the tooth was finally prepared and impressions were taken before Coverage ended.

3. Root canal work, if the pulp chamber was opened and the canal was explored to the apex before Coverage ended.

Section 3 How the Plan Works

BlueCare Dental PPO In-Network Coverage – Your out-of-pocket will be less when choosing an In-Network Provider. In-Network Providers have signed an agreement with BCBSTX to accept the Allowable Amount as payment in full. Such Participating Providers have agreed to not bill you for Covered Service amounts over the Allowable Amount.

Therefore, you will be responsible only for the $50 Calendar Year deductible, if it has not already been met.

Out-of-Network Coverage – Your out-of-pocket will be greater when choosing an Out-of-Network Provider.

Out- of-Network Providers have not signed an agreement with BCBSTX to accept the Allowable Amount as payment in full. Therefore, you are responsible for the amount billed over the Table of Allowance and the $50 Calendar Year deductible, if it has not already been met.

Allowable Amount The Allowable Amount is the maximum amount of benefits BCBSTX will pay for Eligible Dental Expenses you incur under the Plan.

Review the definition of Allowable Amount in the DEFINITIONS section of this Benefit Booklet to understand the guidelines used by BCBSTX.

Course of Treatment In cases where there is more than one professionally acceptable covered procedure or Course of Treatment, benefits will be covered for the least costly procedure or Course of Treatment, as determined by the Plan. If the Participant requests or accepts a more costly service, the person is responsible for expenses that exceed the amount covered for the least costly service.

Each time you need dental care, you can choose:

An In-Network Provider An Out-of-Network Provider

• Less out-of-pocket maximums. Providers have contracted to accept a lower Allowable Amount as payment in full for Eligible Dental Expenses.

• You are not required to file a claim.

• You are not balanced billed for costs exceeding BCBSTX’s

Allowable Amount for an In-Network Provider.

• Reimbursement based on the Table of Allowance.

• You or the Out-of-Network Provider are required to file a claim form(s).

• You may be balanced billed for costs exceeding the Table of Allowance.

In each event as described above you will be responsible for the following:

• Any applicable Deductibles;

• Services that are limited or not covered under the Plan.

If your Provider is not an In-Network Provider, you may be responsible for payment in full at the time services are rendered.

To find an In-Network Provider, log on to the BCBSTX website at www.bcbstx.com/coa and search for a Provider using Provider Finder, or call the Dental Customer Service 888-907-7880.

Identification Card The Identification Card tells Providers that you are entitled to benefits under your Employer's dental care Plan with BCBSTX. The card offers a convenient way of providing important information specific to your coverage including, but not limited to, the following:

• Your Subscriber identification number.

• Your group number. This is the number assigned to identify your Employer's dental care Plan.

Remember to carry your Identification Card and present it to your Provider when receiving dental care services or supplies. Do not let anyone who is not named in your coverage use your Identification Card to receive benefits.

Please remember that any time a change in your family occurs, it may be necessary for a new Identification Card to be issued to you (refer to the DENTAL BENEFITS section for instructions). Upon receipt of the change in information, BCBSTX will provide a new Identification Card.

Predetermination of Benefits If a Course of Treatment for non-emergency services can reasonably be expected to involve Eligible Dental Expenses in excess of $300, a description of the procedures to be performed and an estimate of the Provider's charge should be filed with and predetermined by BCBSTX prior to the commencement of treatment.

BCBSTX may request copies of existing radiographic images, photographs, models, and any other records used by the Provider in developing the Course of Treatment. BCBSTX will review the reports and materials, taking into consideration alternative Courses of Treatment. BCBSTX will notify you and the Provider of the benefits to be provided under the Plan. Predetermination gives you and your Provider the opportunity to know the extent of the benefits available. Benefit payments may be reduced based on any claims paid after a predetermination estimate is provided.

Section 4 Dental Benefits Maximum Benefits The maximum amount of cumulative benefits payable to each covered person, including Preventive, Basic, Major, and Orthodontia Care, is:

• Calendar Year Maximums - $1,000.

• Orthodontia Lifetime Maximums - $1,000. Orthodontia maximums apply to Calendar Year Maximums.

http://www.bcbstx.com/coa

Deductible Each covered person is required to meet a $50 Deductible each Calendar Year before the Plan pays benefits for Basic, Major, and Orthodontia Care. The deductible does not apply to Preventive Care.

Covered Expenses Covered Expenses are the Allowable Amounts payable under the Plan. Dental services must be performed by or under the supervision of a Provider and must be essential for the care of the teeth. Dental services must begin while the person is covered under the Plan.

