Wayne County Retirees Voluntary Dental Benefit Plan Enrollment Booklet Table of Contents

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2 Wayne County Retirees Voluntary Dental Benefit Plan Enrollment Booklet Table of Contents Announcement Letter Enrollment Instructions... 3 Voluntary Dental Plan Side-by-Side Comparison... 4 Plan Information Delta Dental Plan PPO DENCAP Dental Plan DMO Golden Dental Plan DMO Enrollment Form... 17

3 Warren C. Evans County Executive August 1, 2016 To: All Wayne County Retirees We are pleased to provide you with your 2016 Voluntary Dental Enrollment Booklet which contains important information about three different Voluntary Dental Plans being made available during an Open Enrollment period, now through August 31, 2016 for coverage that will begin on October 1, This booklet contains information about the benefits and costs for the new plans being offered through: DELTA DENTAL PPO DENCAP DENTAL DMO* GOLDEN DENTAL DMO* This is your opportunity to enroll you and your eligible dependents in a new Voluntary Dental Plan. You will find specific benefit and provider information for each of the dental plans in this booklet starting on page 4. If you decide to enroll in one of these voluntary dental plans, you will be responsible for the full cost of the plan, payable through a deduction from your pension check. Premium payment deductions will begin with your pension check to be issued on October 1, 2016, and will be applied as the premium payment for the month of October If you do not receive a pension check through the Wayne County Employees Retirement System (WCERS), please contact TMR & Associates, Inc. at the number listed below to make alternative arrangements for payment. Please note that the Delta Dental PPO plan is not available to retirees who do not receive a pension check through the WCERS. If you are currently enrolled in a voluntary dental plan through Wayne County, YOU MUST STILL MAKE A SELECTION AND RE-ENROLL during this Open Enrollment, regardless of the dental plan in which you are enrolled today. Your current Wayne County dental plan enrollment will be cancelled effective October 1, Since current dental plan premium payments have been set up to pay in arrears (for example, premium deduction for dental benefits for the month of August is taken from the pension check issued on or about September 1 st ), your last premium payment deduction for your current dental plan will occur with the pension check to be issued on or about October 1, Please note, if you elect a new dental plan effective October 1, 2016, you will have two premium payment deductions in your October 1, 2016 pension check one for your current dental plan premium for the month of September and the other for the new dental plan premium for the month of October. If you made your dental plan premium payments on an annual basis via bank draft instead of payroll deduction, contact TMR & Associates for instructions on obtaining reimbursement for any advance premiums you already paid for October 2016 and thereafter. DEPARTMENT OF PERSONNEL / HUMAN RESOURCES BENEFITS & DISABILITY ADMINISTRATION DIVISION 1

4 In order to enroll in a Voluntary Dental Plan, your completed Enrollment Form must be submitted by August 31, Instructions for submitting your form can be found on Page 3 of this booklet. Please take the time to read this booklet before completing the Enrollment Form and then keep it so you can refer to it throughout the year. Should you have questions about the voluntary dental benefits offered you may contact the insurance carrier directly at the numbers listed below to speak with a representative. If you call, be sure to identify yourself as a Wayne County Retiree so that they can provide you with better assistance. Delta Dental PPO (800) Dencap Dental DMO (888) or (313) Golden Dental DMO (800) or (586) If you need additional assistance, please contact our voluntary benefit program agency, TMR & Associates at (313) or (800) Sincerely, Livia A. Calderoni, Director Benefits & Disability Administration Division *DMO A dental maintenance organization (DMO) is a structured type of dental plan. In this type of plan, a set group of dentists provides broad and affordable care at a low monthly premium. If you select a DMO plan, you will need to choose a primary dentist to work with and you must let the plan provider or carrier know if you want to change your dentist. 2

