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

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-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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Covered California

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

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eir en

tire

lic

ense

d service area for

eac

hproduct type w

hich the

y ar

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lica

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th SADP and Family De

ntal

Plan products, an

tl may off

er only their In

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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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Dental Pla

n New Ent

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Attachmenf D1 SADP Rates Ind

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Issuer Name:

P~od

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ia Health Be

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t Ex

chan

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n New Entrant Application

Atta

chme

nt D2 Family Dental Pla

n Ra

tes in

divi

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Issuer Name:

Prod

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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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Individual SHOP)