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State of CalifarniaOffice of Administrative Law
In re•California Health Benefit Exchange.
Regulatory Action:
Title 10, California Code of Regulations
Adopt sections: 6424, 6440Amend .sections:Repeal sections:
NOTICE OF APPROVAL OF EMERGENCYREGULATORY AGTION
Government Code Sectipns 11346.1 and11349.6
OAL File No. 2014-0227.06 E
This. emergency regulatory action adopts two new sections to Title 10 of the CaliforniaCode of Regulations. One provision establishes the requirements for eligible applicantsto request recertification as a Standalone. Dental Plan far the plan year 2015 for theIndividual Exchange and for the SHOP Exchange or for approval of proposed familydental plans for either the SHOP or individual Exchanges. The other provisionestablishes the requirements for eligible applicants to request certification as either astandalone dental plan or an issue of family .dental plans in the individual Exchange andfor the SHOP. Exchange,
OAL approves this emergency regulatory action pursuant to sections 11346.1 and11349.6 of the Government Code.
This emergency regulatory action is effective on 3/10/2014 and will expire on 9/9/2014.The Certificate of Compliance for this action is due no later than 918/2014.
~~'
Date: 311012014Thanh H hAttorney
For: DEBRA M. CORNEZDirector
Original: Peter LeeCopy: Andrea Rosen
STATE OFCAUFORNIA—OFFIC~ f ,:'~'~N IE'.i'0.~i~ Y' ._~ ~ ~- ' ~ ,~ .,;,'~~SP,P, 111St1"UCt10flS OhNOTICE PUBLI~R,~"EQNt~~G1JLk'FIf~~{~'~URii~ISSf€11~ ̀ ~~ reverse)S?D. 4!u~rREV. M~2073)
OAL FILE NOTICE FILE NUMBER REGUTATORV ACfiON NUMBER EMERGENCY NUMBER
t~ur~o~~~G, Z. I ~0~~{ -n~a?-o ~rFor use by Office of Administrative Law (OAL) only
NOTICE
California Health Benefit Exchange
REGULATIONS
For use by Secretary of State only
'•. ~'r~ " . .`~~ _..--~..V . _ -
A. PUBLICATIt3N OF NOTICE (Complete for publication in Notice Register)1. SUBJECT OFNOTICE TITLES) FIRST SECTION AFFECTED 2. REQUESTED PUBLICATION DATE
3. NOTICE TYPE 4. AGENCY CONTACT PERSON TELEPHONE NUMBER FAX NUMB R (Optional)Notice re ProposedRequlato Action ❑Other
OAL. USA ~'i;TION GN ̂ Rr~p6$ED NOTE E ~:~ NOTiCE REGISTER NUM9~,R PUBLICAT~t~N QRTE
~~~X ~ appmvad as ~ Rpprovatf as ~ Disapproved!S~,~nviitted Maiif+sci Wrthdiawn
B. SUBMiSSlON OF REGULATIONS iComplete when submitting regulations)
1a. SUBJECT OFREGULATION(S) 1b. ALL PREVIOUS RELATED OAL REGULATORY ACTION NUMBERS)
Dental Plan Recertification and New Entrant
2. SPECIFYCAUFORNIACODEOFREGULATIONSTITLE(5)ANDSECTION{5) pncludingNtle26,iftoxicsrelated)
SECTIOM(S) AFFECTED ADOPT
(List all section numbers) 6424 and 6440
individually. /~~BC~i AMEND
additional sheet if needed.)TItLE(S) REPEAL
10
3. TYPE OF Fl~ING -
Regular Rulemaking (Gov.Code §7 7346)
❑ Resubmittai of disapproved orwithdrawn nonemergentyfiling (Gov. Code §§11344.3,
~ Certificate of Compliance: The agency o~cer namedbelow certifies that this agency complied with theprovisions of Gov. Code §411346.2-11347.3 eitherbefore the emergency regulation was adopted orwithin the time period required by statute.
❑Emergency Readopt (Gov.Code, §17 346.1(h)}
❑File &Print
❑Changes Without RegulatoryEffect (dal. Code Regs., title7, §700)
~ Print Only
11349.4)
Emergenty (Gov. Code,§t1346.1(b})
~ Resubmittal of disapproved or wfthdrawnemergency filingiGov.Code, 311346.1)
~ Other (Specify)
4. ALL BEGINNING AND ENDING DATES OF AVAILABILITY OF MODIFIED REGULATIONS ANDlOR MATERIAL ADDED 70 THE RUIEMAKING FILE (Cal. Code Regs. title t, §44 and Gov. Code §11347.1)
5. EPPECfIVE DATE OF CHANGES (Gov. Code, 5§ 17 343.4, 11346.1(d);eal. Code Regs., title 7, §100 )
o Effective January 1, April 1, Juiy 1, or X Effective on filing with §700 Changes Without EffectiveOctober 1 (Gov. Code §11343.4(a)) ~ Secretary of State ~ Regulatory Effect ~ other (SpecKy)
6. CHECK IF THESE REGULATIONS REQUIRE NOTICE TO, OR REVIEW, CONSULTATION, APPROVAL OR CONCURRENCE BY, ANOTHER AGENCY OR ENTITY
Department of Finance (Form STD. 399} (SAM §6660) ~ Fair Political Practices Commission ~ State Fire Marshal
Other (Specify)
Andrea Rosen 76)228-8343.
8• 1 certify that the attached copy of the regulation{s) is a true and correct copy For use
of the regulations) identified on this form, that the information specified on this formis true and correct, and that 1 am the head of the agency taking this action,or a designee ea f the agency, and am authorized to make this certification.
SIGNATURE OF AG Y OR D NEE DATE
r' ~~~/'~
K~c,~+~.. D;
andrea.
Law (DAL) only
Title 10, California Gode of Regulations
Adopt Section 6424 to read:
Section 6424: Standalone Dental Plan (SADP) Issuer 2015 Renewal Application
The purpose of this section is to set forth the requirements for eligible applicants torequest recertification as a SADP for the Plan Year 2015 for the individual Exchangeand for the SHOP Exchange or for approval of proposed family dental plans for eitherthe SHOP or Individual Exchanges. Applicants must complete the SADP Issuer 2015Renewal Application Version 2-19-14. a form incorporated by reference in order torequest recertification of its SADP plan offerings as SADPs for 2015 Plan _Year and torequest approval of a proposed family dental plan. If an applicant meets therequirements for recertification as a SADP, that issuer will be certified to offer marketand sell certified SADPs through Covered California far the Plan Year 2015. If anapplicant fails to meet the requirements for certification as a SADP for 2015 CoveredCalifornia, in .its sole discretion, may decline to recertify applicant's SADP. CoveredCalifornia, in its sole discretion, shall determine if the applicant's proposal for
a familydental plan in a given geographic service area, is necessary as described in Part 1.4 ofthe New Dental Plan Application for Plan Year 2015 Version 2-19-14 which isincorporated by reference in 10 CCR Section 6440.
(a) The definitions included in 10 CCR 6410 shall govern this section. Any otherapplicable terms not defined in Section 6410 are defined in subdivision td).
fib) Applicants eligible to complete the Standalone Dental Plan (SADP) Issuer 2015Renewal Application Version 2-19-14, a form incorporated by reference, to be certifiedto participate in the Individual Exchange and the SHOP Exchange in 2015 are limited toentities below:
1) Anthem Blue Cross Life and Health Insurance Company and Blue Cross ofCalifornia (DBA Anthem Blue Crossl
2) California Physicians' Service, dba Blue Shield of California3) Delta Dental of California4) Guardian Life Insurance Company of America and Managed Dental Care of
California5} LIBERTY Dental Plan of California, -Inc., a CA corporation6) Metropolitan Life Insurance Company and Safeguard Health Plans, Inc7) Premier Access Insurance Company and Access Dental Plan of California, Inc
tc) Submission Requirements: Entities eligible to apply for recertification to participatein the Individual or SHOP Exchange or who intend to submit a progased family dental
plan must comply with the- submission date and requirements in (c)~2) if the events insubdivision tc)(3~ do not occur.
(1) Submit a notice to Covered California indicatinq intent to request recertificationno later than 5:00 pm Pacific Time on March 17 2014:
(2) Complete the application in subdivision ~d~ and submit to Covered California in itsentirety no later than 5:Q0 pm Pacific Time on May 1 2014
(3) If the California Legislature amends Health and Safety Code §1399 849(cZ(1) andInsurance Code ~ 10965.3 #o set the start of open enrollment for the 2015 planyear as November 15, 2014 or any another date applicants are required tocomplete the application in subdivision (d) and submit to Covered California in its
(d) Standalone Dental Plan (SADP Issuer 2015 .Renewal Application Applicants whoare eligible to complete the Standalone Dental Plan (SADP) Issuer 2015 RenewalApplication Version 2-19-14, a form incomeorated by reference for participation in theindividual or SHOP Exchange must complete the SADP Issuer 2015 RenewalApplication Version 2-79-14, a farm incoporated by reference
Authority cited: Sections 100504,100505. Government Code.
Reference cited: Sections 1.00502,100503,100504 100505 Government Code
Title 10, California Code of Regulations
Rdopt Section 6440 to read:
Section 6440: Dental Plan_New Entrant Application for Plan Year 2015
The purpose of this section is to set forth the requirements for eligible ap lipcants torequest certification as a either a standalone dental plan or an issuer of family dentalplans in the individual Exchange and for the SHOP Exchange_A~plicants mustcomplete the Dental Plan New Entrant Application for Plan Year 2015 Version 2-19-14a form incorporated by reference in order to request certification of its~lan offerings aseither a standalone dental plan or family dental plan for the 2Q15 Plan Year. If anapplicant meets the requirements for certification and if Covered California in its solediscretion, determines that additional dental plans as proposed by the applicant meetthe requirements and are necessary some or all of that applicant's proposed plans maybe certified as standalone dental plans or family dental plans for the Plan Year 2015 Ifan applicant fails to meet the requirements for certification as a standalone dental planor a family dental plan for 2015 or if Covered California, in its sole discretiondetermines that the applicant's offerings in a given geographic service area are notnecessary, as described in Part 1.4 of the Dental Plan New EntrantApplication for PlanYear 2015 Version 2-19-14, Covered California may decline to certify some or all of theapplicant's proposed dental plans for 2015.
(a) The definitions included in 10 CCR 6410 shall govern this section. Anv otherapplicable terms not defined in Section 6410 are defined in subdivision (d).
fib) Applicants eligible to complete the Dental Plan New Entrant A,~plication for PlanYear 2015 Version 2-19-14, a form incorporated by reference, include any plan licensedto offer dental benefits in California in 2015 in either the individual or small~rou~market.
Vic) Submission Requirements: Entities eligible to apply for.certification toparticipate inthe Individual or SHOP Exchange must comply with the submission date and .requirements in (c)(2) if the events in subdivision c}(3) do not occur:
(1) Submit a notice to Covered California indicatin intent to request certification nolater than 5:00 pm Pacific Time on March 17, 2014.
(2) Complete the application in subdivision (d) and submit to Covered California in itsentirety no later than 5:00 pm Pacific Time on May 1, 2074.
(3) If the California Legislature amends Health and Safety Code ~1399.849(c~~,1) andInsurance Code X10965.3 to set the start of open enrollment for the 2015 planyear as November 15, 2014 or any another date, applicants are required to
complete the application in subdivision (d) and submit to Covered California in itsentirety on or before S:OOpm Pacific Time on June 2 2014.
(d) Dental Plan New Entrant Application for Plan Year 2015: Applicants who are eligibleto complete the Dental Plan New Entrant Application for Plan Year 2015 Version 2-19-14, aform incorporated by reference, for participation in the Individual or SHOPExchange must complete the Dental Plan New Entrant Application for Plan Year 2015Version 2-19-14, a form incorporated by reference.
't l~i~l!~~~1~i~111 ~~C~~~~1~L ~ l~l~l~~~~~J 1 !~~ l~l ~~ ~~~ ~L~1 ~~L Ate.. ~ ~1~~1~~ ~(
Reference cited: Sections 7 00502, 100503,100504,100505 Government Code.