5 ENROLLMENT INSTRUCTIONS This booklet contains information about the three different providers and dental plans they offer starting on page 4. Please review the material and, after making your selection, complete the Voluntary Dental Plan Benefits Enrollment Form found on Page 17. Part I Retiree Information Please be sure to complete all of the required information in this section, including providing your Retiree ID, so that the carrier will be able to issue coverage. Your Retiree ID can be found on your Pension Check or your Direct Deposit Authorization (DDA). Part II Coverage Selection Place an X in the box to indicate the plan and coverage type of your selection. Once you have chosen a Dental Plan, you must select the type of coverage (Single / 2-Person / Family). The monthly premium is displayed in this section. Please note that if you select a DMO Plan (DENCAP or Golden Dental) you must identify the following: DENCAP DMO*: Provider Number This number is located next to the name of the Provider you select Golden Dental DMO*: Facility Number This number is located under the name of the Provider you select. Part III Dependent Information Please be sure to provide the requested information for each dependent to be enrolled in the dental plan. Part IV Authorization This section must be signed and dated by the Retiree. Once you have completed and signed the form, use the attached self-addressed, postage-paid envelope to return this form to TMR & Associates, Inc. Alternatively, you may also fax this information to (313) , or handdeliver this form to TMR & Associates, Inc., at 601 Abbott Street, Detroit, MI THIS ENROLLMENT FORM MUST BE RETURNED BY AUGUST 31, 2016 Rates are valid from October 1, 2016 through December 31, 2017 *DMO - A dental maintenance organization (DMO) is a structured type of dental plan. In this type of plan, a set group of dentists provides broad and affordable care at a low monthly premium. If you select a DMO plan, you will need to choose a primary dentist to work with and you must let the plan provider or carrier know if you want to change your dentist. 3

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7 Delta Dental Will Make You Smile When it comes to pearly whites, everyone wants to save a little green. With a Delta Dental PPO SM plan, you ll get the dental care you need at a price you can afford. Delta Dental PPO (Standard) Dental benefit highlights Delta Dental PPO dentist Plan pays Delta Dental Premier* dentist 1 Nonparticipating dentist 1 Diagnostic and preventive benefits Diagnostic and preventive services Includes exams and cleanings twice per calendar year and space maintainers 100% 80% 80% Emergency palliative treatment to temporarily relieve pain 100% 80% 80% Brush biopsy to detect oral cancer 100% 80% 80% Radiographs bitewing X-rays once per calendar year and full mouth X-rays (which include bitewing X-rays) once per fiveyear period 100% 80% 80% Basic services Minor restorative services fillings and crown repair 50% 50% 50% Endodontic services root canals 50% 50% 50% Periodontic services to treat gum disease 50% 50% 50% Oral surgery services extractions and dental surgery 50% 50% 50% Major restorative services crowns 50% 50% 50% Other basic services miscellaneous services 50% 50% 50% Relines and repairs to bridges, implants and dentures 50% 50% 50% Major services Prosthodontic services bridges, implants and dentures once per tooth per five-year period 50% 50% 50% 1 When services are received from a Delta Dental Premier or Nonparticipating dentist, the percentages shown above indicate the portion of Delta Dental s PPO Fee Schedule (or the Nonparticipating Dentist Fee) that will be paid for those services. This amount may be less than what the dentist charges or Delta Dental approves, and you will be responsible for paying the difference. Maximum payment $1,000 per person total per calendar year on diagnostic and preventive, basic and major services Deductible $25 deductible per person per calendar year limited to a maximum deductible of $75 per family per calendar year on all services except diagnostic and preventive services, emergency palliative treatment, brush biopsy and X-rays. Waiting periods Major restorative and prosthodontic services will not be covered until after a person is enrolled in the dental plan for 12 consecutive months. Minor restorative, endodontic, periodontic, and other basic services; oral surgery; and relines and repairs will not be covered until after a person is enrolled in the dental plan for six consecutive months. Waiting periods may be waived for all services if the member was covered for at least 12 months under the immediately preceding dental plan. Most dentists participate with at least one Delta Dental network. To see if your current dentist is part of the Delta Dental PPO network, visit OVER 5

