Exhibit C - Cost Exhibit.xlsx

This is a Cost Exhibit for Colorado's Dental Benefit Program, specifically detailing the pricing and operational requirements for a Dental Preferred Provider Organization (DPPO) Administrative Services Organization (ASO) contract. The exhibit consists of seven interconnected Excel worksheets that establish the framework for dental plan administration and network management across five contract years spanning from July 1, 2027, through June 30, 2032. Offerors must complete detailed information regarding their organization, pricing structure, provider networks, and benefit plan designs while adhering to strict formatting requirements, including maintaining all pre-labeled rows and columns and submitting responses in Excel format with electronic signatures. The contract covers administration for 37,134 active participants and COBRA enrollees annually and requires vendors to demonstrate comprehensive service capabilities including claims administration with at least 12 months of runout administration, network access and maintenance, reporting, ID card production with state branding, and member services.

Pricing is structured on a per-subscriber-per-month (PSPM) basis for base administration fees covering dental claim administration and network access, with additional optional services available at the client's discretion. Offerors must provide re-priced claims based on their current provider contracts, demonstrating discounts applied to both in-network and out-of-network claims, along with discount guarantee details. The exhibit requires detailed provider network information, including unique provider counts by specialty and geographic location using three-digit zip codes, as well as geo-access analysis demonstrating compliance with urban (1 in 2 miles), suburban (1 in 5 miles), and rural (1 in 10 miles) access standards. Two benefit plan designs are proposed—a Basic Plan with 70% basic restorative and 50% major restorative coverage with $1,500 annual maximums, and a Basic Plus Plan with 80% basic and 50% major coverage with $3,000 annual maximums—both including orthodontia benefits capped at $1,500 lifetime maximums and frequency limitations on specific services such as fillings, crowns, and implants.