Lynx



LYNXEXHIBIT J Dental Insurance Proposal WorksheetWORKSHEET INSTRUCTIONS: Answer the questions as completely as possible. Do not refer the reader to another section of your pany Contact Information:Company Name:Corporate Headquarters Address:Local Office Address:RFP Contact Name:RFP Contact Phone:Contact Fax:Contact E-mail:Administrative ServicesReferences List below five (5) references of your Company where similar services are provided. References shall be for clients managed for a minimum of three (3) years with at least one (1) Florida public sector client.ClientContact NamePhone #/ Email Address# Years of Contractual RelationshipList the number of covered lives your Company insures for dental insurance:CategoryOrange County Area (Orange, Seminole, Lake, and Osceola Counties)State of FloridaHMO Covered Lives PPOCovered LivesIndicate your Company’s retention of dental insurance clients for the past 3 years:Retention for the past 3 yearsPlan typeOrange County Area (Orange, Seminole, Lake, and Osceola Counties)State of FloridaHMO PPOProvide the following information regarding the personnel your Company will assign to LYNX:FunctionNameLocationYears of ExperienceYears with CompanyDental DirectorAccount ManagerDedicated Account Service RepresentativeProvide the following information regarding administrative services:Administrative ServicesResponseConfirm that your company will provide an experienced local client service representative, a client manager, and a strategic account manager, with expert support.Confirm that your proposal includes a comprehensive customer service component that is accessible, effective and efficient.Confirm that your Company will provide LYNX employees toll-free access to trained customer service representatives at a minimum from 8:00 a.m. to 5:00 p.m. Eastern Time, Monday through Friday.Confirm that your Company will provide claims administration, payment, and eligibility information timely and accurate.Has your Company experienced any HIPAA privacy breaches in the last 2 years that were required to be disclosed to HHS? If yes, please explain. Confirm that your proposal includes internet based administrative services for eligibility.Confirm that your company will provide a mobile friendly website or mobile application and internet based dental consumer tools for plan members to help: understand dental procedures and their cost; locate network general dentists and specialists; review claims history and current status of claims processing; and determine annual deductibles and annual maximums.Confirm that your Company will provide member electronic administrative services to include: requests for ID cards, member claim forms, network provider directory, dental plan coverage and limitations and exclusions, and information on claims processing status.Confirm that your Company will provide claim forms that will be easily accessible to members and Providers. Electronic claims submission would be preferable.Confirm that your Company will assist LYNX with annual enrollment by: training the benefits staff on plans; attending at least 5 on-site enrollment meetings in Orange County, Florida; providing web portal interface for annual enrollment; and agreeing to accept the LYNX’s enrollment file. Confirm that your Company will be responsible for coordinating delivery of all required enrollment and policy materials to the various agencies listed under this RFP, as well as being responsible for all costs of producing, printing, and mailing/distributing adequate quantities of marketing and administrative supplies (e.g., claim forms, summary plan booklets, and informational brochures) as designated by the LYNX. Please include a sample in the proposal behind Exhibit J.Confirm that your Company will issue ID cards to enrolled employees upon initial enrollment, or when an eligibility transaction changes information on the previously issued card. Permanent ID cards shall be mailed to the employees' home addresses within fourteen (14) days after the Proposer receives an eligibility update transaction.Confirm that your Company will develop, design, print and distribute Certificates of Coverage in a design and format acceptable to LYNX while meeting all filing requirements, provide the Certificate in PDF for placement on the LYNX Intranet web site and mail Certificates of Coverage to each participant’s home.Confirm that your Company will meet as needed with LYNX on administrative issues related to the dental plans, meet quarterly to