8 Delta Dental PPO dentists help you save. When dentists agree to become part of Delta Dental s PPO network, they agree to accept established fees for services. These fees are less than what the dentist would normally charge, so you know you ll be saving money before you even sit down in the dentist s chair. Our PPO dentists have also agreed not to balance bill you for the difference between the agreed-upon fee and their usual fee. The dentist deals with claim payments and forms. When you use a Delta Dental network dentist, claim payments are sent directly to that dentist after they submit your claim for you. If you visit a dentist who isn t in Delta Dental s network, you may have to file your own claims and claim payments may be sent directly to you. Out-of-network dentists may require you to pay the full cost of your care right at the office and wait to be reimbursed. Our PPO network is one of the largest in the nation. With more than 107,200 dentists participating in more than 293,000 locations nationwide, the Delta Dental PPO network is one of largest in the U.S. 2 This not only gives you a great selection of dentists to choose from; there s a good chance your current dentist already participates in Delta Dental s PPO network. 2 Delta Dental Plans Association, March Example savings for a common procedure Estimated charge Maximum allowed fees Delta Dental PPO fee Percentage paid by Delta Dental Amount Delta Dental pays Amount dentist can balance bill Total amount you pay Your total cost savings Delta Dental PPO dentists Delta Dental Premier dentists Nonparticipating dentists $ 1,200 $ 850 $850 50% $ 425 $ 0 $ 425 $ 350 $ 1,200 $ 975 $850 50% $ 425 $ 125 $ 550 $ 225 $ 1,200 $ 1,100 $850 50% $ 425 $ 100 $ 775 $ 0 Delta Dental PPO dentists Delta Dental Premier dentists Nonparticipating dentists Delta Dental PPO dentists have agreed to charge $850 for the $1,200 service, a savings of $350. Your Delta Dental plan covers 50 percent of the cost. Assuming you ve already met your deductible for the year, Delta Dental will pay $425 and you ll pay $425. Delta Dental Premier dentists have agreed to charge $975 a savings of $225 compared to the fee the dentist usually charges. If you ve met your deductible, Delta Dental will cover 50 percent of the $850 PPO fee, paying $425. The dentist can bill you the difference between the PPO fee and the maximum allowed fee, making your bill $550. That s an extra $125 you will owe when compared to what you would have paid with a Delta Dental PPO dentist. Nonparticipating dentists have not agreed to charge lower fees and can bill the full $1,200. Delta Dental will pay based on the $850 PPO fee, which means Delta Dental s share of the tab is $425. The dentist can bill you the difference between Delta Dental s payment and what they charge. This leaves you with a bill of $775, which includes the $350 the nonparticipating dentist can balance bill. NOTE: Payment examples above are illustrative only. Fees and reimbursements can vary by location and dentist. They do however represent how payment is determined. FLI-6346 v1 PA 5/16 6

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13 Wayne County Retirees Save! Money Highest Coverage Levels! Serving Michigan families since

14 Why spend more when you don t have to? Highest benefits available Lowest out-of-pocket cost for your family Quality care in neighborhood offices Extensive provider network 100% coverage on preventive care Choose Golden Plans to secure the highest dental benefits available 100% Cleaning 100% On X-Rays 100% Fillings 100% Fluoride Applications 100% Exams No Waiting Periods! No Costly Deductibles! Affordable Premiums! Lab Fees Included in Coverage! No Plan Offers More! How do I join? Step One Complete the enclosed Dental Health Care Enrollment Form. Step Two Include the provider/facility number of the primary care dentist you have selected. (See Primary Care Provider Directory) Step Three Complete the enclosed Wayne County Dental Plan Pension Deduction Authorization Form. Step Four Return completed Dental Health Care Enrollment/ Wayne County Dental Plan Pension Deduction Authorization Form in the self addressed, postage paid envelope to TMR & Associates, Inc. 601 Abbott Street, Detroit, MI How soon will my benefits take effect? Applications received prior to the 15th of the month will become eligible the 1st of the following month. Can I have the monthly premium deducted from my Wayne County pension account? Yes you may, by completeing the premium deduction authorization section of the enclosed Wayne County Dental Plan Pension Deduction Authorization Form the dental premium cost shall be deducted from your monthly retirement check. How do I choose a dentist? A member can choose from the attached Primary care Provider Directory or visit and click on the Find a Dentist Tool. Enter your zip code to find a provider in your area. Who can I contact if I have questions about Golden Dental Plans? A Golden Dental Plans representative is always available Monday-Friday from 9 am 5 pm at , or us at questions@goldendentalplans.com Annual Maximum $3, Per Family Member 100% coverage on restorative needs 80% coverage on prosthetic care 70% coverage on specialty care Save $3,000 on orthodontics NO OTHER PLAN COMPARES! 12

