fulfilling life
Group benefits proposal for City of Vernon
Lynn Nguyen
151 Kalmus Dr, Suite J4
Costa Mesa, CA 92626
818-907-9071
License #0K16753
Dental Insurance Proposal
Presented By
KEENAN & ASSOCIATES
License #0451271
September 16, 2026
Ameritas Life Insurance Corp.
2 Based on the information provided to
us, we've prepared this proposal to
meet the needs of City of Vernon and
its people. Every benefits solution we
offer -- from fully insured coverage to
administrative service arrangements --
represents our promise to provide
products that help protect the health of
your employees and serve your
organization. If any of your information
or needs change, we will be happy to
provide an updated proposal.
Dental Plan Design Summary .............3
Covered Procedure Summary .............4
Dental Features/Benefits.....................5
Assumptions/Requirements.................6
Limitations/Exclusions .........................8
DHMO Plan Summary.........................9
ameritas.com
City of Vernon
Plan Design Summary
3 Dental Summary Proposed Effective Date: 1/1/2027
Plan 1
Plan Benefit In Network Out of Network
Type 1 100% 100%
Type 2 90% 90%
Type 3 50% 50%
Deductible $25/Calendar Year $25/Calendar Year
Waived Type 1 Waived Type 1
$75/family $75/family
Maximum (per person) $3,000/Calendar Year $2,000/Calendar Year Preventive PlusSM Included Included
PPO Freedom of Choice®
Allowance Type 1 Discounted Fee 90th U&C
Type 2 Discounted Fee 90th U&C
Type 3 Discounted Fee 90th U&C
Waiting Period None None
DHMO See DHMO page for details See DHMO page for details Annual Open Enrollment Included Included
Orthodontia Summary
Allowance All Plan Designs: In Network, discounted fee. Out of Network, U&C.
Plan Benefit 50%
Coverage for Adults No
Lifetime Maximum (per person) $2,000
Waiting Period None
Takeover Benefit Initial Insureds & New Enrollees
Monthly Rates
Employee (EE) $74.41
EE + Spouse $146.64
EE + Children $179.60
EE + Spouse & Children $273.97
Rates are guaranteed for 24 months following the effective date listed above and include Orthodontia if part of plan design.
Rates include: home address mailing.
PLEASE NOTE: Rates assume enrollment in our electronic certificate (eCert) program. If you choose to receive paper certificates, monthly rates will increase.
Employee Participation Requirements Eligible Employees: 319 The greater of 15% or 5 lives
Contributory
City of Vernon
Covered Procedure Summary
4 Plan 1
In Network Out of Network
Plan Design
Summary
100/90/50
$25/Calendar Year
Waived Type 1
$75/family
$3,000
100/90/50
$25/Calendar Year
Waived Type 1
$75/family
$2,000
Type 1
Procedure
(Frequency)
⚫ Routine Exam
(1 per benefit period)
⚫ Bitewing X-rays
(2 per benefit period)
⚫ Full Mouth/Panoramic X-rays
(1 in 5 years)
⚫ Cleaning
(2 per benefit period)
⚫ Fluoride for Children 18 and under
(1 per benefit period)
⚫ Sealants (age 15 and under)
⚫ Routine Exam
(1 per benefit period)
⚫ Bitewing X-rays
(2 per benefit period)
⚫ Full Mouth/Panoramic X-rays
(1 in 5 years)
⚫ Cleaning
(2 per benefit period)
⚫ Fluoride for Children 18 and under
(1 per benefit period)
⚫ Sealants (age 15 and under)
Type 2
Procedure
(Frequency)
⚫ Periapical X-rays
⚫ Space Maintainers
⚫ Fillings for Cavities
⚫ Restorative Composites
(anterior and posterior teeth)
⚫ Endodontics (nonsurgical)
⚫ Endodontics (surgical)
⚫ Periodontics (nonsurgical)
⚫ Periodontics (surgical)
⚫ Denture Repair
⚫ Simple Extractions
⚫ Complex Extractions
⚫ Anesthesia
⚫ Periapical X-rays
⚫ Space Maintainers
⚫ Fillings for Cavities
⚫ Restorative Composites
(anterior and posterior teeth)
⚫ Endodontics (nonsurgical)
⚫ Endodontics (surgical)
⚫ Periodontics (nonsurgical)
⚫ Periodontics (surgical)
⚫ Denture Repair
⚫ Simple Extractions
⚫ Complex Extractions
⚫ Anesthesia
Type 3
Procedure
(Frequency)
⚫ Onlays
⚫ Crowns
(1 in 7 years per tooth)
⚫ Crown Repair
⚫ Implants
⚫ Prosthodontics (fixed bridge; removable complete/partial dentures)
(1 in 7 years)
⚫ Onlays
⚫ Crowns
(1 in 7 years per tooth)
⚫ Crown Repair
⚫ Implants
⚫ Prosthodontics (fixed bridge; removable complete/partial dentures)
(1 in 7 years)
Current Dental Terminology © American Dental Association.