review plan performance, and make available a Dental Director for ongoing involvement in clinical, provider, and plan performance issues. Plan Design and Provider Network Indicate whether your Company’s proposed plans resemble the benefits and service types as outlined in the RFP.Low Plan BenefitsLow PlanResponseAnnual Maximum NAAnnual Deductible NAPreventive Services 100% in networkBasic Services Schedule of BenefitsMajor Services Schedule of BenefitsOrthodontiaSchedule of BenefitsOut of Network Allowance Schedule of BenefitsLOW PPO Plan BenefitsLOW PlanResponseAnnual Maximum $1,000 per person per calendar year Annual Deductible $50 per person to family max$150 for Basic or Major Services onlyPreventive Services 100% in network Basic Services 70% in networkMajor Services including Implants 40% in networkOrthodontiaChild Under 18:Paid at 40% in network up to lifetime limit of $1,000Adult:NoneOut of Network Allowance Maximum Allowable CostHigh PPO Plan BenefitsHigh PlanResponseAnnual Maximum $1,500 per person per calendar yearAnnual Deductible $50 per person / $150 family max for Basic or Major Services onlyPreventive Services 100% in networkBasic Services 80% in networkMajor Services including Implants50% in networkOrthodontiaPaid at 50% in network up to lifetime limit of$1,00015% discount for adultsOut of Network Allowance 90th percentile of Usual &Customary RateIndicate whether your Company’s proposed plans resemble the service type coverage as outlined in the RFP.Preventive ServicesService TypeLow PPO & High PPOResponsePeriodic Oral ExamTwice per calendar yearProphylaxis (cleaning)Twice per calendar yearBitewing x-raysTwo sets per calendar year Fluoride Treatment Limited to children under age 14 twice per calendar yearBasic ServicesService TypeLow PPO & High PPOResponseFull Mouth x-raysOnce every 60 monthsSpace Maintainer Limited to children under age 14 once per lifetime per tooth areaSealantsLimited to children under age 16, for non-restored, non-decayed first and second permanent molars, once per tooth every 60 monthsRestorative Amalgams & CompositesInitial placement and replacement of existing filling but only if at least 24 months have passed since the filling was placed or a new surface of decay is identified on the tooth. Resin composite fillings are not to be limited based on tooth placement.Periodontal Maintenance (available in place of eligible routine cleaning)Twice per calendar year following active therapyPeriodontal non-surgical treatment Once per quadrant in any 24 month period Simple ExtractionsAs necessaryMajor ServicesService TypeLow PPO & High PPOResponseAnesthesiaIn connection with oral surgical proceduresInlay, Onlay, Crown One replacement for the same tooth surface within 84 months Removable Dentures and PartialsReplacement of a non-serviceable denture if installed more than 84 months Implants and bridges Once per tooth in a 60 month period Provide the following information regarding your proposed Plan Design and Network Services.Plan Design and Network ServicesResponseConfirm that your Company has proposed one DHMO and two PPO dental plans as outlined section 4 of the Scope of Services in the RFP.Confirm that the proposed dental plans match or closely resemble the classification of Service Types and the Dental Plan Limitations as outlined in the RFP’s Proposed Plans. Any deviations must be listed. Confirm that the plans being proposed do not to include any additional waiting periods or reduction in services for initial plan entrants and also for late entrants selecting coverage during annual enrollment and/or mid-year election Section 125 changes in status.Confirm that your proposal includes a comprehensive network of DHMO or PPO dentists and specialists in the Orange County Area and the network includes statewide and national coverage. The Orange County Area includes. Orange, Seminole, Lake, and Osceola CountiesProvide an HMO and PPO network directory behind Exhibit JConfirm that your Company’s network has a stable list of providers with less than 3% turnover in any year.Indicate your Company’s number of HMO dentists in your network by County. Count a dentist with multiple offices in a single County only once.CountyGeneralPedodontistPeriodonticsEndodontistOral Surgeon OrthodontistOrangeSeminoleOsceolaLakeTotalIndicate your Company’s number of PPO dentists in your network by County. Count a dentist with multiple offices in a single County only once.CountyGeneralPedodontistPeriodonticsEndodontistOral Surgeon