RFP No. HHS001708 Exhibit C

Exhibit C, Deliverables - Liquidated Damages Matrix # Service/

Component1 Performance Standard2 Measurement

Period3 Measurement Assessment4

Liquidated Damages

Operations Readiness (OR)

OR-1 Section 2.5, Transition Phase Scope, of Exhibit G, Dental Services SOW.

Section 2.6, Operations Phase Scope, of Exhibit G, Dental Services SOW.

The Dental Contractor must be operational no later than the agreed upon Operational Start Date. HHSC, or its agent, will determine when the Dental Contractor is considered to be operational based on the requirements in Sections 2.5 and 2.6 of the Exhibit G, Dental Services

SOW.

Operational Start Date

Each Day of noncompliance, per Program.

HHSC may assess up to $10,000 per Day and per Program of noncompliance for each Day beyond the Operational Start Date that the Dental Contractor is not operational until the Day that the Dental Contractor is operational, including all systems.

OR-2

Section 2.5.3.6, System Readiness and Transfer of Data, of Exhibit G, Dental Services SOW.

The Dental Contractor must submit to HHSC or to the designated Readiness Review contractor the following plans for review, no later than 120 Days prior to the Operational Start Date:

1. Disaster Recovery Plan;

2. Business Continuity Plan;

3. Security Management Plan;

4. Joint Interface Plan;

5. Risk Management Plan;

6. Systems Quality Assurance Plan;

and

7. Change Management Plan.

Transition Phase

Each Day of noncompliance, per plan, per Program.

HHSC may assess up to $1,000 per Day of noncompliance and per plan, per Program for each Day a Deliverable is not submitted or is late, inaccurate, or incomplete.

1 Derived from Exhibit A, Dental Contract Terms and Conditions, Exhibit B, Uniform Managed Care Manual (UMCM), or Exhibit G, Dental Services

SOW.

2 Standard specified in Exhibit G, Dental Services SOW. Note: Where the due date states 30 Days, the Dental Contractor is to provide the Deliverable by the last Day of the month following the end of the reporting period. Where the due date states 45 Days, the Dental Contractor is to provide the Deliverable by the 15th Day of the second month following the end of the reporting period.

3 Period during which HHSC will evaluate service for purposes of tailored remedies.

4 Measure against which HHSC will apply remedies.

# Service/ Component1

Performance Standard2 Measurement Period3

Measurement Assessment4

Liquidated Damages

OR-3

Section 2.5.3.7, Operations Readiness, of Exhibit G, Dental Services

SOW.

Final versions of the Provider directory must be submitted to the HHSC Administrative Services Contractor no later than 95 Days prior to the Operational Start Date.

Transition Phase

Each Day of noncompliance, per Provider directory, per Program.

HHSC may assess up to $1,000 per Day of noncompliance and per Provider directory, per Program for each Day the Provider directory is not submitted or is late, inaccurate, or incomplete.

DSOR-1 Section 2.5.3.6, System Readiness and Transfer of Data, of Exhibit G, Dental Services SOW.

The Dental Contractor must timely and successfully meet Readiness Review requirements set forth in Section 2.5, Transition Phase Scope, of Exhibit G, Dental Services SOW, no later than 90 Days prior to the Operational Start Date.

Transition Phase

Each Day of noncompliance.

HHSC may assess up to $25,000 per Day of noncompliance for each Day beyond the 90 Days prior to the Operational Start Date due date that the Dental Contractor has not met a particular Readiness Review standard unless a delay is otherwise approved in writing by HHSC.

DSOR-2 Section 2.5.3.7, Operations Readiness, of Exhibit G, Dental Services

SOW.

The Dental Contractor must submit updated financial documents and Material Subcontractor information as listed in Sections 5.5, Required Financial Information, 5.5.2, Material Subcontractor Information, and 5.5.4, Financial Statements and Financial Solvency, of the Solicitation document as part of the Financial and Organizational Readiness Review mandated in Section 2.5.3.9, Other Reports for Organizational and Financial Readiness Review, of Exhibit G, Dental Services SOW.

Transition Phase and Operations Phase

Per Day, per incident of noncompliance, per Dental Contractor.

HHSC may assess up to $1,000 per Day, per incident of noncompliance, and per Dental Contractor.

General/ Administrative (GA)

GA-1 General Requirement:

Failure to Perform an Administrative Service

Exhibit A, Dental Contract Terms and Conditions

Sections 2.5, Transition Phase Scope; 2.6, Operations Phase Scope; and 2.7, Turnover Phase Scope; of Exhibit G, Dental Services SOW.

The Dental Contractor fails to timely, accurately, or completely perform a Dental Contractor Administrative Service that is not otherwise associated with a performance standard in this matrix and, in the determination of HHSC, such failure either: (1) results in actual harm to a Member or enrollee or places a Member at risk of imminent harm, or

(2) materially affects HHSC’s ability to administer the Dental Program.

Ongoing Per Day, per incident of noncompliance, per Program

HHSC may assess up to $5,000 per Day and per Program for each incident of noncompliance.

GA-2 General Requirement:

Failure to Provide a Covered Service

Exhibit A, Dental Contract Terms and Conditions.

Sections 2.5, Transition Phase Scope; 2.6, Operations Phase Scope; and 2.7, Turnover Phase Scope; of Exhibit G, Dental Services SOW.