A Covered Expense is considered incurred on the date when:

1. The final impression is taken for dentures and partials.

2. Fixed bridgework, crowns, inlays, and onlays are prepared to receive the restoration.

3. The pulp chamber is opened for root canal therapy.

4. Bands and appliances are placed for Orthodontia Care.

5. Any other covered service is provided.

Preventive Care Covered services include:

1. Routine oral examinations, limited to two per Plan Year.

2. Intraoral X-rays, limited to one series every five years.

3. Bitewing X-rays, limited to two series per Plan Year.

4. Prophylaxes (teeth cleanings), limited to two per Plan Year.

5. Fluoride Treatment limited to one per Plan Year. Covered for dependents through age 12 only.

6. Sealants. Covered for dependents through age 16 only.

7. Emergency treatment for relief of dental pain on a day for which no other benefit, other than X-rays, is payable.

Basic and Major Care Except for gold restorations and prosthetics, covered services are limited to:

1. Oral Surgery, including extractions, cutting procedures in the mouth, and treatment of fractures and dislocations of the jaw.

2. Treatment of the gums and supporting structures of the teeth.

3. Root canal therapy and other endodontic treatment.

4. General anesthetics and their administration.

5. Antibiotics and therapeutic injections administered by a Provider.

6. Restorations for teeth broken down by decay or Injury.

Limitations

1. Services provided must be necessary for:

• Preventive care.

• Treatment of dental disease or defect.

• Treatment of an Injury.

2. Covered services for gold restorations and prosthetic services are limited to:

• Repair and rebasing of existing dentures that have not been replaced by a new denture.

• Full or partial dentures, fixed bridges, or the addition of teeth to an existing denture.

3. Services of a Dental Hygienist are covered only if the Dental Hygienist is working under the supervision of a Provider.

4. Oral exams are Covered Expenses only when service is not duplicated by another procedure performed on the same day.

5. Orthodontia Care eligible expenses are reimbursed at 100% of the allowable amount for In-Network providers and up to the Table of Allowance for Out-of-Network providers, as work progresses and as the receipts are submitted.

6. Replacement of any prosthesis (bridge, denture, crown, or orthodontic appliance) within five years of City coverage after it was first placed is not covered, unless replacement is needed because of initial placement of an opposing full prosthesis or the extraction of teeth; or the prosthesis is a stay plate, or a similar temporary prosthesis, and while in the mouth, has been damaged beyond repair as a result of an Injury occurring while covered. Stolen or lost prostheses are not covered. Temporary or duplicate devices are not covered.

Expenses Not Covered Covered Expenses do not include, and no payment will be made on the following:

1. Expenses in excess of the amounts listed in the Table of Allowances for the Plan or in excess of the frequency limitations.

2. Expenses in excess of the Plan Calendar Year or Orthodontia Lifetime Maximums.

3. Services performed for cosmetic reasons, except to correct a congenital anomaly of a Dependent child under 19 years of age.

4. Replacement of missing, lost, or stolen appliances.

5. Replacement at any time of a bridge or denture which meets or can be made to meet commonly held dental standards of functional acceptability.

6. Expenses incurred after termination of coverage except for dental services which were initiated prior to termination, and which were delivered to the covered person within 31 days after the date of termination.

7. Dental procedures covered by one of the medical benefit plans sponsored by the City.

8. Work-related illness, injury, or complication thereof, arising out of the course of employment.

9. Charges which a covered person is not required to pay, including charges for services furnished by any hospital or organization which normally makes no charge if the patient has no hospital, surgical, medical, or dental coverage.

10. Appliances or restorations, other than full dentures, whose primary purpose is to alter vertical dimension, stabilize periodontally involved teeth, or restore occlusion.

11. Crowns for teeth restorable by other means, or for the purpose of periodontal splinting.

12. Drugs or medications other than antibiotic drug injections.

13. Bite registration or analysis.

14. Instruction, planning, or training services performed for problems associated with diet, oral plaque control, or preventive dental care.

15. Precision or semi-precision instruments.

16. Implants and related services, except implant supported prosthetics.

17. Transplants.

18. Denture duplication.

19. Overdentures.

20. Charges incurred for missed appointments.

21. Night guards.

22. Splints.

23. Dental services that do not have uniform dental endorsement.

24. Placement of bands and regular maintenance of braces, resulting from:

• Mandibular or maxillofacial surgery to correct growth defects, jaw disproportions, or malocclusion, except for the correction of a congenital anomaly of a Dependent child under 19 years of age.

• Appliances or restorations used solely to increase vertical dimension, to reconstruct occlusion, or to correct or treat temporomandibular joint (TMJ) dysfunction or TMJ pain syndrome.

