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 insurance entity licensed by DBR, and that it meets the following requirements: • Meets that requirements under R.I. Gen. Laws section 27-18.9-8: Benefit Determination and Utilization Review Act • Is certified as a utilization review entity by a nationally known health utilization management organization. The Contractor agrees to forward to EOHHS any complaints received from the Rhode Island Department of Business Regulation (DBR) or OHIC. The Contractor also agrees to forward to EOHHS a copy of any correspondence sent by the Contractor to DBR or OHIC which pertains to the Contractor’s contract status with any institution or provider group as it relates to it managed Medicaid network. The Contractor shall notify EOHHS of any person or corporation that has five percent (5%) or more ownership or controlling interest in the Contractor. At least annually, and within 30 days of any change in accreditation, the Contractor will inform EOHHS as to whether it has been accredited by a private independent accrediting entity. If the contractor has received accreditation by a private independent accrediting entity, in accordance with 42 CFR § 438.332(b)(1), 42 CFR § 438.332(b)(2), and 42 CFR§ 438.332(b)(3), the Contractor will authorize the private independent accrediting entity to provide EOHHS a copy of its most recent accreditation review, including its accreditation status, survey type, and level (as applicable); recommended actions or improvements, corrective action plans, and summaries of findings; and the expiration date of the accreditation. 2.3 DENTAL PLAN(S) ADMINISTRATION Contractor agrees to maintain sufficient administrative staff and organizational components to comply with all program standards described within this Agreement. At a minimum, Contractor agrees to include each of the functions noted in Sections 2.3.A and 2.3.B below. Contractor agrees to staff qualified persons in numbers appropriate to its size of enrollment. Contractor shall be required to have In-State presence to conduct outreach, approved marketing efforts, and attend or preside at meetings with stakeholders at community agencies throughout the State at health fairs and in other health related events. Contractor may combine functions or split the responsibility for a function across multiple departments, as long as it can demonstrate that the duties of the function are being carried out. Similarly, Contractor may contract with a third-party (subcontractor) to perform one or more of these functions, subject to the subcontractor conditions described in Section 3.5.D. of the Agreement.
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Sources: Agreement for the Medicaid Rite Smiles Program, Agreement for the Medicaid Rite Smiles Program
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 insurance entity licensed by DBR, and that it meets the following requirements: • Meets that requirements under R.I. Gen. Laws section 27-18.9-8: Benefit Determination and Utilization Review Act • Is certified as a utilization review entity by a nationally known health utilization management organization. The Contractor agrees to forward to EOHHS any complaints received from the Rhode Island Department of Business Regulation (DBR) or OHIC. The Contractor also agrees to forward to EOHHS a copy of any correspondence sent by the Contractor to DBR or OHIC which pertains to the Contractor’s contract status with any institution or provider group as it relates to it managed Medicaid network. The Contractor shall notify EOHHS of any person or corporation that has five percent (5%) or more ownership or controlling interest in the Contractor. At least annually, and within 30 days of any change in accreditation, the Contractor will inform EOHHS as to whether it has been accredited by a private independent accrediting entity. If the contractor has received accreditation by a private independent accrediting entity, in accordance with 42 CFR § 438.332(b)(1), 42 CFR § 438.332(b)(2), and 42 CFR§ 438.332(b)(3), the Contractor will authorize the private independent accrediting entity to provide EOHHS a copy of its most recent accreditation review, including its accreditation status, survey type, and level (as applicable); recommended actions or improvements, corrective action plans, and summaries of findings; and the expiration date of the accreditation.
2.3 DENTAL PLAN(S) ADMINISTRATION Contractor agrees to maintain sufficient administrative staff and organizational components to comply with all program standards described within this Agreement. At a minimum, Contractor agrees to include each of the functions noted in Sections 2.3.A and 2.3.B below. Contractor agrees to staff qualified persons in numbers appropriate to its size of enrollment. Contractor shall be required to have In-State presence to conduct outreach, approved marketing efforts, and attend or preside at meetings with stakeholders at community agencies throughout the State at health fairs and in other health related events. Contractor may combine functions or split the responsibility for a function across multiple departments, as long as it can demonstrate that the duties of the function are being carried out. Similarly, Contractor may contract with a third-third- party (subcontractor) to perform one or more of these functions, subject to the subcontractor conditions described in Section 3.5.D. of the Agreement.
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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 insurance entity licensed by DBR, and that it meets the following requirements: • Meets that requirements under R.I. Gen. Laws section 27-18.9-8: Benefit Determination and Utilization Review Act • Is certified as a utilization review entity by a nationally known health utilization management organization. The Contractor agrees to forward to EOHHS any complaints received from the Rhode Island Department of Business Regulation (DBR) or OHIC. The Contractor also agrees to forward to EOHHS a copy of any correspondence sent by the Contractor to DBR or OHIC which pertains to the Contractor’s contract status with any institution or provider group as it relates to it managed Medicaid network. The Contractor shall notify EOHHS of any person or corporation that has five percent (5%) or more ownership or controlling interest in the Contractor. At least annually, and within 30 days of any change in accreditation, the Contractor will inform EOHHS as to whether it has been accredited by a private independent accrediting entity. If the contractor has received accreditation by a private independent accrediting entity, in accordance with 42 CFR § 438.332(b)(1), 42 CFR § 438.332(b)(2), and 42 CFR§ 438.332(b)(3), the Contractor will authorize the private independent accrediting entity to provide EOHHS a copy of its most recent accreditation review, including its accreditation status, survey type, and level (as applicable); recommended actions or improvements, corrective action plans, and summaries of findings; and the expiration date of the accreditation.
2.3 DENTAL PLAN(S) ADMINISTRATION Contractor agrees to maintain sufficient administrative staff and organizational components to comply with all program standards described within this Agreement. At a minimum, Contractor agrees to include each of the functions noted in Sections 2.3.A and 2.3.B below. Contractor agrees to staff qualified persons in numbers appropriate to its size of enrollment. Contractor shall be required to have In-State presence to conduct outreach, approved marketing efforts, and attend or preside at meetings with stakeholders at community agencies throughout the State at health fairs and in other health related events. Contractor may combine functions or split the responsibility for a function across multiple departments, as long as it can demonstrate that the duties of the function are being carried out. Similarly, Contractor may contract with a third-party (subcontractor) to perform one or more of these functions, subject to the subcontractor conditions described in Section 3.5.D. of the Agreement.
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