The Dental Contractor fails to timely provide a Dental Contractor Covered Service that is not otherwise associated with a performance standard in this matrix and, in the determination of HHSC, such failure results in actual harm to a Member or places a Member at risk of imminent harm.

Ongoing Each Day of noncompliance, per incident of noncompliance.

HHSC may assess up to $7,500 per Day of noncompliance for each incident of noncompliance.

GA-3 Sections 2.5, Transition Phase Scope; 2.6, Operations Phase Scope; and 2.7, Turnover Phase Scope; of Exhibit G, All reports and Deliverables as specified in Sections 2.5, 2.6, and 2.7 of Exhibit G, Dental Services SOW, must be submitted timely and be accurate and complete according to the timeframes and requirements stated in the Contract (including all attachments) and the UMCM.

Ongoing Per Day of noncompliance, per Program.

Unless other liquidated damages apply to specific reports and Deliverables herein, HHSC may assess up to $250 per Day of noncompliance, per Program, if the monthly, quarterly, or annual report/Deliverable is not

Dental Services

SOW.

Exhibit B, UMCM.

(Specific reports or Deliverables listed separately in this matrix are subject to the specified liquidated damages.)

submitted or is late, inaccurate, or incomplete.

GA-4 Sections 2.5, Transition Phase Scope; 2.6, Operations Phase Scope; and 2.7, Turnover Phase Scope; of Exhibit G, Dental Services

SOW.

Exhibit B, UMCM.

All reports as specified in Sections 2.5, 2.6, 2.7 of Exhibit G, Dental Services SOW must be submitted according to the format or template requirements stated in the Contract (including all attachments) and Exhibit

B, UMCM.

Ongoing Per incident of noncompliance, per Program.

Unless other liquidated damages apply to specific reports and Deliverables herein, HHSC may assess up to $1,000 per incident of noncompliance, per Program, if either the monthly, quarterly, or annual report is not submitted in the format/template required by

HHSC.

Privacy/ Security (PS) PS-1 Section 6.07, HIPAA, and Article 9, Disclosure, Confidentiality, Privacy, and Security of Information, of Exhibit A, Dental Contract Terms and Conditions.

The Dental Contractor must meet all privacy standards under applicable State or federal law, rule, regulation and HHSC Contract requirement.

Transition Phase and Quarterly during Operations Phase

Per quarterly reporting period, per violation.

HHSC may assess up to $5,000 per quarterly reporting period for each privacy violation of applicable federal or State law or the HHSC privacy standards in the Contract.

PS-2 Section 6.07, HIPAA, and Article 9, Disclosure, Confidentiality, Privacy, and Security of Information, of Exhibit A, Dental Contract Terms and Conditions.

The Dental Contractor must meet all security standards under applicable State or federal law, rule, regulation and HHSC contract requirement.

Transition Phase and Quarterly during Operations Phase

Per quarterly reporting period, per violation.

HHSC may assess up to $1,000 each security violation of security requirements under federal or State law or the HHSC security standards in the Contract.

PS-3 Section 6.07, HIPAA, and Article 9, Disclosure, Confidentiality, Privacy, and Security

The Dental Contractor must meet all confidentiality standards under applicable State or federal law, rule, Transition Phase and Quarterly during

Per quarterly reporting period, per

HHSC may assess up to $5,000 each breach by Dental of Information, of Exhibit A, Dental Contract Terms and Conditions.

regulation and HHSC contract requirement.

Operations Phase privacy/security incident.

Contractor scenario as required by HHSC.

PS-4 Section 6.07, HIPAA, and Article 9, Disclosure, Confidentiality, Privacy, and Security of Information, of Exhibit A, Dental Contract Terms and Conditions.

The Dental Contractor must meet the privacy breach notification and/or breach response standard required by applicable federal and State law and HHSC contract requirements.

Transition Phase and Quarterly during Operations Phase

Per Day, per violation of breach notification and/or response standards of an actual or suspected privacy breach which may or actually requires notification to HHSC, an individual, the press and/or a federal regulatory body or may require appropriate mitigation and/or remediation activity.

HHSC may assess up to $1,000 per Day for each Dental Contractor violation of breach notice, breach response standard for each violation and/or for each privacy violation impacting an individual according to applicable federal or state breach notification law or the HHSC breach notification and response standards in the Contract.

Material Subcontractors (MS)

MS-1 Section 4.08, Subcontractors and Agreements with Third Parties, of Exhibit A, Dental Contract Terms and Conditions.

Unless otherwise provided in this Contract, the Dental Contractor must provide HHSC with written notice no later than three Business Days after receiving notice from a Material Subcontractor of its intent to terminate a Subcontract.

Transition Phase, Measured Quarterly during the

Phase

Per Day of noncompliance.

HHSC may assess up to $5,000 per Day of noncompliance.

MS-2 Section 4.08, Subcontractors and Agreements with Third Parties, of Exhibit A, Dental

Unless otherwise provided in this Contract, the Dental Contractor must provide HHSC with written notice no later than 180 Days prior to the termination date of a Material

Transition Phase, Measured Quarterly during the

Per Day of noncompliance.

per Day of noncompliance.

Contract Terms and Conditions.

Subcontract for MIS systems operation or reporting.

MS-3 Section 4.08, Subcontractors and Agreements with Third Parties, of Exhibit A, Dental Contract Terms and Conditions.

Unless otherwise provided in this Contract, the Dental Contractor must provide HHSC with written notice no later than 90 Days prior to the termination date of a Material Subcontract for non-MIS Dental Contractor Administrative Services.

