Exhibit G, Medicaid and CHIP Dental Services Statement Of Work (SOW).pdf

RFP No. HHS0017108 Exhibit G

Exhibit G - Medicaid and Children’s Health Insurance Program (CHIP) Dental Services Statement of Work

(SOW)

RFP No. HHS0017108

Dental Services for Texas Children’s Medicaid and Children’s Health Insurance Program Members SOW

Table of Contents

ARTICLE 1 INTRODUCTION

Overview of HHSC Texas Children’s Medicaid Dental Services and CHIP Dental Services Programs

Eligible Population

Definitions and Exhibits

Mission Statement

Mission Objectives

1.5.1 Network Adequacy and Access to Care

1.5.2 Quality

1.5.3 Timeliness, Accuracy, and Transparency of Claim Payment

1.5.4 Delivery of Health Care to Diverse Populations

1.5.5 Continuity of Care

1.5.6 Cost Effective Provision of Services

Service Area

Authority

ARTICLE 2 SCOPE OF WORK

Required Federal and State Approval and Funding

Remedies and Liquidated Damages

Antitrust

Member Eligibility, Enrollment, and Disenrollment

2.4.1 Eligibility Determination and Disenrollment

2.4.2 Member Enrollment

2.4.3 Member Disenrollment

2.4.4 Span of Coverage

2.4.5 Verification of Member Eligibility

Transition Phase Scope

2.5.1 Introduction

2.5.2 Administration and Key Personnel

2.5.3 Readiness Review

2.5.4 Prioritization Plan

2.5.5 Continuity Of Care and Out Of Network Providers

2.5.6 Texas Department of Insurance Licensure, Certification, or Approval

2.5.7 Dental Contractor Accreditation

Operations Phase Scope

2.6.1 Administrative Services

2.6.2 Administrative and Contract Management

2.6.3 Operations Phase Readiness, Operational, and Targeted Reviews

2.6.4 Future Initiatives

2.6.5 HHSC Performance Review and Evaluation

2.6.6 Provider Credentialing and Re-credentialing

2.6.7 Provider Relations Including Manual, Materials, and Training

2.6.8 Payer-to-Payer Data Exchange

2.6.9 Provider Hotline

2.6.10 Provider Advisory Group

2.6.11 Provider Reimbursement

2.6.12 Dental Contractor Termination of Provider Contracts

2.6.13 Provider Protection Plan

2.6.14 Member Services

2.6.15 Requirements Common to All Member-facing Hotlines

2.6.16 Member Education

2.6.17 Dental Contractor Website

2.6.18 Smart Phone Application

2.6.19 CMS Interoperability and Patient Access

2.6.20 Marketing and Prohibited Practices

2.6.21 Quality Improvement and Performance Evaluation

2.6.22 Utilization Management

2.6.23 Financial Requirements for Covered Services

2.6.24 Reporting Requirements

2.6.25 Management Information System Requirements

2.6.26 Fraud, Waste, and Abuse

2.6.27 Complaints and Managed Care Organization Provider Appeals

2.6.28 Provider Complaints and Appeals System

2.6.29 Member Complaint and Appeal System

2.6.30 Covered Services

2.6.31 Access to Care

2.6.32 Teledentistry

2.6.33 Provider Network

2.6.34 Out-of-State Providers

2.6.35 Value-Added Services

2.6.36 Case-by-case Services

2.6.37 First Dental Home Services for Medicaid Members

2.6.38 Continuity of Care

2.6.39 Texas Health Steps

2.6.40 Provisions related to Covered Services

Turnover Phase Scope

2.7.1 Turnover Plan

2.7.2 Transfer of Data and Information

2.7.3 Turnover Services

2.7.4 Post Turnover Services

Terms and Conditions of Payment

2.8.1 Calculation of Monthly Capitation Payment

2.8.2 Time and Manner of Payment

2.8.3 Certification of Capitation Rates

2.8.4 Modification of Capitation Rates

2.8.5 Capitation Rate Structure

2.8.6 Dental Contractor Input During Rate Setting Process

2.8.7 Adjustments to Capitation Payments

2.8.8 Experience Rebate

2.8.9 Payment By Members

2.8.10 Restriction on Assignment of Fees

2.8.11 Liability for Taxes

2.8.12 Liability for Employment-related Charges and Benefits

2.8.13 No Additional Consideration

2.8.14 Federal Disallowance

Data Location

2.9.1 Breach and Security Incident Disclosure Requirements

ARTICLE 1 INTRODUCTION

OVERVIEW OF HHSC TEXAS CHILDREN’S MEDICAID DENTAL SERVICES AND

CHIP DENTAL SERVICES PROGRAMS

The principal objectives of Medicaid and Children’s Health Insurance Program (CHIP) managed care children’s dental services are to provide quality, comprehensive dental services in a manner that improves the oral health of the Members through Preventive care, health education, early intervention, and to promote improved access to quality care, thereby significantly improving health outcomes for the target populations.

Members’ primary and Preventive Medicaid and CHIP dental services are provided statewide through Dental Contractors. Each Dental Contractor is responsible for contracting with general dentists, pediatric dentists, and dental specialists to create a robust delivery Network.