25. Temporary restorations.

26. Services for procedures which began prior to the effective date of Coverage under the Plan, including services for Orthodontia Care and prosthetics, if initial treatment or banding began prior to the effective date of Coverage under the Plan.

27. Infection control fees.

28. Charges assessed by the Provider for the completion of a claim form.

29. Services provided by any government agency, whether Federal, State, County, or City.

30. Non-billed services.

Section 5 Claims Filing and Appeals Procedures Filing of Claims Required In-Network Providers will file your claim directly to BCBSTX for services provided to you or any of your covered Dependents. At the time services are provided, inquire if they will file the claim form for you. To assist Providers in filing your claims, you should carry your Identification Card with you.

If the Out-of-Network Provider does not file the claim on your behalf, you will need to file the claim to BCBSTX using a Participant-filed claim form provided by BCBSTX. You can obtain a Dental Claim Form from the BCBSTX website at www.bcbstx.com/coa. Follow the instructions on the reverse side of the form to complete the claim.

Remember to file each Participant's expenses separately because any Deductibles, maximum benefits, and other provisions are applied to each Participant separately. Include itemized bills from the Provider printed on their letterhead and show the:

1. services performed;

2. dates of service;

3. charges; and

4. name of the Participant involved

Visit the BCBSTX Website for Dental Claim Forms and Other Useful Information at: www.bcbstx.com/coa

Mail completed Forms to: Blue Cross and Blue Shield of Texas Dental Claims Division P.O. Box 660247 Dallas, Texas 75266-0247

Who Receives Payment Benefit payments will be made directly to the Providers when they bill the claim to BCBSTX. Written agreements between BCBSTX and some Providers may require payment directly to them. Any benefits payable to you, if unpaid at your death, will be paid to your beneficiary or to your estate, if no beneficiary is named.

Except as provided in the Assignment and Payment of Benefits section, rights and benefits under the Plan are not assignable, either before or after services and supplies are provided.

Benefit Payments to a Managing Conservator Benefits for services provided to your minor Dependent child may be paid to a third party if:

• Third party is named in a Court Order as managing or possessory conservator of the child; and

• BCBSTX has not already paid any portion of the claim.

For benefits to be payable to a managing or possessory conservator of a child, the conservator must submit to BCBSTX, with the claim form, proof of payment of the expenses and a certified copy of the Court Order naming that person the managing or possessory conservator.

http://www.bcbstx.com/coa

BCBSTX may deduct from its benefit payment any amounts it is owed by the recipient of the payment. Payment to you or your Provider, or deduction by BCBSTX from benefit payments of amounts owed to BCBSTX, will be considered in satisfaction of its obligations to you under the Plan.

An Explanation of Benefits (EOB) for Dental Care summary is sent to you so you will know what has been paid.

When to Submit Claims All claims for benefits under the Plan must be properly submitted within 90 days after the date you receive the services or supplies. Claims not submitted and received by BCBSTX within 90 days do not invalidate or reduce a claim if:

• It was not reasonably possible to provide the claim within that time;

• The written claim is provided as soon as reasonably possible; and

• Unless the claimant does not have the legal capacity to provide it, the claim is provided not later than twelve

(12) months after that date the claim is otherwise required.

Receipt of Claims BCBSTX A claim will be considered received by BCBSTX for processing upon actual delivery to BCBSTX's Administrative Office in the proper manner and form and with all the information required. If the claim is not complete, it may be denied, or BCBSTX may contact either you or the Provider for the additional information.

Review of Claim Determination Claim Determinations When BCBSTX receives a properly submitted claim, it has authority under the Plan to interpret and determine benefits in accordance with the Plan provisions. BCBSTX will receive and review claims for benefits and will accurately process claims consistent with administrative practices and procedures established in writing between BCBSTX and the Plan Administrator.

After processing the claim, BCBSTX will notify the Participant by way of an EOB for Dental Care.

If a Claim Is Denied or Not Paid in Full If the claim is denied in whole or in part, you will receive a written notice from BCBSTX with the following information, if applicable:

1. The reasons for the determination;

2. A reference to the benefit Plan provisions on which the determination is based;

3. A description of additional information which may be necessary to perfect the claim and an explanation of why such material is necessary;

4. Subject to privacy laws and other restrictions, if any, the identification of the claim, date of service, dental care Provider, claim amount (if applicable), and a statement describing denial codes with their meanings. Upon request, treatment codes with their meanings and the standards used are also available;

5. The right to request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits;

6. Any internal rule, guideline, protocol or other similar criterion relied on in the determination, and a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge on request;

7. An explanation of the scientific or clinical judgment relied on in the determination as applied to claimant's dental circumstances, if the denial Experimental/Investigational treatment was based on Dental Necessity, or similar exclusion, or a statement that such explanation will be provided free of charge upon request; and

8. Contact information for applicable office of health insurance consumer assistance or ombudsman.

Timing of Required Notices and Extensions Separate schedules apply to the timing of required notices and extensions, depending on the type of claim. There are two types of claims as defined below.

