Recitals 2 Article 1 General Provisions 4 a 1 Purpose 4 b 2 Applicable Law and Regulation 4
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- 3.2.2 Standard Benefit Designs
- 3.2.3 Offerings Outside of the Exchange
- 3.2.4 Pediatric Dental Benefits
- 3.2.5 Segregation of Funds
x)3.2 Benefit Standards3.2.1 Essential Health BenefitsEach QHP offeredperated by Contractor under the terms of this Agreement shall provide essential health benefits in accordance with the Benefit Plan Design requirements set forth at Attachment 2, and as required under this Agreement, and applicable laws, rules and regulations, including California Health and Safety Code § 1367.005, California Insurance Code § 10112.27, California Government Code § 100503(e) and as applicable, 45 C.F.R. § 156.200(b). 3.2.2 Standard Benefit DesignsDuring the term of this Agreement, Contractor shall offer the QHPs products identified in Attachment 1 and provide the benefits and services at the cost-sharing and actuarial cost levels described in the Benefit Plan Design summarized at Attachment 2 (“Benefit Plan Designs”), and as may be amended from time to time under applicable laws, rules and regulations or as otherwise authorized under this Agreement. 3.2.3 Offerings Outside of the Exchangea) Contractor acknowledges and agrees that as required under State and Federal law, QHPs and substantially similar plans offered by Contractor outside the Exchange must be offered at the same rate whether offered inside the Exchange or outside the Exchange directly from the issuer or through an agentAgent. b) In the event that Contractor sells products outside the Exchange, Contractor shall fairly and affirmatively offer, market and sell all products made available to individuals and small businesses in the Exchange to individuals and small businesses seeking coverage outside the Exchange consistent with California law. c) For purposes of this Section, “product” does not include contracts entered into pursuant to Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code between the Department of Health Care Services (DHCS) and health care service plans for Healthy Families beneficiaries or to contracts entered into pursuant to Chapter 7 (commencing with Section 14000) of, or Chapter 8 (commencing with Section 14200) of, Part 3 of Division 9 of the Welfare and Institutions Code between the DHCS and health care service plans for enrolled Medi-Cal beneficiaries. 3.2.4 Pediatric Dental BenefitsWhen Contractor elects to embed and offer Pediatric Dental Essential Health Benefit services either directly or, through a subcontract with a dental plan issuer authorized to provide Specialized Health Care Services, to Enrollees under applicable laws, rules and regulations pursuant to: (i) a certificate of authority issued by the CDI under § 699 et seq. of the California Insurance Code, and/or (ii) a license issued by the DMHC pursuant to the Knox-Keene Health Care Service Plan Act of 1975 § 1340 et seq. of the California Health and Safety Code. Contractor shall require its dental plan subcontractor to comply with all applicable provisions of this Agreement, including, but not limited to, standard benefit designs for the embedded pediatric dental benefit, as well as any network adequacy standards applicable to dental provider networks and any pediatric dental quality measures as determined by the Exchange. Coordination of Benefits. If a Contractor’s Qualified Health Plan provides coverage for the Pediatric Dental Essential Health Benefit, Contractor shall include a Coordination of Benefits (COB) provision in its Evidence of Coverage or Policy Form that (i) is consistent with Health and Safety Code § 1374.19 or Insurance Code § 10120.2 and (ii) provides that the Qualified Health Plan is the primary dental benefit plan or policy under that COB provision. This provision shall apply to Contractor’s QHPs offered both inside and outside of the Individual and Covered California for Small Business Exchanges, except where 28 CCR § 1300.67.13 or 10 CCR § 2232.56 provides for a different order of determination for COB in the small group market. 3.2.5 Segregation of FundsContractor shall comply with federal requirements relating to the required segregation of funds received for abortion services in accordance with the Affordable Care Act Section 1303 and 45 C.F.R. § 156.280. 3.2.6 Prescription Drugsa) Formulary changes. Except in cases where patient safety is an issue, Contractor shall give affected Exchange Enrollees, and their prescribing physician(s), sixty (60) days written notice prior to the removal of a drug from formulary status, unless it is determined that a drug must be removed for safety purposes more quickly. This notice requirement shall apply only to single source brand drugs and the notice shall include information related to the appropriate substitute(s). The notice shall also comply with all requirements of the Health and Safety Code and Insurance Code, including provisions prohibiting Contractor from limiting or excluding coverage for a drug to a Plan Enrollee in cases where the drug had been previously approved for coverage by Contractor for a medical condition of the Plan Enrollee, except under specified conditions. To the extent permitted in State and Federal law, an exception to the notice requirement will be allowed when Contractor continues to cover a drug prescribed for a Plan Enrollee without interruption and under the same conditions, including copayment and limits that existed prior to the removal of the drug from formulary status. b) Internet Link to Formularies. Contractor shall comply with applicable State and Federal laws relating to prescription drug formularies, including posting the formularies for each product offered on the Contractor’s Internet Wweb site as required by Health and Safety Code §1367.205 and Insurance Code §10123.192. Contractor shall provide to the Exchange and regularly update information necessary for the Exchange to link to the Contractor’s drug formularies for each of the QHPs Contractor offers so that the Exchange can ensure it complies with its obligation under Government Code §100503.1. c) Contractor shall have an opt-out retail option for mail order drugs to allow consumers to receive in-person assistance, and this option shall have no additional cost. However, as specified in the standard benefit designs, Contractor may offer mail order prescriptions at a reduced cost-share. d) Contractor shall provide consumers with an estimate of the range of costs for specific drugs. e) Contractor shall have a sufficient number of dedicated pharmacy customer service representatives available during call center hours for consumers and advocates to obtain clarification on formularies and consumer cost-shares for drug benefits.
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