15 Golden Dental Plans Never pay full price for dental care again Schedule of Benefits CLASS I Preventative and Diagnostic Exams*...100% X-rays Periapical, Bitewings*, (FMX or Panoramic**)...100% Prophylaxis*...100% Fluoride* (Up to age 19)...100% Sealants (1st and 2nd Molars only - once in lifetime up to age 14)...100% Space Maintainers (Primary Teeth only up to age 14)...100% CLASS II Basic Restorative Fillings...100% Extractions or Root Canal (Performed by General Dentist)...100% CLASS III Prosthetic Single Crowns***...80% Bridges...80% Partial or Complete Dentures...80% CLASS IV Specialty Care**** Endodontics...70% Periodontics...70% Oral Surgery...70% Pedodontics...70% CLASS V Orthodontics Ortho Lifetime Maximum Child (Up to age 19)...$3,000 Retiree (Member and Spouse)...$3,000 Cosmetic Dentistry Zoom Bleaching ($700 Value)...$ Veneers and Implants...25% Discount Dental Hygiene Supplies...10% Discount Contact GDP for participating providers Annual Maximum...$3, Per Family Member Monthly Premium Single $24.00 per month Monthly Premium Family of Two $39.00 per month Monthly Premium Family of Three to Five $58.00 per month *Every 6 months at General Dental Provider **Full mouth series of X-rays are only a covered benefit once every 36 months. ***Crowns are covered in a period of once every 5 years. ****All Specialty appointments must accompany a primary care dentist referral. 13

16 Primary Care Provider Directory CITY FACILITY NO. OFFICE NAME ADDRESS ADDRESS 2 ZIP CODE PHONE NUMBER Allen Park 514 Great Expressions 6760 Allen Rd. Suite (313) Ann Arbor 513 Great Expressions 2360 E. Stadium Blvd. Suite (734) Belleville 3834 Accurate Dental Dentures 781 Sumpter Rd (734) Brighton 915 Great Expressions 7743 Grand River Ave. Suite (810) Burton 3854 Hamilton Community Health Network, Inc. G-3375 S. Saginaw St (810) Canton Clinton Twp. 517 Great Expressions 5958 Canton Center Rd. Suite (734) Midwestern Dental Ctr Ford Rd (734) Great Expressions Moravian Dr (586) Great Expressions Canal Rd. Suite (586) Commerce Twp Anchor Family Dentistry, PLC Union Lake Rd. Suite (248) Dearborn 2498 Raffic Mackie, DDS 7911 Wyoming St (313) Dearborn Dental Group 6950 Schaefer Road Suite A (313) Great Expressions 2021 Monroe St. Suite (313) Dearborn Dental 1308 Monroe St (313) Care Dental, PLLC 5237 Oakman Blvd (313) Great Expressions Michigan Ave (313) Midwestern Dental Ctr Schafer Hwy. 2nd Floor (313) Great Expressions Ford Rd (313) Modern American Dental Clinic W. Warren Ave (313) Dearborn Heights 3812 River Oaks Dental* Ann Arbor Trail (313) Detroit 557 Warren Bedford Dental 5024 Bedford St (313) Great Expressions Morang Dr (313) King Dental Center East Warren Ave (313) Lucas-Perry Dental Group PLLC 4727 St. Antoine St. Suite (313) Shadows O. Bedell, DDS Plymouth Rd (313) Shadows O. Bedell, DDS 9200 Greenfield Rd (313) Shadows O. Bedell, DDS Van Dyke Ave (313) Dedicated Dental Services 645 Griswold St. Suite (313) Great Expressions(Midtown) 3670 Woodward Ave. Suite 101B (313) East Lansing 3718 Blanche Martin, DDS 6020 Hagadorn Rd (517) Eastpointe 532 Great Expressions E. Ten Mile Rd (586) Farmington 3173 Jacquelyn Chu, DDS W. 12 Mile Rd. Suite (248) Dental Spot Northwesten Hwy (248) Midwestern Dental Ctr Grand River Ave (248) Great Expressions Orchard Lake Rd. Suite (248) Art Dental Center Orchard Lake Bldg. C (248) Ferndale 3742 Great Expressions 8890 W. Eight Mile Rd (248) Flint Garden City 3739 Great Expressions G-3368 S. Linden Rd (810) Great Expressions 2483 S. Linden Rd. Suite (810) Hamilton Community Health Network, Inc N. Saginaw St (810) Hamilton Community Health Network, Inc N Saginaw St (810) Great Expressions Cherry Hill Road Suite B (734) T.L.C. Dentistry Ford Rd (734) Grand Blanc 535 Great Expressions 8185 Holly Rd. Suite (810) Grosse Pte. 530 Great Expressions Mack Ave (313) General Provider Directory, continued on reverse side. 14

