ModifiedExecutive Office of Health and Human ServicesPolicy N/A

Amendment No. 10 — Medicaid RIte Smiles Managed Care Dental Services Agreement (UnitedHealthcare)

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Amendment No. 10 modifies the contract between EOHHS and UnitedHealthcare for the Rhode Island Medicaid RIte Smiles dental managed care program, updating compliance, program integrity, contract terms, attachments, and provider obligations.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyAmendment No. 10 — Medicaid RIte Smiles Managed Care Dental Services Agreement (UnitedHealthcare)

Policy CodePolicy N/A

Change TypeMaterial revisions to compliance and program integrityupdated attachments and contract terms

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionSubmit the Contractor's written compliance plan to EOHHS for review and approval within 90 days of execution.

SourceLink

POLICY UPDATE CHANGES

A requirement that each individual or group provider meet Rhode Island Medicaid's location, physical presence, and telehealth requirements (210-RICR-20-001) is inserted into Network Compliance (Section 2.8.A).

Section 2.18 Compliance is deleted and replaced with a new, detailed compliance section (Exhibit A) specifying compliance plan submission, a designated in-state Compliance Officer, monitoring/auditing, overpayment reporting, and other program integrity obligations.

A new Section 2.19 - Program Integrity is inserted (Exhibit B referenced).

Attachment E (Contractor's Monthly Capitation Rates) is replaced with a new attachment dated April 9, 2026 and retitled for SFY 2027; Attachment F (Actuarial Basis) is replaced by reference to the SFY 2027 Data Book and Actuarial Certification dated April 9, 2026.

Attachment G Special Terms and Conditions Section I.1.C "Dental Expenses" is updated to define Dental Expenses and require reduction by recoveries from other payers and adjustments.

90 daysCompliance plan submission deadline

30 daysOverpayment reporting timeframe

35 daysOwnership/disclosure deadline

$25,000Business transaction disclosure threshold

129,732Estimated avg monthly enrollment

five (5)Contract option periods

Compliance, Program Integrity, and Rate Summaries

inv-01: Compliance and Program Integrity Requirements

Compliance and program integrity obligations that affect contractor operations and oversight of network providers include:

Submit an electronic copy of the Contractor's written compliance plan, including operating policies, procedures, workflows, and organizational chart, to EOHHS for review and approval within 90 days of execution and annually thereafter.

Designate a Compliance Officer who is physically located in and dedicated to the State of Rhode Island and who reports directly to the Chief Executive Officer and the Board of Directors.

Establish a Regulatory Compliance Committee at the Board and senior management levels to oversee the organization's compliance program and contract requirements.

Implement effective training, communication, disciplinary guidelines, internal monitoring and auditing, investigations, corrective actions, and sampling or other verification methods to confirm services represented as delivered by network providers were received by members.

Report all overpayments identified or recovered to the State within thirty (30) calendar days and promptly notify the State of changes in enrollee circumstances that may affect eligibility (including change of address and death).

Comply with applicable Federal and State requirements and applicable provisions of the contract to guard against fraud and abuse (e.g., 42 CFR § 438.608).

Ensure no prohibited affiliations with debarred, suspended, or excluded individuals or entities and provide written disclosures of ownership and control as required.

Require network providers to meet Rhode Island Medicaid's location, physical presence, and telehealth requirements per 210-RICR-20-001 and be enrolled with the State consistent with 42 CFR 455.400 et seq.

inv-02: Program Integrity / FWA Compliance Criteria

Program Integrity and Fraud Prevention Program requirements the Contractor must implement and maintain for Rhode Island Medicaid.

Comply with Federal and State fraud, waste, and abuse laws (including 42 CFR Part 455, Section 1902(a)(68) of the Social Security Act, and 42 CFR § 438.608) and follow written directions from EOHHS' Office of Program Integrity.

Implement a Fraud Prevention Program with a dedicated Fraud Prevention Officer who reports to the Medical Director, Chief Compliance Officer, and Board of Directors and participates in required EOHHS quarterly oversight meetings (including MFCU representation).