Transition Phase, Measured Quarterly during the

HHSC may assess up to $5,000 per Day of noncompliance.

MS-4 Section 4.08, Subcontractors and Agreements with Third Parties, of Exhibit A, Dental Contract Terms and Conditions.

Unless otherwise provided in this Contract, the Dental Contractor must provide HHSC with written notice no later than 30 Days prior to the termination date of any other Material Subcontract.

Transition Phase, Measured Quarterly during the

HHSC may assess up to $5,000 per Day of noncompliance.

Claims (CL)

CL-1 Section 2.6.24.1, General Reporting Requirements, of Exhibit G, Dental Services SOW.

Chapter 5, Deliverables, Report Formats, Due Dates, of Exhibit B, UMCM.

Claims Summary Report:

The Dental Contractor must submit monthly Claims Summary Reports to HHSC by Program by the last Day of each month following the reporting period.

Operations Phase

Per Day of noncompliance, per Program.

HHSC may assess up to $1,000 per Day of noncompliance and per Program that the report is not submitted or is late, inaccurate, or incomplete.

CL-2

Sections 2.6.28.1, Provider Appeal of Dental Contractor Claims Determination, and 2.6.28.3.2, CHIP Provider Appeal of Dental Contractor Claims Determination, The Dental Contractor must resolve at least 98% of appealed claims within 30 Days from the date the appealed claim is filed with the Dental Contractor.

Operations Phase and Turnover Phase

Per month, per Program.

For the first occurrence of noncompliance: HHSC may assess up to $1,750 per month and per Program that a Dental Contractor’s monthly performance percentages fall below the performance standards.

of Exhibit G, Dental Services SOW.

Chapter 2, Texas Claim Procedures, of Exhibit B, UMCM.

For each subsequent occurrence of noncompliance: HHSC may assess up to $8,500 per month and per Program that a Dental Contractor’s monthly performance percentages fall below the performance standards.

CL-3 Section 2.6.11.1, Claims Project, of Exhibit G, Dental Services SOW.

Chapters 2, Texas Claims Procedures, and 5, Deliverables, Report Formats, Due Dates, of Exhibit B, UMCM.

The Dental Contractor must complete all Claims Projects within 60 Days of the claims project's start date unless the Dental Contractor enters into a written agreement with the Provider before the initial expiration of the 60 Days to establish the claims projects agreed upon timeframe.

Operations Phase

Per incident of noncompliance.

HHSC may assess up to $5,000 per incident of noncompliance. A claim’s project incident of noncompliance is considered any claims project not completed within 60 Days of the claims project’s start date.

CL-4 Section 2.6.25.3, Claims Processing Requirements, of Exhibit G, Dental Services SOW.

Chapter 2, Texas Claims Procedures, of Exhibit B, UMCM.

For a Clean Claim not adjudicated within 30 Days of receipt by the Dental Contractor, the Dental Contractor must pay the provider interest at 18% per annum, calculated daily for the full period in which the Clean Claim remains unadjudicated beyond the 30-Day claims processing deadline. Interest owed to the provider must be paid on the same date as the claim.

Operations Phase and Turnover Phase

Per month, per claim, per Program.

HHSC may assess up to $1,000 per month, per claim, and per Program if the Dental Contractor fails to pay interest timely.

CL-5

Section 2.6.25.3, Claims Processing Requirements, of Exhibit G, Dental Services SOW.

Chapter 2, Texas Claims Procedures, of Exhibit B, UMCM.

The Dental Contractor must comply with the claims processing requirements and standards as described in Section 2.6.25.3 of Exhibit G, Dental Services SOW and in Chapter 2 of Exhibit B, UMCM.

The Dental Contractor must pay or deny 98% of Clean Claims within 30

Operations Phase

Per month and per Program.

For the first occurrence of noncompliance: HHSC may assess up to $1,750 per month and per Program that a Dental Contractor’s claims performance percentages fall below the performance standards.

For each subsequent occurrence of noncompliance: HHSC may

Days of the claim being submitted to the Dental Contractor.

assess up to $8,500 per month and per Program that a Dental Contractor’s monthly claims performance percentages fall below the performance standards.

CL-6

Section 2.6.25.3, Claims Processing Requirements, of Exhibit G, Dental Services SOW.

Chapter 2, Texas Claims Procedures, of Exhibit B, UMCM.

The Dental Contractor must comply with the claims processing requirements and standards as described in Section 2.6.25.3 of Exhibit G, Dental Services SOW and in Chapter 2 of Exhibit B, UMCM.

The Dental Contractor must pay or deny 99% of Clean Claims within 90 Days of the claim being submitted to the Dental Contractor.

Operations Phase

Per month, and per Program.

For the first occurrence of noncompliance: HHSC may assess up to $1,750 per month and per Program that a Dental Contractor’s monthly claims performance percentages fall below the performance standards.

For each subsequent occurrence of noncompliance: HHSC may assess up to $8,500 per month and per Program that a Dental Contractor’s monthly claims performance percentages fall below the performance standards.

Encounter Data (ED)

ED-1 Section 2.6.25.2, Encounter Data, of Exhibit G, Dental Services SOW.

The Dental Contractor must submit complete and accurate Encounter Data transmissions in accordance with Section 2.6.25.2 of Exhibit G, Dental Services SOW.

Measured Quarterly during Operations Phase

Per Day, per incident of per Program.