ELIGIBLE POPULATION

For the purposes of this RFP, the eligible population are the individuals identified below, who are qualified to participate in the Dental Program:

1. Children, birth through age 20, who are eligible for Medicaid Texas Health Steps services, including Supplemental Security Income recipients; and

2. All children under the age of 19 who are enrolled in CHIP.

3. Medicaid recipients other than:

a. Recipients age 21 and over;

b. All recipients, regardless of age, residing in Medicaid-paid facilities such as nursing homes, state supported living centers, or Intermediate Care Facilities for Individuals with Intellectual Disabilities; and

c. STAR Health program recipients

DEFINITIONS AND EXHIBITS

Defined terms have the meaning described in HHS0017108 RFP, Exhibit A, Dental Contract Terms and Conditions, and Exhibit B, Uniform Managed Care Manual (UMCM), unless the context clearly indicates otherwise. Capitalized terms are defined, are proper nouns, or serve to define an acronym.

Also, Services may not have been incorporated into Exhibit B, Uniform Managed Care Manual (UMCM) at the time of the SOW’s publication. In the event they have not been, such Services will be added as part of the current HHSC UMCM change process, and the Contract will be amended as appropriate.

MISSION STATEMENT

HHSC’s mission in this SOW is to:

1. Ensure continuous and uninterrupted delivery of comprehensive dental services, and the effective management of healthcare data and information; and

2. Ensure Members receive integrated, high-quality oral healthcare that holistically addresses their needs, resulting in improved-health outcomes.

MISSION OBJECTIVES

HHSC will prioritize desired outcomes and benefits for the Medicaid and CHIP Dental populations and may focus its monitoring efforts on the Dental Contractor’s ability to provide exceptional results for the mission objectives. The mission objectives of this SOW are as follows:

1.5.1 NETWORK ADEQUACY AND ACCESS TO CARE

The Dental Contractor must provide timely access to quality dental care through a Network designed to meet the needs of the Member populations served. The Dental Contractor must create and maintain a robust Network accessible to all Members for prompt delivery of all Medically Necessary Covered Dental Services. The Dental Contractor must provide Members with access to qualified Providers within the travel distance, travel time, and waiting time for appointment standards defined in this SOW.

1.5.2 QUALITY

The Dental Contractor must ensure all Members receive quality services in the most efficient and effective manner possible. The Dental Contractor must provide high quality Services in a professional and ethical manner. The Dental Contractor and Providers must implement new and creative approaches, with approval from HHSC, that ensure quality services, cost-effective service delivery, and careful stewardship of public resources.

1.5.3 TIMELINESS, ACCURACY, AND TRANSPARENCY OF CLAIM PAYMENT

The Dental Contractor’s ability to ensure that providers receive timely, accurate, and transparent payment for rendered services is a critical component of the Dental Program.

The Dental Contractor must comply with HHSC’s claims adjudication requirements in a timely manner, as set forth in Chapter 2 of Exhibit B, Texas Medicaid and CHIP - Uniform Managed Care Manual (UMCM). HHSC will require strict adherence to claims adjudication standards.

1.5.4 DELIVERY OF HEALTH CARE TO DIVERSE POPULATIONS

The Dental Contractor must deliver all Covered Dental Services without discrimination.

The Dental Contractor shall implement a Cultural Competency plan to avoid disparities in the delivery of dental services to diverse populations and provide services in a culturally competent manner.

1.5.5 CONTINUITY OF CARE

Transition to a new Dental Contractor from an existing dental contractor, as a result of procurement and at all other times, shall be as seamless as possible for Members and their Providers. Established Member and Provider relationships, existing treatment protocols, and ongoing care plans shall not be impacted significantly during Members’ transition to a new Dental Contractor.

1.5.6 COST EFFECTIVE PROVISION OF SERVICES

A primary goal in having a managed care dental model is to provide more cost-effective Services to Members. This includes both dental and administrative costs. In conjunction with this objective, the Dental Contractor must be transparent in its reporting of cost and other data to HHSC, and must provide complete, accurate, reliable, and non-misleading information in its reports to HHSC.

SERVICE AREA

In this RFP, there is a single, statewide, Service Area (SA). Each Dental Contractor must serve both Medicaid and CHIP Members in all areas of Texas under this statewide service delivery model. HHSC, however, has designated Dental Reporting Regions for the sole purpose of measuring a Dental Contractor’s Network adequacy. See Section 2.6.31.2.

AUTHORITY

The Texas Legislature has designated HHSC as the single state agency to administer the Medicaid program and CHIP through managed care models in the State of Texas. See Tex.

Health & Safety Code Chapters 62 and 63 and Tex. Hum. Res. Code Chapter 32. Under Tex. Gov’t Code Chapters 531, 532, and 540, HHSC has authority to contract with Dental Contractor to carry out the duties and functions of the Medicaid managed care program relating to dental services as described by Title XIX of the Social Security Act and CHIP managed care program as described by Title XXI of the Social Security Act. HHSC remains the only entity authorized to contract with a Dental Contractor and to modify any resulting Contract or otherwise further bind the State of Texas. The Dental Contractor must be authorized to provide dental services and the individuals signing the Contract must have authorization to bind the Dental Contractor.

