HomeMy WebLinkAbout42-93 RESOLUTION1
RESOLUTION NO. 4 9 - 9 3
A RESOLUTION AUTHORIZING THE APPOINTMENT OF
BLUE CROSS AND BLUE SHIELD OF ARKANSAS AND ITS
SUBSIDIARY U.S ABLE LIFE AS THE GROUP INSURANCE
PROVIDER FOR CITY EMPLOYEE'S HEALTH, DENTAL,
LIFE, ACCIDENTAL DEATH AND DISMEMBERMENT AND
LONG TERM DISABILITY PLANS.
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF
FAYETTEVILLE, ARKANSAS.
Section L. That the City Council hereby appomts Blue Cross and Blue Shield of
Arkansas and its subsidiary U.S. Able Life as the group insurance provider for City employee's
health, dental, life, accidental death and dismemberment and long term disability plans
,Section 2. That the term of this msurance contract is for one year commencmg May
1, 1993 with options for four one year annual renewals upon agreement by the City and Blue
Cross/Blue Shield.
Section 3. That the Mayor is authorized to execute the attendant msurance contracts
consisting of a group medical and dental retention and liability agreement, life and long term
disability renewal notification forms, a copy of each which are attached hereto marked Exhibit
"A" and made a part hereof.
PASSED AND APPROVED this AL day of April , 1993.
ATTEST:
BY:
APPROVED:
BY:
4,40/44
Sherry
Thomas, City Clerk
Fred Hanna, Mayor
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AMENDMENT NO. 1 TO BE ATTACHED AND MADE A PART OF GROUP POLICY NO 2467-001
Issued
City of Fayetteville
to -
(Policyholder)
The group policy is hereby amended as follows:
The "Eligibility" provision on Page 10 is deleted in its
entirety and the following shall apply:
Persons eligible to be covered under this policy are those
who qualify for the class (es) described in the Policy
Application.
No person may be insured as both an employee (or member) and
as a dependent at the same time. If a family plan is
elected, only one person in the family may be insured as an
employee (or member).
This includes anyone who may become eligible while the
policy is in force.
Employees who work on a full-time basis for the Employer are
eligible for insurance after completion of the required
waiting period, provided they are in a class of Employees
who are included. Employees will be considered to work on a
full-time basis if they customarily work at least 40 hours
per week.
The effective date of this amendment is May 1, 1993
Nothing contained herein shall be held to alter or affect any of the terms and conditions of said policy other
than as herein stated.
Dated at Little Rock, Arkansas, this day of 19 73
City of Fayetteville
(Policyholder)
C-719411.a4Peresidertit
(Signature)
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P-23 (10-88)
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AMENDMENT NO 2 TO BE ATTACHED AND MADE A PART OF GROUP POLICY NO 2467-001
City of Fayetteville
Issued to•
The group policy
The maximum amount
refers to number
application under
Item # 5 on the
and employee is
first $25,000 of
The effective date of this amendment
Nothing contained herein shall
than as herein stated.
Dated at Little Rock, Arkansas,
City of Fayetteville
(Policyholder)
is hereby amended as follows:
of coverage is changed to $100,000. This
3 shown on the attachment to the
"Applicable Principal Sum".
application, premiums are paid by employer
changed as follows: Employer pays for the
employee only coverage.
is April 1, 1993
be held to alter or affect any of the terms and conditions of said policy other
this 616 day of OlaM 191U____
(Policyholder)
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C.79 President
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P-23 9141)
U$MLe Life $
PM. Box 4650
Little Rock, ARI72203
(501) 375-7200
Policyholder:
RENEWAL NOTIFICATION FORM
CITY OF FAYETTEVILLE
Description of Classes:
ALL FULL TIME EMPLOYEES
Remarks:
Current Premium Rates
Renewal Premium Rates:
LIFE
2 X ANNUAL
SALARY
MAXIMUM
$150,000
.28
.28
AD&D
2 X ANNUAL
SALARY
MAXIMUM
$150,000
.07
.07
Renewal Date 05/01/93
Marketing Representative KUEHN
Group #: 2467
Date Typed: 3/3/93
STD DEP LIFE
CERTIFICATION OF ENROLLMENT AND ELIGIBILITY
We have reviewed the enrollment in the above group plan and our employee records. We certify that:
1. The employer contribution is Life & AD&D - % STD -
IMPORTANT NOTE If Employer Contribution is 100%, all digible employees must be enrolled. If employees are
required to pay any part of the premium, employees enrolling more than 31 days after completing their waiting period
will be required to furnish Evidence of Insurability.
2. There are
pasons eligible to participate in the plan and are enrolled.
3. All persons enrolled in the plan are:
(a) members of an eligible dass of employees;
(b) are actively at work at least hours per week, are actively working at their normal place of
employment, working in our regular business and are not in a hospital, nursing home, convalescent
facility, or are not convalescing from illness or injury at home and
(c) are directly compensated by us for their services.
EXCEPTIONS: For any person enrolled not meeting the above requirement, the following information is provided:
NAME DATE LAST WORKED REASON FOR EXCEPTION
Marketing Representative
UND-001 (2-91)
1444,s40
Group 7ministrator
5/-6-73
Date
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GLP-ABR (9-92)
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Benefits Rider
Policy No.: LA2467
CITY OF FAYETTEVILLE
Date of This Rider: 05/01/93
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Group Life Accelerated
This rider is made part of Group
Policyholder:
Effective
This page and the pages that follow are part of this rider.
NOTICE OF POSSIBLE TAX CONSEQUENCES
Please be advised that receipt of the accelerated benefits described in this Rider may be
taxable. Any person who receives accelerated benefits should consult his personal tax
advisor.
DEFINITIONS
INSURED PERSON means an insured employee or an insured dependent. Each will be insured
for the benefits of this rider only if he becomes and remains insured for life insurance benefits
under the group policy.
TERMINAL ILLNESS means a medical condition:
1. which is expected to result in the insured person's death within 6 months; and
2. from which the insured person is not expected to recover.
WAITING PERIOD means a period of 180 consecutive days which begins on the date a person's
insurance takes effect under this rider.
ELIGIBLE CLASSES
1. All employees under age 70 who are insured for a minimum of $10,000 of life insurance
under the group policy.
2. All dependents of the person described in 1 above, if they are insured for a minimum of
$10,000 of life insurance under the group policy and are under age 70.
DATE PERSONS ARE ELIGIBLE FOR INSURANCE UNDER THIS RIDER
A person will be eligible for such insurance on the later of: .
1. the date he is eligible for life insurance under the group policy, or
2. the effective date of the group policy rider.
GLP-ABR (9-92)
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GLP-ABR (9-92)
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Group Life Accelerated
This rider is made part of Group
Policyholder:
Effective
This page and the pages that follow are
NOTICE OF POSSIBLE TAX CONSEQUENCES
Please be advised that receipt of the
taxable. Any person who receives
advisor.
DEFINITIONS
INSURED PERSON means an insured
for the benefits of this rider only if he
under the group policy.
TERMINAL ILLNESS means a medical
1. which is expected to result in the insured
2. from which the insured person is not
WAITING PERIOD means a period of
insurance takes effect under this rider.
ELIGIBLE CLASSES
1. All employees under age 70 who
under the group policy.
2. All dependents of the person described
$10,000 of life insurance under the
DATE PERSONS ARE ELIGIBLE FOR
A person will be eligible for such insurance
1. the date he is eligible for life insurance
2. the effective date of the group policy
Benefits Rider
Policy No.: LA2467
CITY OF FA ILLE
Date of This Rider: 05/01/93
part of this rider.
accelerated benefits described in this Rider may be
accelerated benefits should consult his personal tax
employee or an insured dependent. Each will be insured
becomes and remains insured for life insurance benefits
condition:
person's death within 6 months; and
expected to recover.
180 consecutive days which begins on the date a person's
are insured for a minimum of $10,000 of life insurance
in 1 above, if they are insured for a minimum of
group policy and are under age 70.
INSURANCE UNDER THIS RIDER
on the later of:
under the group policy, or
rider.
GLP-ABR (9-92)
Group Life Accelerated Benefits Rider (continued)
NON -CONFINEMENT REQUIREMENT
An employee or his dependent might be confined for medical treatment in an institution or at home on
the date his insurance is to take effect under this rider. If so, his insurance will take effect on the day
following his final medical discharge from such confinement.
THE ACCELERATED BENEFIT
The accelerated benefit is an advance payment to the person who:
1. is terminally ill, and
2. elects to receive part of his insurance amount under the group policy, subject to the maximum and
minimum benefit requirements stated below.
We will pay an accelerated benefit to the insured employee when we receive the following after the
waiting period:
I. a written request for payment of the accelerated benefit, and
2. due proof that the insured person is terminally ill.
The accelerated benefit will be paid once and in one lump sum to the insured employee.
Cast of Providing The Accelerated Benefit
The accelerated benefit amount as determined below will be discounted to reflect the cost of providing
the benefit. We will calculate the discount on the date we receive the request for payment of the
accelerated benefit. The discount will be based on the coupon rate of the current 10 year U S Treasury
Note.