Maintain written policies and procedures for detection, investigation, and reporting of FWA, including program integrity risk assessments, annual and ad-hoc reviews, provider screening and enrollment protocols, and quarterly exclusion checks against Federal and State lists (e.g., OIG, SAM).

Provide reporting mechanisms including confidential hotline and anonymous/email reporting, a non-retaliation (whistleblower) policy, prompt investigation timelines, annual program evaluation, and continuous quality improvement.

Notify EOHHS in writing within thirty (30) calendar days of discovery of any overpayments or underpayments and immediately upon discovery of suspected provider/subcontractor/member fraud; cooperate with EOHHS investigations, which may direct and retain recoveries.

Maintain Program Integrity staffing: at least two additional dedicated SIU/audit employees with regular RI presence and at minimum one full-time investigator physically located in Rhode Island per 50,000 Members (or fraction); provide contact information to EOHHS.

Complete a minimum of five EOHHS-acceptable provider site audits per contract year using statistically valid random samples (minimum 30 records or 10% of records, sometimes 50 for large populations); EOHHS may waive the minimum.

Develop and submit a written Fraud, Waste and Abuse Compliance Plan to EOHHS within 90 days of contract execution and annually thereafter; EOHHS will notify approval/denial/modification within 60 days. Submit revisions for approval at least 60 days prior to implementation (30 days for Readiness Review submissions).

Ensure the Compliance Plan includes: FWA reporting requirements; risk assessments (including after program-integrity actions); lists of automated pre- and post-payment claims edits; desk audits and surveillance/UM protocols; investigation and follow-up procedures; protections for reporters; procedures for handling State-provided information on providers under investigation; monthly comparisons against death and exclusion lists and monthly exclusion checking with an electronic database and reporting to EOHHS; work plans for announced/unannounced site visits for high-risk providers; and prompt termination provisions for inactive providers.

EOHHS discretion and Contractor consequences

EOHHS may waive audit minimums, consider substitution of SIU positions, require modifications to the compliance plan, conduct onsite audits of Contractor files, and refer matters to the Attorney General's MFCU.
If audits identify overpayments to the Contractor, EOHHS may demand repayment within 30 days, offset payments, refer to MFCU, or seek interest; underpayments to the Contractor will be remedied within 30 days.
Contractor may refuse to enter into, renew, or may terminate provider agreements for failure to disclose required information or for disqualifying convictions/exclusions; Contractor must notify EOHHS within required timeframes when excluded individuals are identified.

inv-03: SFY 2027 capitation rate summary

Exhibit C provides capitation rate values and components for SFY 2027 by age group; select reported values include:

Total RIte Smiles — Estimated Average Monthly Enrollment: 129,732; Base Benefit Expense: $16.43; Provider Incentives: $0.01; Administrative Cost Allowance: $1.87; Underwriting Margin: $0.37; SFY 2027 rate: $18.69; SFY 2026 rate: $18.10; Percent change: 3.3%.

Rate References, Components, and Operational Thresholds

Capitation/Actuarial referencesmixed

	Attachment E updated to SFY 2027 capitation rates (Attachment E dated April 9, 2026).
	Attachment F replaced by reference to the State Fiscal Year 2027 RIte Smiles Capitation Rates Data Book and Actuarial Certification dated April 9, 2026.

Capitation rate components by age group (Total RIte Smiles shown)mixed

	Est. Average Monthly Enrollment = 129,732.
	Base Benefit Expense = $16.43.
	Provider Incentives = $0.01.
	Administrative Cost Allowance = $1.87.
	Underwriting Margin = $0.37.
	SFY 2027 Capitation Rate = $18.69 (SFY 2026 = $18.10; % change = 3.3%).

inv-06: Business transaction disclosure threshold — $25,000 (12 months)

Threshold$25,000 in any 12-month period

Reporting triggerProviders must furnish full ownership/subcontractor information for transactions exceeding the threshold upon written request