For the initial quarter: HHSC may assess up to $500 per Day, per incident of noncompliance, and per Program that the Dental Contractor fails to submit complete and accurate Encounter Data in the quarter.

For each subsequent quarter:

HHSC may assess up to $1,000 per Day, per incident of noncompliance, and per Program for each quarter the Dental Contractor fails to submit complete and accurate Encounter Data.

ED-2 Section 2.6.25.2, Encounter Data, of Exhibit G, Dental Services SOW.

The Dental Contractor will be subject to liquidated damages if the Quarterly Encounter Reconciliation Report (which reconciles the year-to-date paid claims reported in the Financial Statistical Report (FSR) to the appropriate paid dollars reported in the Vision 21 Data Warehouse) includes more than a 2% variance.

Operations Phase

Per quarter, per incident of noncompliance, per Program.

HHSC may assess up to $2,500 per quarter, per incident of noncompliance, and per Program if the Dental Contractor is not within the 2% variance.

per quarter, per incident of noncompliance, and per Program for each additional quarter that the Dental Contractor is not within the 2% variance.

ED-3 Section 2.6.25.2, Encounter Data, of Exhibit G, Dental Services SOW.

The Dental Contractor must submit Encounter Data transmissions and include all Encounter Data and Encounter Data adjustments processed by the Dental Contractor on a monthly basis, not later than the 30th Day after the last Day of the month in which the claim(s) are adjudicated.

Measured Quarterly during Operations Phase

Per month, per incident of noncompliance, per Program.

For the initial quarter: HHSC may assess up to $2,500 per month, per incident of noncompliance, per Program if the Dental Contractor fails to submit Encounter Data in a quarter.

For each subsequent quarter:

HHSC may assess up to $5,000 per month, per incident of noncompliance, per Program for each month in any subsequent quarter that the Dental Contractor fails to submit monthly Encounter Data.

Hotlines (HL)

HL-1 Sections 2.6.9, Provider Hotline, and 2.6.15.1, Member Hotline, of Exhibit G, Dental Services SOW.

The Dental Contractor must operate toll-free Member and Provider hotlines from 8 AM – 5 PM, local time Monday through Friday, excluding State-approved holidays.

Operations Phase and Turnover Phase

Per month, per incident of noncompliance, per hotline, per Program.

HHSC may assess up to $100 per month, per incident of noncompliance, per hotline, and per Program for each hour, or portion thereof, that appropriately staffed hotlines are not operational.

If the Dental Contractor’s failure to meet the performance standard is caused by a Force Majeure Event, HHSC will not assess liquidated damages unless the Dental Contractor fails to implement its Disaster Recovery Plan.

HL-2 Section 2.6.15, Requirements Common to All Member-facing Hotlines, of Exhibit G, Dental Services SOW.

Call hold rate: At least 80% of calls must be answered by hotline staff within 30 seconds.

Phase and Turnover Phase

For each percentage point below the standard, per hotline, per Program, per monthly reporting period.

HHSC may assess up to $100 for each percentage point below the standard, per hotline, and per Program that the Dental Contractor fails to meet the requirements for a monthly reporting period for any Dental Contractor operated hotlines.

HL-3 Sections 2.6.9, Provider Hotline, and 2.6.15, Requirements Common to All Member-facing Hotlines, of Exhibit G, Dental Services SOW.

Call abandonment rate: The call abandonment rate must be 7% or less.

Operations Phase and Turnover Phase

For each percentage point above the standard, per hotline, per Program, per monthly reporting period.

HHSC may assess up to $100 for each percentage point above the standard, per hotline, and per Program that the Dental Contractor fails to meet the requirements for a monthly reporting period for any Dental Contractor operated hotlines.

HL-4 Sections 2.6.9, Provider Hotline, and 2.6.15, Requirements Common to All Member-facing Hotlines, of Exhibit G, Dental Services SOW.

The average hold time must be two minutes or less.

Operations Phase and Turnover Phase

Per month, per hotline, per Program for each 30 second time increment, or portion thereof, by which the average hold time exceeds

HHSC may assess up to $100 per month, per hotline, and per Program for each 30 second time increment, or portion thereof, by which the average hold time exceeds the maximum acceptable hold time.

the maximum acceptable hold time.

Complaints/Appeals (CA)

CA-1 Sections 2.6.29.1.

Children’s Medicaid Dental Services Member Complaint and Appeal System, and 2.6.29.2, CHIP Member Complaint and Appeal Process, of Exhibit G, Dental Services SOW.

The Dental Contractor must resolve at least 98% of Member Complaints within 30 Days from the date the Complaint is received by the Dental Contractor.

Operations Phase

Per monthly reporting period, per Program.

HHSC may assess up to $250 per monthly reporting period and per Program if the Dental Contractor fails to meet the performance standard.

CA-2 Sections 2.6.28.2, Children’s Medicaid Dental Services Provider Complaints, and 2.6.28.3, CHIP Dental Services Complaints and Appeals, of Exhibit G, Dental Services SOW.

The Dental Contractor must resolve at least 98% of Provider Complaints within 30 Days from the date the Complaint is received by the Dental Contractor.

Operations Phase

Per monthly reporting period, per Program.

HHSC may assess up to $250 per monthly reporting period and per Program if the Dental Contractor fails to meet the performance standard.

