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?????A.N." <br />Mayfield Village <br />397379 <br />Cleveland Regional Group Sales Office <br />6480 Rockside Woods Blvd. South, Suite 170 <br />Cleveland, OH, 44131 <br />Phone: (216) 447-1908 ; Toll Free: (800) 222-0447 <br />Fax: (216) 447-1912 <br />DENTAL PLAN DESIGN CHANGE SUMMARY <br />. <br /> <br />_ . _ . ? _ . . . . , ,m .? ?. . .., .,?. ,,,... ?.. ?,.K, . : . ... ... . ......._ : <br />A?terlnatiwiP lan? , <br />? . ,., , ?.., = . ..? ? <br />Current Plan Design Alternative Plan Design <br />Coniract Type DG 2000 Contract Type DG 2000 <br />Plan Type PPO Plan - W 1 Plan Type Split Maximum Plan - Rl <br />Participation 75-100% Participation 75-1000/o <br /> In-Network Out-of-Network In-Network Out-of-Network <br />Reimbursement Based On Fee Schedule R& C- 90th %ile Reimbursement Based On Fee Schedule R& C- 90th %ile <br />Coinsurance Coinsurance <br />Preventive 1005/0 1000/0 Preventive 1000/0 1000/0 <br />Basic 100% 80% Basic 1000/0 80% <br />Major 60% 50% Major 60% 50% <br />Deductible Deductible <br />Amount $25 $25 Amount $50 $50 <br />Waived for Prev. Srvcs? Yes Yes Waived for Prev. Srvcs7 Yes Yes <br />Maximum $1,000 $1,000 Maximum $1,250 $750 <br /> Maidmum Rollover Detail: <br /> Tlueshold: $300 <br /> Rollover amount: $150 <br /> In-network Only Rollover amount: $200 <br /> Maximum Rollover Account Limit: $500 <br /> - If a member submits a claim and does not exceed the $300 paid claims ttueshol <br /> during the benefit year, Guardian will roll over $150 into their Maximum Rollove <br /> Account (MRA) for use in future years. <br /> - If a member uses Guardian Preferred Providers exclusively during the benefit year, th <br /> amount is increased to $200. <br /> - Each employee and dependent maintain separate MRAs based on their own claim <br /> activity. <br /> - Each member's MRA may not exceed the $500 Maximum Rollover Account Limit <br /> - For calendar year accumulation cases with a plan anniversary date in Oct, Nov, o <br /> Dec, the Maximum Rollover feature starts as of the fust full benefit year. <br /> (For example, if a plan renews in November of 2005, claims activity in 2006 will be us <br /> to detertnine rollover amounts for use in 2007.) <br /> - For all other cases, we will use claims ac[ivity from the entire current benefit year to <br /> detecmine rollover amounts for use in the next benefit year. <br />DentalGuazd Options: DenlalGuard Oprions (changes from the cutrent plan design): <br />None None <br />Dependent Age Limits 20/26 Dependent Age Limits 20/26 <br />Current Plan Design Rates Alternative Plan Design Rates <br /> MonUily Monthly <br /> Premium Count Montlil Rate Premium Count Monthl Rate <br />Employee $313.40 10 $3134 Employee $292.00 10 $29.20 <br />Employee + Spouse $927.94 13 „ ., , $71.38 <br />? Employee + Spouse $864.50, „ 13 $66.50 <br />Employee + Child $90.15 <br />$360.60 4 Employee + Child $335.92 4 " $83.98 <br />Family $3,775.80 29 $130.20 Family $3,517.41 29 $121.29 <br />Total $5,377.74 56 Tornl $5,009.83 56 <br /> (sss) <br /> Raf,? Ghan 01 ue to aiWesa ;'?? ,Chain`'`e?? <br />/ <br /> <br />Planholder Siguature <br />GP-1-DG2000 <br />I authmiu Guardien to c6ange au wmpany's Dental plen design in the Altemative Plan Design shown above. <br />Authorized Signahue: Title: Date: <br />All plm chmige requan must 6e m$vad in the Guerdim Hama Offia lS days prinrm the effactive dete of tLanga <br />Dete Prep : 19 006