A claims atiministrative fee of 5150 will be deducted from the amount of the Accelerated Benefit paid.
Amount of Accelerated Benefit
The maximum accelerated benefit will be equal to the lesser of:
1. 30% of the insured person's life insurance amount as shown in the Schedule of Benefits of his
certificate, less the discount and the claims administrative fee; or
2. $50,000 less the discount and the claims administrative fee.
An insured employee's life insurance amount may be scheduled for a reduction within 6 months after the
date he requests the payment of the accelerated benefit. In this case, the maximum accelerated benefit
will be limited to the lesser of:
1. 30% of the life insurance amount which will be in effect after the scheduled reduction, less the
discount and the claims administrative fee; or
2. $50,000 less the discount and the claims administrative fee.
The minimum accelerated benefit for the insured employee or the insured dependent will be 53.000 less
the discount and the claims administrative fee
Written Request for Payment of the Accelerated Benefit
After the waiting period, the insured employee may request payment of an accelerated benefit in writing.
If the insured person is not the owner of the certificate, the owner must request payment of the
accelerated benefit in writing. ff the insured person is a minor or incompetent, his guardian must request
payment of the accelerated benefit in writing.
GLRABR (9-92)
Group Life Accelerated Benefits Rider (continued)
P 11
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Proof of Terminal Illness
Proof that an insured person is terminally ill must be given to us. The proof must be certified by a
licensed physician and in a form that is satisfactory to us. We are not obligated to ask for any proof.
Any delay in submitting proof will not cause a request to be denied so long as the proof is given to us
as soon as reasonably possible.
After receipt of such proof, we may require the insured person to be examined by a licensed physician
of our choice, at our expense. If there is a disagreement between the two physicians, we may require
the insured person to be examined by another licensed physician of our choice, at our expense. The
decision of the third physician will be final.
EFFECT OF PAYMENT OF AN ACCELERATED BENEFIT ON GROUP POLICY PROVISIONS
The insured person's amount of life insurance under the group policy will be reduced by the amount of
an accelerated benefit paid to him, plus the discount. As a result, the following will be based on such
reduced life insurance amount:
1. the amount of life insurance payable to the beneficiary when the insured person dies;
2. the amount of life insurance the insured person can convert under the group policy; and
3. the premiums payable for the insured person's life insurance under the group policy after an
accelerated benefit is paid to the insured employee, if such premiums are not waived.
The payment of an accelerated benefit will not affect the amount of the insured person's Accidental Death
and Dismemberment Benefits under the group policy, if any.
EXCLUSIONS
We will not pay an accelerated benefit if:
1. the insured person has made an absolute assignment of his life insurance under the group policy;
2. all or part of the insured person's life insurance under the group is to be paid to his child(ren) or
former spouse as part of a court approved divorce agreement;
3. we do not receive written consent by any irrevocable beneficiary; or
4. the terminal illness is a result of intentional self-inflicted injury or attempted suicide.
DATE THIS RIDER ENDS FOR AN INSURED PERSON
With respect to an insured person this rider will end at the earliest of:
1. the date the accelerated benefit is paid to him or on his behalf;
2. the date his life insurance ends under the group policy; or
3. the policy anniversary on which he is age 70.
This rider is subject to all provisions of the group policy which are not inconsistent with the terms of this
rider.
Signed at our Home office on the effective date.
Poticy older
40,1447.,
Signature President
USAble Life
•ef JAMES B. B HOUSE
GLP-ABR (9-92) 3
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USAble Life
little Roth, Manses
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AMENDMENT NO 5 TO BE ATI'ACHED AND MADE A PART OF GROUP POLICY NO 2467
City of Fayetteville
(Policyholder)
Issued to.
The group policy is hereby amended as follows:
Paragraph No. 1 under the "Employee Eligibility" provision
on Page 5 is deleted in its entirety and the following shall
apply:
Employees who work on a full-time basis for the Employer are
eligible for insurance after completion of the the required
waiting period, provided they are in a class of Employees
who are included. Employees will be considered to work on a
full-time basis if they customarily work at least 40 hours
per week.
The effective date of this amendment is
May 1, 1992
Nothing contained herein shall be held to alter or affect any of the terms and conditions of said policy -other
than as herein stated.
Dated at Little Rock, Arkansas, this LA day of
CiliT a TaYetteville
- , -(Pthicyholder)
(Signature)
gre
(:4;
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ALS—
President
P-23 (10-88)
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USAble Life
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LONG TERM DISABILITY RENEWAL NOTIFICATION
Company Name:
Group Number:
Representative:
Renewal Date:
Date Typed:
Amount of Benefit:
Benefit Period:
CITY OF FAYETTEVILLE
2467-100
FRANCIS KUEHN
05/01/93
3/3/93
60X OF MONTHLY SALARY NOT TO EXCEED $6,000
TO AGE 65 WITH RBD
Present Rate per $100 of Covered Payroll: $.56
*****************************************
Renewal Rate Per $100 of Covered Payroll: $.46
Number of LTD Employees Currently Insured: 371
Monthly Covered Payroll: $700.424
*****************************************
PLEASE COMPLETE THE FOLLOWING
Percentage of Company Contribution:
Number of Eligible Employees:
Remarks:
Group Administrator: 1\
USAble Life Representative!
*****************************************************************
MARKETING REPRESENTATIVE REASSIGNMENT
From! To:
Regional Manager
Dir. of Mkt. USAble Date
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AMENDMENT NO. TO BE ATTACHED AND MADE A PART OF GROUP POLICY NO.2467..-100
Issued to:
Clty of Fa ettevi.1 1 a
(Policyholder)
The group policy is hereby amended as follows:
It is agreed that the folllowing changes are hereby made to
Form No. GLTD P(5-89):
Item #6 of the application (Eligible Classes) is changed as
follows: All regular full time employee's working a minimum of
40 regularly scheduled hours per week.
The effective date of this amendment is May 1 1.991
Nothing contained herein shall be held to alter or affect any of the terms and conditions of said policy other
than as herein stated.
Dated at Little Rock, Arkansas, this kA_day of
19 IF 3
('it f tr
(Policyholder)
/4/(AVIii
(Signature)
President
P-23 (10-88)
I4PI
ARICA/13AS BLUE CROSS AND BLUE SF=
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2• A MUTUAL INSURANCE CCM4PANY
Retention Agreement for
CITY OF FAYETTEVILLE AND FAYETTEVILLE PUBLIC LIBRARY
Group Numbers 090041 and 090042
This Retention Agreement applies to the above group.
The Agreement is a retrospective refund calculation, and will be determined using earned
premiums and incurred claims of Blue Cross, Blue Shield, and Extended Benefits coverage. The
effective date of the Agreement is to be May 1, 1993. Each policy year constitutes a period
for accountability of premiums and incurred claims, and hereafter will be referred to as a
refund period. The refund will be calculated one hundred and eighty (180) days after the end
of each policy year.
The composition of the formula used to determine the refund amount and the definition of
each item contained in the formula are as follows:
ELIGIBILITYFOR COVERAGE UNDER THE GROUP: In addition to any other eligibility
requirements, group members must work at least 40 hours per week in order to be eligible for
coverage under the above named groups.
EARNED PREMIUM: Blue Cross, Blue Shield, and Extended Benefits income for the
refund period.
RETENTION: The amount retained by Arkansas Blue Cross and Blue Shield for claims
administration expense, general administration expenses, general contingency, insurance risk,
and large claim pool. The retention used in establishing the refund amount is 17.1% of
earned premium.
CLAMSCOST: Claims cost is the amount of earned premium required to pay policy
benefits for claims incurred during the refund period. Provided, however, that large claim
ad3ustments shall be based on those amounts actually paid per covered person during the term
of the Agreement, whether those paid amounts were incurred before or during the term of the
agreement. See Paragraph LARGE CLAIM ADJUSTMENT.
LAME CLAIM ADJUSTMENT: The Large Claim Pool base agreed to by the Carrier and
the Group is $ 50,000.00 per covered person per policy year. At the time of settlement, only
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the $ 50,060.00 per covered person per policy year will be applied toward the determination
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of the Retkospective Refund and Stabilization Reserve Fund.
RATE STABILIZATION RESERVE: The amount of earned premium maintained in reserve
for the Group by Arkansas Blue Cross and Blue Shield to offset unusual fluctuations in
claims. This will be 13.4% of earned premium for the policy year beginning May 1, 1993.
Once the reserve is established, it will be credited with interest earned during subsequent
periods. If an underwriting loss is incurred during the refund period, it will be charged
against the rate stabilization funds. Negative balances in the rate stabilization fund will
be carried forward to the next refund period.
REFUND: The retrospective refund shall be earned premium less retention, minus
claims cost less large claim adjustment, minus the adjustment to the stabilization fund. The
formula is illustrated as follows:
(EARNED PREMIUM - RETENTION) - (CLAIMS COST - LARGE CLAIN ADJUSTMENT) - ADJUSTMENT TO STABILIZATION FUND =
REFUND.