City of Vernon
Features/Benefits
5 Ameritas Dental Network
⚫ The Ameritas Dental Network is one of the nation’s largest. Network providers have agreed to charge 25-50% less than their regular rates which helps benefit dollars go further.
⚫ Members can visit any dentist, in- or out-of-network. And family members do not need to visit the same provider. Members can even visit dental providers in Mexico and still receive coverage.
U&C
We determine the Usual and Customary (U&C) allowance listed on the plan summary page using information including data from a nationally recognized independent data source. Plan members are reimbursed based on the appropriate amounts in the dentist's ZIP Code area. A percentile of these amounts is used to set the plan’s coverage limit. We review our U&C allowances annually.
Preventive PlusSM
⚫ With this plan option, benefits for Type 1/Preventive procedures are not deducted from the plan member's annual maximum benefit. This saves the entire annual maximum for the Type 2/Basic and Type 3/Major procedures that are covered by your plan.
Composites on Molars
This dental proposal includes a benefit for composite fillings on the molars located in the back of the mouth. This complements the composite filling benefit we already offer on bicuspids, which are the teeth next to the molars. Dental composites consist of a core plastic material, also known as resin, mixed with fillers to achieve various levels of strength, wear resistance and color. The result is a more natural-looking, tooth-color filling.
Worldwide Support
If a member has a dental emergency outside the U.S., AXA Assistance can help. AXA provides credible provider referrals and can even help with making the appointment. Providers referred by AXA are not members of the Ameritas network. AXA contact information is available in the secure member account.
Deductibles
After the date that $75 in accumulated deductibles with network providers, or $75 in accumulated deductibles with a non-network provider, has been met within a family, the entire deductible or any remaining portion of the deductible amount for any other family members will be waived for the rest of that calendar year. At no time can a family member contribute more than the selected deductible amount.
City of Vernon
Assumptions/Requirements
6 ⚫ If you purchase group insurance through Ameritas, your producer will receive compensation from Ameritas Group. This compensation may include one or more of the following:
⚫ Commission or override commission based on customary or negotiated scales. ⚫ Additional compensation based on factors such as the volume of premium, cases or lives placed by your producer with Ameritas, or persistency.
⚫ Fees for administrative or consulting services.
If you have any questions about the amount or type of compensation, please contact your producer. ⚫ Some states require that producers be appointed with Ameritas Life Insurance Corp. before any presentation or solicitation of this plan design.
⚫ This proposal is not a contract or a certificate of insurance. It contains proposed rates and benefits that are based on preliminary enrollment data. Such rates and benefits are subject to adjustment if final enrollment varies from the preliminary data. ⚫ The rates are based on Standard Industry Code 922013. ⚫ This proposal is based on the assumption it will be sold in conjunction with a bona fide cafeteria plan regulated by Section 125 of the Internal Revenue code, and it must meet all of the Section 125 requirements. Ameritas Life Insurance Corp. reserves the right to request a copy of the employer's Section 125 cafeteria plan. If you select Ameritas Life Insurance Corp.'s plan and implement it through a cafeteria approach regulated by Section 125, we will require that all eligible employees and dependents requesting benefits: (a) make annual selections, and (b) remain in the plan for a minimum of one year. Changes in these selections will not be allowed except for certain "life event" or family status changes such as marriage, birth, death or termination of employment. ⚫ This proposal assumes a Section 125 plan year of January 1, 2027 to January 1, 2028. ⚫ Benefits could be available for all full-time, active employees working at least 30 hours per week and dependents who have completed the designated waiting period.
⚫ This proposal is being made as a result of information provided in the request for a proposal. It is intended for informational purposes and is not an offer to contract. If City of Vernon wishes to apply for group insurance based upon this proposal, City of Vernon may complete a Preliminary Application for Group Insurance. The Application will be subject to review and approval by the Home Office of the Company. If the Application is accepted, the final rates and benefits will be based on verification of this information and final enrollment.