CA-3 Sections 2.6.29.1.1, Medicaid Dental Contractor’s Internal Appeal Process for Members, 2.6.29.1.2, Expedited Medicaid Dental Contractor Internal Appeals, 2.6.29.2, CHIP

Member Complaint and Appeal Process, of Exhibit G, Dental Services SOW.

The Dental Contractor must resolve at least 98% of Member appeals within the specified timeframes for standard and expedited appeals.

Per monthly reporting period, per Program.

HHSC may assess up to $500 per monthly reporting period and per Program if the Dental Contractor fails to meet the performance standard.

CA-4

Sections 2.6.28.2, Children’s Medicaid Dental Services Provider Complaints;

2.6.29.1, Children’s Medicaid Dental Services Member Complaint and Appeal System; 2.6.29.2, CHIP Member Complaint and Appeal Process; of Exhibit G, Dental Services SOW.

Chapter 3, Critical Elements, of Exhibit

B, UMCM.

The Dental Contractors must resolve Provider and Member Complaints received by HHSC and referred to the Dental Contractors no later than the due date indicated on HHSC’s notification form unless an extension is granted by HHSC. The Dental Contractor response must be submitted according to the timeframes and requirements stated within the Dental Contractor notification correspondence (letter, email, etc.).

Measured Quarterly

Per Day, per incident of noncompliance, per Program.

HHSC may assess up to $250 per Day and per incident of noncompliance, per Program for each Day beyond the due date specified within the Dental Contractor notification Correspondence.

DSCA-1

Section 2.6.29.1.3, Access to State Fair Hearing and External Medical Review (EMR) for Medicaid Members, of Exhibit G, Dental Services

SOW.

The Dental Contractor must ensure that the appropriate staff members who have firsthand knowledge of the Medicaid Member’s appeal be able to speak and provide relevant information on the case attend all State Fair Hearings as scheduled.

Transition Phase and Operations Phase

Per quarter, per incident of noncompliance.

HHSC may assess up to $1,000 per quarter and per incident of noncompliance for each State Fair Hearing that the Dental Contractor fails to attend as required by HHSC.

DSCA-2 Sections 2.6.28.2, Children’s Medicaid Dental Services Provider Complaints;

2.6.28.3, CHIP

Complaints and Appeals from Providers; 2.6.29.1, Children’s Medicaid Dental Services Member Complaint and Appeal System;

2.6.29.2, CHIP

Member Complaint and Appeal Process;

The Dental Contractor must categorize and process Provider and Member Complaints and Dental Contractor Appeals using the same definitions provided in the Dental Contract Terms and Conditions.

Transition Phase and Operations Phase

Per incident HHSC may assess up to $500 per incident in which a Complaint or Appeal is miscategorized or is not consistent with Complaint or Appeal definitions in the Terms and Conditions.

of Exhibit G, Dental Services SOW.

Provider Networks (PN)

PN-1 Sections 2.6.31, Access to Care;

2.6.31.1, Appointment Accessibility and Service Initiation;

2.6.31.2, Access to Providers; 2.6.31.4, Monitoring Access; of Exhibit G, Dental Services SOW.

The Dental Contractor must comply with the Contract’s distance or time standards and benchmarks for Member access.

Quarterly Per quarter, per incident of noncompliance, per Program, per county, and per Provider type.

HHSC may assess up to $1,000 per quarter, per incident of noncompliance, per Program, per county, and per Provider type.

PN-2 Section 2.6.21.5, Alternative Payment Models with Providers and Value Based Payments with Providers, of Exhibit G, Dental Services

SOW.

Chapter 8, Provider, of Exhibit B, UMCM.

The Dental Contractor must meet minimum APM ratios as follows:

• Measurement Year 1:

o Minimum Overall APM Ratio:

>=25% o Minimum Risk-Based APM Ratio: >=2%

• Measurement Year 2:

o Minimum Overall APM Ratio:

Year 1 Overall APM Ratio +25% o Minimum Risk-Based APM Ratio: Year 1 Risk-Based APM Ratio +25%

• Measurement Year 3:

o Minimum Overall APM Ratio:

Year 2 Overall APM Ratio +25% o Minimum Risk-Based APM Ratio: Year 2 Risk-Based APM Ratio +25%

Measured on November 1 of each calendar year for the previous calendar year period.

Per member per month (PMPM), per period of measurement.

Failure to meet calendar year target for overall APM, and not eligible for exception, based on HHSC's exception criteria:

up to $0.10 per Member per month (PMPM) for period of measurement.

Failure to meet target for Risk Based APM, and not eligible for exception:

up to $0.10 per Member per month (PMPM) for period of measurement.

• Measurement Years 4, and subsequent years:

o Minimum Overall APM Ratio:

>=50% o Minimum Risk Based APM Ratio: >=10%

PN-3 Section 2.6.33, Provider Network, of Exhibit G, Dental Services SOW.

Chapter 5, Deliverables, Report Formats, Due Dates, of Exhibit B, UMCM.

No more than 20% of total dollars billed to a Dental Contractor for "other outpatient services" may be billed by Out-of-Network providers.

Quarterly

Per quarter, per Program.

HHSC may assess up to $25,000 per quarter and per Program.

Marketing and Member Materials (MM)

MM-1 Section 2.6.20, Marketing and Prohibited Practices, of Exhibit G, Dental Services SOW.

Chapter 4, Marketing Policies and Practices, of Exhibit

B, UMCM.

The Dental Contractor must meet all Marketing and Member Materials policy requirements and may not engage in prohibited marketing practices.