The refund shall be paid to City of Fayetteville and Fayetteville Public Library.
TERMINATION: In the event the Group terminates Blue Cross and Blue Shield
coverage during the policy year, any refund or rate stabilization reserve due the Group will
be considered liquidated damages. If the termination occurs at the end of a policy year, any
refund of rate stabilization reserve due the Group will not be settled until twelve (12)
months following the group's termination.
This Agreement may be terminated by either the Policy Holder or the Plan at the end of
the policy year by thirty (30) days prior notice in writing.
ARKANSAS BLUE AND BLUE SHIELD, A MUTUAL INSURANCE COMPANY
Signed ohn B. Greer,
Senior Vice President,
Group Services
3- -
Date:
CITY OF FAYETTEVILLE AND FAYETTEVILLE PUBLIC LIBRARY
09/9)
Date:
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AMENDMENT TO THE BLUE CROSS AND BLUE SHIELD
GROUP CONTRACT
FOR
CITY OF FAYETTEVILLE
Group Number 090041
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Effective May 1, 1990, CITY OF FAYETTEVILLE, Group
Number 090041, is hereby changing their anniversary
date from April 15 to May 1.
This Amendment becomes a part of the Blue Cross and Blue
Shield Group Contract.
George K. Mitchell
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, Arkansas 72201
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GROUP INSURANCE AGREEMENT
WITH
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A MUTUAL INSURANCE COMPANY
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This is an agreement between Arkansas Blue Cross and Blue Shield, A
Mutual Insurance Company (We, Us) and the Group Employer (You,
Your) whose name and signature appears on the Application for
Insurance made apart hereof.
ARTICLE I. WE AGREE:
In consideration of the premiums set forth in Schedule A, attached
hereto, we agree to:
Section 1. Provide to your enrolled employees and their
eligible dependents the health benefits set forth in the Benefit
Certificate, attached hereto and incorporated herein. Such
benefits are subject to all terms therein.
ARTICLE II. UNLESS OTHERWISE AGREED IN WRITING, THE MEMBER AGREES
TO:
Section 1. Pay us the charges for each enrolled employee
and their dependents every month, in advance.
Section 2. Act as the agent of your employees (not of us) in
all dealings between we and such employees, including:
a. paying premiums to us;
notifying us of changes in membership status:
securing and forwarding to us applications for coverage
for new employees;
d. providing employees all communications and notices from
us.
Section 3. Abide by our regulations as specified in the
enrollment regulations contained in the group folder provided by
us.
Section 4. Establish and maintain this membership by
having 75% (or more) of eligible employees enrolled.
GMC
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AMENDMENT TO THE ARKANSAS
BLUE CROSS AND BLUE SHIELD
GROUP MASTER CONTRACT
a
ARTICLE III, Section 2., is hereby amended by deleting it in
its entirety and substituting the following paragraph
therefor:
We may amend the terms of this Contract. If we do so,
we will give 30 days written notice to you. Such change
shall be effective on the date fixed in the notice.
This Amendment becomes a part of the Arkansas Blue Cross and
Blue Shield Group Master Contract.
GMC -R/90
George K. Mitchell
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, Arkansas 72201
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AMENDMENT TO THE ARKANSAS BLUE CROSS
AND BLUE SHIELD GROUP CONTRACT
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In ARTICLE IV, Section 1, the bracketed subparagraph is
hereby amended to read as follows:
[THE ANNUAL MEETING OF THE MEMBERS SHALL BE HELD EACH
YEAR AT THE HOME OFFICE, LOCATED AT 601 GAINES STREET,
LITTLE ROCK, ARKANSAS, ON THE THIRD MONDAY IN MARCH AT
1:00 P.M. (PROVIDED, IF SUCH DAY SHALL BE A LEGAL
HOLIDAY, THEN AT THE SAME TIME AND PLACE ON THE NEXT
SUCCEEDING DAY WHICH IS NOT A LEGAL HOLIDAY)].
The Proxy is hereby amended to read as follows:
PROXY
I hereby appoint the Board of Directors ("Board") of
Arkansas Blue Cross and Blue Shield, A Mutual Insurance
Company ("Company"), as my proxy to act on my behalf at all
meetings of Members of the Company. This appointment shall
include such persons as the Board may designate by resolution
to act on its behalf. This proxy gives the Board, or its
designee, full power to vote for me on all matters that may
be voted upon at any meeting. The annual meeting of Members
is held each year at the home office of the Company located
at 601 Gaines Street, Little Rock, Arkansas, on the third
Monday of March at 1:00 p.m. If the third Monday of March is
a legal holiday, then the meeting will be at the same time
and place on the next day after, which is not a legal
holiday. Special meetings may be called upon notice mailed
not less than ten (10) nor more than sixty (60) days prior to
such meeting. This proxy, unless revoked, shall remain in
effect during my membership in the Company. I may revoke
this proxy in writing by advising the Company of such at
least five (5) days prior to any meeting. I may also revoke
my proxy by attending and voting in person at any Members'
meeting.
This Amendment becomes a part of the Arkansas Blue Cross and
Blue Shield Group Contract.
2/89
act -c,
George K. Mitchell
President and Chief Executive Officer
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ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
Ns
601 Gaines Street -" r7)\-\.
Little Rock, Arkansas 72201
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ARTICLE III. BOTH PARTIES AGREE:
Section 1. Coverage shall depend upon receipt of premiums
by us at our Home Office. The first premium is due on the contract
date. Subsequent premiums shall be paid in advance.
Section 2. We may amend the terms of this Contract. If we
do so, we will give 30 days written notice to you. Such change
shall be effective on the date fixed in the notice. Unless both of
us agree, any change in benefits and premiums shall occur on the
anniversary date.
Section 3. All statements by you or your enrolled employees
will be deemed representations and not warranties, unless there is
fraud. No statement will be used to void coverage or reduce
benefits unless it is in a written document signed by you or the
enrolled employees and they are given a copy of it.
Section 4. Either of us can cancel this Contract by 30 days
written notice to the other. We cannot cancel before the last day
of any period for which we have received premiums.
ARTICLE IV. POLICY PROVISIONS RELATIVE TO MEMBERSHIP, MEETINGS
AND VOTING
Section 1: Annual Meeting. An annual meeting of the members
shall be held each and every calendar year in the State of Arkansas
for the purpose of electing directors, receive and consider
reports as to the business and affairs of the Corporation, and
transacting such other business as may properly come before the
meeting. The meeting shallrbe held between January 1 and April 1
of each year at such place, date and time as shall be fixed by the
Board of Directors or the Chief Executive Officer. The Board of
Directors may, from time to time, provide that the place, date and
time of the annual meeting shall be set forth in the policy of
members as provided in Article IIII Section 3 of these ByLaws.
[THE ANNUAL MEETING OF THE MEMBERS SHALL BE HELD EACH YEAR AT
THE HOME OFFICE OF THE COMPANY ON THE THE THIRD THURSDAY IN
MARCH AT 1:00 P.M. (PROVIDED, IF SUCH DAY SHALL BE A LEGAL
HOLIDAY, THEN AT THE SAME TIME AND PLACE ON THE NEXT
SUCCEEDING DAY WHICH IS NOT A LEGAL HOLIDAY)) .
Section 2: Special Meetings. A special meeting of members
for any purpose may be called by the Board of Directors or Chief
Executive Officer, and shall be called by the Chief Executive
Officer or the Secretary at the request of members holding one-
third (1/3) of the voting power entitled to vote thereat. Such
request shall state the purpose or purposes of the meeting and no
other business outside the scope of the stated purpose or purposes
shall be transacted. Unless ordered by the Board of Directors, the
time and place of each special meeting of members shall be
determined by the Chief Executive Officer.
GMC 1
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Section 3: Notice of Meetings. So long as each insurance
policy issued by the Corporation sets forth the place, date and
hour of the annual meeting of members, no notice of any annual
meeting shall be required to be given to any member, regardless of
the number or nature of proposals to be considered and voted upon
at the annual meeting. If notice of the annual meeting is not set
forth in each insurance policy, written or printed notice of the
annual meeting and every special meeting of the members, stating
the place, date, time and the purpose or purposes of such meeting
shall be given to the members entitled to vote at such meeting not
less than ten (10), nor more than sixty (60), days before the date
of the meeting. All such notices shall be given, either personally
or by mail, by or at the direction of the Chief Executive Officer
or Secretary unless ordered by the Board of Directors. Notices
which shall be mailed shall be deemed to be "given" when deposited
in the United States Mail addressed to the member at the member's
address as it appears on the records of the Corporation, with
postage prepaid [first class mail, if the notice is mailed thirty
(30) days or less before the date of the meeting], and any notice
transmitted other than by mail shall be deemed to have been "given"
when delivered to the member.
Section 4: Quorum. Except as otherwise provided by
applicable law, a majority of the members of the Corporation
(present in person or by proxy) shall be necessary to constitute a
quorum for the transaction of business at any annual or special
meeting of the members of the Corporation.
