PE DELTA DENTAL PH RFP 190140 (002).PDF

CONTRACT NO: C-86-19-025-3-05 / PH RFP 190140 AMENDMENT NO: 5
AMENDMENT TO
CONTRACT
Between
MARICOPA COUNTY
By and Through
DEPARTMENT OF PUBLIC HEALTH
and
DELTA DENTAL PLAN OF ARIZONA
I. The above-named contract is hereby amended as specified below:
A. Contract Expiration date shall be updated to February 28, 2025
B. An additional $2M will be added, bringing the new Not to Exceed to $13M. An updated
Administrative Services Fee schedule, effective March 1, 2024, begins on page 2 of this
amendment.
Term and Conditions shall be updated to include:
6.39 WRITTEN CERTIFICATION PURSUANT to A.R.S. § 35-393.01:
if Contractor engages in for-profit activity and has 10 or more employees, and if
this agreement has a value of $100,000 or more, Contractor certifies it is not
currently engaged in, and agrees for the duration of this agreement to not engage
in, a boycott of goods or services from Israel. This certification does not apply to
a boycott prohibited by 50 U.S.C. § 4842 or a regulation issued pursuant to 50
U.S.C. § 4842.
6.40 WRITTEN CERTIFICATION PURSUANT to A.R.S. § 35-394:
Contractor warrants and certifies that it does not currently, and agrees for the
duration of the Agreement, that it will not use:
1. the forced labor of ethnic Uyghurs in the People’s Republic of China,
2. any goods or services produced by the forced labor of ethnic Uyghurs
in the People's Republic of China,
3. any contractors, subcontractors or suppliers that use the forced labor
or any goods or services produced by the forced labor of ethnic
Uyghurs in the People's Republic of China. If Contractor becomes
aware during the term of this Agreement that the Contractor is not in
compliance with this paragraph, Contractor shall notify the County
within five business days after becoming aware of the
noncompliance. If the Contractor fails to provide a written certification
to the County that the Contractor has remedied the noncompliance
within 180 days after notifying the County of its noncompliance, then
the agreement terminates, except that if the agreement termination
date occurs before the end of the 180-day period, the agreement
terminates on the agreement termination date.
7 All other terms and conditions of the original contract shall remain in full force and effect.
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CONTRACT NO: C-86-19-025-3-05 / PH RFP 190140 AMENDMENT NO: 5
Updated Administrative Fee Schedule
Delta Dental of Arizona
Dental Renewal for Maricopa County Office of Health Promotion & Education #4715
Effective March I, 2024
Administrative Services Fees
Fee per subscriber ‘ per month Renewal Fee(s)
March 1, 2024 through February 28. 2025
Subscriber only $3.91
Overall Percent Change
Recommended Equivalency Rate(s)
March 1, 2024 through February 28, 2025
Subscriber only $59.16
In addition to the Administrative Service Fee, Delta Dental shall invoice client for the cost of claims pursuant to
the contract. Delta Dental considers remittance of payment as acceptance of the contract and will begin
administering benefits accordingly.
‘Rating Requirements
Minimum chent contributions: 100% for subscriber.
Participation requirements: 100%
Rating Assumptions
The fee is valid for the effective date noted above and is quaranteed through the period shown above.
Fee includes broker commission, if applicable.
A Girectory of participating dentists is available online at www.deltadentalaz.com/find
Group will provide each Subscriber with copies of the Certificate, the applicable Summary(ies) of Benefits, the
Appeals Packet (if applicable), and all privacy notices and other notices from Delta Dental as may be required by
any applicable federal or state law, at such intervals as may be required by law.
The plan specifications are subject to exclusions and limitations. Refer to the Summary of Benefits for more
information.
December 1, 2023 4715-10012000
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CONTRACT NO: C-86-19-025-3-05 / PH RFP 190140 AMENDMENT NO: 5
IN WITNESS WHEREOF, the parties agree to the changes indicated herein:
FOR AND ON BEHALF OF FOR AND ON BEHALF OF
MARICOPA COUNTY DELTA DENTAL PLAN OF ARIZONA
BLeA7Z-Zeo—
By: By:
Chairman, Board of Supervisors Delta Dental Plan of Arizona
SL ¢feo2/
Date Date 4
ATTEST
Clerk of the Board
Date
APPROVED AS TO FORM
Attorney for Maricopa County
Date
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