Transition Phase, Measured Quarterly during the Operations Phase

Per quarter, per incident of noncompliance.

HHSC may assess up to $1,000 per quarter per incident of noncompliance.

MM-2 Section 2.6.20, Marketing and Prohibited Practices, of Exhibit G, Dental Services SOW.

Chapter 4, Marketing Policies and Practices, of Exhibit

B, UMCM.

The Dental Contractor must meet all Social Media policy requirements and may not engage in any prohibited Social Media practices.

Transition Phase, Operations Phase, and Turnover Phase

Per Business Day, per incident of noncompliance.

HHSC may assess up to $500 per Business Day for each incident of noncompliance.

MM-3

Section 2.6.14.1, Member Materials, of Exhibit G, Dental Services SOW.

No later than the 5th Business Day following the receipt of the Enrollment File from the HHSC Administrative Services Contractor, the Dental Contractor must mail a Member’s ID card and Member handbook to the Account Name or Case Head for each new Member. When the Account Name or Case Head represents two or more new Members, the Dental Contractor is only required to send one Member handbook.

Transition Phase, Operations Phase, and Turnover Phase

Per incident of noncompliance.

HHSC may assess up to $500 per incident of the Dental Contractor’s failure to mail Member Materials to the Account Name or Case Head for each new Member.

Management Information Systems (MI)

MI-1 Section 2.6.25, Management Information System Requirements, of Exhibit G, Dental Services SOW.

The Dental Contractor’s MIS must be able to resume operations within 72 hours of employing its Disaster Recovery Plan.

Measured Quarterly during the Operations Phase

Per Day of noncompliance, per Program.

HHSC may assess up to $5,000 per Day of noncompliance, per Program.

MI-2 Section 2.6.25.1, System-Wide Functions, of Exhibit G, Dental Services

SOW.

The Dental Contractor’s MIS system must meet all requirements in Section

2.6.25.1 of Exhibit G, Dental Services

SOW.

Measured Quarterly during the Operations Phase

Per Day of noncompliance, per Program.

HHSC may assess up to $5,000 per Day of noncompliance, per Program.

Financial Reporting (FR)

FR-1 Section 2.6.24.3.2, Financial Reporting Requirements, of Exhibit G, Dental Services SOW.

Chapter 5, Deliverables, Report Format, Due Dates, of Exhibit B, UMCM.

Financial Statistical Reports (FSR):

For each Program, the Dental Contractor must file quarterly and annual FSRs. Quarterly reports are due no later than 30 Days after the conclusion of each State Fiscal Quarter (SFQ). The first annual report is due no later than 120 Days after the end of each Contract Year and the second annual report is due no later

Quarterly and Annually during the Operations Phase and continuing during the Turnover Phase.

All reports pertaining to periods during

Per Day of noncompliance, per Program.

HHSC may assess up to $1,000 per Day of noncompliance, per Program for each report that is not submitted or is late, than 365 Days after the end of each Contract Year.

which the Contract was operational continue to be due, even if report due dates are after the Turnover Phase.

FR-2 Section 2.6.24.3.2, Financial Reporting Requirements, of Exhibit G, Dental Services SOW.

Chapter 5, Deliverables, Report Format, Due Dates, of Exhibit B, UMCM.

Claims Lag Report must be produced timely, and are accurate, and complete on a quarterly basis based on the State fiscal quarter and must be submitted by the last Day of the month following the reporting period.

Operations Phase and Turnover Phase

Per Day of noncompliance, per Program.

HHSC may assess up to $1,000 per Day of noncompliance and per Program for each report that is not submitted or is late, inaccurate, or incomplete.

FR-3 Section 2.6.24.3.2, Financial Reporting Requirements, of Exhibit G, Dental Services SOW.

Chapter 5, Deliverables, Report Format, Due Dates, of Exhibit B, UMCM.

Affiliate Report must be submitted on an as-occurs basis and annually by September 1 of each year in accordance with the UMCM. The “as-occurs” update is due within 30 Days of the event triggering the change.

Transition Phase and Operations Phase

Per Day of noncompliance.

HHSC may assess up to $1,000 per Day of noncompliance the report is not submitted or is late, inaccurate, or incomplete.

FR-4 Section 2.6.24.3.2, Financial Reporting Requirements, of Exhibit G, Dental Services SOW.

Chapter 5, Deliverables, Report Format, Due Dates, of Exhibit B, UMCM.

Report of Legal and Other Proceedings and Related Events: The Dental Contractor must comply with UMCM requirements regarding the disclosure of certain matters involving the Dental Contractor, its Affiliates, or its Material Subcontractors, as specified. This requirement is both on an as-occurs basis and an annual report due by September 1st. The as-occurs report is due no later than 30

Transition Phase and Operations Phase

Per Day of noncompliance.

HHSC may assess up to $1,000 per Day of noncompliance the report is not submitted or is late, inaccurate, or incomplete, or has material omissions.

Days after the event that triggered the notification requirement.

FR-5

Section 2.6.23, Financial Requirements for Covered Services, of Exhibit G, Dental Services SOW.

Third Party Liability and Recovery (TPL/TPR) Reports: The Dental Contractor must submit TPL/TPR reports quarterly by Dental Contractor Program and plan code, as described in UMCM Chapter 5.

Operations Phase

Per Day of noncompliance, per TPL/TPR report.

HHSC may assess up to $500 per Day of noncompliance and per TPL/TPR report that is not submitted or is late, inaccurate, or incomplete.