Section 5: Voting Rights. Each member shall be entitled to
one vote for each policy held by him upon each matter coming to a
vote at meetings of members. Provided, a group policyholder shall
be entitled to a number of votes equal to the number of certificate
holders insured under the group policy. Such vote may be exercised
in person or by written proxy.
Section 6: Vote Required. A majority of the voting power
represented at any meeting of members shall be necessary and
sufficient to approve any given matter. There shall be no
cumulative voting.
Section 7: Proxy. At all meetings of members a member may
vote by proxy executed in writing by the member or by the member's
duly authorized attorney in fact. Such proxy shall be filed with
the Secretary before commencement of the meeting or at such later
time as shall be expressly permitted by the Corporate officer
presiding at such meeting. Each application for an insurance
policy issued by the Corporation shall contain a provision
pursuant to which the policyholder thereof grants a revocable
proxy to the Board of Directors with respect to all matters to be
considered and voted upon by members at any meeting for the term of
such insurance policy.
GMC 2
C 0
•
•
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A MUTUAL INSURANCE COMPANY
601 Gaines Street
Little Rock, Arkansas 72201
(herein called the Company)
GROUP APPLICATION AND PROXY
COMPANY, IN CONSIDERATION
of the application made by
CITY OF FAYETTEVILLE
(herein called the Member)
•
Group Master Contract Number 090041 and in consideration of
payment by the Member of the charges as herein provided in Schedule
A, agrees to provide the benefits described in the Benefit
Certificate, which is a part of the Group Master Contract. This
agreement shall be for a period of twelve (12) months beginning at
12:01 a.m. on April 15, 1987, (the Effective Date) to
April 15, 1988, (the Anniversary Date) and from year to year
thereafter, unless the Contract is cancelled as provided therein.
The premiums shall be paid in advance of the Effective Date and
thereafter as provided herein. This Application is made and
delivered in the State of Arkansas. It is governed by the laws of
such and is subject to the terms and conditions of the Group
Contract, which is apart of this Application by reference.
Signed at
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A MUTUAL INSURANCE COMPANY
•
Ct9IMC, t C P
Authorized Signature
GMC 3
ThawIGLeip
Authomzed Signature
AMENDMENT TO THE BLUE CROSS AND BLUE SHIELD
GROUP CONTRACT
FOR
CITY OF FAYETTEVILLE
GROUP NUMBER 090041
Schedule A of the Blue Cross and Blue Shield Group Contract
is amended to show the rates effective May 1, 1991.
Charges for each enrolled employee shall be as follows:
Monthly Charge
Per
Covered Employee
ONE PERSON FAMILY
COVERAGE COVERAGE
Blue Cross --Blue Shield
Dental
Total
$91.29 $218.76
8.48 29.71
$99.77 $248.47
Initial charges shall be paid on the Effective Date and no
coverage shall be in effect until such payment is received
by the Plan. Subsequent charges shall be payable on or
before the same day as the Effective Date of each month
thereafter.
This Amendment becomes a part of the Blue Cross and Blue
Shield Group Contract.
George K. Mitchell
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, AR 72201
c LV
AMENDMENT TO THE BLUE CROSS AND BLUE SHIELD
GROUP CONTRACT
FOR
CITY OF FAYETTEVILLE
Group Number 090041
Schedule A of the Blue Cross and Blue Shield Group
is amended to show the rates effective May 1, 1991.
Contract
Charges for each enrolled employee shall be as follows:
Monthly Charge
Per
Covered Employee
ONE PERSON FAMILY
COVERAGE COVERAGE
Blue Cross --Blue Shield
$91.29
$218.76
Dental
8.48
29.71
Total
$99.77
$248.47
Initial charges shall be paid on the Effective Date and
no coverage shall be in effect until such payment is received
by the Plan. Subsequent charges shall be payable on or before
the same day as the Effective Date of each month thereafter.
This Amendment becomes a part of the Blue Cross and Blue
Shield Group Contract.
George K. Mitchell
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, Arkansas 72201
•jL I
AMENDMENT TO THE BLUE CROSS AND BLUE SHIELD
GROUP CONTRACT
FOR
CITY OF FAYETTEVILLE
Group Number 090041
Schedule A of the Blue Cross and Blue Shield Group Contract
is amended to show the rates effective May 1, 1990.
Charges for each enrolled employee shall be as follows:
Monthly Charge
Per
Covered Employee
Blue Cross --Blue Shield
Dental
Total
ONE PERSON
COVERAGE
$ 94.60
7.83
$102.43
FAMILY
COVhRAGF.
$226.70
27.43
$254.13
Initial charges shall be paid on the Effective Date and
no coverage shall be in effect until such payment is
received by the Plan. Subsequent charges shall be payable on
or before the same day as the Effective Date of each month
thereafter.
This Amendment becomes a part of the Blue Cross and Blue
Shield Group Contract.
George K. Mitchell
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, Arkansas 72201
0
AMENDMENT TO THE BLUE CROSS AND BLUE SHIELD
GROUP CONTRACT
FOR
CITY OF FAYETTEVILLE
Group Number 090041
Schedule A of the Blue Cross and Blue Shield Group Contract
is amended to show the rates effective April 15, 1989.
Charges for each enrolled employee shall be as follows:
Monthly Charge
Per
Covered Employee
Blue Cross --Blue Shield
Dental
Total
ONE PERSON
COVERAGE
$82.98
7.83
$90.81
Initial charges shall be paid on the E
no coverage shall be in effect until
received by the Plan. Subsequent charges
or before the same day as the Effective
thereafter.
FAMILY
COVERAGE
$198.86
27.43
$226.29
ffective Date and
such payment is
shall be payable on
Date of each month
This Amendment becomes a part of the Blue Cross and Blue
Shield Group Contract.
George K. Mitchell
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, Arkansas 72201
COPY
.. ,
AMENDMENT TO THE BLUE CROSS AND BLUE SHIELD
GROUP CONTRACT
FOR
CITY OF FAYETTEVILLE
Group Number 090041
Schedule A
of
the Blue
Cross
and Blue
Shield
Group Contract
is amended
to
show the
rates
effective
April
15, 1988.
Charges for each enrolled employee shall be as follows:
Monthly Charge
Per
Covered Employee
ONE PERSON FAMILY
COVERAGE COVERAGE
Blue Cross --Blue Shield $61.74 $147.96
Initial charges shall be paid on the Effective Date and
no coverage shall be in effect until such payment is
received by the Plan. Subsequent charges shall be payable on
or before the same day as the Effective Date of each month
thereafter.
This Amendment becomes a part of the Blue Cross and Blue
Shield Group Contract.
George K. Mitc e l
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, Arkansas 72201
C (a pY
AMENDMENT TO THE BLUE CROSS AND BLUE SHIELD
GROUP CONTRACT
FOR
CITY OF FAYETTEVILLE
Group Number 090041
Schedule A of the Blue Cross and Blue Shield Group Contract is
amended to show the rates effective April 15, 1987.
Charges for each enrolled employee shall be as follows:
Monthly Charge
Per
Covered Employee
ONE PERSON FAMILY
COVERAGE COVERAGE
Blue Cross --Blue Shield $65.68 $157.40
Initial charges shall be paid on the Effective Date and no
coverage shall be in effect until such payment is received by
the Plan. Subsequent charges shall be payable on or before the
same day as the Effective Date of each month thereafter.
This Amendment becomes a part of the Blue Cross and Blue Shield
Group Contract.
George K. Mitchell
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, Arkansas 72201
CoLrr
•
SCHEDULE A
CHARGES FOR EACH ENROLLED EMPLOYEE SHALL BE AS FOLLOWS:
Blue Cross --Blue Shield
Monthly Charge
Per
Covered Employee
(Group No. 090041 )
ONE PERSON FAMILY
COVERAGE COVERAGE
$ 64.89 $ 155.51
Initial charges shall be paid on the Effective Date and no coverage
shall be in effect until such payment is received by the Company.
Subsequent charges shall be payable on or before the same day as
the Effective Date of each month thereafter.
GMC 4 COPY
PROXY
I hereby appoint the Board of Directors ("Board') of Arkansas Blue Cross
and Blue Shield, A Mutual Insurance Company ("Company") as my proxy to
act on my behalf at all meetings of members of the Company. This
appointment shall include such persons as the Board may designate by
resolution to act on its behalf. This proxy gives the Board, or its
designee, full power to vote for me on all matters that may be voted
upon at any meeting. The annual meeting of Members is held each year at
the home office of the Company on the third Thursday of March, at 1:00
o'clock p.m. beginning March 17, 1988. If the third Thursday of March
is a legal holiday, then the meeting will be at the same time and place
on the next day after, which is not a legal holiday. Special meetings
may be called upon notice mailed not less than ten (10) nor more than
sixty (60) days prior to such meeting: This proxy, unless revoked, shall
remain in effect during my membership in the Company. I may revoke this
proxy in writing by advising the Company of such at least five (5) days prior to
any meeting. I may also revoke my proxy by attending and voting in person at
any Members' meeting.