1. Pre-Service Claim is any request for benefits or a determination with respect to which the terms of the benefit Plan condition receipt of the benefit on approval of the benefit in advance of obtaining dental care.

2. Post-Service Claim is notification in a form acceptable to BCBSTX that a service has been rendered or furnished to you. This notification must include full details of the service received, including your name, age, sex, identification number, the name and address of the Provider, an itemized statement of the service rendered or furnished, the date of service, the claim charge, and any other information which BCBSTX may request in connection with services rendered to you.

Dental Claims Type of Notice or Extension Timing If your claim in incomplete, BCBSTX must notify you within:

30 days

If you are notified that your claim is incomplete, you must then provide completed claim information to the Claim Administrator within:

45 days after receiving notice

BCBSTX must notify you of any adverse claim determination:

If the initial claim is complete, within: 30 days After receiving the completed claim (if the initial claim is incomplete), within:

45 days

This period may be extended one time by BCBSTX for up to 15 days, provided that BCBSTX both: (1) determines that such an extension is necessary due to matters beyond the control of the Plan and (2) notifies you in writing, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which BCBSTX expects to render a decision.

Claim Appeal Procedures Claim Appeal Procedures - Definitions An “Adverse Benefit Determination” means a denial, reduction, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, or failure to provide in response to a claim, Pre-Service Claim, or make payment for, a benefit resulting from the application utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental/Investigational or not Dentally Necessary or appropriate. If an ongoing Course of Treatment had been approved by BCBSTX and BCBSTX reduces such treatment (other than by amendment or termination of the Employer's benefit Plan) before the end of the approved treatment period, that is also an Adverse Benefit Determination.

How to Appeal an Adverse Benefit Determination You have the right to seek and obtain a full and fair review of any determination of a claim, any determination of a request for preauthorization, or any other determination made by BCBSTX in accordance with the benefits and procedures detailed in your Plan. An appeal of an Adverse Benefit Determination may be filed by you or a person authorized to act on your behalf. In some circumstances, a dental care Provider may appeal on their own behalf.

Your designation of a representative must be in writing as it is necessary to protect against disclosure of information about you except to your authorized representative. To obtain an Authorized Representative Form, you or your representative may call BCBSTX at the number on the back of your Identification Card. If you believe BCBSTX incorrectly denied all or part of your benefits, you may have your claim reviewed. BCBSTX will review its decision in accordance with the following procedure:

1. Within 180 days after you receive notice of an Adverse Benefit Determination, you may call or write to

BCBSTX to request a claim review. If the appeal is made orally, BCBSTX will acknowledge the request in writing and include a one-page appeal form sent to the appealing party. BCBSTX will need to know the reasons why you do not agree with the Adverse Benefit Determination.

Send your request to: Dental Claim Review Section, Blue Cross and Blue Shield of Texas, P.O. Box 660247, Dallas, Texas 75266-0247

2. BCBSTX will honor telephone requests for information; however, such inquiries will not constitute a request for review. Any complaint concerning dissatisfaction or disagreement with an Adverse Benefit Determination constitutes an appeal.

3. In support of your claim review, you have the option of presenting evidence and testimony to BCBSTX. You and your authorized representative may ask to review your file and any relevant documents and may submit written issues, comments and additional dental information within 180 days after you receive notice of an Adverse Benefit Determination or at any time during the claim review process.

BCBSTX will provide you or your authorized representative with any new or additional evidence or rationale and any other information and documents used in the review of your claim without regard to whether such information was considered in the initial determination. No deference will be given to the initial Adverse Benefit Determination.

Such new or additional evidence or rationale will be provided to you or your authorized representative sufficiently in advance of the date a final decision on appeal is made in order to give you a chance to respond. If the initial benefit determination regarding the claim is based in whole or in part on a dental judgment, the appeal determination will be made by a Provider associated or contracted with BCBSTX and/or by external advisors, but who were not involved in making the initial denial of your claim.

If you have any questions about the claims procedures or the review procedure, write to BCBSTX Administrative Office or call 888-907-7880.

Timing of Appeal Determinations BCBSTX will render a determination on an appeal of an Adverse Benefit Determination as soon as possible but not later than 30 days after the appeal has been received by BCBSTX.

If You Need Assistance If you have any questions about the claims procedures or the review procedure, write or call BCBSTX at 888-907- 7880. The BCBSTX Customer Service is available from 8:00 a.m. to 6:00 p.m., Monday through Friday.