ARTICLE 2 SCOPE OF WORK

REQUIRED FEDERAL AND STATE APPROVAL AND FUNDING

The SOW is contingent upon federal and State approvals and funding, including Centers for Medicare and Medicaid Services (CMS) approval and funding. Should any part of the SOW under this Contract relate to a State program that is no longer authorized by law (e.g., which has been vacated by a court of law, or for which CMS has withdrawn federal authority, or which is the subject of a legislative repeal), the Dental Contractor must do no work on that part after the effective date of the loss of program authority. The State will adjust Capitation Payments and Capitation Rates to remove costs that are specific to any program or activity that is no longer authorized by law. If the Dental Contractor works on a program or activity no longer authorized by law after the date the legal authority for the work ends, the Dental Contractor will not be paid for that work. If the State paid the Dental Contractor in advance to work on a no-longer-authorized program or activity and under the terms of this Contract the work was to be performed after the date the legal authority ended, the payment for that work must be returned to the State. However, if the Dental Contractor worked on a program or activity prior to the date legal authority ended for that program or activity, and the State included the cost of performing that work in its payments to the Dental Contractor, the Dental Contractor may keep the payment for that work even if the payment was made after the date the program or activity lost legal authority.

REMEDIES AND LIQUIDATED DAMAGES

All areas of responsibility and all requirements of the Dental Contractor in the Contract will be subject to performance evaluation, review, and audit by HHSC or it’s designee. All responsibilities or requirements not fulfilled by the Dental Contractor may have remedies, and HHSC may assess damages, including liquidated damages. Refer to Exhibit A, Dental Contract Terms and Conditions, and Exhibit C, Deliverables-Liquidated Damages Matrix, for liquidated damage values and Chapter 5 of Exhibit B, Uniform Managed Care Manual (UMCM) for remedies and dispute requirements. For the avoidance of doubt, and as set forth in Section 4.08 of Exhibit A, subcontracting any function does not relieve or lessen the Dental Contractor’s obligation to meet the express requirements of the Contract and the expectations of the Parties, notwithstanding any references or omissions to Subcontractors, within this SOW.

ANTITRUST

Dental Contractor will assign to HHSC all of Dental Contractor’s state and federal antitrust claims and causes of action that relate to all goods, Services, or Deliverables provided for or related to the Contract.

MEMBER ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT

HHSC makes no guarantees or representations to the Dental Contractor regarding the number of eligible Members who will ultimately be enrolled into the Dental Contractor or the length of time any enrolling Members will remain enrolled with the Dental Contractor.

The Dental Contractor has no ownership interest in its Member base, and therefore cannot sell or transfer this base to another entity.

2.4.1 ELIGIBILITY DETERMINATION AND DISENROLLMENT

HHSC or its designee will make eligibility determinations for each potential enrollee for the Dental Program. Should a Member become ineligible for Medicaid or CHIP Dental, HHSC will disenroll the Member from the managed care plan.

For Medicaid, the Dental Contractor must notify HHSC within ten Business Days, and five Business Days for CHIP, if the Dental Contractor becomes aware that a Member has moved outside of the State or that a Member is no longer eligible, for example, if the Member has moved outside of the State or is deceased the Dental Contractor must inform HHSC.

2.4.2 MEMBER ENROLLMENT

HHSC or its designee will enroll and disenroll eligible individuals in the Dental Program.

The Dental Contractor will accept individuals in accordance with 42 CFR § 438.3(d). HHSC will establish the default assignment methodologies, as described in 1 Tex. Admin. Code §

353.403 and § 370.303, to enroll individuals who do not select a Dental Plan or Main Dentist. Once an eligible individual is enrolled, a file is sent to the Dental Contractor on a daily and monthly basis to notify the Dental Contractor that the individual is enrolled as a Medicaid or CHIP Member. The Dental Contractor is not allowed to induce or accept disenrollment from a Member. The Dental Contractor must refer the Member to HHSC or its designee for information regarding enrollment or disenrollment. HHSC or its designee will electronically transmit to the Dental Contractor new Member information and change information applicable to active Members.

Medicaid Members are given the opportunity to request a termination or change their enrollment from one dental plan to another. A Medicaid Member can request to change dental plans for any reason. There is no limit to the number of times that a Member can change plans, however, Members cannot change plans more than once a month. Enrollment effective dates are determined based on system processing dates in relation to State cut-off.

State cut-off is a systems date that is usually in the middle of the month and is used to set the enrollment effective date. If the member requests a plan change before State cut-off, the plan change is effective on the first day of the following month. If the request is received after State cut-off, the plan change will be effective on the first day of the second month following the request.

Children enrolled in CHIP receive Dental Program coverage for 12 months. Should a Member become ineligible for CHIP, HHSC will disenroll the Member from the Dental Program.

CHIP Members are given the opportunity to request a termination or change enrollment from one dental plan to another within the first 90 Days after Dental Program coverage begins. If a Member requests a change from one dental plan to another, the change will be prospective, and the effective date will be the first day of the month in which the Member appears on the Member Enrollment File for the receiving dental plan.

HHSC or its designee enrolls and disenrolls Members from dental plans. HHSC or its designee will not allow Members to change CHIP dental plans after their first 90 Days of coverage unless granted an exception for a “good cause” event. HHSC determines “good cause” events that qualify a CHIP Member to change dental plans after the 90 Days.

Additionally, CHIP Members who have exhausted their annual benefit limits are not allowed to change dental plans.

Members who are disenrolled, because they are temporarily ineligible for Medicaid Dental, will be automatically reenrolled into the same Dental Contractor, if available. Temporary loss of eligibility is defined as a period of six months or less. CHIP Members who are disenrolled because they are temporarily ineligible will be given 15 Days to choose a Dental Contractor. If a choice is not received, the Member will be defaulted according to 1 Tex.