/EEY%LCr 3?
Address
GROUP NUMBER G' 900 f/
Si natuv4 and Title )
Dated this day of , 193.
GMC
5
COPY
DENTAL GROUP CONTRACT BETWEEN
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A MUTUAL INSURANCE COMPANY
Lf f
FAYETTEVILLE PUBLIC LIBRARY
Group Number 090042
A64 I COPY
I
•
DENTAL GROUP INSURANCE AGREEMENT
WITH
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A MUTUAL INSURANCE COMPANY
This is an agreement between Arkansas Blue Cross and Blue
Shield, A Mutual Insurance Company (We, Us) and the Group
Employer (You, Your) whose name and signature appears on the
Application for Insurance made a part hereof.
ARTICLE I. WE AGREE:
In consideration of the premiums set forth in Schedule A,
attached hereto, we agree to:
Section 1. Provide to your enrolled employees and their
eligible dependents the dental benefits set forth in the
Benefit Certificate, attached hereto and incorporated herein.
Such benefits are subject to all terms therein.
ARTICLE II. UNLESS OTHERWISE AGREED IN WRITING, THE MEMBER
AGREES TO:
Section 1. Pay us the charges for each enrolled employee
and their dependents every month, in advance.
Section 2. Act as the agent of your employees (not of
us) in all dealings between we and such employees, including:
a. paying premiums to us;
b. notifying us of changes in membership status;
c. securing and forwarding to us applications for
coverage for new employees;
d. providing employees all communications and notices
from us.
Section 3. Abide by our regulations as specified in the
enrollment regulations contained in the group folder provided
by us.
A64 2 Copy
AMENDMENT TO THE ARKANSAS
BLUE CROSS AND BLUE SHIELD
DENTAL GROUP MASTER CONTRACT
ARTICLE III, Section 3., is hereby amended by deleting it in
its entirety and substituting the following paragraph
therefor:
We may amend the terms of this Contract. If we do so,
we will give 30 days written notice to you. Such change
shall be effective on the date fixed in the notice.
This Amendment becomes a part of the Arkansas Blue Cross and
Blue Shield Dental Group Master Contract.
George K. Mitchell
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, Arkansas 72201
DGMC-R/90
Section
4. Establish and
maintain
this membership by
having 75% (or
more) of eligible
employees
enrolled.
ARTICLE III. BOTH PARTIES AGREE:
Section 1. Dental coverage shall depend upon receipt of
premiums by us at our Home Office. The first premium is due on
the contract date. Subsequent premiums shall be paid in
advance.
Section 2. That the separate Fee Schedule and amendments
thereto shall become a part of this Contract.
Section 3.
We may
amend the terms of this
Contract. If
we do so, we
will give
30 days written notice
to you. Such
change shall
be effective on the date fixed
in the notice.
Unless both of
us agree,
any change in premiums
shall occur on
the anniversary date.
Section 4.
All statements by you
or your
enrolled
employees will
be deemed representations and not warranties,
unless there
is fraud. No statement will
be used
to void
coverage or reduce
benefits unless it is in a
written
document
signed by you
or the enrolled employees and
they are
given a
copy of it.
Section 5. Either of us can cancel this Contract by 30
days written notice to the other. We cannot cancel before the
last day of any period for which we have received premiums.
ARTICLE IV. POLICY PROVISIONS RELATIVE TO MEMBERSHIP, MEETINGS
AND VOTING
Section 1: Annual Meeting. An annual meeting of the
members shall be held each and every calendar year in the State
of Arkansas for the purpose of electing directors, receive and
consider reports as to the business and affairs of the
Corporation, and transacting such other business as may
properly come before the meeting. The meeting shall be held
between January 1 and April 1 of each year at such place, date
and time as shall be fixed by the Board of Directors or the
Chief Executive Officer. The Board of Directors may, from time
to time, provide that the place, date and time of the annual
meeting shall be set forth in the policy of members as provided
in Article III, Section 3 of these ByLaws.
[THE ANNUAL MEETING OF THE MEMBERS SHALL BE HELD EACH YEAR
AT THE HOME OFFICE, LOCATED AT 601 GAINES STREET, LITTLE
ROCK, ARKANSAS, ON THE THIRD MONDAY IN MARCH AT 1:00 P.M.
(PROVIDED, IF SUCH DAY SHALL BE A LEGAL HOLIDAY, THEN AT
THE SAME TIME AND PLACE ON THE NEXT SUCCEEDING DAY WHICH
IS NOT A LEGAL HOLIDAY)).
464 3 Copy
e
Section Special Meetings. A special meeting of
members for any purpose may be called by the Board of Directors
or Chief Executive officer, and shall be called by the Chief
Executive Officer or the Secretary at the request of members
holding one-third (1/3) of the voting power entitled to vote
thereat. Such request shall state the purpose or purposes of
the meeting and no other business outside the scope of the
stated purpose or purposes shall be transacted. Unless ordered
by the Board of Directors, the time and place of each special
meeting of members shall be determined by the Chief Executive
Officer.
Section 3: Notice of Meetings. So long as each insurance
policy issued by the Corporation sets forth the place, date and
hour of the annual meeting of members, no notice of any annual
meeting shall be required to be given to any member, regardless
of the number or nature of proposals to be considered and voted
upon at the annual meeting. If notice of the annual meeting is
not set forth in each insurance policy, written or printed
notice of the annual meeting and every special meeting of the
members, stating the place, date, time and the purpose or
purposes of such meeting shall be given to the members entitled
to vote at such meeting not less than ten (10), nor more than
sixty (60), days before the date of the meeting. All such
notices shall be given, either personally or by mail, by or at
the direction of the Chief Executive Officer or Secretary
unless ordered by the Board of Directors. Notices which shall
be mailed shall be deemed to be "given" when deposited in the
United States Mail addressed to the member at the member's
address as it appears on the records of the Corporation, with
postage prepaid [first class mail, if the notice is mailed
thirty (30) days or less before the date of the meeting], and
any notice transmitted other than by mail shall be deemed to
have been "given" when delivered to the member.
Section 4: Quorum. Except as otherwise provided by
applicable law, a majority of the members of the Corporation
(present in person or by proxy) shall be necessary to
constitute a quorum for the transaction of business at any
annual or special meeting of the members of the Corporation.
Section 5: Voting Rights. Each member shall be entitled
to one vote for each policy held by him upon each matter coming
to a vote at meetings of members. Provided, a group
policyholder shall be entitled to a number of votes equal to
the number of certificate holders insured under the group
policy. Such vote may be exercised in person or by written
proxy.
Section 6: Vote Required. A majority of the voting power
represented at any meeting of members shall be necessary and
sufficient to approve any given matter. There shall be no
cumulative voting.
A64 4 COP
Section 7: Proxy. At all meetings of members a member
may vote by proxy executed in writing by the member or by the
member's duly authorized attorney in fact. Such proxy shall be
filed with the Secretary before commencement of the meeting or
at such later time as shall be expressly permitted by the
Corporate officer presiding at such meeting. Each application
for an insurance policy issued by the Corporation shall contain
a provision pursuant to which the policyholder thereof grants a
revocable proxy to the Board of Directors with respect to all
matters to be considered and voted upon by members at any
meeting for the term of such insurance policy.
A6.4 5 COPY
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A MUTUAL INSURANCE COMPANY
601 Gaines Street
Little Rock, Arkansas 72201
(herein called the Company)
DENTAL GROUP APPLICATION AND PROXY
COMPANY, IN CONSIDERATION, AND UPON ACCEPTANCE BY THE COMPANY
of the application made by
FAYETTEVILLE PUBLIC LIBRARY
(herein called the Member)
Dental Group Master Contract Number 090042 and in consideration
of payment by the Member of the charges as herein provided in
Schedule A, agrees to provide the dental benefits described in
the Dental Benefit Certificate, which is a part of the Dental
Group Master Contract. This agreement shall be for a period of
twelve (12) months beginning at 12:01 a.m. on April 15, 1989,
(the Effective Date) to April 15, 1990, (the Anniversary Date)
and from year to year thereafter, unless the Dental Contract is
cancelled as provided therein. The premiums shall be paid in
advance of the Effective Date and thereafter as provided
herein. This Application is made and delivered in the State of
Arkansas. It is governed by the laws of such and is subject to
the terms and conditions of the Dental Group Contract, which is
a part of this Application by reference.
Signed at
i9 .
, this
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A MUTUAL INSURANCE COMPANY
Accepted:
Group
Authorized Signature Authorized Signature
A64 6 COPY
I.
AMENDMENT TO THE BLUE CROSS AND BLUE SHIELD
GROUP CONTRACT
FOR
FAYETTEVILLE PUBLIC LIBRARY
GROUP NUMBER 090042
Schedule A of the Blue Cross and Blue Shield Dental Group
Contract is amended to show the rates effective May 1, 1991.