FR-6 Section 2.6.24.3.2, Financial Reporting Requirements, of Exhibit G, Dental Services SOW.

MCO Disclosure Statement: The Dental Contractor must submit an annual submission no later than September 1st each year and a change notification after a certain specified change, no later than 30 Days after the change.

Transition Phase, Operations Phase and Turnover Phase

Per Day of noncompliance.

HHSC may assess up to $1,000 per Day of noncompliance the report is not submitted or is late, FR-7

Section 2.6.24.3.2, Financial Reporting Requirements, of Exhibit G, Dental Services SOW.

TDI Examination Report the Dental Contractor must furnish a timely, accurate, and complete report with a full and complete copy of any examination report issued by TDI or another state, by no later than 10 Days after receipt of the final version from TDI.

Additionally, by September 1st each year, the Dental Contractor must notify HHSC of the anticipated date of the next issuance of a state department of insurance financial examination report. This annual notification should include a list of any other states in which the Dental Contractor is potentially subject to such examination reports, or a statement that the Dental Contractor is not such a subject in any other state.

Transition Phase, Operations Phase and Turnover Phase

Per Day of noncompliance.

HHSC may assess up to $1,000 per Day of noncompliance the report is not submitted or is late, FR-8 Section 2.6.24.3.2, Financial Reporting Requirements, of Exhibit G, Dental Services SOW.

TDI Financial Filings: The Dental Contractor must submit copies to HHSC of reports submitted to TDI no later than ten Days after the Dental Contractor’s submission to TDI.

Transition Phase and Operations Phase

Per Day of noncompliance.

HHSC may assess up to $500 per Day of noncompliance the report is not submitted or is late, inaccurate, or incomplete.

FR-9 Section 2.6.24.3.2, Financial Reporting Requirements, of Exhibit G, Dental Services SOW.

Filings with Other Entities and Other Existing Financial Reports: The Dental Contractor must submit an electronic copy of the reports or filings pertaining to the Dental Contractor, or its parent, or its parent’s parent no later than 30 Days after such report is filed or otherwise initially distributed.

Transition Phase and Operations Phase

Per Day of noncompliance.

HHSC may assess up to $500 per Day of noncompliance the report is not submitted or is late, inaccurate, or incomplete.

FR-10 Section 2.6.24.3.2, Financial Reporting Requirements, of Exhibit G, Dental Services SOW.

Chapter 5, Deliverables, Report Formats, Due Dates, of Exhibit B UMCM.

Audit Reports: The Dental Contractor must comply with UMCM requirements regarding notification or submission of audit reports.

Operations Phase

Per Day of noncompliance.

HHSC may assess up to $500 per Day of noncompliance the report is not submitted or is late, FR-11

Section 2.6.24.3.2, Financial Reporting Requirements, of Exhibit G, Dental Services SOW.

Employee Bonus and/or Incentive Payment Plan must be submitted no later than 30 Days after the Effective Date of the Contract.

Operations Phase

Per Day of noncompliance.

HHSC may assess up to $500 per Day of noncompliance the report is not submitted or is late, inaccurate, or incomplete.

FR-12 Section 2.6.24.3.2, Financial Reporting Requirements, of Exhibit G, Dental Services SOW.

Registration Statement (aka “Form B”) must be submitted no later than ten Days after the Dental Contractor’s submission of the item to TDI.

Operations Phase

Per Day of noncompliance.

HHSC may assess up to $500 per Day of noncompliance the report is not submitted or is late, inaccurate, or incomplete.

HHSC Office of the Inspector General (IG)

IG-1 Sections 2.5.3.7, Operations

The Dental Contractor must submit and comply with the requirements of

Transition Phase, Per Day, per incident of per Day per incident of

Readiness, and 2.6.26, Fraud, Waste, and Abuse, of Exhibit G, Dental Services

SOW.

the HHSC-approved Fraud, Waste, and Abuse Compliance Plan.

Phase, and Turnover Phase noncompliance, per Program.

noncompliance, and per Program.

IG-2 Section 2.6.26, Fraud, Waste, and Abuse, of Exhibit G, Dental Services SOW.

The Dental Contractor must perform pre-payment review for identified providers as directed by HHS OIG within ten Business Days after notification.

Transition Phase, Operations Phase, and Turnover Phase

Per Day, per incident of noncompliance, per Program.

HHSC may assess up to $1,000 per Day, per incident of noncompliance, and per Program.

IG-3 Section 2.6.26.2, General Requests for and Access to Data, Records, and Other Information, of Exhibit G, Dental Services

SOW.

The Dental Contractor must respond to HHSC OIG requests for information in the manner and format requested.

Transition Phase, Operations Phase, and Turnover Phase

Per Day of noncompliance, per Program.

HHSC may assess up to $1,000 per Day of noncompliance, per Program that the information is not submitted or is late, inaccurate, or incomplete.

This amount will increase to $5,000 per Day of noncompliance, per Program for the fourth and each subsequent occurrence within a 12-month period.

IG-4 Section 2.6.24.1, General Reporting Requirements, of Exhibit G, Dental Services SOW.

Chapter 5, Deliverables, Report Formats, Due Dates, of Exhibit B, UMCM.

The Dental Contractor must submit a Fraudulent Practices Referral to the HHS OIG within 30 Business Days of receiving a report of possible Fraud, Waste, or Abuse from the Dental Contractor’s SIU.