17 Primary Care Provider Directory CITY FACILITY NO. OFFICE NAME ADDRESS ADDRESS 2 ZIP CODE PHONE NUMBER Harper Woods 4078 Northeast Dental Group - DBA Eastland Dental Vernier Rd (313) Hazel Park 2563 Sunlite Dental John R. Rd (248) Huntington Woods 3837 Feels Best Dentistry Woodward Ave. Suite (248) Lansing Lathrup Village 552 Midwestern Dental Ctr Martin L. King Blvd (517) Great Expressions 6035 Executive Dr. Suite (517) Great Expressions Southfield Rd (248) Southfield Cosmetic & Dental Ctr Southfield Rd. Suite (248) Lincoln Park 3743 Great Expressions 3257 Fort St (313) Livonia 537 Great Expressions 9134 Middlebelt Rd (734) Awesome Dental Care Five Mile Rd (734) Great Expressions Ann Arbor Rd. Suite (734) Madison Heights 3523 Great Expressions 1269 W. 13 Mile Rd (248) Milford 3891 The New Global Dentistry, PLC 1201 N. Milford Rd. Suite (248) Monroe 539 Great Expressions 530 South Monroe St (734) Northville 4083 DentalWorks Traditions Drive (248) Novi 2617 DentalWorks Novi Rd (248) Great Expressions W. 10 Mile Rd. Suite (248) Oak Park 923 Great Expressions W. 10 Mile Rd (248) Okemos 3486 Great Expressions 1869 West Grand River Ave (517) Oregon 4089 DentalWorks 3555 Navarre Ave (419) Oxford 3898 Great Expressions 129 S. Washington (248) Pontiac Rochester Roseville 1125 Great Expressions 1620 N. Perry St. Suite (248) Great Expressions 667 N. Martin Luther King Blvd (248) DentalWorks 3070 S. Rochester Rd (248) Great Expressions 1428 N. Rochester Rd (248) DentalWorks Gratiot Ave (586) Great Expressions Gratiot Ave (586) Royal Oak 2797 Antonio S. Abate, DDS 1228 Catalpa Dr (248) Shelby Twp. 542 Great Expressions Mile Rd (586) Southfield 515 Great Expressions Telegraph Rd (248) Freemans Family Dentistry Greenfield Rd Suite (313) James A. Watson, DDS Mile Road Suite (248) Southgate 1081 Great Expressions Trenton Rd (734) St. Clair Shores 3731 James Skoney, DDS Harper Ave (586) DentalWorks Lakeside Circle (586) Sterling Heights 4081 Happy Smile Family Dental Dequindre Road (586) Great Expressions 2041 Fifteen Mile Rd (586) Midwestern Dental Ctr Van Dyke Ave (586) Taylor 588 Dupuis Dental Goddard Rd (734) Toledo 3721 Great Expressions 1555 S. Byrne Rd (419) DentalWorks 3408 W. Cental Ave (419) Great Expressions 5950 Airport Hwy. Suite (419) Trenton 3830 Alpha Dental Center Allen Rd (734) Troy 2694 DentalWorks 300 W. 14 Mile Rd (248) Great Expressions 6535 Rochester Rd (248) General Provider Directory, continued on reverse side. 15