Admin. Code § 353.403 and § 370.303.

If Medicaid and CHIP Dental eligibility is re-activated after being terminated in error, the Member will be retroactively enrolled with the Dental Maintenance Organization (DMO) that the Member was previously enrolled with to avoid a gap in coverage. The retroactively enrolled Medicaid Members will be sent on a daily file to the Dental Contractor, and the Dental Contractor must upload the daily enrollment file into its system within 24 hours of receipt. Retroactively enrolled CHIP Members will appear on the Dental Contractors monthly Enrollment File with the retroactive start date.

2.4.3 MEMBER DISENROLLMENT

HHSC or its designee will disenroll eligible individuals in the Dental Program. The Dental Contractor is not allowed to induce or accept disenrollment from a Member. The Dental Contractor must refer the Member to HHSC or its designee.

A Dental Contractor has a limited right to request that a Member be disenrolled from the Dental Contractor without the Member’s consent. HHSC must approve any Dental Contractor request for disenrollment of a Member for cause. Dental Contractor must take reasonable documented measures to correct Member behavior prior to requesting disenrollment. Reasonable documented measures may include providing education and counseling regarding the offensive acts or behaviors. A Member may only be disenrolled for cause under the following circumstances:

1. Member misuses or loans Member’s Dental Contractor membership card to another person to obtain services;

2. Member’s behavior is disruptive or uncooperative to the extent that Member’s continued enrollment in the Dental Contractor seriously impairs the Dental Contractor’s or Provider’s ability to provide services to either the Member or other Members, and the Member’s behavior is not related to a developmental, intellectual, or physical Disability or Behavioral Health (BH) condition; and

3. Member steadfastly refuses to comply with managed care restrictions.

HHSC will notify the Member of HHSC’s decision to disenroll the Member if all reasonable measures have failed to remedy the problem. If the Member disagrees with the decision to disenroll the Member from Dental Contractor, HHSC will notify the Member of the availability of the Complaint procedure and, for Medicaid Members, HHSC’s State Fair Hearing process.

Dental Contractor cannot request disenrollment based on an adverse change in the Member’s health status or utilization of services that are Medically Necessary for treatment of a Member’s condition.

Members taken into conservatorship by the Department of Family and Protective Services (DFPS) will be disenrolled from the Dental Contractor effective the date of conservatorship and enrolled in the STAR Health Program unless otherwise determined by DFPS.

2.4.4 SPAN OF COVERAGE

The Dental Contractor must accept all persons who choose to enroll as Members in the Dental Contractor, or who are assigned as Members in the Dental Contractor by HHSC, without regard to the Member’s previous coverage or any other factor.

HHSC will conduct continuous open enrollment for Medicaid and CHIP Dental Eligibles.

Supplemental Security Income (SSI) status is effective on the date HHSC’s eligibility system identifies the Member as Type Program 13 (TP 13). HHSC will update the eligibility system within 45 Days of official notice of the Member’s SSI status by the Social Security Administration (SSA). For CHIP Dental Program Members identified as TP13, when HHSC has updated the State’s eligibility system, following standard eligibility cut-off rules, HHSC will allow the CHIP Member to prospectively move to the Medicaid Dental Program. HHSC will not retroactively disenroll a Member from the CHIP Dental Program.

2.4.5 VERIFICATION OF MEMBER ELIGIBILITY

Dental Contractors are prohibited from entering into an agreement to share information regarding their Members with an external vendor that provides verification of Medicaid recipients’ eligibility to Medicaid providers. All such external vendors must contract with the State and obtain eligibility information from the State.

Defaulted Members may change their assigned dental plan under the conditions described in Section 2.4.2.1 for Medicaid Members and Section 2.4.2.2 for CHIP Members.

TRANSITION PHASE SCOPE

This section includes the requirements for the Transition Phase, which begins on the Effective Date and includes those activities that must take place between the Effective Date and the Operational Start Date of a Contract resulting from award through procurement or an assignment and assumption due to termination, expiration, merger, or acquisition.

2.5.1 INTRODUCTION

The Dental Contractor must successfully complete each of the Transition Phase tasks per the approved Transition Plan. HHSC and the Dental Contractor will work together during the Transition Phase to:

1. Define project management and reporting standards;

2. Establish communication protocols between HHSC and the Dental Contractor;

3. Provide points of contacts for other HHSC contractors;

4. Establish a schedule for key activities and milestones; and

5. Clarify expectations for the content and format of the Contract Deliverables.

The Dental Contractor must adhere to established deadlines and successfully complete each of the Transition Phase tasks per the approved Transition Plan, including, but not limited to:

1. Providing all materials requested by HHSC or its designee;

2. Providing access to all facilities, systems, staff, etc.; and

3. Clearly identify and request all necessary information needed from HHSC, other contractors, and Providers in a manner that does not delay the schedule or work to be performed.

The Transition Phase includes Readiness Reviews, which must be completed to HHSC’s satisfaction no later than 90 Days prior to the Operational Start Date, unless otherwise indicated throughout this Section 2.5 or agreed upon by HHSC.

No later than 30 Days after the Effective Date the Dental Contractor must submit an initial Transition Plan, and thereafter throughout the Transition Phase, the Dental Contractor must update the Transition Plan and submit these updated plans to HHSC on a monthly basis for review. HHSC may require more frequent reporting as it determines necessary.