Dental Claim Review Section Blue Cross and Blue Shield of Texas, P. O. Box 660247, Dallas, Texas 75266-0247 If you need assistance with the internal claims and appeals or the external review processes that are described below, you may call 888-907-7880. In addition, for questions about your appeal rights or for assistance, you can call the Employee Benefits Security Administration at 866-444-EBSA (3272).

Notice of Appeal Determination BCBSTX will notify the party filing the appeal, you, and, if a clinical appeal, any dental care Provider who recommended the services involved in the appeal, by a written notice of the determination.

The written notice to you or your authorized representative will include:

1. The reasons for the determination;

2. A reference to the benefit Plan provisions on which the determination is based;

3. Subject to privacy laws and other restrictions, if any, the identification of the claim, date of service, dental care

Provider, claim amount (if applicable), and a statement describing denial codes with their meanings and the standards used. Upon request, treatment codes with their meanings are also available;

4. The right to request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits;

5. Any internal rule, guideline, protocol or other similar criterion relied on in the determination, and a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge on request;

6. An explanation of the scientific or clinical judgment relied on in the determination, or a statement that such explanation will be provided free of charge upon request; and

7. Contact information for applicable office of health insurance consumer assistance or ombudsman.

If BCBSTX denies your appeal, in whole or in part, or you do not receive a timely decision, you have the right to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Your external review rights are described in the How to Appeal a Final Internal Adverse Determination to an Independent Review Organization (IRO) section below.

How To Appeal A Final Internal Adverse Determination to an Independent Review Organization (IRO) An “Adverse Determination” means a determination by BCBSTX or its designated utilization review organization that a dental care service that is a covered service has been reviewed and, based upon the information provided, is determined to be Experimental/Investigational, or does not meet BCBSTX’s requirements for Dental Necessity, or appropriateness and the requested service or payment for the service is therefore denied or reduced

A “Final Internal Adverse Benefit Determination” means an Adverse Benefit Determination that has been upheld by BCBSTX at the completion of BCBSTX's internal review/appeal process.

This procedure (not part of the complaint process) pertains only to appeals of Adverse Determinations.

Any party whose appeal of an Adverse Determination is denied by BCBSTX may seek review of the decision by an IRO. At the time the appeal is denied, BCBSTX will provide you, your designated representative or Provider of record, information on how to appeal the denial, including the approved form, which you, your designated representative, or your Provider of record must complete.

1. BCBSTX will submit dental records, names of Providers and any documentation pertinent to the decision of the

IRO.

2. BCBSTX will comply with the decision by the IRO.

3. BCBSTX will pay for the independent review.

Upon request and free of charge, you or your designee may have reasonable access to, and copies of, all documents, records and other information relevant to the claim or appeal, including:

1 . Information relied upon to make the decision;

2 . Information submitted, considered or generated in the course of making the decision, whether it was relied upon to make the decision;

3 . Descriptions of the administrative process and safeguards used to make the decision;

4 . Records of any independent reviews; conducted by BCBSTX;

5 . Dental judgments, including whether a service is; Experimental/Investigational or not Dentally Necessary or appropriate; and 6 . Expert advice and consultation obtained by BCBSTX in connection with the denied claim, whether the advice was relied upon to make the decision.

The appeal process does not prohibit you from pursuing other appropriate remedies, including injunctive relief; a declaratory judgment or other relief available under law.

Interpretation of Employer's Plan Provisions The Plan Administrator has given BCBSTX the limited authority to process claims per the terms and conditions of the Plan and to determine benefits in accordance with the Plan's provisions.

All powers to be exercised by BCBSTX or the Plan Administrator shall be exercised in a non-discriminatory manner and shall be applied uniformly to assure similar treatment to persons in similar circumstances.

Actions Against Blue Cross Blue Shield of Texas No lawsuit or action in law or equity may be brought by you or on your behalf prior to the expiration of 60 days after Proof of Loss has been filed in accordance with the requirement of the Plan and no such action will be brought at all unless brought within three years from the expiration of the time within which Proof of Loss is required by the Plan.

Section 6 General Provisions Agent The Employer is not the agent of BCBSTX.

Amendments The Plan may be amended or changed at any time by agreement between the Employer and BCBSTX.

Assignment and Payment of Benefits If a written assignment of benefits is made by a Participant to a Provider and the written assignment is delivered to BCBSTX with the claim for benefits, BCBSTX will make any payment directly to the Provider, Payment to the Provider discharges BCBSTX’s responsibility to Participant for any benefits available under the Plan.