⚫ California state law requires that coverage shall be provided to Registered Domestic Partners that is equal to, and subject to the same terms and conditions as, the coverage provided to a spouse. Registered Domestic Partner means a partner of the Insured as long as the partnership meets the requirements for such relationship as defined in Section 297 of the California Family Code or the functional equivalent registration of any other state or local jurisdiction. ⚫ Ameritas does not issue coverage to individuals residing in Europe. ⚫ The situs State of California has passed legislation which requires dependent children to be considered covered up to age 26 regardless of student status.
⚫ For residents of New Mexico, coverage will be administered in accordance with the minimum benefit standards required by New Mexico law. Please consult your sales representative with questions regarding these requirements. ⚫ Please let us know if you need a Spanish-language version of the Certificate. ⚫ The employer and employee both contribute to the employee and dependent cost. THE POLICYHOLDER IS REQUIRED TO CONTRIBUTE AT LEAST 25% OF THE TOTAL EMPLOYEE AND DEPENDENT PREMIUM. (An employee may never pay all of the employee premium.)
City of Vernon
Assumptions/Requirements
7 ⚫ This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period. An employee who elects to participate at an election period other than the initial election period or annual open enrollment period will be a Late Entrant and subject to the Late Entrant provision. ⚫ This proposal assumes a Section 125 plan year of January 1, 2027 to January 1, 2028. ⚫ A person initially covered under the DHMO dental plan may elect coverage under this policy at an annual enrollment switch period (with evidence of DHMO coverage) without application of the Late Entrant provision, if the election is made within 31 days of termination under the DHMO plan. If this coverage is elected later than 31 days following termination under the DHMO plan, the Late Entrant provision will be applied. A plan member may switch from this Indemnity dental plan to the DHMO plan and return as many times as desired with no Late Entrant restrictions, but only during the annual enrollment switch period. ⚫ If a person is covered at any time under Ameritas Life Insurance Corp.'s policy, elects coverage under the DHMO plan, and later re-elects coverage under Ameritas Life Insurance Corp.'s policy, the person will be treated as a new employee with no credit for previous coverage under this policy. If a patient begins receiving dental work under the Indemnity dental plan and then transfers to the reimbursement program, incomplete dental work will not be covered by Ameritas Life Insurance Corp. ⚫ Ameritas Life Insurance Corp. must be the only Indemnity/PPO carrier offered in addition to the DHMO plan. The carrier/provider on the DHMO plan should not have Indemnity/PPO plans to offer. ⚫ If the employee and their dependent(s) were covered for less than 6 months on the DHMO plan, the employee and their eligible dependent(s) may not switch to this plan until the following annual enrollment switch period. ⚫ If there is no employer contribution to the plan, a Section 125 plan must be in place for the group. ⚫ This proposal assumes 30% of the benefit eligible employees are retirees. If this percentage changes, Ameritas Life Insurance Corp. reserves the right to revise the rates retroactive to the effective date of the dental benefits to accommodate this change.
City of Vernon
Dental and (if applicable) Orthodontia Limitations/Exclusions 8 Covered Expenses will not include and no benefits will be payable for expenses incurred:
⚫ for any treatment which is for cosmetic purposes, except as specifically listed in the Table of Dental Procedures. ⚫ to replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed partial denture within seven years of the date of the last placement of these items. However, if a replacement is required because of an accidental bodily injury sustained while the person is covered, it will be a Covered Expense.
⚫ for any procedure begun before the plan member was covered under the dental expense benefit. ⚫ for any procedure begun after the member's insurance under the dental expense benefit terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the member's insurance under the dental expense benefit terminates. ⚫ to replace lost or stolen appliances.
⚫ for appliances, restorations, or procedures to:
⚫ alter vertical dimension;
⚫ restore or maintain occlusion;
⚫ splint or replace tooth structure lost because of abrasion or attrition ⚫ for any procedure which is not shown on the Table of Dental Procedures. ⚫ for orthodontic treatment (unless otherwise specified in this contract.) ⚫ for charges for which the plan member is not liable or which would not have been made had no insurance been in force. ⚫ for services which are not required for necessary care and treatment or are not within the generally accepted parameters of care. ⚫ because of war or any act of war, declared or not.