;. ~m;
fAS.61$tR ~t 9~I~
4'
'~"
SADP Iss
uer 2015 Renewal Application
The Exchange intends to make thi
s en
tire
application available ele
ctro
nica
lly.
Please complete the
following:
Issu
er Name
NAIL Company
Code
NAIC Grou Code
Re ul
ator
sFederal Employer
ID HIOS/Issuer ID
Corp
orat
e Office
Address
Ci State
ZIP
Prim
ary Contact
Name
Cont
act Title
Cont
act Phone
Number
Contact E-mail
Check all app
lica
ble categories: ❑SADP Ind
ivid
ual;
❑SADP SHOP; ❑F
amil
y Dental Plan
Indi
vidu
al';
❑Fam
ily Dental Pla
n SHOP2
On<behalf of
the
SADP issuer stated above, 1 hereby attest th
at I meet the
requirements in
this Renewal App
lica
tion
and certify tha
tthe information provided on this Ap
plic
atio
n and in any attachments hereto ar
e tr
ue, co
mple
te, and acc
urat
e. I un
ders
tand
tha
t
Fami
ly Dental Plan Ind
ivid
ual means an app
rove
d sp
ecia
lize
d he
alth
plan th
at covers sp
ecif
ied ad
ult de
ntal
ser
vice
s and sp
ecif
ied pe
diat
ric
dent
al services wh
ich in
clud
e, at a min
imum
, th
e pe
diat
ric de
ntal
Essential Health Benefit as out
line
d in California Health and Saf
ety Code Section
1367
.005
and California Insurance Code 101
12.2
7, off
ered
in the ln
divi
dua!
Exc
hang
e..
Z Fa
mily
Dental Pian SHOP Ind
ivid
ual means an approved spe
cial
ized
hea
lth pl
an tha
t co
vers
spe
cifi
ed adu
lt den
tal services and spe
cifi
edpe
diat
ric de
ntal
ser
vice
s wh
ich in
clud
e, at a min
imum
, the pe
diat
ric de
ntal
Essential Hea
lth .Benefit as outlined in California Health and Saf
ety
Code Section 1367A05 and California In
sura
nce Code 101
12.2
7, of
fered in
the
SHOP Exchange.
P~+'
~~~-
SADP iss
uer 2015 Renewal Application Version 2-1
9-14
t _
`'"-'.
fit
Page 1 of 13
,~--
,,
"~
SADP Issuer 2015 Ren
ewal
Application
Cove
red California may rev
iew th
e validity of my att
esta
tion
s and the information provided
in response to<thisapplication and
dece
rtif
y Is
suer
's Standalone De
ntal
Pla
ns offered on the
Exchange should th
e in
form
atio
n provided be found to be ina
ccur
ate.
confirm th
at i ha
ve the
capacity to
bind th
e' SADP iss
uer st
ated
above to th
e te
rms of
this
renewal application.
Date
:Si
gnat
ure:
Prin
ted Name:
Titl
e:
~e~u
irer
reen
ts
fede
ral
Stat
e Board
Yes/Pdc~ Commen$s/Explanatiar~
i L~vv
Lave
Policy
~ s (R
espo
nses
shall not
—_ —~---—__--
— _
__
_ __
~— _.-
- ex
ceed
250
wor
dsL Lic
ense
d and in Good Sta
ndin
~.~
Conf
irm that SADP iss
uer po
sses
ses and
§~ 6F2oo~b>~a>
main
tain
s its li
cens
e to
off
er health insurance and
Yes
is in good sta
ndin
g wi
th applicable st
ate,
and
❑N
ofederal au
thor
itie
s. (See Appendix A —De
fini
tion
of
Good Standin
~ ~2
Are you seeking any mat
eria
l modification of an
exis
ting
lic
ense
fro
m th
e Ca
lifo
rnia
Dep
artm
ent of
Managed Hea
lth Care for
any com
merc
ial.
indi
vidu
al. or small gr
oup pr
oduc
ts offered or
❑Yes
prop
osed
to be off
ered
through Cov
ered
❑N
oCa
lifornia?
If yes
, complete Attachment A
(Reg
ulat
ory Filings) to
exp
lain
what modifications
you are seeking and when those are ant
icip
ated
to
be a
roved.
1.3'
By sub
mitt
ing th
is app
lica
tion
, SADP iss
uer ag
rees
to negotiate a con
trac
t or
con
trac
t amendment fo
r❑Y
es2015 in good fai
th wit
h Co
vere
d California that wi
ll❑
No
establish th
e te
rms and conditions of
the
business
relationshi .
11. Pro
vide
r Network Adequac
SADP Issuer 2015 Ren
ewal
App
lica
tion
Version 2-1
9-14
Page 2 of
13
,•
C~V6~~
~~,.
k3~r
~~st
sk&
'~%"
-v nn
SADP Issuer 2015 Renewal Application
Requirements
Federal
State
Board
Yes/No
Comments/Explanation
Law
L.aw
Policy
s (Responses shall not
__ ~
exceed 250 words)
--2.
1As a general requirement, SADP issuer must
45 CFR
Heaitn
maintain continuing compliance with California
§156:23Q(a~~2~
sa e
provider network adequacy standards, laws &
code
regulations established by the applicable regulatory
§13~7•Q
a' enc .
A
licant understands that
rovider
9
Y Pp
p3' 28
ccR §
network adequacy for its Covered California
~3oQ.67 -
products wil
l be determined by the applicable state
•2.2 a"d
Ins
❑ YeS
regulatory agency and ver
ifie
d by Covered
code§
❑N
oCalifornia.
~0~33.5
SADP issuer agrees to maintain a leg
ally
compliant
ccR ~
provider network far each product offering (DPPO,
22ao-
DHMO, DEPO) wh
ich includes sufficient number
22do.5
and types of providers to ensure that all services
are accessible in a timely fashion to its Covered
California enrollees.
-~~2
SADP issuer agrees to maintain its provider
network and continue to meets regulatory
requ
irem
ents
based on SADP's 2015 Covered
'California projected and actual enrollment. Submit
❑Y
es
2015 enrollment projections by product that SADP
~No
issuer intends to propose for 2015 by completing
Attachment B1 (SADP 2015 Enrollment
Proj
ecti
ons)
and, if
applicable, Attachment B2
Famil
Dental Pla
n 2015 Enrollment Pro~ections .
2.3
SADP products proposed for 2015 must cover the
entire geo
grap
hic service ar
ea for which the issuer
is licensed
in a rat
ing region. Provide an updated
geographic service area by product type for 2015
❑Y
es
and include any changes from your 2014 service
❑N
oarea b com letin
and u Ioadin throu
h SERFF3
3 System for Electronic Ra
te and Form Fil
ing;
developed and owned by the National Ass
ocia
tion
of Insurance Commissioners
SADP Issuer 2015 Renewal Application Version 2-19-~4
Page 3 of 13
~~
~~' CO~iftE#;!
~~.~
~t~t
?s~t
arM
SADP Iss
uer 2015 Renewal Application
Requirerr~er~ts
~~e
dera
! ~S
tate
Boar
siYe
sJtV
a ;Comments/Explana#ion
fiLavv
+L.
aw
~Policy
~ s (Responses shall not
_--
___.
— __ _
--_
'exceed 250 words
the most current Service Are
a Te
mpla
te loc
ated
at:
http
:i/w
ww.s
erff
com/
plan
management dat
a te
mplates.htm and Attachment C (Pla
n Type by Rat
ing
Regi
on Individual &SHOP). Is
Applicant making
any changes to 2414 se
rvice area?
If yes
, describe
brie
f) .
IIL Contractin wi
th Den
tal Providers Vl
tho Serve the
Low Income and UninsuredPo ul
atio
ns3.
1Describe how SADP iss
uer is
continuing to
meet or
exce
ed Cov
ered
Cal
ifor
nia'
s ne
twor
k co
ntra
ctin
grequirements as defined in Appendix C Contracting
with
Den
tal Providers Who Serve the Low-In
come
and Uninsured Po ulation.
IV. Qualit and Relive` S stem Reform
4.1
Describe ̀SA
DP's
pro
cess
to en
sure
tha
t SADP
issu
er can com
ply wi
th SADP Con
trac
t Da
taSubmission Requirements (a
s'de
fine
d'in
Appendix
B #o Co
vere
d Ca
lifo
rnia
.4.
2SADP agr
ees to
submit claims and enc
ount
er d
ata
in the requested format to a third par
ty vendor
❑Yes
selected' by Cov
ered
Cal
ifor
nia fo
r the pu
rpos
e of
❑N
aerformin
clinical anal
ics.
4.3
Conf
irm that SADP wi
ll sub
mit,
upon req
uest
, to
the
Exchange dental utilization reporting to
include the
measure numerator, denominator, and rat
e for th
e❑Y
esre
quir
ed measures set
in App
endi
x' D Cov
ered
❑ No
Cali
forn
ia SADP Performance Standards: Qu
alit
yand Relive S stem Standards.
V. O e
rational Readiness and Ca acit
5.1
SADP iss
uer confirms that'it can and wil
(-❑Y
esaccurately, ap
prop
riat
ely and timely po
pula
te and
CJ No
4 Cl
aims
and encounter data re
flec
t a health ca
re vis
it by an enr
olle
e to a provider of care or
serv
ice.
SADP Issuer 2015 Renewal Application Version 2-1
9-14
Page 4 of 13
r.---~
~C+DV~Rt~~
l P"
SADP Iss
uer 2015 Renewal Application
R~quirem~nts
~'ederai
State
hoard
YeslNo Comments/Explanation
Law
Law
Poli
cys (R
esponses sha
ll not
submit SERFF tem
plat
es at the request of
Covered
exceed 250 wards
Cali
forn
ia fior:
{1) :Rates
(2) Ser
vice
Area
(3) Plan/Benefit Designs
'4 Nefinrork
5.2
Demonstrate thr
ough
exi
stin
g SADP con
trac
tat
a2 u.s.c. §
compliance or systems testing tha
t SADP iss
uer
132Qd et
seq
operates systems whi
ch can acc
urat
ely an
d ti
mely
4s c.
F.R.
Part
report ele
ctro
nic data to Co
vere
d California using
162
federal le
al standards fo
r el
ectr
onic
transactions.
~•3
Demonstrate, through submission of
a March 2014
audi
t report or sy
stem
s te
stin
g, as ap
plic
able
, that
SAP issuer ca
n accept 834, 820 and oth
erstandard tra
nsac
tion
ele
ctro
nic files f
or enrollment
anti
premium remittance in an ac
cura
te, co
nsis
tent
and ti
mely
fashion and u
tilize the
information #or
its
inte
nded
ur ose see Attachments D1 & D2
5•?~
Prov
ider
dir
ecto
ry data fo
r bo
th Ind
ivid
ual and
SHOP Exchange products must be included in
this
§~56
.2so
~b7
Yes
submission.
❑N
o5.5
Describe how SADP iss
uer'
s computer systems
can acc
urat
ely and timely ma
inta
in an ele
ctro
nic
interface wi
th CaIHEERS. Unless ap
plic
ant can
demonstrate this requirement th
roug
h co
ntra
ctco
mpli
ance
, ap
plic
ant must be available for testing
;da#a interfaces wi
th the Exchange no lat
er than
July 1, 2014. SADP issuer must mai
ntai
n computer
systems for
tes
ting
any future mo
difi
cati
ons to the
inte
rfac
e de
si nand data in
terc
han
e.5.
6De
scri
be the SADP iss
uer'
s systems abi
lity
to
enerate in
voic
es for
new members, which must be
SADP Issuer 2015 Renewal App
lica
tion
Version 2-~
9-14
Page 5 of 13
`'', CO~''~tEpE
4 i~
ar+~
SADP Iss
uer 2015 Renewal Application
Requirements
Fede
ral
Stat
eBoard
Yes/No ~
Com
rnen
tslE
xpla
nati
onLa
~nr
Law
Policy
I s (R
espo
nses
shall not
—--- _ _
_ _ __ ---
_ ___
~!exceed 250 words)
i_--
_ _
_—
full op
erat
iona
l no lat
er than October 15, 20
14.