If there are changes that occur to the information after the deadlines listed above, the Dental Contractor must notify HHSC within five Business Days. HHSC will have the sole discretion to accept or reject updates to information.

During the Transition Phase, the Dental Contractor must remedy any identified Transition Phase deficiencies within 10 Days of HHSC’s request. The Dental Contractor must notify HHSC of any deficiencies upon discovery. If any errors or deficiencies are evident during the Transition Phase, the Dental Contractor must implement an HHSC-approved resolution procedure to address and resolve the errors or deficiencies prior to the Operations Phase.

The Dental Contractor must secure advanced written approval from HHSC for a delay in the Operational Start Date or a delay in the Dental Contractor’s compliance with the applicable Readiness Review requirements.

The Dental Contractor is required to mitigate risk associated with not being prepared for the Operations Phase in coordination with HHSC with consideration of the following high-level processes:

1. At the start of Readiness Review, HHSC will identify key events based on a Deliverable timeline that the Dental Contractor must achieve by a specified time;

2. To ensure the Dental Contractor is on track to meet Readiness Review milestones, HHSC may conduct Readiness Review meetings on a weekly basis;

3. If the Dental Contractor consistently fails to meet the established Readiness Review milestones, it will be identified as high-risk and targeted for increased technical assistance;

4. Upon Dental Contractor’s remediation of the issues identified by HHSC to HHSC’s satisfaction, the Dental Contractor status will change to “Go;” and

5. Readiness Review will occur prior to the Operational Start Date, and if at this point the Dental Contractor is identified as a “No-Go” the Operational Start Date may be delayed in HHSC’s sole discretion.

2.5.2 ADMINISTRATION AND KEY PERSONNEL

The Dental Contractor must comply, to the satisfaction of HHSC, with all provisions set forth in this SOW, including all applicable provisions of State and federal laws, rules, regulations, and waiver agreements with CMS.

No later than the Effective Date, the Dental Contractor must:

1. Designate and identify Key Personnel that meet the requirements in Section 4.02 of

Exhibit A;

2. Supply HHSC with current résumés of each Key Personnel and the percentage of allocated time Key Personnel are dedicated to the Contract;

3. Report on any organizational information that has changed since submission of the

Dental Contractor’s Proposal and oral presentation, such as updated job descriptions and updated organizational charts, including Management Information System (MIS) job descriptions and an MIS staff organizational chart, if applicable;

4. Provide the organizational chart for Material Subcontractors; and

5. Provide necessary information by submitting Form 5871, Disclosure of Ownership for the Contractor and Material Subcontractors, for HHSC to confirm the identity and determine the exclusion status of the Dental Contractor and their Material Subcontractors as well as any owner or person with a controlling interest or who is an agent or managing employee of the Dental Contractor through routine checks of federal databases as required in 42 C.F.R. § 438.602(d).

During the Transition Phase, the Dental Contractor must notify HHSC no later than five Days following a change in the Key Personnel or Material Subcontractors.

In the case of Contract termination or expiration, the Dental Contractor must provide HHSC with the Key Personnel who will facilitate ongoing activities and requirements described in the Turnover Plan. In the case of merger or acquisition, the Dental Contractor must provide HHSC with the Key Personnel who will facilitate ongoing activities and requirements described in the Transition Plan. The Dental Contractor will also provide HHSC with the Material Subcontractor’s functions and responsibilities as identified in Chapter 5 of Exhibit B, Uniform Managed Care Manual (UMCM).

2.5.3 READINESS REVIEW

During the Readiness Review, the Dental Contractor must satisfy the requirements identified in the subsections below. HHSC reserves the right to update the Readiness Review requirements and related reporting at any time prior to and during the Contract Term.

No later than 60 Days prior to the Operational Start Date, the Dental Contractor must submit a statement identifying any material changes in its financial condition. The Dental Contractor and its ultimate parent must definitively state whether either entity has, or has not, experienced any material financial deterioration subsequent to submission of its Proposal or not disclosed in its Proposal. This statement must also state whether there are, or are not, any known or potential issues with respect to changes in ownership or control.

The Dental Contractor must not submit "not applicable," "N/A," or a similar response, or leave blank.

If either the Dental Contractor or its ultimate parent has experienced any such material financial deterioration, the statement must also identify and briefly describe any changes to the financial statements, including changes to net worth, cash flow, loss of contracts, credit, audit issues, regulatory issues, legal issues, major contingencies, and any known potential material issues.

No later than 60 Days before the Operational Start Date, the Dental Contractor must submit documentation demonstrating it secured all required bonds in accordance with Texas Department of Insurance (TDI) rules, Tex. Ins. Code ch. 843, and Article 15 of Exhibit A.

If the Dental Contractor intends to include employee bonus or incentive payments as allowable administrative expenses, the Dental Contractor must furnish a written Employee Bonus and/or Incentive Payments Plan to HHSC. The written plan must include a description of the Dental Contractor’s criteria for establishing bonus and/or incentive payments, the methodology to calculate bonus and/or incentive payments, and the timing of bonus and/or incentive payments. The Employee Bonus and/or Incentive Payment Plan and description must be submitted during the Transition Phase, no later than 30 Days after the Effective Date of the Contract. If the Dental Contractor substantively revises the Employee Bonus and/or Incentive Payment Plan during the Operations Phase, the Dental Contractor must submit the revised plan to HHSC at least 30 Days in advance of its effective date.

