DENTAL PLAN PROGRAM STANDARDS Clause Samples
The "Dental Plan Program Standards" clause establishes the minimum requirements and operational guidelines that a dental plan must meet to be considered compliant under the agreement. This typically includes specifications regarding covered services, provider qualifications, claims processing procedures, and quality assurance measures. By setting these standards, the clause ensures that all parties have a clear understanding of the expectations for dental plan administration, thereby promoting consistent service quality and protecting the interests of plan participants.
DENTAL PLAN PROGRAM STANDARDS.
2.1 GENERAL This article describes the operational and financial standards with which Contractor must comply in full. The standards have been set to allow plans flexibility in their approach to meeting program objectives, while ensuring that the special needs of these populations are addressed. EOHHS and the Contractor will work collaboratively to build a successful program that will achieve the stated goals and requirements of EOHHS. EOHHS and the Contractor will engage in a planning period initiating at the start of this contract to address opportunities for program improvements. EOHHS agrees to purchase, and Contractor agrees to fulfill all requirements and to furnish or arrange for the delivery of, the scope of services as specified in this Article. In return for Capitation Payments (as defined in Sections 1.9 and 2.15 of this Agreement), the Contractor agrees to provide eligible members with the dental care and services described in this Article II and Attachment A hereto. Contractor shall furnish or arrange for the personnel, facilities, equipment, supplies, pharmaceuticals, and other items and expertise necessary for, or incidental to, the provision of dental care services specified below, at locations including, but not limited to, the entire State of Rhode Island, to Members covered by this agreement and enrolled with Contractor. In accordance with 42 CFR § 438.6, Contractor will provide or arrange for the provision of Covered Services under this Risk Contract. Contractor’s legal responsibility to EOHHS is to assure that all activities specified in this contract are carried out and will not be altered if a service is arranged by Contractor or provided by a subcontractor.
2.2 LICENSURE/CERTIFICATION The Contractor certifies that it is licensed in Rhode Island as an HMO under the provisions of Chapter 27-41, “the HMO Act” or that it will become licensed as a Health Maintenance Organization (HMO) or Health/dental plan (HP) in the State of Rhode Island by the Rhode Island Department of Business Regulation prior to signing an Agreement with EOHHS. If Contractor is not a licensed HMO in Rhode Island, the Contractor certifies that it is either a nonprofit hospital service corporation that is licensed by the Rhode Island Department of Business Regulation (DBR) under Chapter 27-19 of the Rhode Island General Laws, a nonprofit medical service corporation that is licensed by DBR under Chapter 27-20 of the Rhode Island General Laws, or another health insura...
DENTAL PLAN PROGRAM STANDARDS. 3. Section 2.13 (B)(ii), Encounter Data Reporting- General Requirements, is amended by INSERTING the following paragraph after the first paragraph of this section: “The Contractor will comply with the requirements of Section 6507 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), regarding “Mandatory State Use of National Correct Coding Initiatives,” including all applicable rules, regulations, and methodologies, as amended or modified, in accordance with EOHHS policy.”
DENTAL PLAN PROGRAM STANDARDS. 1. Section 2.5.B Dental Plan Enrollment Procedures is amended by DELETING paragraph 3 and REPLACING it with the following: “Contractor agrees to enroll, in the order in which he or she applies or is assigned, any eligible beneficiary who selects it or is assigned to it, regardless of the beneficiary’s race, color, national origin, sex, sexual orientation, disability, age, ethnicity, language needs, health status, or need for health services.”
2. Section 2.5.B Dental Plan Enrollment Procedures is amended by DELETING paragraph 6 and REPLACING it with the following: “The Contractor shall not use any policy or practice that has the effect of discriminating against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, or disability.”
3. This Attachment is amended by DELETING the Attachment in its entirety and REPLACING it with a new ATTACHMENT E dated April 25, 2025 and the Attachment is now titled “ATTACHMENT E: CONTRACTOR’S MONTHLY CAPITATION RATES SFY 2026.”
4. This Section is further amended by ADDING the SFY 2026 Capitation Rate Development and Rate Change Summary table, to ATTACHMENT E, see Exhibit A.
5. This Attachment is amended by DELETING the Attachment in its entirety and REPLACING it with a new Attachment F dated April 25, 2025.
DENTAL PLAN PROGRAM STANDARDS