~•~
Describe SADP issuer's systems which must
acce
pt pre
mium
payments fro
m members no lat
erth
an t~ctober 15, 2014 made using pap
er che
cks,
cash
ier'
s ch
ecks
, money orders, EFT and all
general pu
rpos
e pre-paid debit cardsand credit
cards. if
suc
h systems ar
e not cu
rren
tly in pla
ce,.
describe pla
ns to implement such systems,
incl
udin
g any pot
enti
al vendors,
if applicable, and
an implementation wo
rk Ian wi
th tim
elin
e.5.8
Desc
ribe
how SADP iss
uer wi
ll maintain sufficient
staffing in th
e cu
stom
er service cen
ter to
meet
contractual
erFormance oats.
5.9
Describe SADP iss
uer'
s pl
ans th
at are in pl
ace fo
rth
e pu
rpos
e of
det
ecti
ng and reporting inc
iden
ts of
frau
d, was
te and abuse. Provide a description of
such
lans and the
ir eff
icac
.5.
~oDescribe any education eff
orts
SADP iss
uer
prov
ides
to:
members to help them ide
ntif
y and
repo
rt possible fr
aud scams. Describe SADP's
procedures to re
port
fraud scams to la
wen
forc
emen
t.5.11
Desc
ribe
SADP iss
uer'
s safeguards against Social
Securit / id
enti
t fraud.
5.12
SADP must com
ply with applicable federal and
stat
e pr
ivac
y la
ws and reg
ulat
ions
, and has
❑Yes
appr
opri
ate procedures in pl
ace to
detect and
❑N
ore
s and to
rivac and securit incidents.
5.~3
'SADP iss
uerm
ust ad
here
to Co
vere
d California
nami
ng conventions promulgated thr
ough
a fut
ure
administrative rul
emak
ing by Cov
ered
California for
2015
.
SADP Issuer 2015 Renewal Application Version 2-1
9-14
Page 6 of 13
~r-r-' __
_.-'
\
`. C~~~~'~~9
., r_
~ .r
..,, ~ ~,
SADP Iss
uer 2015 Renewal Application
Requirements
Fede
ral
State
Board
Yes/Na
Comments/Explanation
Law
Law
Policy
s {Re
spon
ses sha{i no
texceed 25Q words_~~
Vi. Rates for 2015
6.1
Submit premium rat
es for
every proposed SADP by
rati
ng region fo
r 2015 com
plet
ing At
tach
ment
E1
SADP Rates Individual &SHOP. If
applicable,
.submit premium rates for
every pro
pose
d Fa
mily
Dent
al Plan by com
plet
ing At
tach
ment
E2 Fam
ily
Dental Plan Rates ind
ivid
ual & SHQP
6,2
Provide in
form
atio
n requested ab
out documents
requ
ired
to be fil
ed with the applicable reg
ulat
or as
outl
ined
in Attachment A for
2015 pro
duct
sproposed to be off
ered
thr
ough
Covered Cai
ifom
ia.
Complete Att
achm
ent A.and provide upd
ates
to
this
information as additional documents are
subm
itte
d to
the
a
licable re
ul
ator
.VI
L 2~~5Standard Benefit Plan Desi n
~•~
SADP issuer must adhere to 2015 standard benefit
'aOyes
plan
- designs which will be ado
pted
through
futu
read
mini
stra
tive
rul
emak
in .
❑ No
7.2
SADP issuer agrees to submit its .p
roposed 2015
❑Y
es
plan
s fo
r its li
cens
ed geographic service ar
ea(s
)•❑
No
7.3
Comply wit
h Ca
lifo
rnia
sta
te benefit pla
n laws in
❑Y
es
effect for
2015, in
cluding th
ose pe
rtai
ning
to>
plan
deli n re ui
reme
nts.
❑N
o
SADP Iss
uer 2015 Renewal Application Version 2-1
9-14
Page 7 of
13
Appendix A: Definition of Good Standing
Regulatory
Definition of Good Standing Agency
Relevant
To EHB
Relevant toSupplemental
Verification that issuer holds a state health care serviceplan license or insurance certificate of authority
• Approved for what lines of business (e.g. commercial,small group, individual) DMHC X X
• Approved to operate in what geographic service areas DMHC X X
• Most recent financial exam and medical survey report DMHC X X
• Most recent market conduct exam reviewed CDI X X
Affirmation of no materials statutory or regulatoryviolations, including penalties levied, in the past fwo yearsin relation to any of the following, where applicable:
• Financial solvency and reserves reviewed DMHC and CDI X X
• Administrative and organizational capacity DMHC X X
• Benefit Design
• State mandates (to cover and fo offer) DMHC and CDI X
• Essential health benefitss Pediatric Dental DMNC and CDIonly X
• Basic health care services CDI X
• Copayments, deductibles, out-of-pocket DMHC and CDImaximums X
• Actuarial value confirmation (using 2015 DMHC and CDIActuarial Value Calculator) X
• Network adequacy and accessibility standards: DMHC and CDI X
• Provider contracts DMHC and CDI X
• Uniform disclosure (summary of benefits andDMHC and CDI
coverage}X
• Claims payment policies and practices DMHC and CDI X X
• Provider complaints bMHC and CDl X X .
• Utilization review policies and practices DMHC and CDI X X
• Quality assurance/management policies and practices DMHC X
• Enrollee/Member grievances/complaints and appeals DMHC and CDI
policies and practices X X
• Independent medical review DMHC and CDI X
Marketing and advertising DMHC and CDI X
• Guaranteed issue individual and small group DMHC and CDI X X
5 Covered California, in its sole discretion and in consultation with the appropriate health insurance regulator,determines what constitutes a material violation for this purpose.
~l a ',~ Ct3YE1R~~Q` i:~ ~aaK~~~~~
SADP Issuer.2015 Renewal Application
Appendix B: SADP Contract Data Submission Requirements
SADP issuer shall provide. to the Exchange. information regarding SADP issuer's membershipthrough the Exchange in a consistent manner to that which SADP issuer currently provides to itsmajor purchasers. SADP issuer and the Exchange shall work together in good faith to furtherdefine mutually agreeable information and formats for SADP issuer to provide to the Exchange,in all cases to remain generally consistent with the information shared 6y SADP issuer with itsmajor. purchasers.
SADP Issuer 2015 Renewal Application Version 2-19-14
f .~_
`~ 3 L~46H4~Y
E3 ~~:~ ,,: :, LSR f3 Rfi19A
"" SADP Issuer 2015 Renewal Application
Appendix C: Contracting with Dental Providers UVho Serve the Low-Income andUninsured Population
SADP issuer shall maintain a network that includes participation of dental providers with ahistory of serving uninsured and low income populations that are available through SADP toprovide reasonable and timely access to Specialized Health Care Services to low-incomepopulations in each geographic region where SADP Issuer's SADPs provide services toEnrollees.
(a) For purposes of this Section, "participation of dental providers with a history ofserving uninsured and low income po~ ulations" shall be determined by theExchange in its reasonable discretior`in accordance with the followingconditions: (i) Federally Qualified Health Centers (FQHC) providers plotted on alow-income population map by county and (ii) other providers who serve the low-
~ ~~y income population, defined as those providers for whom at least 20% of patientsp~ ~,~~~ served are low income, by county an ased on consideration of various
~`°' '~ factors, including, (i) the nature, type and distribution of SADP Issuer'scontracting arrangements with FQHCs who provide dental services in eachgeographic region in which SADP issuer provides Specialized Health CareServices to Enrollees, (ii) the inclusion of a sufficient number of providers thatparticipate or have participated with the Medi-Cal and/or Healthy Familiesprogram, and (iii) other factors as mutually agreed upon by the Exchange and theSADP Issuer regarding its ability to serve the low income population.
(b) "Low-income populations" shall be defined as families living at or below 200% ofFederal poverty level.
(c} SADP Issuer shall notify the Exchange with respect to any material changes asof and throughout the term of this Agreement to its contracting arrangements withFQHCs that provide dental services and' other information relating to contractingwith providers who serve the low-income and uninsured populations.
SADP Issuer 2015 Renewal Application Version 2-19-14
x~ ~ ~ c~~~~~~t 4" c .~,~.r~~~~~,~
"' SADP Issuer 2015 Renewal Application
Appendix D: Covered California SADP Performance Standards: Quality and DeliverySystem Standards.
Covered California will work with SADP Issuers as
Utilization Measures appropriate to adjust measure .sets where an SADPIssuer does not have aif of the specific Utilization
measures.
Annual Preventive/Diagnostic Visit Age.. Expectation PerformanceGroup
Measure includes all members ages 1through 18 years of age. as of 2-3 75%December 31, 201.4. (denominator) whohad: at least one preventive or 4-6 75%0diagnostic dental visit in 2014(numerator) with no .more than one gapin enrollment of up to 45 days during207 4.
7-10 75%
11-14 75%
15-1$ 75%
Annual Dental Uisit (ADV)
Measure includes all members .ages 2through 18 years as of December 31,2014 {denominator) who had at leastone dental visit in 2014 (numerator)with no more than one gap. inenrollment of up to 45 days. during20~ 4.
Age.'Group
Expectation Performance
' 2.3 7~%
4-6 `75%
~_~ p 7~%
11-14 75%0
15-18 75%0
Examinations/Oral Health Evaluations-(OHE)
Measure includes members enrolledfor at least 11 of the 12 .months of 2014{denominator) who receivedcomprehensive or periodic oral healthevaluation (D1020 or D1050) in 2014{numerator); members under the ageof three.. not receiving service D 1020 arD1 Q50 are also. included if theyreceived an oral health evaluation andcounseling with the primary care giver(D0145) in 2014.
AgeGroup
Expectation Performance
2-3 75%0
4-6 75%0
7-10 75%
``11-14 °' `75°l0
15-1$ `75%
SADP Issuer 2015 Renewal Application Version 2-19-14
~_ ,o < cov~~~ss
~ ~~." -~CRi.ircrrt~t -
SADP Issuer 2015 Renewal Application
Preventive Dental Services
(PDS).
AgeGroup
Expectation Performance
Measure includes members enrolled 2-3 75%for at least 11 of the 12 months in 2014
4-6 75%(denominator) who received anypreventive dental service (D1000=D1999) in 2014 (numerator). 7-10 75%
11-14 75%
15-18 75%
Continuity of care {coc) Measurement begins 2014, first Reporting YearMeasure includes members who 2016 `
continuously enrolled in the same planAgeGroup
Expectation Performancefor 2 years with no gap in coveragewho received a comprehensive orperiodic oral health evaluation (D1020>
2-3 n/aD1050) or a prophylaxis (D1110,D1120} in 2014 (denominator) and who
4-6 75%received a comprehensive or periodicoral health evaluation (D0120, D1050)
7-10 75%or a prophylaxis in 2015 (numerator).
11-14 75%
15-18 75%
Filling to Preventive Services Ratio(FPSR).
AgeGroup
Reportin 2014
Set Performance Standards in2015
Measure includes members- enrolled 2_3for at least 11 of the 12 months of2014 who received one or more fillings 4-6(D2000-D2999) in 2014 (denominator)
7-10and who also received a topical fluoride(D1203, D1204, or D1206) a sealant
11-14application (D1351, D1352) oreducation to prevent caries (D1310 and
15-18D1330) in 2014 (numerator).
Use of Dental Treatment Services Report only, monitor trends over time(UDTS).
Measure includes members enrolledfor at least 11 of the 12 months of 2014
AgeGroup
(denominator) who received any dentaltreatment other than diagnostic or
2_3
preventive services (D2000-D9999) in2014 (numerator).
4-6
SADP Issuer 2015 Renewal Application Version 2-19-14
'r c C.$~Y~R~t3~; e~&~~o~~a~
`'~ SADP Issuer 2015 Renewal Application
7-10
11-14
15-18
Overall Utilization of Dental Services(OUDS),
Measure includes members enrolled+r~in for at least 11 of the 12 months of2014 {denominator) who received anydental service (D0100-D9999),including preventive services, during2014 (numerator).
AgeGroup
Expectation PerFormance
2-3 75%
4-6 75%
7_10 75%
11-14 75%
15-1$ 75%
SADP Issuer 2415 Renewal Application Version 2-19-14
'. ̀e COYEREO,i~~ QA4IPORNIA ,...