Charges for each enrolled employee shall be as follows:
Monthly Charge
Per
Covered Employee
ONE PERSON FAMILY
COVERAGE COVERAGE
Dental $8.48 $29.71
Initial charges shall be paid on the Effective Date and no
coverage shall be in effect until such payment is received
by the Plan. Subsequent charges shall be payable on or
before the same day as the Effective Date of each month
thereafter.
This Amendment becomes a part of the Blue Cross and Blue
Shield Dental Group Contract.
George K. Mitchell
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, AR 72201
COPY
4
AMENDMENT TO THE BLUE CROSS AND BLUE SHIELD
DENTAL GROUP CONTRACT
FOR
FAYETTEVILLE PUBLIC LIBRARY
Group Number 090042
Schedule A of the Blue Cross and Blue Shield Dental Group
Contract is amended to show the rates effective
May 1, 1991 .
Charges for each enrolled employee shall be as follows:
Monthly Charge
Per
Covered Employee
ONE PERSON FAMILY
COVERAGE COVERAGE
Dental $8.48 $29.71
Initial charges shall be paid on the Effective Date and no
coverage shall be in effect until such payment is. received
by the Plan. Subsequent charges shall, be payable on or
before the same day as the Effective Date of each month
thereafter.
This Amendment becomes a part of the Blue Cross and Blue
Shield Dental Group Contract.
George K. Mitchell
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, Arkansas 72201
COLD)Y
TO THE BLUE CROSS AND BLUE SHIELD
DENTAL GROUP CONTRACT
FOR
FAYETTEVILLE PUBLIC LIBRARY
Group Number 090042
Schedule A of the Blue Cross and Blue Shield Dental Group
Contract is amended to show the rates effective May 1, 1990.
Charges for each enrolled employee shall be as follows:
Monthly Charge
Per
Covered Employee
ONE PERSON FAMILY
COVERAGE COVERAGE
Dental
$7.83 $27.43
Initial charges shall be paid on the Effective Date and no
coverage shall be in effect until such payment is received
by the Plan. Subsequent charges shall be payable on or
before the same day as the Effective Date of each month
thereafter.
This Amendment becomes a part of the Blue Cross and Blue
Shield Dental Group Contract.
George K. Mitchell
President and Chief Executive Officer
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, Arkansas 72201
cOY
SCHEDULE A
CHARGES FOR EACH ENROLLED EMPLOYEE SHALL BE AS FOLLOWS:
Monthly C
Per
Covered Em
(Group No.
ONE PERSON
COVERAGE
harge
D1 oyee
090042)
FAMILY
COVERAGE
Blue Cross --Blue Shield $7.83 $27.43
Dental Services
Initial charges shall be paid on the Effective Date and no
coverage shall be in effect until such payment is received by
the Company. Subsequent charges shall be payable on or before
the same day as the Effective Date of each month thereafter.
A64 7 copy
•.
PROXY
I hereby appoint the Board of Directors ("Board") of Arkansas
Blue Cross and Blue Shield, A Mutual Insurance Company
("Company"), as my proxy to act on my behalf at all meetings of
members of the Company. This appointment shall include such
persons as the Board may designate by resolution to act on its
behalf. This proxy gives the Board, or its designee, full
power to vote for me on all matters that may be voted upon at
any meeting. The annual meeting of Members is held each year
at the home office of the Company located at 601 Gaines Street,
Little Rock, Arkansas on the third Monday of March, at 1:00
p.m. If the third Monday of March is a legal holiday, then the
meeting will be at the same time and place on the next day
after, which is not a legal holiday. Special meetings may be
called upon notice mailed not less than ten (10) nor more than
sixty (60) days prior to such meeting. This proxy, unless
revoked, shall remain in effect during my membership in the
Company. I may revoke this proxy in writing by advising the
Company of such at least five (5) days prior to any meeting. I
may also revoke my proxy by attending and voting in person at
any Members' meeting.
Address
-
By: �.�, 7-ici <� ..�
GROUP NAME
Group Number
Signature and Title'
,
Dated this ! / day of << 19 "! J
A64 8 COPY
ADDENDUM TO DENTAL GROUP CONTRACT A64
FEE SCHEDULE OF DENTAL PROCEDURES
LIST OF MAXIMUM DENTAL PROCEDURE ALLOWANCES
FOR THE FULL SCHEDULE OF DENTAL SERVICES INCLUDED IN THIS CONTRACT
PREVENTIVE - P
RESTORATIVE - R
ORTHODONTIC - D
APPROVED TREATMENT PLAN - A.T.P.*
(Prior Authorization Required
For Coverage)
BY REPORT - BR* (Narrative Description Required)
The amounts in this schedule are
not intended to fix the value of
services performed by dentists.
Dentists may charge their usual
fees for services.
MAXIMUM
CODE PROCEDURE COVERAGE ALLOWANCE
DIAGNOSTIC
00100
Clinical Oral Examination
00110
Initial oral examination
P
$21
00120
Periodic oral examination
P
17
00130
Emergency oral examination
p
21
00200
Radioaraohs
00210
Intraoral - complete series
P
49
(including bitewings)
00220
Intraoral Periapical - single
P
13
first film
00230
Intraoral Periapical - each
P
11
additional film (4 maximum number
of services)
00240
Intraoral - occlusal, film
P
21
00250
Extraoral - first film
p
21
00260
Extraoral - each additional film
p
16
A64 8/92
1
COPY
• 00270
Bitewings - single film
P
13
00272
Bitewings - two films
p
18
00274
Bitewings - four films
p
22
00290
Posterior -anterior and lateral
P
43
skull and facial bone, survey film
00310
Sialography
p
BR*
00320
Temporomandibular joint arthrogram,
P
BR*
including injection
00321
Temporomandibular joint, film
P
59
00330
Panoramic - maxilla and mandible film
P
39
00340
Cephalometric film
p
42
00400
Tests and Laboratory Examinations
00460
Pulp vitality tests (includes all
P
18
all teeth tested on same date of
service)
00470
Diagnostic casts
p
26
00471
Diagnostic photographs
P
11
01100
Dental Prophylaxis
01110
Prophylaxis, Adults
P
32
01120
Prophylaxis, Children
p
23
01200
Topical Fluoride Treatments
(office
procedure, coverage through
age
18)
01201
Topical application of fluoride
P
31
(including prophylaxis) - child
01203
Topical application of fluoride
P
11
(excluding prophylaxis) - child
01300
Other Services
01351
Sealant - per tooth
F
17
01500
Space Maintenance - Passive Appliances
(14 Years of age and under)
01510
Fixed - unilateral type
P
110
01515
Fixed - bilateral type
P
155
01520
Removable unilateral type
P
150
01525
Removable bilateral type
P
160
01550
Recementation of space maintainer
p
24
02100
Amalaam Restoration (polishing bases included)
02110
Amalgam - one surface, primary
P
31
A64 8/92
2
copy
Fl
02120
Amalgam -
two surfaces, primary
P
44
02130
Amalgam -
three surfaces, primary
P
54
02131
Amalgam -
four or more surfaces,
p
65
primary
02140
Amalgam -
one surface, permanent
P
34
02150
Amalgam -
two surfaces, permanent
p
47
02160
Amalgam -
three surfaces, permanent
P
59
02161
Amalgam -
four or more surfaces,
P
71
permanent
02200
silicate
Restorations
02210
Silicate
cement per restoration
P
34
02330
Resin - one surface, anterior
P
42
02331
Resin - two surfaces, anterior
p
52
02332
Resin - three surfaces, anterior
P
65
02335
Resin, four or more surfaces or
P
80
involving incisal angle, anterior
02336
Composite resin crown, anterior -
P
80
primary
02380
Resin - one surface, posterior -
p
48
primary
02381
Resin - two surfaces, posterior -
P
56
primary
02382
Resin - three or more surfaces,
p
71
posterior - primary
02385
Resin - one surface, posterior -
P
52
permanent
02386
Resin - two surfaces, posterior -
P
67
permanent
02387
Resin - three or more surfaces,
p
73
posterior - permanent
02500
02510
Inlay Restorations
Inlay - metallic, one surface
R
BR*
02520
Inlay - metallic two surfaces
R
305
02530
Inlay - metallic, three surfaces
R
325
02540
Onlay - metallic, per tooth
R
340
(in addition to inlay)
02610
Inlay - porcelain/ceramic -
R
165
one surface
A64 8/92
Copy
I
a
0?620 Inlay - porcelain/ceramic - R 330
two surfaces
02630 Inlay - porcelain/ceramic - R 340
three surfaces
02700-02800
Crowns - Single
Restoration Only
02710
Crown resin (laboratory)
R
145
02720
Crown - resin with high
R
375
noble metal
02721
Crown - resin with
R
340
predominantly base metal
02722
Crown - resin with noble metal
R
360
02740
Crown - porcelain/ceramic substrate R
385
02750
Crown - porcelain fused to high
R
405
noble metal
02751
Crown - porcelain fused to
R
355
predominantly base metal
02752
Crown - porcelain fused to
R
370
noble metal
02790
Crown - full cast high noble
R
360
metal
02791
Crown - full cast predominantly
R
310
base metal
02792
Crown - full cast noble metal
R
335
02810
Crown - 3/4 cast metallic
R
385
02900
Other Restorative Services
02910
Recement inlay
P
24
02920
Recement crown
P
26
02930
Prefabricated stainless steel
P
80
crown - primary tooth
02932
Prefabricated resin crown
P
79
C?940
Fillings (sedative)
p
22
02950
Core buildup - including any pins
P
62
02951
Pin retention - per tooth, in
P
17
addition to restoration
02952
Cast post and core in addition
P
160
to crown
02954
Prefabricated post and core in
P
93
addition to crown
02962
Labial veneer (porcelain laminate),
R
A.T.P.*
laboratory --photographs and x-rays
required
02980
Crown repair, (narrative required)
P
BR*
A64 8/92
601?(
•
ENDODONTICS
S.