Disclosure Authorization If you file a claim for benefits, it will be necessary that you authorize any Provider, insurance carrier, or other entity to furnish BCBSTX all information and records or copies of records relating to the diagnosis, treatment, or care of any individual included under your coverage. If you file claims for benefits, you and your Dependents will be considered to have waived all requirements forbidding the disclosure of this information and records.

Participant/Provider Relationship The choice of a Provider should be made solely by you or your Dependents. BCBSTX does not furnish services or supplies but only makes payment for Eligible Dental Expenses incurred by Participants. BCBSTX is not liable for any act or omission by any Provider. BCBSTX does not have any responsibility for a Provider's failure or refusal to provide services or supplies to you or your Dependents. Care and treatment received are subject to the rules and regulations of the Provider selected and are available only for treatment acceptable to the Provider.

Refund of Benefit Payments If BCBSTX pays benefits for Eligible Dental Expenses incurred by you or your Dependents and it is found that the payment was more than it should have been, or was made in error, BCBSTX has the right to a refund from the Participant to or for whom such benefits were paid, any other insurance company, or any other organization. If no refund is received, BCBSTX may deduct any refund due to them from any future benefit payment.

Reimbursement When BCBSTX pays benefits under the Plan and it is determined that a negligent third party is liable for the same expenses, BCBSTX has the right to receive reimbursement from the monies payable from the negligent third party equal to the amount BCBSTX has paid for such expenses. The Participant hereby agrees to reimburse BCBSTX from any monies recovered from a negligent third party as a result of a judgment against, settlement with, or otherwise paid by the third party. The Participant agrees to act against the third party, furnish all information, and provide assistance to BCBSTX regarding the action taken, and execute and deliver all documents and information necessary for BCBSTX to enforce our rights of reimbursement.

BCBSTX’s process to recover by subrogation or reimbursement will be conducted in accordance with Texas Civil Practice and Remedies Code Title 6, Chapter 140.

Coordination of Benefits The availability of benefits specified in This Plan is subject to Coordination of Benefits (COB) as described below.

This COB provision applies to This Plan when a Participant has health/dental care coverage under more than one Plan.

If this COB provision applies, the order of benefit determination rules should be looked at first. Those rules determine whether the benefits of This Plan are determined before or after those of another Plan. The benefits of This Plan shall not be reduced when This Plan determines its benefits before another Plan; but may be reduced when another Plan determines its benefits first.

Coordination of Benefits – Definitions Plan means any group insurance or group-type coverage, whether insured or uninsured.

This includes:

• Group or blanket insurance;

• Franchise insurance that terminates upon cessation of employment;

• Group hospital or medical/dental service plans and other group prepayment coverage;

• Any coverage under labor-management trustee arrangements, union welfare arrangements, or employer organization arrangements;

• Governmental plans, or coverage required or provided by law.

This does not include:

• Any coverage held by the Participant for hospitalization, dental and/or medical- surgical expenses which is written as a part of or in conjunction with any automobile casualty insurance policy;

• A policy of health insurance that is individually underwritten and individually issued;

• School accident type coverage; or

• A state plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States

Social Security Act, as amended).

Each contract or other arrangement for coverage is a separate Plan. Also, if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate Plan.

1. This Plan means the part of this Benefit Booklet that provides benefits for health/dental care expenses.

2. Primary Plan/Secondary Plan

3. The order of benefit determination rules state whether This Plan is a Primary Plan or Secondary Plan covering the Participant. A Primary Plan is a Plan whose benefits are determined before those of the other Plan and without considering the other Plan's benefit. A Secondary Plan is a Plan whose benefits are determined after those of a Primary Plan and may be reduced because of the other Plan's benefits.

4. When there are more than two Plans covering the Participant, This Plan may be a Primary Plan as to one or more other Plans and may be a Secondary Plan as to a different Plan or Plans.

5. Allowable Expense means a necessary, reasonable, and customary item of expense for health/dental care when the item of expense is covered at least in part by one or more Plans covering the Participant for whom claim is made.

6. Claim Determination Period means a Plan Year. However, it does not include any part of a year during which a Participant has no coverage under This Plan, or any part of a year before the date this COB provision or a similar provision takes effect.

7. We or Us means BCBSTX.

Order of Benefit Determination Rules General Information

When there is a basis for a claim under This Plan and another Plan, This Plan is a Secondary Plan which has its benefits determined after those of the other Plan, unless (a) the other Plan has rules coordinating its benefits with those of This Plan, and (b) both those rules and This Plan's rules require that This Plan's benefits be determined before those of the other Plan.

Rules

This Plan determines its order of benefits using the first of the following rules which applies:

1. Non-Dependent/Dependent. The benefits of the Plan which covers the Participant as an Employee or retiree, member or subscriber are determined before those of the Plan which covers the Participant as a Dependent.