OrthodontistOrangeSeminoleOsceolaLakeTotalIndicate the following coverage limitations and/or exclusions for your Proposal.ProcedureLimitations or ExclusionsPre-Existing ConditionsOut-of-area emergency treatmentProsthetics for previously missing teethAccess to a pediatric dentistContinuation of Orthodontic coverage for treatment in progressReferrals to SpecialistsList any other limitations or exclusionsFinancial, Reporting and Data InterfacePlease indicate the proposed services your Company will provide.Financial, Reporting and Data InterfaceResponseConfirm that eligibility for the Group Dental Insurance will be calculated on a Monthly basis and premiums will be due and payable on a monthly basis.Confirm that your Company will agree to allow LYNX to self-administer the premium bill.Confirm that your Company agrees to receive eligibility electronically.Confirm that your Company will complete eligibility discrepancy reporting on a weekly basis.Confirm that your Company will report eligibility, claims and utilization data on a quarterly basis and provide the utilization report, at a minimum: Monthly plan membership, Paid premiums, Amount of paid claims broken down by service type, and Network vs. non- network utilization. Please include a sample in the proposal behind Exhibit JConfirm your Company’s capability of recording and maintaining information regarding LYNX specific service-related calls and complaints reported by members and LYNX representatives as well as provide reports on the information to the LYNX quarterly.Confirm that your Company will conduct annual member satisfaction surveys, specific to LYNX, and share the results with the LYNX.Confirm that your Company will provide the LYNX with electronic access to review standard dental reports.Confirm that your Company’s experience relative to the performance guarantees will be reviewed with LYNX on a quarterly basis.Cost and GuaranteesComplete the information for each Plan regarding the Scheduled and Allowed In-Network amounts and Service Tiers Listed below.HMO Plan: Complete the chart below indicating the scheduled amounts for the services listed: ADA CodeServicesDHMO PlanPatient Cost Proposed Limits / Deviations D0120PERIODIC EXAM?D0140LIMITED ORAL EXAM?D0150COMPREHENSIVE EXAM?D0220FIRST PERIAPICAL X-RAY?D02722 BITEWING X-RAYS?D02744 BITEWING X-RAYS?D0330PANORAMIC X-RAY?D1110ADULT CLEANING?D1206FLUORIDE VARNISH?D1208TOPICAL FLUORIDE EXCL VARNISH?D1351SEALANT-PER TOOTH?D2391COMPOSITE FILLING?D2392COMPOSITE FILLING?D2393COMPOSITE FILLING?D2710Crown - resin based composite (indirect)?D2740PORCELAIN CROWN?D2751Crown - Porcelain Fused to Predominantly Base Metal?D2950CORE BUILD-UP?D3220 Pulpotomy - Removal of Pulp, Not Part of a Root Canal?D3310Anterior Root Canal (Permanent Tooth) (Excluding Final Restoration)?D3320Bicuspid Root Canal (Permanent Tooth) (Excluding Final Restoration)?D3330Molar Root Canal (Permanent Tooth) (Excluding Final Restoration)?D4341PERIO SCALINGD4910PERIO CLEANINGD6970Cast Post and Core, In Addition to Fixed Partial Denture RetainerD6972Prefabricated Post and Core In Addition to Fixed Partial Denture Retainer-Base Metal PostD7140TOOTH EXTRACTIOND7210SURG EXTRACTIOND8080ORTHOLow PPO Plan: Indicate the Service Tier as follows: 1 for Preventive; 2 for Basic; and 3 for Major Services. For the Adjusted Maximum Allowed amount for In Network, list the amount that would be adjusted to reflect the per cent of the Network allowable amount as it would be adjusted for the Service Tier. For example, if the total allowed for a procedure is $100 and the Service Tier is 60% In Network, the Adjusted Maximum Allowable would be $60. ADA CodeServicesLOW PPO PlanService TierAdjusted Maximum Allowed (In Network)D0120PERIODIC EXAMD0140LIMITED ORAL EXAMD0150COMPREHENSIVE EXAMD0220FIRST PERIAPICAL X-RAYD02722 BITEWING X-RAYSD02744 BITEWING X-RAYSD0330PANORAMIC X-RAYD1110ADULT CLEANINGD1206FLUORIDE VARNISHD1208TOPICAL FLUORIDE EXCL VARNISHD1351SEALANT-PER TOOTHD2391COMPOSITE FILLINGD2392COMPOSITE FILLINGD2393COMPOSITE FILLINGD2710Crown - resin based composite (indirect)D2740PORCELAIN CROWND2751Crown - Porcelain Fused to Predominantly Base MetalD2950CORE BUILD-UPD3220 Pulpotomy - Removal of Pulp, Not Part of a Root CanalD3310Anterior Root Canal (Permanent Tooth) (Excluding Final Restoration)D3320Bicuspid Root Canal (Permanent Tooth) (Excluding Final Restoration)D3330Molar Root Canal (Permanent Tooth) (Excluding Final Restoration)D4341PERIO SCALINGD4910PERIO CLEANINGD6970Cast Post and Core, In Addition