~" SADP Issuer 2015 Renewal Application
Appendix B: SADP Contract Data Submission Requirements
SADP issuer shall provide to the Exchange information regarding SADP issuer's membershipthrough the Exchange in a consistent manner to that which SADP issuer currently provides to itsmajor purchasers. SADP issuer and the Exchange shall work together in good faith to furtherdefine mutually agreeable information and formats for SADP issuer#o provide to the Exchange,in all cases to remain generally consistent with the information shared by SADP issuer with itsmajor purchasers.
SADP Issuer 2015 Renewal Application 2-19-14
Cali
forn
ia Health Be
nefi
t Exchange
SADP Issuer 2015 Renewal App
lica
tion
Attachment A- Regulatory Fil
ings
Issu
er Name:
Instructions:
Please provide the
req
uest
ed det
ails
associated wi
th any Reg
ulat
ory an
dlor
Pro
duct
filings ne
cess
ary to
obt
ain approval of products/plans tha
t are to be sub
mitt
ed in re
spon
seto thi
s application.
Regulatory
Product Fi
ling
Ex
pect
ed Date. Amendment
Init
ial Fi
ling
Regulatory
Fili
ng Nur„ber
Number
Date of
for Re
view
/
Number
Date
AgencV
(if applicable)
ti# ~
pniic~bte}
Subm
issi
on
Aoer
ov~I
flf
~ aeo
fica
ble:
) tlf a
oolic~.~hlF
Atta
chme
nt A -Regulatory Filings
California Health Benefit ExchangeSADP Issuer 2015 Renewal App{icationAttachment B1 - SADP 2015 Enrollment Projections
Issuer Name:Produc#:Market:
Rlease complete Attachment B1 enrollmenf projection for each product and market type. Enrollmentprojection should reflect anticipated enrollment January 1, 2015 through December 1, 2015
Ratin Re ion CounProduc#DHMO/DPPO 20'15 SADP Enrollment Pro~ections
Re ion 1 AI ineRe ion 1 Del NorteRe ion 1 Siski ouRe ion 1 ModocRe ion 1 LassenRe ion 1 ShastaRe ion 1 TriniRe ion 1 HumboldtRe ion 9 TehamaRe ion 1 ' PlumasRe ion 1 NevadaRe ion 1 Sierra:Re ion-1 MendocinoRe ion 1 LakeRe ion 1 ButteRe' ion 9 GlennRe' ion 1 SutterRe ion 9 YubaRe ion 1 ColusaRe ion 1 AmadorRe ion 1 CalaverasRe ion 1 Tuo{umneRe ion 2 Na aRe ion 2 SonomaRe ion 2 SolanoRe ion 2 MarinRe ion 3 SacramentoRe ion 3 PlacerRe ion 3 EI DoradoRe ion 3 YofoRe ion 4 San FranciscoRe ion 5 Contra CostaRe ion 6 AlamedaRe ion 7 Sanfa ClaraRe ion 8 San MateoRe ion 9 Santa CruzRe ion 9 MontereRe' ion 9 San BenitoRe ion 10 San Joa uinRe ion 10 Stanislaus
Attachment B1 - SADP 2015 Enrollment Projections
Ratin Re ion CountProductDHMOlDF'PO` 2015 SADP Enrollment Pra'ections
Re ion 10 MercedRe ion 10 Mari osaRe ion 10 TulareRe ion 11 FresnoRe ion 11 Kin sRe ion 11 MaderaRe ion 12 San Luis Obis oRe ion 12 VenturaRe ion 12 Santa BarbaraRe ion 13 MonaRe ion 13 In oRe ion 13 Im erialRe ion 14 KernRe ion 15 Los An elesRe ion 16 Los An elesRe ion 17 San BernardinoRe ion 17 RiversideRe ion 18 Oran eRe ion 19 San Die o
Attachment B1 - SADP 2015 Enrollment Projections
California Health Benefit ExchangeSADP Issuer 2015 Renewal ApplicationAttachment B2 -Family Dental Plan 2015 Enrollment Projections
Issuer Name:Product:Market:
Please complete Attachment 61 enrollment projection for each product`and market type. Enrollmentprojection should reflect anticipated enrollment January 1, 2015through DeCember1, 2015
Ratin Re ior~ CoupProductDHMO/DPF'O
2015 Family Den#al Pian EnrollmentPro~ections
Re ion 1 AI ineRe ion 1 De► NolteRe ion 1 Siski ouRe ion 1 ModocRe ion 1 LassenRe ion 1 ShastaRe ion 1 TriniRe ion 1 HumboldtRe ion 1 TehamaRe ion 1 Plu~rtasRe ion 1 NevadaRe ion 1 SierraRe ion 1 `MendocinoRe ion 1 LakeRe ion 1 ButteRe ion 7 GlennRe ion 1 SutterRe ion 1 Yuba.Re ion 1 ColusaRe ion 1 AmadorRe ion 1 CalaverasRe ion 1 TuolumneRe ion 2 Na aRe ion'2 SonomaRe ion 2 SolanoRe ion 2 MainRe ion 3 SacramentoRe ion 3 PlacerRe ion 3 ECDaradoRe ion 3 YoloRe ion 4 San FranciscoRe ion 5 Cr~ntra CostaRe ion 6 AlamedaRe ion 7 Santa ClaraRe ion 8 San MateoRe ion 9 Santa CruzRe ion 9 MontereRe ion 9 San'BenitoRe ion 10 San Joa ̀uinRe ion 10 Stanislaus
Attachment B2 - SADP 2015 Enrollment Projections
Ratin Re ion CountProductDHMOfDPPQ
2015 Family Dental Plan EnrollmentFro~ections
Re ion 10 MercedRe ion 10 Mari osaRe ion 10 TulareRe ion 11 FresnoRe ion 11 Kin sRe ion 11 MaderaRe ion 12 San Luis Obis oRe ion 12 VenturaRe ion 12 Santa BarbaraRe ion 13 MonoRe ion 13 in oRe ion 13 Im erialRe ion 14 KernRe ion 15 Los An elesRe ion 16 Los An alesRe ion 17 San BernardinoRe ion 17 RiversideRe ion 18 Oran eRe ion 19 San Die o
Attachment B2 - SADP 2015 Enrollment Projections
Cali
forn
ia Health Be
nefi
t Exchange
SADP Iss
uer 2015 Renewal App
lica
tion
Attachment C -Plan Type by Rat
ing Region {Individual 8~ SHOP)
Issuer Name:
Inst
ruct
ions
:Pl
ease
ind
icat
e the products pro
pose
d with an "X.
" Note that Issuers are re
quir
ed to su
bmit
proposals tha
t include their en
tire
lic
ense
d service ar
ea for
each
prod
uct type on which the
y ar
e bi
ddin
g. App
lica
nts ar
e encouraged, but no
t required to bi
d on both SADP and Family Dental Plan, and
may offer only their
Indi
vidu
al or Small Group products.
Attachment C - Pian Type by Rating Reg
ion (Individual SHOP)
DPPO
~ DHMQ
~ DPPO
,
DHMO
~ DPPO
~ DHMO
~ DPPO
I DHMO
•-..
~ ~~~i~________________
-..
~ ~Q~1~~________________
_--__
____--_S__
~~~
~1Wii~~~.
.•_-~_____________
Attachment C - Pian Type by Rating Reg
ion (I
ndiv
idua
l SHOP)
Cali
forn
ia Hea
lth Be
nefi
t Exchange
SADP;Issuer 2015 Renewal App
lica
tion
Atta
chme
nt D1 - $34 Enrollment Files
Marc
h2014 834 Enr
ollm
ent File Error L.i
stin
834 Enrollment Fi
les Sent to Carrier •
File Names
Number of
Members in Fi
leCa
rrie
r 999 Response Fil
e Sent
to Ca1HEERS
'
No. of Rejected
File
s in
999
Response Due to
Carr
ieri
ssue
sError Rate
ex: TO_999999_1tVD_2014030515897.edi
500ex: FROM_99999_IND_201403D56
408%a
Atta
chme
nt D1 - 834 Enrollment Fi
le Err
or Listing
Cali
forn
ia Hea
lth Benefit Exchange
SADP Iss
uer 2015 Renewal Applicati
onAttachment D2 - 834 Eff
ectu
atio
n Fi
les Marc
h 2014 834 Eff
ectu
atio
n File Error Listing
834 Effectuation Fi
les Sent from the
Carrier -
File
Names
Number of
Members in
File
CaIHEERS 999 Response File Sent to
CaIHEERS
No, of Re
ject
edFi
les in 999
Response Due to
Carrier Is
sues
Error
Rate
ex: FROM_99999_IND 201
403a
5158
97.e
di500ex:TO 99999 IND 2Q1
4030
5657
7899
.edi
40.
8%
Atta
chme
nt D2 - 834 Eff
ectu
atio
n File Error Listing
California Hea
lth Benefit Exchange
SADP Issuer'20'! 5 Renewal App
lica
tion
Attachment E1 - SADP Rat
es Individual &SHOP
Issuer Name
Product:
DPPO
Nefi
nror
k:
Proposed Calendar Year 2015 Premiums
•• .
•-
,..
....
~ 1~~
.. .
1 .;~~;y
. ..
C~~a T
..,...
...
,. ,.
....
...
g.....
.::
... ~.,,a:
.... ....
:::.:.;:
.,
,,...,
.;:~:
=......:
..-.
• ~ •
a -~----------
w ~
~ ----~
s~~■s~~~~ ~
~~
8 9
Atta
chme
nt E1 - SADP Rates (I
ndividual SHOP)
California Hea
lth Benefit Exchange
SADP Iss
uer 2015 Renewal App
lica
tion
Attachment D - SADP Premium Individual &SHOP
Issuer Na
me:.
,
Product:
DHMO
Network:
Attachment E1 - SADP Rat
es (I
ndividual SHOP)
Cali
forn
ia Health Benefit Exchange
SADP Issuer2015 Ren
ewaf
Appl
icat
ion
Attachment E2 -Family Dental Pl
an Rates Ind
ividual &SHOP
Issu
er Name:
Product:
DPPO
Network:
Proposed Calendar Ye
ar 2015 Premiums
.•'
~,.,
~....
......
......
......
......
._.,
..:ate,-
~ ..
...:-:
:,....
:r.,.-
....:,
::.:,.
.-.,,:
.....
~.. ~`
..:
:.,w.~
......
.w.~~.
~,...
..~.
.r
..:.
;~~tl~_
a,:,✓
;:
Attachment E2 -F
amil
y Dental Plan Ra
tes (Individual SHOP)
Cali
forn
ia Health Benefit Exchange
SADP Iss
uer 2015 Renewal Application
Attachment D - SADP Premium Ind
ivid
ual &SHOP
Issuer Name:
Prod
uct:
DHMO
Network:
Attachment E2 -F
amily Dental Pian Rates {I
ndiv
idua
l SHOP)
Den~~I Plan ~e~ Entr~n. .A I ica~~an f+~r Plan Y~ r 201~~
F~brua 2~ 214
560 J Street, Suite 290, Sacramento, CA 95814www.coveredca.com
This page intentionally left blank.
Dental Plan New Entrant Application 2-19-2014
Covered California
Table of Contents
1. General Information an Bd ackground ..........., ................,.,.. ....................................... ................. 41.1 Attestation .......::.....:......................................................:.:.....:..... ........:................................41.2 Purpose .......................................................:............ ......... ...................................................41.3 Background ..:.............................:....:...............................................:...................................51.4 Application Evaluation and Selection ....................................................:..................................61.5 Availability ............................:..............................................:..........:...:.............................81.6 intention
to Submi# a Response ................. ..............................................................................81.7 Application .Library ..................................:......:.....................:.................:...:..:.:...................91.8 Key Action
Dates ...........................................:.....................................................................92
, Technical:Requirements ........................:.................... .................................; '...................................93. Plan or Policy Submission Requirements ............................................................................................114.