However, if the Participant is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is:

• Secondary to the Plan covering the Participant as a Dependent; and

• Primary to the Plan covering the Participant as other than a Dependent (e.g., a retired Employee), then the benefits of the Plan covering the Participant as a Dependent are determined before those of the Plan covering that Participant other than as a Dependent.

2. Dependent Child/Parents Not Separated or Divorced. Except as stated in rule 3 below, when This Plan and another Plan cover the same child as a Dependent of different parents:

• The benefits of the Plan of the parent whose birthday falls earlier in a Calendar Year are determined before those of the Plan of the parent whose birthday falls later in that Calendar Year; but

• If both parents have the same birthday, the benefits of the Plan which covered one parent longer are determined before those of the Plan which covered the other parent for a shorter period.

However, if the other Plan does not have the rule described in this rule, but instead has a rule based on gender of the parent, and if, as a result, the Plans do not agree on the order of benefits, the rule in the other Plan will determine the order of benefits.

3. Dependent Child/Parents Separated or Divorced. If two or more Plans cover a Participant as a Dependent child of divorced or separated parents, benefits for the child are determined in this order:

• First, the Plan of the parent with custody of the child;

• Then, the Plan of the spouse of the parent with custody, if applicable;

• Finally, the Plan of the parent not having custody of the child.

However, if the specific terms of a court decree state that one of the parents is responsible for the health/dental care expense of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. The Plan of the other parent shall be the Secondary Plan. This rule does not apply with respect to any Plan Year during which any benefits are actually paid or provided before the entity has that actual knowledge.

4. Joint Custody. If the specific terms of a court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the health/dental care expenses of the child, the Plans covering the child shall follow the order of benefit determination rules outlined in rule 2.

5. Active/Inactive Employee. The benefits of a Plan which covers a Participant as an Employee who is neither laid off nor retired are determined before those of a Plan which covers that Participant as a laid off or retired Employee. The same would hold true if a Participant is a Dependent of a person covered as a retired Employee and an Employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule does not apply.

6. Continuation Coverage. If a Participant whose coverage is provided under a right of continuation pursuant to federal or state law is also covered under another Plan, the following shall be the order of benefit determination:

a. First, the benefits of a Plan covering the Participant as an Employee, member or subscriber (or as that Participant's Dependent);

b. Second, the benefits under the continuation coverage.

7. Longer/Shorter Length of Coverage. If none of the above rules determine the order of benefits, the benefits of the Plan which covered an Employee, member or subscriber longer are determined before those of the Plan which covered that Participant for the shorter period of time.

Effect on the Benefits of This Plan

1. When This Section Applies This section applies when This Plan is the Secondary Plan in accordance with the order of benefits determination outlined above. In that event, the benefits of This Plan may be reduced under this section.

2. Reduction in this Plan's Benefits When this Health Care Plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all Health Care Plans are not more than the total Allowable Expenses. In determining the amount to be paid for any claim, this Plan will calculate the benefits it would have paid in the absence of other health/dental care coverage and apply that calculated amount to any Allowable Expense under its Health Care Plan that is unpaid by the primary plan. This Plan may then reduce its payment by the amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all Health Care Plans for the claim equal 100 percent of the total Allowable Expense for that claim. In addition, this Plan must credit to its Plan Deductible (if applicable) any amounts it would have credited to its Deductible in the absence of other health/dental care coverage.

Right to Receive and Release Needed Information We assume no obligation to discover the existence of another Plan, or the benefits available under the other Plan, if discovered. We have the right to decide what information we need to apply these COB rules. We may get needed information from or release information to any other organization or person without telling, or getting the consent of, any person. Each person claiming benefits under This Plan must give us any information concerning the existence of other Plans, the benefits thereof, and any other information needed to pay the claim.

Facility of Payment A payment made under another Plan may include an amount that should have been paid under This Plan. If it does, we may pay that amount to the organization that made that payment. That amount will then be treated as though it were a benefit paid under This Plan. We will not have to pay that amount again.

Right to Recovery If the amount of the payments We make is more than We should have paid under this COB provision, we may recover the excess from one or more of:

• the persons we have paid or for whom we have paid;

• insurance companies; or

• Hospitals, physicians, or other Providers; or

• any other person or organization.

Termination of Coverage BCBSTX is not required to give you prior notice of termination of coverage. BCBSTX will not always know of the events causing termination until after the events have occurred.