HHSC reserves the right to disallow all or part of a plan that it deems inappropriate. Any such payments are subject to audit, and must conform with Chapter 6 of Exhibit B, Uniform Managed Care Manual (UMCM).

No later than 60 Days prior to the Operational Start Date, the Dental Contractor must submit an updated listing of Material Subcontractors. Material Subcontractors include Affiliates and non-Affiliates. Additional documentation may be required at HHSC’s discretion. This updated list must, at a minimum, include the following:

1. The Material Subcontractor’s legal name, trade name, acronym, dba, and any other name under which the Material Subcontractor does business, or has done business, in the past five years;

2. The full and exact legal name of the Material Subcontractor’s ultimate parent;

3. All of the Dental Contractor’s estimated annual payments to each Material Subcontractor that may be included, directly or indirectly, in any Financial Statistical Report (FSR) submitted by the Dental Contractor under the Contract or any other HHSC contract, including separate amounts for each Material Subcontractor;

4. The physical address, mailing address, and telephone number of the Material Subcontractor’s headquarters and the name of its chief executive officer;

5. A definitive statement regarding whether the Material Subcontractor is an Affiliate of the Dental Contractor or an unrelated third party;

6. If the Material Subcontractor is an Affiliate:

a. The name of the Material Subcontractor’s parent organization, and the

Material Subcontractor’s relationship to the Dental Contractor;

b. The proportion, if any, of the Material Subcontractor’s total revenues that are received from non-Affiliates. If the Material Subcontractor has significant revenues from non-Affiliates, then also indicate the portion, if any, of those external, non-Affiliate revenues that are for services similar to those that the Dental Contractor would procure under the proposed Subcontract;

c. A description of the proposed method of pricing under the Subcontract;

d. A statement as to whether there is, or is not, any anticipated mark-up, margin, profit, or amount in excess of actual costs incurred by the Material Subcontractor that is anticipated to be included in the pricing;

e. The number of employees, both staff and management, who are dedicated full-time to the Affiliate’s business. Do not include any staff or management that have other duties in addition to working on this specific Affiliate’s business;

f. Whether the Affiliate’s office facilities are separate from the Dental Contractor and the Dental Contractor’s ultimate parent. If Affiliate’s office facilities are not completely separate from the Dental Contractor and Dental Contractor’s owner, identify the approximate number of square feet of office space that are dedicated solely to the Affiliate’s business;

g. An organization chart for the Affiliate, showing head count, Key Personnel names, titles, and locations; and

h. Indicate if the staff and management of the Affiliate are directly employed by the Affiliate itself or employed by a different legal entity such as an ultimate parent corporation. The employee’s Form W-2 identifies the name of the corporation and is indicative of the actual employer;

7. Whether the Material Subcontractor or any of its Affiliates had a managed care contract with a state, federal, or governmental agency terminated or not renewed for any reason within the past five years. In such instance, the Dental Contractor must describe the issues, the parties involved, and provide the name, title, email address and telephone number of the principal contact for the party with whom the contract was held. The Dental Contractor must also describe any corrective action taken by the Material Subcontractor to prevent any future occurrence of the problem that may have led to the termination or non-renewal; and

8. Necessary information for the State to confirm the identity and determine the exclusion status of the Dental Contractor’s Material Subcontractors as well as any owner or person with a controlling interest or who is an agent or managing employee of the Dental Contractor through routine checks of federal databases as required in 42 C.F.R. § 438.602(d).

The Dental Contractor must list the Material Subcontractors in descending order of estimated Dental Contractor annual payments to the Material Subcontractor across all HHSC contracts, wherein such payments may be included, directly or indirectly, in an FSR.

Additional documentation may be required at HHSC’s discretion.

The Dental Contractor must participate in Readiness Review as dictated by HHSC for the expansion of managed care Programs, including the addition or transition of services to managed care.

HHSC will provide a test plan to the Dental Contractor outlining the activities the Dental Contractor needs to perform prior to the Operational Start Date. The Dental Contractor must be prepared to assure and demonstrate system readiness. During systems readiness, the Dental Contractor must:

1. Submit a systems readiness plan for HHSC approval 30 Days after the Contract Effective Date to test and validate the interfaces among trading partners for the operational and administrative areas listed in Section 2.6.25;

2. Plan and execute system readiness test cycles with all trading partners, to include all interfaces based on the activities provided in systems readiness plan, six months prior to the Operational Start Date;

3. Accept secure transmission of data files and information among trading partners per the file structure, with data elements, and on a frequency specified in HHSC’s Joint Interface Plan (JIP) located in a centralized secure file transfer site designated by

HHSC;

4. Demonstrate to HHSC that systems services will not be disrupted or interrupted during the Operations Phase by successfully completing all tasks in the systems readiness plan;

5. Coordinate with HHSC, other trading partners, and contractors to ensure the business and systems continuity for the processing of all dental claims and data;

6. Satisfy internet website and portal requirements described in Section 2.6.17;

7. Submit to HHSC descriptions of data flow, process flow, and interfaces for each key business process described in Section 2.6.25;

8. Submit documentation on systems and facility security as defined in the Security Management Plan;

9. Provide a summary of external audit reports, including findings and corrective actions, relating to the Dental Contractor’s MIS and subsystems. The summary must include any Service Organization Controls (SOC) 1 examinations, formerly called Statement on Standards for Attestation Engagements (SSAE) 16 audits, that have been conducted in the 3 years prior to the Effective Date. The Dental Contractor must promptly make additional information on the detail of such system audits available to HHSC upon request;

10. Provide additional documentation to support the readiness of systems as requested by

HHSC;

11. Install and test all hardware, Software, and telecommunications infrastructure required to support the Contract;

12. Define and test modifications to the Dental Contractor’s system(s) required to support the business functions of the Contract;

13. Produce data extracts and receive all electronic data transfers and transmissions; and

14. Demonstrate the ability to produce the 837D Encounter file 90 Days prior to the

Operational Start Date.