Technical Specifications. ..................................................:.................. .......................................:124.1 General......... ..............................................................................................:.................................124.2 Account Management Support ...............................................................:................................124.3 Account Administration .................................;............................................... ;.............................134.4 Member Services .................................................................................................................... 134.5 Care Management ........................................................................................................................ 154.6 Communications &Education ....................................................................................................... 154.7 Provider Network ..........................................................................................................................174.8 Systems and Data Reporting Management ...................................................................................18
5. Performance Measures (Quafity) ........................................................................................................196. Additional Questions and/or Requirements .........................................................................................216.1 Agent Relations, Fees, and Commissions .::.......... ..:...:.......:........:......... :............................216.2 Marketing and Outreach Activities ..........................................................................................21
7. Cost Proposal .................................................::..:........................ ......:......::................................228. Documentation .. ......., ............. ................................................ .......... ... ..... ...............22
Dental Plan New Entrant Application 2-19-2014
Covered California
1. General Information and Background
1.1 Al"TESTATION
Issuer-NameNAIC CompanyCodeNAIC Grou CodeRe ulator sFederal EmployerIDHIOS/Issuer IDCorporate Office.AddressCiStateZIPPrimary ContactName.
Contact TitleContact PhoneNumberContact E-mail
Check applicable categories: ❑SADP Individual; ❑SADP SHOP;
❑Family Dental Plan Individual'; ❑Family Dental Plan SHOP2
On behalf of the Applicant stated above, I hereby attest that I meet the requirements in this New Entrant
Application and certify that the information provided on this Application and in any attachments hereto are
true, complete, and accurate. 1 understand that Covered California may review the validity of my
attestations. and the information provided in response to this application and if Applicant is selected to offer
SADPs and Family Dental Plans, may dece~ify those SADPs and Family Denta( Plans should any material
information provided be found to be inaccurate. I confirm that I have the capacity to bind the issuer stated
above to the terms of this New Entrant application.
Date:Signature:Printed Name:Title:
1.2 PURPOSE
The California Health Benefit Exchange (Exchange) is accepting applications from dental issuers3
(Applicants) to submit proposals to offer, market, and sell dental plans through the Exchange
Family Dental Plan Individual means an approved specialized health plan that covers specified adult dental services
and specified pediatric dental services which include, at a minimum, the pediatric dental Essential Health Benefit as
outlined in California Health and Safety Code Section 1367.005 and California Insurance Code 10112.27, offered in
the Individual Exchange.2 Family Dental Plan SHOP { i~at-means an approved specialized health plan that covers specifie
d adult dental
services and specified pediatric dental services which include, at a minimum, the pediatric dental Essential Health
Benefit as outlined in California Health and Safety Code Section 1367.005 and California Insurance Code 1011227,
offered in the SHOP Exchange.
Dental Plan New Entrant Application 2/19/2014 Page a ~ ~ryet -
Covered California
beginning in 2015. The Exchange will exercise its statutory authority as an "active purchaser4i inreviewing submitted proposals and reserves the right to select or reject any Applicant or #o cancelthis. Application at any time. This Application invites responses from vendors for both .the.Standalone dental Plans (SADP) that will be considered for coverage of the Pediatric DentalEssential Health Benefits (EHB), and for Family Dental PlansS that combine coverage of thePediatric Dental EHB and supplemental coverage and may be purchased on a voluntary basis. TheExchange seeks to award a limited number of .contracts related to the SADP and to the .FamilyDental Plan for each geographic region, while ensuring that statewide coverage is available..
Applications will be accepted from any dental issuer that is licensed to sell dental plans regula#ed bythe California Department of Managed Health Care or a dental insurance product licensed by theCaii#ornia Department of {nsurance, including dental plans and health plans that offer dentalcoverage separate from medical coverage. ,
The. Exchange requires dental issuers to submit proposals for both SADP and Family Denta( Planproducts. Applicants licensed in both the Individual and SHOP markets are encouraged to submitproposais,for bath market segments.
The. matter contained in this. document is strictly related to the 2015 year Issuer Dental PlanApplication.
1.3 BACKGROUND
Soon after the passage of national health care reform through the Patient Protection and AffordableCare Act of 2010 (ACA), California became the first state to enact legislation to establish a qualifiedhealth benefit exchange. (California Government Code § 100500 et seq.; Chapter 655., Statutes of2010-Perez and Chapter 659, Statutes of 2010-Alquist.) The California state law is referred to asthe California Patient Protection and Affordable Care Act (CA-ACA}.
:Effective January 1, 2014, the California Health Benefit Exchange offers a statewide healthinsurance exchange to make it easier for individuals and small businesses to compare plans andbuy health insurance in the private market. Although the focus of the Exchange is on individualsand small businesses who qualify for tax credits and subsidies under the ACA, the Exchange's goalis to make insurance available to all qualified individuals and to all California businesses with fewer.than 50 employees.
The vision of the California Health Benefit Exchange is to improve the health of all Californians byassuring their access to affordable, high quality care coverage. The mission of the California HealthBenefit Exchange is to increase the number of insured Californians, improve health care quality,lower costs, and reduce health disparities through an innovative, competitive marketplace thatempowers consumers to choose the health plan and providers that give them the best value.
:The California Health Benefit Exchange is guided by the following values
• .Consumer-Focused: At the center of the Exchange's efforts are the people it serves, includingpatients and their families, and small business owners and their employees. The Exchange willoffer aconsumer-friendly experience that is accessible to all Californians, recognizing thediverse cu{tural, language, economic, educationa4 and hea4th status needs of those it serves.
3 The term "dental. issuer" used in this document refers to dental plans regulated by the California Department of Managed HealthCare or the,Califomia Department of Insurance. It also refers to the company issuing dental coverage.4 California GC §100505. per AB 1602 §95 Family Dental Plan means an approved specialized health plan that covers specified adult dental services and specified pediatricdental services which include, at a minimum, the pediatric dental Essential Health Benefit as outlined in California Health andSafety Code Section 1367.005 and California Insurance Code 10112.27Dental;Plan New Entrant Application 2-19-2014
Page 5
Covered California
• Affordability: The Exchange will provide affordable health insurance while assuring quality and
access.
• Catalyst: The Exchange will be a catalyst for change in California's health care system, using
its market rate to stimulate new strategies for providing high -quality, affordable healthcare,
promoting prevention and wellness, and reducing health disparities.
• Integrity: The Exchange will earn the public's trust through its commitment fio accountability,
responsiveness, transparency, speed, agility, reliability, and cooperation.
• Partnership: The Exchange welcomes partnerships, and its efforts will be guided by working
with consumers, providers, health plans, employers and other purchasers, government partners,
and other stakeholders.
• Results: The impact of the Exchange will be measured by its contributions to expanding
coverage and access, improving health care quality, promoting better health and health equity,
and lowering costs for all Californians.
In addition to being guided by its mission and values, the Exchange's policies are derived from the
Federal Affordable Care Act which calls upon Exchanges to advance "plan or coverage benefits and
health care provider reimbursement structures" that improve health outcomes. The California
Health Benefit Exchange seeks to improve the quality of care while moderating cost not only for the
individuals enrolled in its plans, but also by being a catalyst for delivery system reform in partnership
with plans, providers and consumers. With the Affordable Care Act and the range of insurance
market reforms that are in the process of being implemented, the health insurance marketplace will
be transformed from one that has focused on risk selection to achieve profitability to one that will
reward better care, affordability, and prevention. The Exchange needs to address these issues for
the millions of Californians who will enroll through it to get coverage, but also must be part of
broader efforts to improve care, improve health, and control health care costs.
The California Health Benefit Exchange must operate within the federal standards in law and
regulation. Beyond what is framed by the federal standards, California's legislature shapes the
standards and defines how the new marketplace for. individual and small group health insurance will
operate in ways specific to their context. Within the requirements of the minimum Federal criteria
and standards, the Exchange has the responsibility to "certify" the Qualified Plans and Standalone
Dental Plans that will be offered in the Exchange for Essential Health Benefits.
The. state legislation to establish the California Health Benefit Exchange directed it to "selectively
contract with carriers so as to provide health care coverage choices that offer the optimal
combination of choice, value, quality, and service" and to establish and use a competitive process
to select the participating health plan Issuers.
These concepts, and the inherent trade-offs among the California Health Benefit Exchange values,
must be balanced in the evaluation and selection of the Qualified Health Plans that will be offered
on the Individual and the SHOP Exchanges.
This application has been designed consistent with the policies and strategies of the California
Health Benefit Exchange Board which calls for the plan selection to influence how competitive the
market will be, the cost of coverage, and how to add value through health care delivery system
improvement.
1.4 APPLICATION EVALUATION AND SELECTION
While evaluating the dental plan proposals, the Exchange will consider the mix of dental plans that
besf meet the Exchange's goals of providing an appropriate range of high: quality choice to
Dental Plan New Entrant Application 2-19-2014 Page 6
Covered California
participants at the best available price, while promoting the broad goals described above. Inconsideration of the mission and values of the Exchange, there are a number of evaluationprinciples that will be applied. These include the following:
Promote affordability for the consumer and small employer —both in terms. ofpremium and at point of care
The Exchange seeks to offer health and dental plans, plan designs and provider networksthat are as affordable as possible to consumers in terms of premiums and. at the .point ofcare, while fostering competition and stable premiums. The Exchange will seek to offerhealfh and dental plans, plan designs and provider networks that will attract maximumenrollment as part of the Exchange's effort to lower costs by spreading risk as broadly aspossible.
Encourage "Value" Competition Based upon Quality, Service, and Price
While premium price and out-of-pocket costs will be a key consideration, contracts will beawarded based on determination of "best value" to the Exchange and its participants. Theevaluation of issuer dental plan proposals will also focus on quality and service components,including past history of perFormance,.reported quality and satisfaction metrics; andcommitment to serve the Exchange population through cooperation with the Exchangeoperations, provider network adequacy, and cultural and linguistic competency. We expectthat some necessary regulatory and rate filings may need to be completed after the due datefor this dental plan application. The application responses, in conjunction with the approvedfilings, will be evaluated by Covered California and used as part of the selection criteria tooffer issuers' products on the Exchange for the 2015 plan year.
Encourage Compefitio~ Based upon Meaningful Dental Plan Choice and ProductDifferentiation: Standard Benefit Plan Designs6
The Exchange is committed to fostering competition by offering dental plans with featuresthat present clear choice and product differentiation. Dental plan applicants are. required topropose at least one of the Exchange's adopted standardized benefit plan designs (DPPO,DHMO or DEPO), in each region for which they submit a proposal. Issuers must proposebo#h SADP and Family Dental Plan products. To the extent possible, both DHMO and DPPOproducts will be offered. Within a given product design, the Exchange will look fordifferences in network providers. Under such criteria, the Exchange may choose not tocontract with two plans with overlapping networks within a rating region.
Encourage Competition Throughout the State
The Exchange must be statewide. Issuers are required to submit dental plan proposals in allgeographic service areas in which they are licensed and have adequate networks, andpreference will be given to issuers that develop dental plan proposals that meet quality andservice criteria while. offering coverage options that provide reasonable access to thegeographically undersenred areas of the state as well as the more densely populated areas.
Encourage Q.Icgnment vrith Providers and Delivery Systems that Serve the LowIncome Population
Central to the Exchange's mission is its performing effective outreach, enrollment andretention. of the low income and culturally diverse population that will be eligible for premium
6 The 2015 Standard Benefit Designs wiH be promulgated through a future administrative rulemaking after the 2015.federal actuarial value calculator is finalized.Dental Plan New Entrant Application 2-19-2014 Page:?
Covered California
tax credits and cost sharing subsidies through the Exchange. Responses that demonstratean ongoing commitment or the development of the capacify to serve the cultural, linguisticand dental care needs of the low income and uninsured populations, beyond the minimumrequirements adopted by the Exchange,... will receive additional consideration. Examples ofdemonstrated commitment may include contracting with Federally Qualified Health Centers,and support or investment in providers and networks that have` historically served thesepopulations in order to improve service delivery and integration.
Encourage Cong Term Partnerships with Health Issuers
A goal of the Exchange is to reward early participation in the Exchange with contractfeatures thaf offer a potential for market share and program stability. The Exchangeencourages Issuer interest in multi-year contracts (plan year 2015 and 2p16) and submittingrates at the most competitive position possible; fosters rate and plan stability andencourages SADP and Family Dental Plan investments in' product design, networkdevelopment, and quality improvement programs. Application responses that demonstratean interest`and commitment to the long-term success of the Exchange's mission are stronglyencouraged, particularly those that that include underserved service areas, and thatleverage Issuer efforts to provide better care, improve health, and lower cost.