Termination of Individual Coverage Coverage under the Plan for you and/or your Dependents will automatically terminate when:

1. Your contribution for coverage under the Plan is not received timely by BCBSTX; or

2. You no longer satisfy the definition of an Employee or retiree as defined in this Benefit Booklet, including termination of employment; or

3. The Plan is terminated; or

4. A Dependent ceases to be a Dependent as defined in the Plan.

Coverage for a child of any age who is medically certified as Disabled and dependent on you will not terminate upon reaching the limiting age shown in the definition of Dependent if the child continues to be both:

• Disabled; and

• Dependent upon you for support and maintenance as defined by the Internal Revenue Code of the United States.

Disabled means any medically determinable physical or mental condition that prevents the child from engaging in self-sustaining employment. The disability must begin while the child is covered under the Plan and before the child attains the limiting age.

Termination of the Group The coverage of all Participants will terminate if the group is terminated in accordance with the terms of the Plan.

If such an event occurs, you or your Dependents should immediately contact your Employer to determine your rights.

If the occurrence of the event requires coverage to terminate and if there is a right to continue the group coverage, the election to do so must be made within a prescribed time period. You or your Dependents may be required to pay your own premium rates. Any continued coverage will be identical to that of similarly situated members of the group, including any changes (see your Dental Schedule of Coverage). Hence, changes in the group premium rates or benefits will change the premium rates or benefits for any continued coverage.

The continued coverage automatically terminates after a period of time (never to exceed three years) but will be terminated earlier upon the occurrence of certain circumstances. These circumstances include, but are not limited to, nonpayment of premium, entitlement to or coverage under Medicare and coverage under any other group health coverage which does not contain a limitation with respect to a preexisting condition of the Participant (even if such coverage is less valuable than your current health plan). Your Employer will give you more detailed information upon your request.

Section 7 Plan Administration Information Plan Administrator City of Austin, Human Resources Department P.O. Box 1088, Austin, Texas 78767-1088 512-974-3284

Claim Administrator Blue Cross and Blue Shield of Texas 888-907-7880 Website: www.bcbstx.com/coa

Section 8 Dental Plan Document Definitions Allowable Amount The maximum amount determined by BCBSTX to be eligible for consideration of payment for a service, supply or procedure.

• For Providers contracting with BCBSTX.

• The Allowable Amount is based on the terms of the Provider's contract and BCBSTX's methodology in effect on the date of service.

• Out-of-Network Providers with BCBSTX.

• The Allowable Amount is based on the amount BCBSTX would have paid for the same covered service, supply, or procedure if performed or provided by In-Network Provider.

• Unless otherwise stipulated by a contract between the Provider and BCBSTX:

• For services performed in Texas – the Allowable Amount is based upon the applicable methodology for Providers with similar experience and/or skills.

• For services performed outside of Texas – the Allowable Amount will be established by identifying Providers with similar experience or skills in order to establish the applicable amount for the procedure, services, or supplies.

• For multiple surgical procedures performed in the same operative area – the Allowable Amount for all surgical procedures performed on the same patient on the same day will be the amount for the single procedure with the highest Allowable Amount plus an additional Allowable Amount for covered supplies or services.

• When a less expensive professionally acceptable service, supply, or procedure is available The Allowable Amount will be based upon the least expensive services. This is not a determination of Dental Necessity, but merely a contractual benefit allowance.

Claim Administrator BCBSTX, as part of its duties as Claim Administrator, may subcontract portions of its responsibilities.

Contracting Provider A Provider who has entered into a written agreement with BCBSTX to participate as a BlueCare Dental Provider.

See In-Network.

Course of Treatment All treatments performed in the mouth during one or more sessions as the result of the same diagnosis, including any complications arising during such treatment.

Court Order A direction issued by a court or a judge requiring a Participant to do or not do something. A Court Order may also include an administrative order.

Coverage Benefits under the BlueCare Dental PPO Plan.

Deductible The amount of Covered Expenses which the covered person must pay each Calendar Year before benefits are paid according to the Plan for any Covered Expenses incurred during the Calendar Year. The Deductible is $50 per covered person and applies to Basic, Major and Orthodontia Care. The deductible does not apply to Preventive Care. The Deductible is taken from the allowable amounts for the covered procedure/service.

Dental Hygienist A person who is licensed to practice dental hygiene in the state where the service is performed, working within the scope of that license.

Dentally Necessary Those services, supplies, or appliances covered under the Plan which are:

• Essential to, consistent with, and provided for the diagnosis or the direct care and treatment of the dental condition or injury; and

• Provided in accordance with and are consistent with generally accepted standards of dental practice in the United States; and

• Not primarily for the convenience of the Participant or his Provider; and

• The most economical supplies, appliances, or levels of dental service that are appropriate for the safe and effective treatment of the Participant.

BCBSTX shall determine whether a service, supply, or…