Description
This model contract establishes the obligations of a Qualified Dental Plan (QDP) issuer that wishes to offer dental coverage through Covered California for the 2015 plan year. The agreement details licensing, network‑adequacy, benefit‑design, enrollment processing, premium collection, participation‑fee payment, extensive data‑reporting, customer‑service standards, and compliance with federal and California health‑insurance regulations. It also sets performance metrics for call‑center responsiveness, ID‑card issuance, grievance handling, and data‑submission timeliness, with penalties for non‑compliance. The contract is a one‑year term ending 12/31/2015, with a mandatory annual recertification process for renewal.
• Core duties include maintaining a compliant provider network, submitting quarterly provider data, and delivering enrollment‑related electronic files (834, 820, 999).
• Financial terms revolve around a participation‑fee of $0.83 per member per month and the submission of premium rate schedules for both Individual Exchange and SHOP markets.
• The contractor must meet strict customer‑service metrics (e.g., ≤3 % call abandonment, ≥99 % ID‑card issuance within 10 business days) and provide extensive quarterly and annual reporting on utilization, risk assessment, and health‑disparities.