1.5 AvA~~B~~~n
The dental plan issuer must be available immediately upon certification as a dental plan to startworking with the Exchange to establish all operational procedures necessary to integrate andinterface with the Exchange information systems, and to provide additional information necessaryfor the Exchange to market, enroll members, and provide dental plan services effective January 1,2015. Successful applicants will also be required to adhere to certain provisions through theircontracts with the Exchange including but not limited to meeting. data interface requirements withthe California Healthcare Eligibility, Enrollment and Retention System (CaIHEERS). The Exchangeexpects to negotiate and sign contracts prior to September 1, 2014. The successful applicantsmust be ready and able to accept enrollment as of October 15, 2014.
1.6 INTENTION TO SUBMITA RESPONSE
Applicants interested in responding to this application should submit the completed Letter of Intentto Apply by March 17, 2014, indicating their interest in applying, their proposed products andservice areas, and to ensure receipt of additional information. Only those Applicants acknowledging
' interest in this Application by submitting a notification of intention #o apply will continue to receiveApplication-related correspondence throughout the application process.
The Applicant's notification letter will identify the contact person for the application process, alongwith contact information that includes an email address and a telephone number. Receipt of thenon-binding letter of intent will be used to issue instructions and login and password information togain access to the online portion of the Applicant submission of response to the Application.
An issuer's submission of an Intent to Apply will be considered confidential information and notavailable to the public; the Exchange reserves the right to release aggregate information aboutissuers' responses: Final Applicant information is not expected to be released until selected issuersand Dental Plan issuers are announced in late June 2014. Confidentiality is to be held by theExchange; Applicant information will not be released to the public but may be shared withappropriate regulators as part of the cooperative arrangement between the Exchange and theregulators.
The Exchange will correspond with only one (1) contact person per Applicant. It shall be theApplicant's responsibility to immediately notify the Contact Person identified in this section, in
Dental Plan New Entrant Application 2-19-2Q14 Page 8
Covered California
writing, regarding any revision to the contact information. The Exchange shall not be responsiblefor application correspondence not received by the Applicant if the Applicant faits to notify theExchange, in writing, of any changes pertaining to the designated contact person.
Application Contact:
Pamela Power
Pamela,power@covered.ca.gov
(916) 228-8374
1.7 APPLICATION LIBRARY
Applicants may access the. Application Library at:https:l/www.coveredca.com/hbe~clsolicitations/Dental%20PIan%20New%20Entrant%2QApplication/
Applicants may access documents and information here that may be useful for developing their..responses. As further documentation related to the application becomes available it will be postedhere.
1.8 KEY. ACTION DATES
Listed below is a series. of key .actions related. to :this Application, along with :the .correspondingdates and times by which each key action. must be taken or completed, If the Exchange finds itnecessary to change any of these dates, such changes will be accomplished through addenda tothis Application.
2. TECHNICAL REQUIREMENTS
Applicants .are required to provide the information requested below. The responses must beprovided through completion of the accompanying attachments.
2.1 Licensed and In Good Standing
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In addition to holding all of the proper and required licenses to operate as a dental plan issuer as
defined herein, the Applicant must demonstrate that it is in good standing with all appropriate local,
state, and federal` licensing authorities.' Good standing means that the Applicant has had no material
fines, penalties levied, citations, or ongoing disputes with applicable licensing authorities in the last
two years.
If Applicant checks "No", you are indicating that you are not in good standing and will be disqualified
from consideration.
❑ Yes, issuer is in good standing
No (explain)
2.2 The Applicant must acknowledge any ongoing labor disputes, penalties, fines, or corrective
action citations for federal or state workplace safety issues.
Does your organization have any ongoing labor disputes, penalties, fines, or corrective action
citations for federal or state workplace safety issues?
If Applicant checks "Yes", please note whether these situations will be addressed by the date
applications are due.
❑ Yes (provide further information)
❑ Na
2.3 The Applicant must acknowledge whether it is seeking a certificate of authority or an
amendment to an existing certificate of authority. from the relevant regulatory agency in order to
meef the requirements of individual and small group products to be offered on the California Health
Benefit Exchange.
Has your organization submitted an application far a new license or material modification of a
current license to the regulatory authorities or for a certificate of authority or an amendment as part
of your organization's response to the Application?
If Applicant checks "Yes", please refer to Attachment A to provide the requested details associated
with this application.
❑ Yes
■ •~
Separate from the Applicant's response to this Application, an Applicant is responsible for
submitting all required material to the California regulatory agency necessary to obtain approval of
products/plans that are to be submitted in response to this application: Applicant must acknowledge
that all such product filings have been submitted for regulatory review.
2.4 Have you submitted, for regulatory review, product filings for plan designs you intend to submit
as dental plan proposals in response to this application?
❑ Yes
No (explain)
Refer to Attachment A to provide the requested details associated with such product filings
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Covered California
2.5 The California Department of Managed Care (DMHC) and the California Department ofInsurar►ce (CDi) have primary responsibility for regulatory review and issuing preliminaryrecommendations to the Exchange of certain selection criteria listed below in the definition of goodstanding in addition to applying the minimum licensure requirements. Confirm you will beresponsive to questions raised by the Exchange and the regulatory agencies in their review.
❑ Yes, confirmed.
❑ No, .not confirmed
See Appendix A Definition of Good Standing.
3. PLAN OR POLICY SUBMISSION REQUIREMENTS
Applicant. must .certify that far each rating region in which' it submits a dental plan .proposal it issubmitting .proposals for the required Standard Plan Designs for SADP and for Family Dental Plans..Applicants must adhere to the 2015 Standard Plan Designs which will be adop#ed in a futureadministrative rulemaking.
.Applicants must submit a proposal for both the SADP and .Family Dental Plan products.
3.1 Have you submitted actuarial value levels) for each product/plan proposed. in a rating region?
❑ Yes
-' No (explain)
Applicants may submit DPPO and/or DHMO product proposals, but must adhere to the .2015Standard Plan Designs far both;the SADP and Family Dental Plan products. If Applicant checks"No", Application will be disqualified from cons dera#ion. If "Yes," please refer to Attachment BPlanType by Rating Region (Individual & .SHOP} to indicate the. rating regions and number of plans forwhich you are submitting a dents! plan proposal
3.2 Applicants are. required to submit product proposals that cover their entire licensed service area,and must certify that #hey have done so. Applicants may choose to submit proposals for only theirIndividual or Sma11 Group licensed area, or may offer coverage in both markets. Applicants licensedin both the individual and SHOP markets are encouraged to submit proposals for both marketsegments.
For each rating region for which you have submitted a dental plan proposal, does your proposalcover the .entire. geographic service area for which your organization. is licensed within .that ratingregion and for which your organization has an adequate. provider network?
C Yes
■
.
If Applicant checks "No", you will be disqualified from consideration. !f "Yes," indicate which zipcodes. are within the licensed geographic service area by type of platform and proposed Exchangeproduct. by completing and. uploading through the System for Electronic Rate and Form Filing(SERFF) the Service Area Template located athttp://www.serff.com/plan management data templates.htm.
3.3 Quality Improvement Strategy
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Consistent with the Exchange's mission to promote better care, better health and lower cost as part
of
a Quality Improvement Strategy, please provide statements confirming your organization will:
3.3.1 Implement a quality assurance program in accordance with Title 2, CCR, Section 1300.70, for
evaluating the appropriateness and quality of the covered services provided to members
❑ Yes, confirmed
❑ No, not confirmed (explain)
3.3.2 Maintain a system of accountability for quality improvement in accordance with all applicable
statutes and regulations, monitoring, evaluating and taking effective action to address any needed
improvements, as identified by the Exchange, in the quality of care delivered to members.
❑ Yes, confirmed
❑ No, not confirmed (explain)
4. TECHNICAL SPECIFICATIONS
These requests are organized into the following categories:
4.1 GENERAL
4.1.1 Provide your active dental membership, as of July 1, 2013, in the state of California. (Please
define by market segment: Individual, Employer-sponsored vs. Voluntary, and Government, if
applicable)
4.1.2 Briefly describe three attributes of your organization that you believe distinguish you from your
competitors.
4.1.3 Describe up to three examples, of your organization's successful innovations to improve
service quality and reduce costs. Discuss scope of the innovation, targeted population, goals,
outcomes (quality and cost), and scalability or plans for dissemination..
4.1.4 Do you offer discount programs related to non-covered services? If so, explain.
Yes, explanation provided
❑ No
4.1.5 Please provide a brief description of any outside vendors that will be utilized.
4.1.6 Provide the physical location of all administrative teams (claims processing, member services,
etc) that you propose to serve The Exchange.
4.2 ACCOUNT MANAGEMENT SUPPORT
4.2.1 Describe whether the account team members (e.g. implementation manager, claims
specialist, member services manager,. etc.) will be dedicated to the Exchange. If the account team
will have other responsibilities, how many other clients will they be responsible for and what
percentage of their time will be committed to the Exchange?
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Covered California
4.2.2 Implementation: Confirm that a dedicated implementation manager v~ill be assigned to leadand coordinate the. implementation activities with the .Exchange. ~f you cannot confirm, pleaseexplain.
4.2.3 Describe the services and support you will provide during the implementation process .andwha# informationlresources will be required of the Exchange. Be specific.
4.2.4 Should your organization be selected, explain how you plan to accommodate the additionalmembership (discuss anticipated hiring needs, staff reorganization, etc.):
~ Member Services• Claims•
,FinancialAdministrative
• Information TechnologyQther (describe)
4.3 ACCOUNT ADMINISTRATION
4,3:1 Confirm the Exchange willbe provided a dedicated claims processing unit. If you cannotconfirm, please explain.
4.3.2 Confirm that the. Exchange wilLretain the right to-annually audiUassess the plan administrator's,compliance with the terms of the contract, :including but not,limited to a claims audit or audit forcause of irregular activity, either directly or through its:authorized agents. Confirm you will provide.2 years' worth of claims. experience with no limit on the. number of claims that may be reviewed andthat any audits will be completed with no additional. cost to the Exchange.
4.3,3 Describe your claims administration procedures. Include. how Reasonable &Customaryexpenseallowance is .determined and what Usual, Customary & Reasonablepercentile is utilized toprocess dental claims.
4.3.4 What guarantees do you provide to ensure members will not be balance billed for in-networkservices?
4.3.5 How do you identify and address inappropriate patterns of dental treatment? Please providedetails.
4.3.6 Describe your fraud &abuse program
4.3.7 What steps do you take to protect patient privacy? How is Protected Health Information (PHI)handled?
4.4 MEMBER SERVICES
4.4.1 Confirm that the Exchange will be provided a dedicated member services unit. If you cannotconfirm, please explain.
4.4.2 Confirm you will produce and distribute ID cards within 48 hours of receip#of clean eligibilitydata. If you. cannot confirm, please explain.
4.4.3. Confirm you will provide a dedicated 1VR (interactive voice response} member servicesnumber?- if you cannot confirm, please explain. -
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Covered California
4.4.4 Is there a mechanism for members to quickly reach a
live
member services representative?
Please describe.
4.4.5 How are after-hours/holiday telephone inquiries handled? (Recorded message by Plan (i.e.
Hours
of operation and directors for'emergency), Interactive Voice Response System (IVR), Live
Response, Health Plan Internet Website, Other.)
4.4.6 Will you make the customer service fine available to participants prior to the effective date?
4.4.7 Indicate which member services options. are available via IVR, Phone Representative, and
Internet (Select ap that apply).
Option IVR Phone Re Website
Veri eli ibilit
Enrollment Chan es
Check claims statusRe uest ID cardRe nest benefit summaReview Ex lanation of BenefitsCheck status of deductibles, maximums, orlimitsAccess customer service via emailObtain a histo of dental claimsProvider referralsCom lete satisfaction surveOther specif
4.4.8 Indicate the ways in which your member services organization is able to accommodate the
special needs of enrollees. (Check all that apply)
• No special accommodations• Have a TDD (Telecommunications Device for the Deaf) or other voice capability for the hear
impaired.....• Translation to non-English languages
Language No TranslationAvailable (check ifappropriate
Translation performedin-house (check ifap ropriate
Translation Contracted(specify contractedorganization's name
S anishVietnamese
Cantonese
Mandarin
Armenian
Russian
Tagalog
HmonDental Plan New Entrant Application 2-19-2014 Page 14
Covered California
Korean
Farsi
Arabic:.