Response deadlineInformation must be submitted within 35 days of request

inv-07: Business transaction reporting threshold — $25,000 in the prior 12 months

Reporting threshold$25,000 in the prior 12 months

ScopeIncludes business transactions with subcontractors and significant transactions with wholly owned suppliers over the prior five years when requested

Recipient of disclosuresInformation submitted to the Secretary of HHS or Rhode Island EOHHS upon request

inv-08: SIU investigator staffing ratio — 1 full-time investigator in RI per 50,000 Members (or fraction)

Minimum investigator staffing ratioOne full-time investigator physically located in Rhode Island for every 50,000 Members (or fraction thereof)

Additional SIU staffAt least two additional dedicated SIU/audit employees with regular RI presence required (in addition to Compliance Officer)

EOHHS substitutionEOHHS may consider written requests to substitute another SIU position in place of an investigator with justification

inv-09: Provider site audit sample minimum — 30 records or 10% (sometimes 50 for large populations)

Minimum sample size30 records or 10% of records per provider (minimum) — sometimes 50 for large populations

Annual audit minimumsMinimum of five EOHHS-acceptable provider site audits per contract year

Extrapolation useSamples must be statistically valid to allow for extrapolation; EOHHS may waive the minimum

inv-10: Estimated Average Monthly Enrollment (Total RIte Smiles) — 129,732

Estimated Average Monthly Enrollment (Total RIte Smiles)129,732

SourceExhibit C — SFY 2027 Capitation Rate Development

UseEnrollment figure used in capitation rate component calculations and SIU staffing ratios

Provider Reporting, Disclosures, and Payment Actions

Documentation Required

Overpayment reporting and suspension of payments

Contractor must report all overpayments identified or recovered to the State within thirty (30) calendar days and must suspend payments to network providers when the State determines there is a credible allegation of fraud per 42 C.F.R. §455.23. The Contractor's compliance provisions also require prompt referral of potential fraud to the EOHHS Office of Program Integrity or the Fraud Control Unit and notification to the State when it receives information about changes in an enrollee's circumstances that may affect eligibility.

Report all overpayments identified or recovered to the State within 30 calendar days.
Suspend payments to a network provider when the State determines there is a credible allegation of fraud (per 42 C.F.R. §455.23).
Promptly refer potential fraud to EOHHS Office of Program Integrity or the Fraud Control Unit and notify State of enrollee changes impacting eligibility.

Documentation Required

Provider disclosure timing and consequences

Providers must supply required ownership and disclosure information when applying, when executing provider agreements, during revalidation, and within thirty-five (35) days after any change in ownership; updated information must also be furnished within thirty-five (35) days of a written request. Failure to disclose required information will prevent approval of a provider agreement or require termination of an existing provider agreement.

Disclose when submitting a provider application.
Disclose when executing a provider agreement with the State.
Disclose upon State request during revalidation of provider enrollment.
Provide updated disclosures within 35 days after any change in ownership or within 35 days of a written request.
Non-disclosure may prevent approval or cause termination of the provider agreement.

Documentation Required

Business transaction disclosure requirements

Providers must, within thirty-five (35) days of a request by HHS or EOHHS, submit full and complete information about any subcontractor ownership for business transactions exceeding $25,000 during the prior twelve (12) months and disclose significant business transactions during the prior five (5) years.

Submit full ownership information for any subcontractor with business transactions > $25,000 in the prior 12 months within 35 days of request.
Disclose significant business transactions with wholly owned suppliers or subcontractors during the prior five (5) years within 35 days of request.
Information must be furnished to HHS or EOHHS upon written request.

Denial Risk

Conviction and exclusion disclosures

Providers must disclose the identity of any person with ownership or control interest, or any agent or managing employee, who has been convicted of a criminal offense related to participation in Medicare, Medicaid, or Title XX; the Contractor must notify EOHHS in writing within ten (10) business days upon identifying an excluded individual and may refuse, not renew, or terminate agreements for nondisclosure or convictions.