Transition Phase, Operations Phase, and Turnover Phase

Per Day of noncompliance, per Program.

HHSC may assess up to $1,000 per Day of noncompliance, per Program, that the referral is not submitted or is late, inaccurate, or incomplete.

This amount will increase to $5,000 per Day of noncompliance, per Program for the fourth and each subsequent occurrence within a 12-month period.

IG-5 Section 2.6.26.4, Payment Holds and Settlements, of Exhibit

The Dental Contractor must submit monthly Dental Contractor open case list reports.

Transition Phase, Operations Phase, and

Per Day of noncompliance, per Program.

HHSC may assess up to $1,000 per Day of noncompliance, per Program that the report is not

G, Dental Services

SOW.

Chapter 5, Deliverables, Report Formats, Due Dates, of Exhibit B, UMCM.

Turnover Phase submitted or is late, inaccurate, or incomplete.

This amount will increase to $5,000 per Day of noncompliance and per Program for the fourth and each subsequent occurrence within a 12-month period.

IG-6

Section 2.6.26.4, Payment Holds and Settlements, of Exhibit G, Dental Services

SOW.

The Dental Contractor must respond to HHSC OIG requests for payment hold amounts accurately and in the manner and format requested.

Transition Phase, Operations Phase, and Turnover Phase

Per incident of

HHSC may assess, per incident of noncompliance, per Program, up to the difference between the amount required to be reported by the Dental Contractor under Chapter 5.5, Office of Inspector General, of Exhibit B, UMCM, and the amount received by the

HHSC OIG.

IG-7 Section 2.6.26.2, General Requests for and Access to Data, Records, and Other Information, of Exhibit G, Dental Services

SOW.

The Dental Contractor fails to submit complete, unredacted and accurate claims data as prescribed by HHSC

OIG.

Transition Phase, Operations Phase, and Turnover Phase

Per Day, per incident of noncompliance, per Program.

HHSC may assess up to $1,000 per Day, per incident of noncompliance, and per Program that the data is not submitted or is late, inaccurate, or incomplete.

This amount will increase to $5,000 per Day, per incident of noncompliance, and per Program for the fourth and each subsequent occurrence within a 12-month period.

IG-8 Section 2.6.26.4, Payment Holds and Settlements, of Exhibit G, Dental Services

SOW.

The Dental Contractor must impose payment suspensions or lift payment holds as directed by HHSC OIG.

Transition Phase, Operations Phase, and Turnover Phase

Per incident of noncompliance, per Dental Contractor.

HHSC may assess up to the amount not held or released improperly per incident of noncompliance and per Dental Contractor.

Frew (FW)

DSFW-1 Section 2.6.24.1 General Reporting Requirements, of Exhibit G, Dental Services SOW.

Chapter 12, Frew, of Exhibit B, UMCM.

Frew Quarterly Monitoring Report – Each quarter, the Dental Contractor must submit timely, accurate, and complete responses to questions on this report’s template addressing the status of Frew Consent Decree paragraphs for Medicaid.

Quarterly during per Dental Contractor.

HHSC may assess up to $1,000 per Day of noncompliance if the reports are not submitted or are late, inaccurate, or incomplete, per Dental Contractor.

DSFW-2 Section 2.6.24.1 General Reporting Requirements, of Exhibit G, Dental Services SOW.

Chapter 12, Frew, of Exhibit B, UMCM.

Farmworker Child Annual Report and Farmworker Child Annual Report Log

– The Dental Contractor must submit an annual report, and an annual log as described in Chapter 12 of Exhibit

B, UMCM.

Annually during the per Day of noncompliance the reports are not submitted or are late, inaccurate, or incomplete, per Program.

Turnover (TO)

TO-1 Section 2.7.4, Post Turnover Services, of Exhibit G, Dental Services SOW.

The Dental Contractor must provide HHSC with a turnover results report documenting the completion and results of each step of the Turnover Plan 30 Days after the turnover of operations.

Measured 30 Days after the turnover of operations

Per Day of noncompliance, per Program.

HHSC may assess up to $250 per Day of noncompliance, per Program the report is not submitted or is late, inaccurate, or incomplete.

TO-2

Section 2.7.4, Post Turnover Services, of Exhibit G, Dental Services SOW.

Twelve months prior to the end of the Contract Term or any extension thereof, unless otherwise specified by HHSC, the Dental Contractor must propose a Turnover Plan covering the possible turnover of the records and information maintained to either the HHSC or a successor Dental Contractor.

Measured at twelve months prior to the end of the Contract Term, or any extension thereof, and ongoing until satisfactorily completed

Per Day of noncompliance, per Program.

HHSC may assess up to $1,000 per Day of noncompliance, per Program, the Turnover Plan is not submitted or is late, TO-3 Section 2.7.2, Transfer of Data and Information, of Exhibit

The Dental Contractor must transfer all data regarding the provision of Covered Services to Members to

Measured at time of transfer of data and

Per Day, per incident of noncompliance

HHSC may assess up to $10,000 per Day, per incident of noncompliance, per Program, G, Dental Services

SOW.

HHSC or a new Dental contractor at the sole discretion of HHSC and as directed by HHSC. All transferred data must comply with the Contract requirements, including HIPAA.

ongoing after the transfer of data until satisfactorily completed during Transition Phase, Operations Phase, and Turnover Phase

(failure to provide data and/or failure to provide data in required format), per Program.

the data is not submitted, is not provided in the required format or is late, inaccurate, or incomplete.