Cambodian
Other (pleases ecif
4.4.9 Confirm you will modify your Customer Service operations, as necessary, to meet therequiremen#s of the Exchange with regard to the following:.
• Operating hours (Exchange requires 8 am to 8 pm Monday -Friday; 8 am - 6 pm Saturday andSunday during Open. Enrollment for the. Individual Exchange)
• Staffing requirements• Training criteria
1f you. cannot confirm, please explain.
4.5 CARE MANAGEMENT
4.5.1 Confirm that the following programs/services will be made available to Exchange enrollees in201.5.
• Risk Assessments• Disease Management Programso Care Reminders
4.5.2 Selected issuers will be required to pro -actively reach out to Exchange enrollees eligible for
Essential Health Benefits. (EHB) to ensure #hat all preventive and diagnostic services are .provided.Describe in detail your approach to ensuring that all enrollees eligible for EHB will receive theseservices within the plan .year.
4.5.3 Outline your approach to use of a Health Assessment to pro-actively identify Exchangeenrollees who are actively in need of covered dental services beyond the preventive and diagnosticdental services covered by the EHB. This will be a contract requirement as well
as part of theevaluation of applications.
4.6 CQMMUNICATIONS &EDUCATION
4.6.1 Provide a description of your standard communications materials.
4.6.2 Will you draft and distribute introductory communications pieces prior to open enrollment?
4.6.3`lndicate which member tools and information you offer and how they may be accessed (IVR,
Web, Member Services Representatives, etc.).
Offered? Access
Plan Design Information
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Covered California
Personal Claim Information.
Explanation of Benefits
Estimate Costs for Services
Actual Cost of Services
General Healthcare Information
Health Library _
Provider Search
Provider quality info
Plan comparisons
Frequently Asked Questions
Other
4.6.4 Please indicate which plan sponsor tools/information you offer and haw they may be accessed(IVR, Web, Member Services Representatives, etc.).
Offered? Access
Enrollment Administration
Eligibility Administration
Provider Performance
Plan Policies
Plan Design
Utilization Analysis
Cost &Trend Analysis
Provider Search
Provider quality info
Dental Plan New Entrant Application 2-19-2014 Page 16
Covered California
Plan comparisons
Frequently Asked Questions
Other
4.6.5 Confirm you will provide the plan sponsor training regarding use of the online tools. How willyou approach this training?
4.6.6 Confirm the online tools provided by your organization #or the Exchange program staff andmembers will be available 99.5 percent of the time, twenty-four (24) hours a day, seven (7) days aweek? If you cannot confirm, describe level of guaranteed availability.
4.7 PROVIDER NETWORK
4.7.1 Use Attachment C1 2015 SADP Enrollment Projections and Attachment C2 20~5.FamilyDenta! Plan Enrollment Projections to submit enrollment projections by product that Applicantproposes for 2015. Enrollment projections for both Individual and SHOP Exchange products are.reported in these attachments, if applicable.
4.7.2 Provider directory data for both Individual and SHOP Exchange products must be included inthis submission.
4.7.3 Applicant must certify that for each rating region in`which it submits a health plan proposal, theproposed. products meet provider network adEquacy standards established by the relevantregulatory agency. Provider network adequacy will be evaluated by the governing regulatoryagency.
Yes, dental plan proposal meets relevant provider network adequacy standards
~l~
4.7.4 Do you own your provider networks or confract with other organizations? If you contract withother organizations, please provide those organizations' names.
4.7.5 Confirm your provider network directory is available online.
4.7.6 Confirm the following indicators are included for each provider within your directory:
• Accepting New Patients?ServicesPravided
• Specialties• Board Accreditation• Languages Spoken• Hours of Operation• Accept Credit. Cards?• C)ther -please describe
4.7.7 How often is your online directory updated? How often is your printed directory updated?
4.7.8 Please provide an indication of network access by completing the following tables for. eachrating region.
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Covered California
Ratin Re ionType of Dentist iSpecialist
Number of Providers Number of Providerswith Open Practices
General /FamilyDentistEndodontistOral Sur eonOrthodontistPediatric DentistPeriodontistOther ex lainTotal
4.7.9 Contracting with Dental Providers Who Serve the Low Income and Uninsured Populations
For SADPs, Applicants should demonstrate the extent to which their proposal includes participationof dental providers with a history of serving low-income and uninsured populations. Preference willbe given to those Applicants that include providers with a history of serving the low-income anduninsured population.
Applicants shall use the county low-income population data to submit the following geo-maps ofeach county within the proposed geographic service area (county maps may be aggregated for theservice area)..
• FQHC providers plotted on a-low-income population map, by county.• Other providers that serve the low-income population, defined as those providers for whom
at least 20% of patients served are low income, by county. Note that a proxy for low-incomepatients may be Medi-Cal or Healthy Families enrollees or individuals eligible for income-based fee consideration.
County data on distribution of the California Low-Income- Population is available within theApplication Library on the Exchange website. Low-income is defined as a family at or below 200%of Federal Poverty Level. The data supplied will allow Applicants to plot contracted FQHC locationson county maps which display the low-income population. Issuers will be responsible for mappingother low-income providers.
Confirm provider network maps are included with other supplemental materials listed in Section 8Documentation.
4.8 SYSTEMS AND DATA REPORTING MANAGEMENT
4.8.1 Confirm you will provide reporting as deemed necessary by the Exchange related toutilization, costs, quality, operations and agreed upon performance guarantees.
4.8.2 Confirm your organization will build all required data interFace capabilities with the Exchange'seligibility and enrollment systems and will report on transactions as deemed necessary by theExchange::
4.8.3 Applicant must be prepared and able to engage with the Exchange to develop data interfacesbetween the Issuer's systems and the Exchange's systems, including CaIHEERS, as early as May
Dental Plan New Entrant Application 2-19-2014 Page 18
Covered California
2014. Applicant must confirm it will implement systems in order #o :accept 834, 820 and otherstandard transaction electronic files for enrollment and premium remittance in an accurate,consistent and timely fashion and utilize information for its intended purpose.
4.8.4 Applicant must be able to accurately, appropriately, and timely populate and submit SERFFtemplates at the request of Covered California'for:
• Rates* Service Area~• Benefit Plan Design
Network
4.8.5 Applicant must be able to submit provider data in a format as required. by Covered Californiaand at intervals requested by Covered California for the purposes of .populating the centralized
...:.provider directory.:..
4.8.6 Applicant must confirm its agreement to submit claims and encounter data in the requestedformat to a third party vendor selected by Covered California for the purpose of performing clinicalanalytics.
4.8.7 Applicant must be available for testing data. interfaces with the Exchange no later than July 1,2014.
4.8.8 Please describe .any concerns you have. around reporting requirements The Exchange maydevelop.
5. PERFORMANCE MEASURES (QUALITY}
Provide target and actual values for the performance indicators that follow.lf you are applying for aregion for which you do not have recent experience, provide your experience for California and no#ethe reason that region specific experience is not available. If you do not have recent Californiaexperience provide your national experience and note the reason that California experience is notavailable.
~ Performance Measure TTarget Actual ~
(pasf 12 j~ months)
Customer Service
1. Claim Turnaround Time: Percentage ofi clean claims processed within 30calendar. days. of receipt
2. Financial Accuracy: Percentage of claim dollars paid accurately
3. Procedural Accuracy: Percentage of claims without any financial error
4. Percentage of callers who- reach a live voice within 30 seconds
5. Percentage of callers whose issue. is resolved on the initial call
6. Average speed to answer
Dental Plan New Entrant Application 2-19-2014 Page39
Covered California
-- -Performance Measure
-
Target Actual
{past 12months}
7. Call abandonment rate
8. Percentage of Web site availability (defined on outages rectified within 1hour)
9. Annual turn-over rate for member services staff
Utilization
1. Percentage of membership that received any covered dental service
2. Percentage of membership that received apreventive/diagnostic dentalservice.
3. Percentage of members receiving dental treatment services (excludingpreventive and diagnostic services)
4. Percentage of members who received a treatment for caries or a caries-preventive procedure
5. Percentage of members with one (1) or more fillings in the past year whoreceived a topical fluoride or sealant application
6. Percentage of pediatric membership (defined as under age 21) thatreceived apreventive/diagnostic service
7. Percentage of members whom reached the plan's maximum annualbenefit
Rating
1. Target Loss Ratio to be calculated as:
(incurred claims+ change in contract reserve +quality improvementexpense) / (earned premiums -income taxes -premium tax)
QDP (Pediatric -Essential Health Benefits) '
Statewide DPPO —Individual
Statewide DPPO —SHOP
Statewide DHMO —Individual
Statewide DHMO —SHOP
5.1 What other metrics are in place to monitor the performance of member services? Provideexamples.
Dental Plan New Entrant Application 2-19-2014 Page 20
Covered California
6. ADDITIONAL QUESTIONS AND/OR REQUIREMENTS
These requests are organized into the following categories:
6.1 AGENT RELATIONS, FEES, AND COMMISSIONS
6.1.1 Do you currently provide agent-oriented marketing materials for the individual and smallbusiness market?
Individual J Yes ~ ~ No
Small Group ❑Yes. ❑ No
if .yes., please .include .sample materials or your broker kit as an attachment labeled "Broker KiY'.
6.1.2 What initiatives is your organization undertaking to partner more effectively with the smallbusiness and agent communities?
6.1.3 What criteria do you use to appoint agents to sell Individual and Small Group products?.Howmany active, appointed agents do yoe~ have?
6.1.4 Does your dental plan have relationships with general agents? If so, please list the generalagents with whom you contract.
6.1.5 Describe your current dental plan agent compensation and override schedule for yourindividual and small group business. If known, provide this information for 2015 as well
6.1.6 Describe any bonus program your company currently has in place for additional agentcompensation.. This may. include cash bonuses or in-kind compensation programs.
6.2 MARKETING AND OUTREACH ACTIVITIES
The Exchange is committed to working closely with SADPs and Family Dental Plans to maximizeenrollment in the Exchange. The Exchange will support enrollment efforts through outreach andeducation, including statewide advertising efforts aimed at prospective and existing members of theCovered California Health Benefit Exchange. SADP and Family Dental Plans are required todevelop and execute their own marketing plans promoting the enrollment in their respectiveExchange plans. Contracted SADP and Family Dental Plans will adhere to the Covered. CaliforniaBrand Style Guidelines for specific requirements regarding an SADP's' or Family Dental Plans' useof the Exchange brand name, logo, and taglines.
fn the questions that follow, please provide detailed information pertaining to the Applicant's. plansfar marke#ing and advertising for the individual and small group market. Where specificmaterialsare requested, please be sure to label the attachments clearly,
6.2.1 Please describe any new positions proposed far your Exchange-related sales and marketingactivities.
6.2.2 Please provide a copy of your most recent summary brochure as an attachment to theresponse to this Application labeled "Summary Brochure".
6.2.3 Please describe your plan to cooperate with Exchange marketing and outreach efforts,including internal and external training, collateral materials and other efforts.
For SHOP Exchange Applicants onlyDental Plan New Entrant Application 2-19-2014 Page 21
Covered California
6.2.4 Applicant must confirm it will comply with contractually-required co -branding of the ID card,premium invoices and termination notices.-The Exchange retains the right to communicate withExchange customers and members.
€ Yes, confirmed
No, not confirmed
6.2.5 Applicant must confirm it will adhere to Covered California naming conventions promulgatedthrough a future administrative rulemaking by Covered California for 2015.
€ Yes, confirmed
€ No, not confirmed
7. COST PROPOSAL
Final negotiated and. accepted premium proposals shall be in effect for the second full year ofoperation of the Exchange, effective January 1, 2015, or for the SHOP plan year. Premiumproposals are considered preliminary and may be subject to negotiation as part of dental plancertification and selection.