03100
Pulp Capping
03110 Pulp Cap - direct (excluding final P 19
restoration)
03200 Pulpntomv
03220 Therapeutic pulpotomy (excluding P 42
final restoration)
03300
and follow-up care)
03310
Anterior (excluding final restoration)
p
200
03320
Bicuspid (excluding final restoration)
p
255
03330
Molar (excluding final restoration)
p
320
03351
Apexification/recalcification initial
p
BR*
visit (apical closure/calcific repair
of perforations, root resorption, etc.)
03352
Apexification/recalcification-interim
p
BR*
medication replacement (apical
closure/calcific repair of perforations,
root resorption, etc.)
03353
Apexification/recalcification-final
p
BR*
visit (includes completed root canal
therapy - apical closure/calcific
repair of perforations, root resorption,
etc.)
3400
Periapical Services
03410
Apicoectomy - periradicular
surgery-
R
165
anterior, separate surgical
procedure
(first root)
03421
Apicoectomy - periradicular
surgery-
R
165
bicuspid (first root)
03425
Apicoectomy - periradicular
surgery-
R
165
molar (first root)
03426
Apicoectomy - periradicular
surgery -
R
93
each additional root
03430
Retrograde filling (per root)
R
80
03450
Root amputation (per root)
R
100
A64 8/92
COPY
St
.
03900 Other Endodontic Procedures
03920 Hemisection (including any root R 105
removal)
03950 Canal preparation and fitting of R 92
prefor.ed dowel or post
s.
04200
Surgical Services
(including usual
post operative services)
04210
Gingivectomy or gingivoplasty -
R
235
per quadrant
04211
Gingivectomy or gingivoplasty -
R
60
per tooth
04220
Gingival curettage, surgical (per
R
110
quadrant). Narrative required.
04240
Gingival flap procedure, including
R
230
root planning - per quadrant
04249
Crown lengthening, hard and soft
R
BR*
tissue
04260
Osseous surgery (including flap
R
410
entry and closure) per quadrant
04261
Bone replacement graft - single site
R
310
(including flap entry, closure and donor site)
04262
Bone replacement grafts - multiple
R
380
sites (including flap entry and closure)
04270
Pedicle soft tissue graft procedure
R
265
04271
Free soft tissue grafts (including
R
325
donor site)
04300
Adjunctive Periodontal Services
04341 Periodontal scaling and root R 89
planing, per quadrant (complete - 6 point -
perio charting, x-rays and documentation of
time involved required)
04345 Scaling in the presence of gingival R 44
inflammation (gross scale, entire mouth)
04910 Periodontal maintenance procedures - R 46
(following active therapy; date of completion
of periodontal service required)
A64 8/92
6 COPY
PRRQSTHQDONTICS - REMOVABLE
05100 Complete Dentures -
05110
Complete upper
R
435
05120
Complete lower
R
435
05130
Immediate upper
R
480
05140
Immediate lower
R
480
05200
Partial Dentures - including six months
post -
delivery care
05211
upper partial - resin base
R
305
(including any conventional clasps,
rests and teeth)
05212
Lower partial - resin base
R
305
(including any conventional clasps,
rests and teeth)
05213
Upper partial - cast metal base with
R
550
resin saddles, (including any conventional
clasps,
rests and teeth)
05214
Lower partial
- cast metal base with
R
550
resin saddles (including any conventional
clasps,
rests and teeth)
05281
Removable unilateral partial denture
- R
260
one piece cast metal, (including clasps
and pontics)
05400
Adjustments to Removable Prostheses.
(including six
05410
Complete denture - upper
R
27
05411
Complete denture - lower
R
27
05421
Partial denture (upper)
R
27
05422
Partial denture (lower)
R
27
05500
Repairs to Complete Dentures
05510
Repair broken complete base
P
56
05520
Repair missing or broken teeth -
P
34
complete denture (each tooth)
05600
Repairs to Partial Dentures
05610
Repair resin saddle or base
P
42
05620
Repair cast framework
P
59
05630
Repair or replace broken clasp
P
BR*
05640
Replace broken teeth - per
P
34
tooth
A64 8/92
7
COPY
If
I
05650 a Add tooth to existing partial P 52
denture
05660 Add clasp to existing partial P 105
denture
05700
Denture Rebase and Reline Procedures
05710
Rebase upper denture
R
180
05711
Rebase complete lower denture
R
180
05720
Rebase upper partial denture
R
155
05721
Rebase lower partial denture
R
155
05730
Reline upper complete denture
R
90
(office reline)
05731
Reline lower complete denture
R
90
(office reline)
05740
Reline upper partial denture
R
65
(office reline)
05741
Reline lower partial denture
R
65
(office reline)
05750
Reline upper complete denture
R
155
(laboratory)
05751
Reline lower complete denture
R
155
(laboratory)
05760
Reline upper partial denture
R
155
(laboratory)
05761
Reline lower partial denture
R
155
(laboratory)
PROSTHODONTICS
FIXED - (EACH ABUTMENT AND EACH PONTIC
CONSTITUTE
A UNIT
IN A
BRIDGE)
06200
Bridge Pontics
06210
Pontic - cast high noble metal
R
365
06211
Pontic - cast predominantly base metal
R
310
06;_2
Pontic - cast noble metal
R
325
06240
Pontic - porcelain fused to high
R
390
noble metal
06241
Pontic - porcelain fused to
R
355
predominantly base metal
06242
Pontic - porcelain fused to noble
R
355
metal
06250
Pontic - resin processed to high
R
375
noble metal
06251
Pontic - resin processed to
R
340
predominantly base metal
06252
Pontic - resin processed to noble metal
R
360
A64 8/92
LtJ
Copy
•9
.
65OQ
Retainers
06520
Inlay metallic - two surfaces
R
295
06530
Inlay metallic - three or more
R
325
surfaces
06540
Inlay metallic - (onlaying cusps)
R
340
06545
Retainer - cast metal for acid etch
R
BR*
fixed prosthesis
06700
Bridge Retainers - Crowns
06720
Crown - resin processed to high
R
375
noble metal
06721
Crown - resin processed to
R
340
predominantly base metal
06722
Crown - resin processed to noble
R
360
metal
06750
Crown - porcelain fused to high
R
405
noble metal
06751
Crown - porcelain fused to
R
355
predominantly base metal
06752
Crown - porcelain fused to noble
R
370
metal
06780
Crown - 3/4 cast high noble metal
R
340
06790
Crown - full cast high noble metal
R
360
06791
Crown - full cast predominantly
R
310
base metal
06792
Crown - full cast noble metal
R
315
6900
Other Fixed Prosthetic Services
06930
Recement bridge
P
37
06970
Cast post and core in addition
R
155
to bridge retainer
06971
Cast post as a part of bridge
R
140
retainer
06972
Prefabricated post and core in
R
93
addition to bridge retainer
06980
Bridges repair (narrative required)
P
BR*
ORAL SURGERY
07100
Extractions - includes local anesthesia
and
routine post -operative care
07110
Single tooth extraction
P
39
07120
Each additional tooth
P
35
07130
Root removal - exposed roots
P
40
A64 8/92
0
07200 Surgical Extractions -
P and routine post -opera
07210
Surgical removal of erupted tooth
R
80
requiring elevation of mucoperiosteal
flap
and removal of bone and/or section of
tooth
07220
Removal of impacted tooth -
R
110
soft tissue
07230
Removal of impacted tooth - partially
R
130
bony
07240
Removal of impacted tooth -
R
165
completely bony
07241
Removal of impacted tooth -
R
210
completely bony, with unusual surgical
complications
07250
Surgical removal of residual tooth
R
87
roots (cutting procedure)
07260
oral antral fistula closure (and/
R
BR*
or antral root recovery)
07270
Tooth reimplantation and/or
R
110
stabilization of accidentally
evulsed or displaced tooth and/
or alveolus
07280
Surgical exposure of impacted or
R
135
unerupted tooth for orthodontic
reasons - including wire attachment
when indicated
OTHER SURGICAL PROCEDUR
07281 Surgical exposure of impacted
or unerupted tooth to aid eruption
07285 Biopsy of oral tissue (hard)
07286 Biopsy of oral tissue (soft)
07300
07310
07320
07340
A64 8/92
Per quadrant - in conjunction
with extractions
Per quadrant - not in conjunction
with extractions
R
Vestibuloplasty - ridge R
extension (secondary epithelialization)
10
75
70
80
LE
220
S
07350
07400
Vestibuloplasty - ridge extension R A.T.P.*
(including soft tissue grafts, muscle reattachments,
revision of soft tissue attachment and management of
hypertrophied and hyperplastic tissue)
07410
Radical excision - lesion diameter
R
77
up to 1.25 cm.