to Fixed Partial Denture RetainerD6972Prefabricated Post and Core In Addition to Fixed Partial Denture Retainer-Base Metal PostD7140TOOTH EXTRACTIOND7210SURG EXTRACTIOND8080ORTHOHIGH PPO Plan: Indicate the Service Tier as follows: 1 for Preventive; 2 for Basic; and 3 for Major Services. For the Adjusted Maximum Allowed amount for In Network, list the amount that would be adjusted to reflect the per cent of the Network allowable amount as it would be adjusted for the Service Tier. For example, if the total allowed for a procedure is $100 and the Service Tier is 60% In Network, the Adjusted Maximum Allowable would be $60.ADA CodeServicesHIGH PPO PlanService TierAdjusted Maximum Allowed (In Network)D0120PERIODIC EXAM?D0140LIMITED ORAL EXAM?D0150COMPREHENSIVE EXAM?D0220FIRST PERIAPICAL X-RAY?D02722 BITEWING X-RAYS?D02744 BITEWING X-RAYS?D0330PANORAMIC X-RAY?D1110ADULT CLEANING?D1206FLUORIDE VARNISH?D1208TOPICAL FLUORIDE EXCL VARNISH?D1351SEALANT-PER TOOTH?D2391COMPOSITE FILLING?D2392COMPOSITE FILLING?D2393COMPOSITE FILLING?D2710Crown - resin based composite (indirect)?D2740PORCELAIN CROWN?D2751Crown - Porcelain Fused to Predominantly Base Metal?D2950CORE BUILD-UP?D3220 Pulpotomy - Removal of Pulp, Not Part of a Root Canal?D3310Anterior Root Canal (Permanent Tooth) (Excluding Final Restoration)?D3320Bicuspid Root Canal (Permanent Tooth) (Excluding Final Restoration)?D3330Molar Root Canal (Permanent Tooth) (Excluding Final Restoration)?D4341PERIO SCALING?D4910PERIO CLEANING?D6970Cast Post and Core, In Addition to Fixed Partial Denture Retainer?D6972Prefabricated Post and Core In Addition to Fixed Partial Denture Retainer-Base Metal PostD7140TOOTH EXTRACTIOND7210SURG EXTRACTIOND8080ORTHOMonthly fully-insured premiums should be presented using the Employee Counts (includes Employees, COBRA and Retirees) in each tier as provided below. TiersHMO Plan Low PPO Plan High PPO PlanEmployee Only115221266Employee + 1365689Employee + 2 or more424755Pricing should be guaranteed year 1 through year 3 (January 1, 2022 – December 31, 2024). HMO PlanMonthly Premium per Contract Tier202220232024Employee Only$$$Employee + 1$$$Employee + 2 or more$$$Low PPO PlanEmployee Only$$$Employee + 1$$$Employee + 2 or more$$$HIGH PPO PlanEmployee Only$$$Employee + 1$$$Employee + 2 or more$$$For years 4 and 5 (January 1, 2025 – December 31, 2025 and January 1, 2026 – December 31, 2026) provide a not to exceed percent. YearsRenewal not to exceed 20252026Disclose any underwriting assumptions that would impact your proposed premium rates.AssumptionImpactProvide details on the premium breakdown assumptions used for the years your Company’s rates are guaranteed. Use the percent of total premiums and apply it to each category.CategoryAssumptionsAnnual Incurred Claims ExpensesAdministrative ExpensesMarginOther (Please specify)TOTAL100%Please provide the following information.IssueResponsePremiums for the dental plans are to be proposed on the three (3) tier model and guaranteed for a minimum of at least three (3) years of the maximum five (5) year contract.Outline an annual maximum incentive benefit, as an option for consideration after a Company has been selected. List cost impact should LYNX implement this benefit.Indicate the Performance Standards and Financial Penalties your Company will include in your contract with LYNX.Performance StandardResponseFinancial PenaltyPlan Implementation to include: Plans loaded and tested by November 1; staff trained by November 20; and ID cards issued by December 20Network Stability with a 3% or less annual turnoverClaims Processing Accuracy of at least 99% of the total number of correct claims divided by the total claims processedClaims Turnaround Time of at least 90% of clean claims processed in 14 calendars days and 100% all claims in 30 daysAccurate and Timely Reporting with Quarterly and Annual reporting due by the 15th of the month and reports to be error freeTelephone Answering Time minimum of 90% calls answered in less than 20 secondsTelephone Abandonment Rate of 2% or lessReturn Call Response Rate minimum of 95% in 24 hoursWeb Inquiry Response Time minimum of 95% in 24 hoursOther OtherAs an officer of the company, I certify that the information contained in our proposal is accurate, and our company will be bound by the contents of our proposal.___________________________________________________________SignatureDate___________________________________Printed Name/Title ................
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