15. Provide HHSC or designee with test data files for systems and interface testing for all external interfaces, this includes testing of the required telephone lines for Providers and Members and any necessary connections to the HHSC Enrollment Broker (EB). The EB will provide test Enrollment Files to new Dental Contractor that does not have previous HHSC Enrollment Files. The Dental Contractor shall demonstrate its system capabilities and adherence to the resulting Contract specifications during Readiness Review.

If the Dental Contractor is a current State of Texas vendor, all existing and unresolved projects and systems issues related to hardware, Software, claims processing, network, and communications systems must be cured no later than 90 Days prior to the Effective Date of the Contract. Uncured issues present after the Effective Date of the Contract will cause the Dental Contractor to fail Readiness Review.

The Dental Contractor must clearly define and document the policies, processes, and procedures required to support day-to-day systems operations. The Dental Contractor must develop, and submit for HHSC review and approval, the following information 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.

The Disaster Recovery Plan and the Business Continuity Plan (BCP) may be combined into one document. At any time during the Contract Term, the Dental Contractor must provide updated plans within 15 Business Days of HHSC’s request.

HHSC will assess the Dental Contractor’s understanding of its responsibilities, the Dental Contractor’s capability to assume the MIS functions required under the Contract, and whether the Dental Contractor can commence operations under the Contract.

The Dental Contractor must clearly define and document the policies and procedures to support day-to-day business activities related to the provision of Covered Dental Services, including coordination with Subcontractors. The Dental Contractor must clearly document all policies and procedures to produce Deliverables. The Dental Contractor must develop, document, and maintain its approach to Quality Assurance.

During Readiness Review, the Dental Contractor must perform the following activities or develop and submit to HHSC the following Deliverables as well as, any additional items HHSC deems necessary to ensure readiness, in accordance with the HHSC operations readiness Deliverables timeline:

1. Operations procedures and associated documentation to support the Dental Contractor’s proposed approach to conducting operations activities in compliance with the Contract. If the Dental Contractor is an incumbent HHSC dental contractor, such revisions shall reflect the guidance and direction given to the Dental Contractor by HHSC to date, provided such is applicable to the SOW;

2. A comprehensive plan for Network adequacy that includes a list of all contracted and credentialed Providers, in a format approved by HHSC. At a minimum, the list must include the Provider types identified in Sections 2.6.31.2 through 2.6.31.2.1.2. The plan must include a description of additional contracting and Credentialing activities scheduled to be completed before the Operational Start Date;

3. A comprehensive plan to recruit and retain Providers statewide to meet the minimum requirements for pediatric dentists, orthodontists, endodontists, periodontists, and oral surgeons. Dental Contractors must recruit orthodontists who provide cleft/craniofacial services in their Networks;

4. A plan documenting how the Dental Contractor will track Provider certifications and trainings, how the Dental Contractor will indicate these designations in the Provider directory, and what system is in place to encourage additional Providers to receive such trainings and certifications from the Dental Contractor;

5. A Member Services staff training curriculum, a Provider training curriculum and related materials, and a plan to provide documentation demonstrating compliance with training requirements (e.g., attendance rosters dated and signed by each attendee or other written evidence of training). Training must meet the requirements of 1 Tex.

Admin. Code § 353.105, and include privacy, Service Coordination, Member advocacy, Dental Contractor Internal Appeal and Complaint System, HHSC State

Fair Hearing process, Covered Services, Value-added Services (VAS), warm transfer, medical necessity, Member harm identification, issue escalation, reporting suspected Abuse, Neglect, or Exploitation (ANE), prohibitions related to restraint and seclusion, and community resource navigation;

6. A coordination plan documenting how the Dental Contractor will coordinate its business activities with those activities performed by HHSC or its contractors, and the Dental Contractor’s Material Subcontractors, if any. The coordination plan must include identification of coordinated activities and protocols for the Transition Phase;

7. A coordination plan for ongoing coordination with HHSC or its contractors, including strategies for sharing information and resolving issues;

8. Drafts of the Member handbook, Provider directory, and Member Identification (ID) card for HHSC's review and approval. The materials must meet the requirements specified in Section 2.6.14 and include the critical elements defined in Chapter 3 of Exhibit B, Uniform Managed Care Manual (UMCM). The Dental Contractor must submit a final Member handbook, Provider directory, and Member ID card incorporating all changes required by HHSC;

9. The required number of the final Provider directories to the HHSC Administrative Services Contractor (HHSC ASC) by the due date specified by HHSC to meet the enrollment schedule;

10. Drafts of the Provider manual and Provider Contract templates to HHSC for review and approval. The materials must meet the requirements specified in Section 2.6.7, and include the critical elements defined in Chapters 3 and 8 of Exhibit B, Uniform Managed Care Manual (UMCM). The Dental Contractor must submit a final Provider manual and final Provider Contract templates incorporating all changes required by HHSC;

