Description
This model contract sets out the obligations, rates, and performance standards for a dental‑plan issuer (the “Contractor”) to sell and administer pediatric Stand‑Alone Dental Plans (SADPs) through Covered California for the 2014 plan year. It requires the Contractor to maintain licensure, meet network‑adequacy standards, collect premiums, pay a $0.83 per member‑per‑month participation fee, and submit extensive monthly, quarterly, and annual reports on enrollment, claims, quality, and financial performance. The agreement also includes detailed provisions on privacy, HIPAA compliance, insurance coverage, dispute resolution, and termination rights, with penalties limited to 10 % of the participation fee and possible credits for exceeding performance metrics.
• Provides pediatric essential health benefit dental coverage, with mandatory orthodontic coverage for children up to age 19.
• Mandates a full suite of administrative functions: enrollment processing via CalHEERS, provider directory maintenance, customer‑service call‑center standards, and data‑submission to the Exchange.
• Enforces strict compliance with federal (ACA, HIPAA) and California (CCR, CDI, DMHC) statutes, including performance‑measurement, quality‑management, and reporting obligations.