18 Primary Care Provider Directory CITY Walled Lake FACILITY NO. OFFICE NAME ADDRESS ADDRESS 2 ZIP CODE PHONE NUMBER 1121 Great Expressions 1080 E. West Maple Rd (248) Midwestern Dental Ctr Nine Mile Rd (586) Universal Dental Ctr Dequindre Rd. 545 Great Expressions E. 12 Mile Rd Creative Dental Center Waterford 546 Wayne 547 Westland West Bloomfield 2226 DentalWorks W. Warren 1127 Great Expressions 6161 Orchard Lake Rd Great Expressions Midwestern Dental Ctr. Kathleen Hurst-Chmielewski, DDS Warren Woodhaven Yale (586) (586) Hoover Rd (586) Great Expressions 4216 Pontiac Lake Rd (248) Great Expressions Michigan Ave (734) Suite 303B (734) (248) Allen Rd (734) Allen Rd Brockway Rd (734) (810) Suite 201 Find a dentist To find a dentist near you go to GDP s Find A Dentist Tool at Enter in your zip code and a maximum distance to find a dentist in your area. Zip Code: Distance: Attention Snowbirds: for a list of providers in Florida and Georgia contact a Golden Dental Plans Representative at toll-free phone fax Hoover Road, Warren, MI

19 Wayne County Retirees VOLUNTARY DENTAL PLAN BENEFITS ENROLLMENT FORM Part I. RETIREE INFORMATION: Please Print Last Name First Name M.I. Retiree ID Number (Located on Pension Check or DDA) Street Address Apt. No. Date of Birth (mm/dd/yyyy) Sex City State Zip Code Marital Status / / Area Code & Telephone Number Address Single Married Divorced Widowed ( ) Part II. COVERAGE SELECTION: Place an "X" in ONE box to indicate the plan and coverage type for your dental selection. Dental Plan Option Provider or Facility No.* One Person Two Person Family Delta Dental Plan PPO N/A $31.86 / mo $63.75 / mo $ / mo DENCAP Dental Plan DMO $22.00 / mo $40.00 / mo $60.00 / mo Golden Dental Plan DMO $24.00 / mo $39.00 / mo $58.00 / mo *Note: If you select DENCAP Dental or Golden Dental you must choose a primary dental office. Please indicate the dental provider DMO Provider Number for DENCAP (beginning on page 8) or the DMO Facility Number for Golden Dental (beginning on page 14) in the space provided next to the plan name. Part III. DEPENDENT INFORMATION: Provide requested information for each dependent to be enrolled in the selected dental plan. Rel. to Retiree Dependent Last Name First Name M.I. Date of Birth (mm/dd/yyyy) Sex Last 4 Digits of Soc. Sec. No. Spouse / / Child / / Child / / Child / / Part IV. Authorization: I have elected to enroll myself and my eligible dependents in the above Voluntary Dental Plan. I understand that this dental plan is NOT sponsored by Wayne County and I understand that Wayne County will not contribute to the costs of the plan I have selected. Accordingly, I understand and agree that I am solely responsible for all costs and expenses associated with the plans. I hereby authorize the Wayne County Employees Retirement System or its paying agent to deduct or recover the cost of the above selected voluntary dental plan from my monthly retirement pension check. Check here if you DO NOT receive a pension check from the Wayne County Employees Retirement System but wish to enroll in either the DENCAP or Golden Dental plan. Note: the Delta Dental PPO plan is not available to retirees who do not receive a pension check through the Wayne County Employees Retirement System. A representative from TMR & Associates will contact you with Direct Payment options. Retiree Signature Date: Return this enrollment form no later than August 31, 2016 in the self-addressed envelope provided and mail to: (313) or (800) Form # WCRVDT2016

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