⚫ for a Program which was begun on or after the member's 19th birthday. ⚫ in any quarter of a Program if the member was not covered under the orthodontic expense benefits for the entire quarter. ⚫ after the member's insurance under the orthodontic expense benefits terminates. ⚫ for a Program begun before the member became covered under this section, unless the member was covered for orthodontic expense benefits under the prior carrier and are both:
⚫ insured under this policy; and
⚫ currently undergoing a treatment program.
Southern California DHMO Dental Rates: LDP-200
Company Name: City of Vernon
Proposed Effective Date: 1/1/2027
9 Rates are guaranteed for 24 months, for groups enrolled 1/1/2026 through 12/31/2027. 4 Tier Rates
DHMO Plans LDP-200
Employee Only $16.26
Employee & Spouse $28.62
Employee & Child(ren) $29.92
Employee & Family $40.33
Group Size: 2 -300; groups over 300 employees contact your representative Rate Assumption: Based on Group Situs Contribution: Valid for Voluntary and Employer Paid Groups Billing: Ameritas Co-packaged Billing Network: CA DHMO Select Coverage Areas: Southern California Regions DHMO Benefit Plan Summary: LDP-200
Code Description Member Copayment
Diagnostic Services
D0120 Periodic oral evaluation $0
D0140 Limited oral evaluation $0
D0150 Comprehensive oral evaluation $0
D0210 Intraoral, complete series of radiographic images $0 D0220 Intraoral, periapical, first radiographic image $0 D0230 Intraoral, periapical, each additional radiographic image $0 D0272 Bitewings, 2 radiographic images $0
D0274 Bitewings, 4 radiographic images $0
D0330 Panoramic radiographic image $0
Preventive Services
D1110 Prophylaxis, adult $0
D1120 Prophylaxis, child $0
Restorative Services
D2140 Amalgam, 1 surface, primary or permanent $0
D2150 Amalgam, 2 surfaces, primary or permanent $0
D2160 Amalgam, 3 surfaces, primary or permanent $0
D2391 Resin-based composite, 1 surface, posterior $35
D2751 Crown, porcelain fused to predominantly base metal* $55 *The total maximum amount chargeable to the member for elective upgraded procedures is $250.00 per tooth.
Endodontic Services
D3330 Root canal, Molar (excluding final restoration) $0 Periodontal Services
D4341 Periodontal scaling & root planing, 4 or more teeth per quadrant $0 D4910 Periodontal maintenance $0
Removable Prosthodontic Services
D5110 Complete denture, maxillary $0
Oral and Max Surgery
D7140 Extraction, erupted tooth or exposed root $0
D7210 Surgical removal of erupted tooth $0
Orthodontia
D8080 Comprehensive orthodontic treatment of the adolescent dentition $1,775 D8090 Comprehensive orthodontic treatment of the adult dentition $1,950 This is only a summary of the Plans. The Dental Plan Contract, complete Benefit Schedule and Evidence of Coverage must be consulted to determine the exact terms, limitations and exclusions of coverage. Groups must meet the terms and conditions. Please see LIBERY's Underwriting Guidelines for more details. Custom rate combinations are available upon request.
Terms and Conditions
10 Rates are subject to change based on underwriting review and discovery of material differences in any of the following:
Dental Underwriting Guidelines
DHMO Group Size 2-300 employees
Contribution Rates are valid for both voluntary and employer paid groups.
Participation A group must have a minimum of two (2) enrolled members to have coverage.
Dual Option
May be offered with Ameritas PPO Plans, or as a standalone DHMO option plan.
Group can have up to two LDP plans, with a minimum of 2 employees in each plan, and minimum of 5 in Ameritas PPO Plan(s).
Billing
There are no monthly billing fees. Group shall pay monthly premiums to LIBERTY in accordance with the premium rates set forth in the Group Application. Billing occurs around the 5th of each month. Premium is due by the 20th prior to month of coverage.
Rates Rates are subject to revision at any time if required by state law. Rates are subject to LIBERTY’s coverage areas.
Coverage Areas
Southern California: Imperial, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Ventura
Northern California: Alameda, Contra Costa, El Dorado, Fresno, Kern, Kings, Madera, Marin, Merced, Monterey, Napa, Placer, Sacramento, San Francisco, San Joaquin, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Shasta, Solano, Sonoma, Stanislaus, Sutter, Tulare, Yolo