Disclose identities of persons with ≥5% direct or indirect ownership or who are managing employees convicted of program-related criminal offenses.
Contractor must notify EOHHS in writing within 10 business days if it identifies an excluded individual with ownership or control interest.
Contractor may refuse to enter into or renew, or may terminate, provider agreements for convictions or for failure to fully and accurately disclose required information.

Prior Authorization

Payment suspension and provider termination actions

Upon receipt of EOHHS notification to suspend payments, the Contractor must suspend payments to the provider within twenty-four (24) hours and must lift a suspension within twenty-four (24) hours of receipt of a suspension-lift notification; the Contractor must review exclusion lists at least monthly and terminate providers excluded from Medicare/Medicaid.

Suspend payments to a provider within 24 hours of EOHHS notification of suspension and immediately inform EOHHS of that action.
Lift payment suspensions within 24 hours of receipt of EOHHS notification to lift and immediately inform EOHHS.
Review LEIE and OIG Exclusions Database at least monthly and terminate providers excluded from Medicare/Medicaid.

Prior Authorization

Prepayment review requirements

All prepayment reviews require pre-approval by the Office of Program Integrity; the Contractor must submit a written request to place providers on prepayment review and complete reviews within twelve (12) months of case initiation, after which the Contractor must reevaluate and submit a new written request to continue review if warranted.

Obtain pre-approval from the Office of Program Integrity before initiating any prepayment review.
Submit a written request to the Office of Program Integrity to place providers on prepayment review.
Complete all prepayment reviews within 12 months of case initiation; reevaluate the case at that time and request a new prepayment review if continuation is necessary.
Prepayment review cannot be used to hold claims indefinitely.

Key Definitions and Required Plans

inv-17: Dental Expenses

DefinitionDental Expenses means those benefits and services Contractor is obligated to provide or pay for pursuant to Section 2.6 and Attachment A, including preventive, diagnostic, endodontic, restorative, periodontal, orthodontic, prosthodontic, emergency, oral surgery, general anesthesia, behavior management, and incentive payments

Reduction requirementDental Expenses must be reduced by payments from the State for recoveries from other payers, TPL, reinsurance, or claim adjustments

Contract referenceDefined in Attachment G, Section I.1.C of Amendment No. 10

inv-18: Contractor's written compliance plan (mandatory)

Mandatory submissionContractor must submit an electronic copy of a written Compliance Plan to EOHHS for review and approval (submission timeframe specified elsewhere)

Required contentsOperating policies and procedures, workflows, organizational chart, designation of an in-state Compliance Officer, training, monitoring/auditing, reporting and corrective action protocols

Ongoing requirementsPlan must be updated and resubmitted as required; EOHHS may require modifications

inv-19: Key defined terms for disclosure and ownership

AgentAny person who has express or implied authority to obligate or act on behalf of an entity

Immediate family memberIncludes spouse, natural or adoptive parent, child, sibling, stepparent, stepchild, stepbrother/stepsister, parents-/children-/siblings-in-law, grandparents/grandchildren, and spouses of grandparents/grandchildren

Indirect ownership interestOwnership interest held through other entities that ultimately have an ownership interest in the entity in question

inv-20: Fraud, Waste and Abuse

DefinitionFraud, Waste and Abuse: suspected or confirmed provider, subcontractor, or member activities that must be reported to EOHHS' Office of Program Integrity and, when appropriate, the Medicaid Fraud Control Unit

Reporting obligationContractor must promptly investigate and report suspected or confirmed FWA to EOHHS and cooperate with investigations

Restrictions during investigationContractor must not contact subjects, negotiate settlements, or accept consideration related to suspected/confirmed fraud without EOHHS approval

inv-21: Exclusion checks / LEIE checks

Monthly checksContractor must perform monthly comparisons of provider files against the SSA Master Death File, GSA SAM, and HHS-OIG LEIE and provide monthly reports to EOHHS