07420
Radical excision - lesion diameter
R
BR*
over 1.25 cm.
Removal of
Tumors. Cysts and Neoplasms
07430
Excision of benign tumor - lesion
R
130
diameter up to 1.25 cm.
07431
Excision of benign tumor - lesion
R
BR*
diameter over 1.25 cm.
07440
Excision of malignant tumor -
R
155
lesion diameter up to 1.25 cm.
07441
Excision of malignant tumor -
R
BR*
lesion diameter over 1.25 cm.
07450
Removal of odontogenic cyst or
R
125
tumor - up to 1.25 cm. diameter
07451
Removal of odontogenic cyst or
R
BR*
tumor - over 1.25 cm. diameter
07460
Removal of non-odontogenic cyst
R
200
or tumor - up to 1.25 cm. diameter
07461
Removal of non-odontogenic cyst or
R
BR*
tumor - over 1.25 cm. diameter
07465
Destruction of lesion(s) by physical
R
BR*
or chemical methods
Excision of
Bone Tissue
07470
Removal of exostosis - maxilla
R
A.T.P.*
or mandible
07500
Surgical Incision
07510
Incision and drainage of abscess -
R
57
intraoral soft tissue
07520
Incision and drainage of abscess -
R
85
extraoral soft tissue
07530
Removal of foreign body, skin
R
120
or subcutaneous alveolar tissue
07540
Removal of reaction - producing
R
130
foreign bodies -- musculoskeletal system
A64 8/92
11
COPY
0550
07560
07600
07610
07620
07630
07640
07650
07660
07670
07680
Sequestrectomy for osteomyelitis
R
Maxillary sinusotomy for removal
R
of tooth fragment or foreign body
Treatment of Fractures - Simple
Maxilla - open reduction, teeth
R
immobilized (if present)
Maxilla - closed reduction, teeth
R
immobilized (if present)
Mandible - open reduction, teeth
R
immobilized (if present)
Mandible - closed reduction,
immobilized (if present)
Malar and/or zygomatic arch
open reduction
Malar and/or zygomatic arch
closed reduction
Alveolus - stabilization of
open reduction splinting
Facial bones
- complicated
reduction
R
with fixation
and multiple
surgical
approaches
teeth R
R
R
teeth, R
130
BR*
850
610
850
610
850
610
610
BR*
07700
Treatment of Fractures -Compound
07710
Maxilla - open reduction
R
1, 200
07720
Maxilla - closed reduction
R
900
07730
Mandible - open reduction
R
1,200
07740
Mandible - closed reduction
R
900
07750
Malar and/or zygomatic arch -
R
1' 200
open reduction
07760
Malar and/or zygomatic arch -
R
850
closed reduction
07770
Alveolus - stabilization of teeth
R
900
- open reduction splinting
07780
Facial bones - complicated reduction
R
BR*
with fixation and multiple surgical approaches
7800
Reduction of Dislocation and Management
of Other
Temporomandibular Joint Dysfunctions
07810
Open reduction of dislocation
R
850
07820
Closed reduction of dislocation
R
610
07830
Manipulation under anesthesia
R
610
07840
Condylectomy
R
905
07850
Surgical discectomy
R
1,500
07860
Arthrotomy
R
A.T.P.*
07880
Occlusal Orthotic appliance
R
BR*
(includes maintenance and adjustment)
A64 8/92
12
copy
07900 Other Oral Suraerw
Repair of Traumatic Wounds
07910 Suture of recent small wounds R 46
up to 5 cm
.07911 Complicated suture - up to 5 cm R 73
07912 Complicated suture - over 5 cm R 155
07920 Skin grafts (identify defect R A.T.P.*
covered, location, and type of graft)
07940
Osteoplasty (that is, for
R
1,685
orthognathic deformities)
07941
Osteotomy - ramus closed
R
850
07942
Osteotomy - ramus open
R
850
07943
Osteotomy - ramus open with
R
970
bone graft
07944
Osteotomy - segmented or subapical
R
BR*
per sextant or quadrant
07945
Osteotomy - body of mandible
R
850
07950
Osseous, osteoperiosteal, periosteal
R
BR*
or cartilage graft of the mandible,
autogenous
or nonautogenous
07955
Repair of maxillofacial soft and
R
BR*
hard tissue defects
07960
Frenulectomy - separate procedure
R
120
(frenectomy or frenotomy)
07970
Excision of hyperplastic tissue -
R
155
per arch
07971
Excision of pericoronal gingiva
R
BR*
07980
Sialolithotomy
R
250
07981
Excision of salivary gland
R
BR*
07982
Sialodochoplasty
R
BR*
07983
Closure of salivary fistula
R
225
07990
Emergency tracheotomy
R
365
08000
ORTHODONTICS
08100
Minor Treatment for Tooth Guidance
08110
Removable appliance therapy
D
A.T.P.*
08120
Fixed or cemented appliance therapy
D
A.T.P.*
A64 8/92
13
C�Op�7
S . a .
• Y O
08200 Minor Treatment to Coptrol Harmful Habits
08`210 Removable appliance therapy D
08220 Fixed or cemented appliance therapy D
08300 Interceptive Orthodontic Treatment
08360 Removable appliance therapy D
08370 Fixed appliance therapy D
Comprehensive Orthodontic Treatment
08400 Treatment of the Permanent Dentition
• e
93
155
A.T.P.*
A.T.P.*
08460
Class I malocclusion
D
A.T.P.*
08470
Class II malocclusion
D
A.T.P.*
08480
Class III malocclusion
D
A.T.P.*
Treatment of the Permanent Dentition
08560
Class I malocclusion
D
A.T.P.*
08570
Class II malocclusion
D
A.T.P.*
08580
Class III malocclusion
D
A.T.P.*
08650
Treatment of the Atypical or
D
A.T.P.*
Extended Skeletal Case
08750
Post Treatment Stabilization
D
A.T.P.*
09000
Adjunctive General Services
Unclassified
Treatment
09110
Palliative (emergency) treatment
P
24
of dental pain, minor procedures
(narrative required)
9200
Anesthesia
09220
General (includes monitoring
P
150
procedures, e.g., blood gases, etc.)
09400
Professional Visits
09420
Hospital calls
P
61
0 900
Miscellaneous Services
09940
Occlusal guards (narrative required)
R
A.T.P.*
09951
Occlusal adjustment - limited
R
A.T.P.*
(narrative required)
A64 8/92
14
Copy
.
AMENDMENT TO THE ARKANSAS BLUE CROSS AND BLUE SHIELD
GROUP CONTRACT
FOR
City of Fayetteville
GROUP NUMBER 090041
Schedule A of the Arkansas Blue Cross and Blue Shield Dental
Group Contract is amended to show the rates effective May 1,
1993.
Charges for each enrolled employee shall be as follows:
Monthly Charge
Per
Covered Employee
ONE PERSON FAMILY
COVERAGE COVERAGE
Dental $ 8.85 $31.02
Initial charges shall be paid on the Effective Date and no
coverage shall be in effect until such payment is received by
the Plan. Subsequent charges shall be payable on or before
the same day as the Effective Date of each month thereafter.
This Amendment becomes a part of the Arkansas Blue Cross and
Blue Shield Dental Group Contract.
�8.vi Cr'
Robert L.
ARKANSAS BLUE
A Mutual
601
Little
Shoptaw, President
CROSS AND BLUE SHIELD,
Insurance Company
Gaines Street
Rock, AR 72201
AMENDMENT TO THE ARKANSAS BLUE CROSS AND BLUE SHIELD
GROUP CONTRACT
FOR
City of Fayetteville
Group Number 090041
Schedule A of the Arkansas Blue Cross and Blue Shield Group
Contract is amended to show the rates effective May 1,
1993.
Charges for each enrolled employee shall be as follows:
Monthly Charge
Per
Covered Employee
ONE PERSON FAMILY
COVERAGE COVERAGE
HEALTH
DENTAL
TOTAL
$113.04 $270.88
8.85 2
121.89 301.90
Initial charges shall be paid on the Effective Date and no
coverage shall be in effect until such payment is received
by the Plan. Subsequent charges shall be payable on or
before the same day as the Effective Date of each month
thereafter.
This Amendment becomes a part of the Arkansas Blue Cross and
Blue Shield Group Contract.
Robert L. Sho aw, President
ARKANSAS BLUE CROSS AND BLUE SHIELD,
A Mutual Insurance Company
601 Gaines Street
Little Rock, Arkansas 72201