Complete Attachment D1 SADP Rates Individual & SHOP to provide premium proposals for theSADP products. Complete Attachment D2 Family Dental Plan Rates Individual &SHOP to providepremium proposals for the Family Dental Plan products. Premium proposals for Individual andSHOP products can be submitted through completion of these attachments. For each dental planproduct, enter preliminary premium for dental plan products to be offered in the Exchange.Premium may vary only by geography (rating region) by coverage tier, and by actuarial value level.
8. DOCUMENTATION
Please confirm that you have provided the following documentation for the Exchange's review.
• An organizational chart of your California operations, including individual and small group lines)of business
• An organizational chart for the team proposed to staff the Exchange account. Show lines ofauthority up to and including the executive management level. Include all functions such asaccount` management, claims, member services, billing; individual and small
group
sales andmarketing department etc.
• A listing of the individuals) who will have primary responsibility for staffing the Exchangeaccount. Please indicate where these individuals fit into the organizational chart requestedabove. Please include the following information and repeat as necessary.
o Namea Title
o Departmento Primary responsibilities
o Phoneo Faxo E-mail
• An implementation project plan and timeline including all necessary steps and events (includingtesting), required to achieve full implementation by January 1, 2015.
• A sample ID card.
• Samples of the following standard member communications materials:o Introductory pre-open enrollment
o Welcome package
Dental Plan New Entrant Application 2-19-2014 Page 22
Covered California
o Summary plan description (SPD)o Preventive reminders
o Explanation of benefits (EOB)o A standard claims form and the associated claim submission instructions
o A sample customer satisfaction surveyo The most recent customer service survey results
o The web address to access your online provider directory• Provider network maps required in Section 4.7.9
Dental Plan New Entrant Application 2-19-2014 Page 23
Appendix A: Definition of Good Standing
Regulatory
Definition of Good Standing Agency
Relevant
To EHBRelevant to
Supplemental
Verification that issuer holds a state health care service
plan license or insurance certificate of authority
• Approved for what lines of business (e.g. commercial,
sma8 group, .individual) DMHC X X
• Approved to operate in what geographic service. areas DMHC X X
• Most recent financial exam and medical survey report DMHC X X
• Most recent market conduct exam reviewed CDI X X
Affirmation of no material' statutory or regulatary
violations, including penalties levied, in the past twa years
in relation to a~ of the following, where applicable:
• Financial solvency and reserves reviewed DMHC and CDI X X
• Administrative and organizational capacity DMHC X X
• Benefit Design
+ State mandates {to cover and to offer) DMHC and CDI X
• Essential health benefits2 Pediatric Dental DMHC and CD!only X
• Basic health care services CDI X
• Copayments, deductibles, out-of-pocket DMHC and CDImaximums X
• Actuarial value. confirmation {using 2015 DMHC and CDIActuarial Value Calculator) X
• Network adequacy and. accessibility standards DMHC and CD! X
• Provider contracts DMHC and CDI X
` ~sclasure {summary of benefits and DMHC and CDl
ovepa e9~X
• Claims. payment .policies and practices DMHC and CDI X X
• Provider complaints DMHC and CDI X X
• Utilization review policies. and. practices DMHC .and CDI X X
• Quality assurance/management policies and practices DMHC X
• Enrollee/Member grievances/complaints and appeals DMHC and CDlpolicies. and. practices X X
• Independent medical review DMHC and CDI X
• Marketing and advertising DMHC and CDI X
• Guaranteed issue individual and small group DMHC and CDI X X
~ Covered California, in its sole discretion and in consultation with the appropriate health insurance regulator, determines what constitutes a
material violation for this purpose,
Dental Plan New Entrant Application Version 2-19-14
Cali
forn
ia Health Benefit
Exchange
Dental Plan New Entrant App
lica
tion
Attachment A Regulatory Filings
Issu
er Name:
Inst
ruct
ions
:Please provide the
req
uest
ed details ass
ocia
ted wi
th any Reg
ulat
ory an
d/or
Pro
duct
fil
ings
nec
essa
ry to obtain approval of pro
duct
stpl
8ns that are to be submitted in re
spon
se to
this application.
Regu
lato
ry
Prod
uct Fi
ling
Expected Dat
e Amendment
Initial Fi
ling
Regu
lato
ry
Fili
ng Number
Number
Date
of
for Review /
Number
Date
Attachment A R
egulatory Fi
ling
s
California Health Benefit Exchange
Dental Pla
n New Entrant Application
Atta
chme
nt B Pla
n Type by Rating Region (Individual ?.
~ SHOPS
Issu
er Name:
Inst
ruct
ions
:Pl
ease
ind
icat
e th
e products pro
pose
d with an "X.
" Note tha
t Issuers ar
e re
quir
ed to submit proposals that include th
eir en
tire
lic
ense
d service area for
eac
hproduct type w
hich the
y ar
e proposing. App
lica
nts are re
quir
ed to propose bo
th SADP and Family De
ntal
Plan products, an
tl may off
er only their In
divi
dual
or
Small Group products.
. . -~
s.
..•
,•••
• •
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~ •
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•
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~ •
~~~~~~~~
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ta1'yelL'J/i~~________________
t~L~1L~11i~~-_.______________
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~3~~_______________~,
'~~'~tt~________________,
c~~~~~~~~~~~s
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t~
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■~
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~~
~~
~~
~~~~c~~~~~~~~~~~~~~~~~~
-Q~~~~~~~~~~~~~~~~~~~
Attachment B Plan Ty
pe by Rating Region (Individual SHOP)
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: :'$S~
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eT
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i
t~~11:JiBi~~
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_~~~__--_
II
t~[{i~JiYL•~
ISfi~1{ls1:iL-C~_--____~
----__
''~,.
Attachment B PlanType by Rating Region (Individual SHOP)
California Health Benefit ExchangeDental Plan New Entrant ApplicationAttachment C1 2015 SADP Enrollment Projections
Issuer Name:Product:Market:
Please complete Attachment C1 enrollment projection for each product and market type. Enrollmentprojection should reflect anticipated enrollment January 1, 2015 through December 1, 2015
Ratin Re ion CountProductDHMO/DPPO 2015 SADP Enrollment Pro'ections
Re ion 1 Ai ineRe ion 1 Del NorteRe ion 1 Siski uRe ion 1 ModocRe ion 1 Lassen 'Re ion 1 ShastaRe ion 1 TriniRe ion 1 HumboldtRe ion 1 TehamaRe ion 1 PlumasRe ion 1 NevadaRe ion 1 SierraRe ion 1 MendocinoRe ion 1 LakeRe ion 1 ButteRe ion 1 GlennRe ion 1 SutterRe ion 1 YubaRe ion 1 ColusaRe ion 1 AmadorRe ion 1 CaiaverasRe ion 1 TuolumneRe ion 2 NaRe ion 2 SonomaRe ion 2 SolanoRe ion 2 MarinRe ion 3 SacramentoRe ion 3 PlacerRe ion 3 EI DoradoRe ion 3 YoloRe ion 4 San FranciscoRe ion 5 Contra CostaRe ion 6 AlamedaRe ion 7 Santa ClaraRe ion 8 San MateoRe ion 9 Santa CruzRe ion 9 MontereRe ion 9 San BenitoRe ion 10 San Joa uinRe ion 10 StanislausRe ion 10 MercedRe ion 10 Mari osaRe ion 10 TulareRe ion 11 FresnoRe ion 11 Kin sRe ion 11 MaderaRe ion 12 San Luis ObisRe ion 12 VenturaRe ion 12 Santa BarbaraRe ion 13 MonoRe ion 13 InRe ion 13 Im erialRe ion 14 KemRe ion 15 Los An eiesRe ion 16 Los An alesRe ion 17 San BernardinoRe ion 17 RiversideRe ion 18 Oran eRe ion 19 San Die o
Attachment C1 SADP Enrollment Projections
California Health Benefit ExchangeDental Plan New Entrant ApplicationAttachment C2 2015 .Family Dental Pian Enrollment Projections
Issuer Name:.Product:Market:
Please complete Attachment G2 enrollment projection for each product and. market type. Enrollmentprojection should reflect anticipated enrollment January 1, 2095 through December 1, 2015
Ratin Re ion .CountProduct~DHMO/DPPO
2015 gamily Dental Plan Enroilr~~entPro ections
Re ion 1 AI ineRe icn 1 DeINortBRe ion 1 Siski uRe ion 1 ModocRe ion' 1 LassenRe ion 1 ShastaRe ion 1 TriniRe ionl `HumboldtRe ion 1 TehamaRe ion 1 PlumasRe ion 1 NevadaRe ion 1 SisrraRe ion 1 AAendocinoRe ion 1 LakeRe ion 1 Butte '-Re" ion 3 GlennRe ion 1 SutterRe ion 1 YubaRe ion 1 GolusaRe ion 1 AmadorRe ion 1 Galave~asRe ion 1 TuolumneRe"ion2 NaRe ion 2 SonomaRe ion 2 SolanoRe ion 2 MarinRe ion 3 SacramentoRe ion 3 PlacerRe ion 3 EI DoradoRe ion 3 YoloRe 'ion 4 San FranciscoRe "ionb Contra CostaRe ion 6 AlamedaRe ion 7 Santa GlaraRe ion 8' `San MateoRe ion 9 Santa CruzRe ion 9 ' MontereRe ion 9 San BenitoRe ion 10 San Joa uinRe ion 10 StanislausRe"ion 10 MercedRe ion 10 Mari osaRe ion 10 TulareRe' ion 11 FresnoRe ion 11 Kin sRe ion 11 MatleraRe ion 12 San Ltiis ObisRe ion 12 VenturaRe ion 12 Santa $arbaraRe ion 13 MonoRe ion 13 In ̀Re ion 13 Im eriaiRe ion 14 KemRe ion'35 Los An elesRe ion 16 Los An alesRe ion 17 San BernardinoRe ion 17 RiversideRe ion 18 Oran eRe ion 19 San Di o
Attachment C2 2015 Family Dental Plan Enrollment Projections
California Health Be
nefi
t Exchange
Dental Plan New Entrant Application
Attachment D1 SADP Rates Ind
ivid
ual 8~ SHOP
Issuer Name:
Prod
uct:
DPPO
Netw
ork:
ProposedCa
lend
ar Yea
r 20
15 Premiums
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~:
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_: ..
.
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iYli
i'iY
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ifld
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iiiY
lii~`iilWl~i~~iiiWii~lid"iffYi~~~ifYiili7i~
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Q~'YJ
ILE~~~~ ------__-__-
r~-_----------
Atta
chme
nt D1 SADP Rates (I
ndividual SHOP]
Cali
forn
ia Hea
lth Benefit Exchange
Dental Pla
n New Ent
rant
App
lica
tion
Attachmenf D1 SADP Rates Ind
ivid
ual &SHOP
Issuer Name:
P~od
uCt:
DHMO
N¢twork:
ProposedCalendar
Year
2015 Premiums
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., .
....
.....
:....
. ...
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8.
.~ ..~= ~~
: ~:
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~..
-t.
,~W~;x~<. r
;'~
DTI
G~~-_-_-
---~~
---_-
~~-
G~_-------_~-
Attachment D1 SADP Rates (Individual SHOP)
Cali
forn
ia Health Be
nefi
t Ex
chan
geDental PBa
n New Entrant Application
Atta
chme
nt D2 Family Dental Pla
n Ra
tes in
divi
dual
&SHOP
Issuer Name:
Prod
uct:
DPPO
Network:
~a ~~' ~----_-------_---
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~5~~~~~~~~~~~~~~~~~~
I G-~~'~~~~~~~e~~~~~~~~~
~~~~~~~~S~e~~~~~~~
GL~tII~~l~~~~~~~~~~~~~~~~~
~~8~~~~~~~~~'~~~~~~~~
~'S~i~~~~~'~0~~'~~~~~~~~
Attachment 02 Family Dental Plan Rates (
Individual SHOP)
California Health Benefit Exchange
Dental Plan New Entrant'Appiication
Attachment d2 Family Dental Plan Rates Individual &SHOP
issuer Name:
Product:
DHMO
Pietwork:
Proposed CalendarYear 2015 Premiu+ns
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.... ..,..:. ay.
..p.
Tfer...
~.•-
C~
t_
-S_-_--~ -~_-.-_--
Attachment D2 Family Dental Plan Rates (
Individual SHOP)
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