Electronic databaseContractor must establish an electronic database capturing identifiable information on owners, agents, and managing employees for exclusion checks

ReportingResults of exclusion comparisons and checks must be reported to EOHHS each month

inv-22: Overpayment / Recoupment

Overpayment definitionOverpayments are funds identified or recovered that must be reported to the State; Contractor procedures must detect and prevent FWA

Reporting timeframeReport all overpayments identified or recovered to the State within sixty (60) days (procedural provision) and elsewhere 30 days referenced for certain overpayments due to potential fraud

Recoupment coordinationRecoupment actions require coordination with the Office of Program Integrity; Contractor may be prohibited from recouping funds already recovered by the State or under investigation

inv-23: Payment suspension

Payment suspension actionContractor must suspend payments to a provider within 24 hours of receipt of EOHHS notification of payment suspension and inform EOHHS immediately

Lift timeframeContractor must lift a payment suspension within 24 hours of receipt of EOHHS notification of a suspension lift and inform EOHHS immediately

Subcontractor requirementContractor must require subcontractors to suspend payments to providers when applicable; failure to comply may lead to contractual remedies

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyAmendment No. 10 — Medicaid RIte Smiles Managed Care Dental Services Agreement (UnitedHealthcare)

Policy CodePolicy N/A

Change TypeMaterial revisions to compliance and program integrityupdated attachments and contract terms

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionSubmit the Contractor's written compliance plan to EOHHS for review and approval within 90 days of execution.

SourceLink

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Amendment No. 10 — Medicaid RIte Smiles Managed Care Dental Services Agreement (UnitedHealthcare)

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Compliance, Program Integrity, and Rate Summaries

inv-01: Compliance and Program Integrity Requirements

Compliance and program integrity obligations that affect contractor operations and oversight of network providers include:

Designate a Compliance Officer who is physically located in and dedicated to the State of Rhode Island and who reports directly to the Chief Executive Officer and the Board of Directors.

Establish a Regulatory Compliance Committee at the Board and senior management levels to oversee the organization's compliance program and contract requirements.

Comply with applicable Federal and State requirements and applicable provisions of the contract to guard against fraud and abuse (e.g., 42 CFR § 438.608).

Ensure no prohibited affiliations with debarred, suspended, or excluded individuals or entities and provide written disclosures of ownership and control as required.

inv-02: Program Integrity / FWA Compliance Criteria

Program Integrity and Fraud Prevention Program requirements the Contractor must implement and maintain for Rhode Island Medicaid.

EOHHS discretion and Contractor consequences

EOHHS may waive audit minimums, consider substitution of SIU positions, require modifications to the compliance plan, conduct onsite audits of Contractor files, and refer matters to the Attorney General's MFCU.
If audits identify overpayments to the Contractor, EOHHS may demand repayment within 30 days, offset payments, refer to MFCU, or seek interest; underpayments to the Contractor will be remedied within 30 days.
Contractor may refuse to enter into, renew, or may terminate provider agreements for failure to disclose required information or for disqualifying convictions/exclusions; Contractor must notify EOHHS within required timeframes when excluded individuals are identified.

inv-03: SFY 2027 capitation rate summary

Exhibit C provides capitation rate values and components for SFY 2027 by age group; select reported values include:

Rate References, Components, and Operational Thresholds

Capitation/Actuarial referencesmixed

	Attachment E updated to SFY 2027 capitation rates (Attachment E dated April 9, 2026).
	Attachment F replaced by reference to the State Fiscal Year 2027 RIte Smiles Capitation Rates Data Book and Actuarial Certification dated April 9, 2026.

Capitation rate components by age group (Total RIte Smiles shown)mixed

	Est. Average Monthly Enrollment = 129,732.
	Base Benefit Expense = $16.43.
	Provider Incentives = $0.01.
	Administrative Cost Allowance = $1.87.
	Underwriting Margin = $0.37.
	SFY 2027 Capitation Rate = $18.69 (SFY 2026 = $18.10; % change = 3.3%).