11. The Dental Contractor’s proposed Dental Contractor Internal Appeal and Complaint System provided in Section 2.6.29;

12. The Dental Contractor’s proposed Provider appeals and Complaints system provided in Section 2.6.28;

13. The Dental Contractor’s proposed Utilization Management (UM) processes provided in Chapter 15 of Exhibit B, Uniform Managed Care Manual (UMCM);

14. The Dental Contractor’s proposed Encounters processes provided in Section 2.6.25.2;

15. The Dental Contractor’s proposed processes affecting claims provided in Section 2.6.25.3;

16. Demonstrate toll-free telephone systems and reporting capabilities for the Member-facing hotlines in accordance with Section 2.6.15 and no less than 60 Days prior to the Operational Start Date;

17. A written Fraud Waste Abuse (FWA) compliance plan for approval in accordance with Chapter 5 of Exhibit B, Uniform Managed Care Manual (UMCM), unless otherwise approved by HHSC. In addition, Section 2.6.26 provides the requirements of the FWA compliance plan, including the requirements for Special Investigative Units (SIUs). If SIU functions are Subcontracted to another entity, the Subcontractor must also meet all the requirements in this section and the FWA requirements stated in Section 2.6.26;

18. A privacy notice, commonly referred to as Notice of Privacy Practice (NPP), as required by Health Insurance Portability and Accountability Act (HIPAA), including 45 C.F.R. § 164.520. The Dental Contractor must provide HHSC with a copy of its privacy notice during Readiness Review for HHSC approval;

19. Fully inform all Providers about the claim submission process and claim data requirements at least 30 Days prior to the Operational Start Date and as a provision within the Dental Contractor’s Provider Contract and the Provider manual;

20. Develop and implement a network access assurance program to continually improve Network access and quality. Under this program, the Dental Contractor must provide enhanced payments to qualified Providers. During Readiness Review, the Dental Contractor must submit a written description of its proposed network access assurance program to HHSC, and must receive HHSC’s written approval before implementing the program;

21. A Cultural Competency plan for approval. The plan must align with the federal and State standards as described in Section 2.6.16.1; and

22. A plan documenting the process it will use to ensure continuation of Covered Services and access to Out-of-Network (OON) providers.

At HHSC’s request, the Dental Contractor must provide HHSC with operating procedures and updates to documentation to support the provision of Services and provide assurance of the Dental Contractor’s understanding of its responsibilities and the Dental Contractor’s capability to assume the functions required under the Contract, based in part on the Dental Contractor’s assurances of operational readiness, information previously submitted to HHSC, and in its Transition Phase documentation.

Beginning three months prior to the Operational Start Date, HHSC will provide the Dental Contractor a monthly Member Prospective Enrollment File (PME).

The Dental Contractor must:

1. Coordinate and comply with the appropriate file layouts and timelines for transfers between Dental Contractors and HHSC; and

2. Load the monthly PME and process changes as needed for Member enrollment.

During the Readiness Review, the Dental Contractor must update the organizational and financial information previously submitted to HHSC.

2.5.4 PRIORITIZATION PLAN

The Dental Contractor must provide a prioritization plan that outlines the priority and Continuity of Care of the Member populations six months prior to the Operational Start Date.

2.5.5 CONTINUITY OF CARE AND OUT OF NETWORK PROVIDERS

During the Transition Phase, HHSC will ensure the Dental Contractor receives files identifying Fee-for-Service (FFS) Members with existing Prior Authorizations (PAs) for services. Dental Contractors will ensure files are shared identifying managed care Members with existing PAs for services are transferred to the appropriate DMO the Member will be enrolled in. The Dental Contractor must describe the process it will use to ensure continuation of these services in its Transition Plan, including the management of OON provider transitions. The Dental Contractor is also required to ensure that Providers are educated about and trained on the process for continuing these services prior to the Operational Start Date.

2.5.6 TEXAS DEPARTMENT OF INSURANCE LICENSURE, CERTIFICATION, OR

APPROVAL

The Dental Contractor must be licensed by TDI in accordance with the Texas Insurance Code. The Dental Contractor must receive TDI licensure, certification, or approval as a dental maintenance organization or an indemnity insurer in all counties in the State no later than 60 Days after the Contract’s Effective Date. If the Dental Contractor fails to provide proof of the required licensure, certification, or approval from TDI by this deadline, HHSC may terminate the Contract at no additional cost to HHSC and with no penalty for HHSC.

The Dental Contractor must indemnify, in accordance with Exhibit A, Dental Contract Terms and Conditions, HHSC for all costs incurred by HHSC or its authorized representatives prior to termination and for all costs relating to replacing the Dental Contractor. Such costs include, without limitation, the cost of securing a replacement vendor, as well as the cost of any claim or litigation, that is reasonably attributable to the Dental Contractor’s failure to receive the requisite contracts, licensures, certifications, and approvals.

2.5.7 DENTAL CONTRACTOR ACCREDITATION

The Dental Contractor must achieve accreditation with the Utilization Review Accreditation Commission (URAC) within six months of the Operation Phase.

OPERATIONS PHASE SCOPE

This section describes requirements for the Operations Phase of the Contract which begins on the Operational Start Date. HHSC will notify the Dental Contractor of its approval to go-live on the Operational Start Date after the completion of Readiness Review.

HHSC may require the Dental Contractor to perform…