ATTACHMENT I SCOPE OF SERVICES PREPAID DENTAL HEALTH PLANS

Transcription

1 ATTACHMENT I SCOPE OF SERVICES PREPAID DENTAL HEALTH PLANS A. Plan Type The Vendor is approved to provide contracted services as a Prepaid Dental Health Plan (). B. Population(s) to be Served 1. Population Groups The shall deliver covered services as defined in Attachment II to the specific population(s) approved below with and as listed in Attachment II, Section III, Eligibility and Enrollment: TABLE 1 TANF SSI Dually Eligible 2. Age Restrictions The s enrollment is restricted as indicated by below in regard to the age range for the population groups referenced in Item 1 above that the is authorized by the Agency to serve: TABLE 2 Age Restriction None Only ages 0 up to 21 Only ages 21 and over Restricted 3. Enrollment Levels and Authorized Counties of Operation The Agency assigns the an authorized maximum enrollment level for each operational county indicated in Exhibit 1 of this attachment. The authorized maximum enrollment level listed is effective on March 1, 2012, or upon Contract execution, whichever is later. a. The Agency must approve in writing any increase or decrease in the s maximum enrollment level for each operational county to be served. AHCA Contract No. FA, Attachment I, Page 1 of 5

2 b. Such approval shall be based upon the s satisfactory performance of terms of the Contract and upon the Agency s approval of the s administrative and service resources, as specified in this Contract, in support of each enrollment level. C. Service Level Required The shall deliver Medicaid covered dental services at the Medicaid State Plan service level. D. Service Level Required 1. Covered Medicaid Services a. The shall ensure the provision of the Medicaid dental services listed below in Table 5 with and as defined in Attachment II, Section I, Definitions and Section V, Covered Services. TABLE 3 Covered Services Chart Diagnostic Services Preventive Services Restorative Services Endodontic Services Periodontic Services Removable Prosthodontic Services Surgical and Extraction Services Orthodontic Services Adjunctive General Services Injectable Medications Oral and Maxillofacial Surgery Services Covered 2. Approved Expanded Benefits a. The shall provide the following expanded benefits to enrollees as specified below in accordance with Contract provisions including Attachment I, Section B., Population(s) to be Served, and Attachment II, Section V, Covered Services, of this Contract. TABLE 4 Expanded Services AHCA Contract No. FA, Attachment I, Page 2 of 5

3 3. Other Service Requirements a. The shall meet the minimum service requirements as outlined and defined in Attachments I and II of this Contract. b. The has agreed to and is authorized by the Agency to use the Medicaid redetermination date data provided in its enrollment files as specified in Attachment II, Section IV, Enrollee Services, Community Outreach and Marketing only if listed by below. TABLE 5 Medicaid redetermination date data The shall use Medicaid redetermination date data as specified in Attachment II, Section IV, Enrollee Services, Community Outreach and Marketing. Authorized E. Method of Payment 1. General This is a fixed price (unit cost) Contract. The Agency will manage this Contract for the delivery of services to enrollees (service units). The will be paid through the Agency s Medicaid fiscal agent, in accordance with the terms of this Contract, a total dollar amount not to exceed subject to the availability of funds in accordance with Attachment II, Section II, Method of Payment. a. The shall be paid capitation payments for each Agency service area, based upon the tables in Exhibit 2 of this attachment. b. All payments made to the shall be in accordance with this section and Attachment II, Section II, Method of Payment. c. Claims and subcapitations paid by prepaid dental contractors to participating dental providers shall reflect the 2011 legislatively appropriated dental fee increase in its entirety and will be used to directly offset the cost of providing direct patient care as opposed to administrative costs. 2. Capitation Rates a. The provider number associated with the capitation rates indicated in Exhibit 2 is provided in Exhibit 1, Maximum Enrollment Levels, of this attachment. AHCA Contract No. FA, Attachment I, Page 3 of 5

4 EHIBIT 1 MAIMUM ENROLLMENT LEVELS Maximum enrollment levels and provider numbers associated with the counties and populations served. Exhibit 2 provides the capitation rate tables respective to the areas of operation listed below. Area 11 Counties: _Miami-Dade Miami-Dade Effective Date: March 1, 2012 County Enrollment Level Provider Number AHCA Contract No. FA, Attachment I, Page 4 of 5

5 EHIBIT 2 CAPITATION RATES County Wide Age-Banded Prepaid Dental Capitation Rates for Miami-Dade County By Age and Eligibility Category Effective March 1, 2012 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS Under Age 1 Age 1-5 Age 6-13 Age TANF $0.07 $9.87 $15.77 $12.93 SSI $0.01 $11.63 $12.16 $8.95 AHCA Contract No. FA, Attachment I, Page 5 of 5