Article 4 – Quality, Network Management and Delivery System Standards

Article 4 – Quality, Network Management and Delivery System Standards

ac)4.1 Exchange Quality Initiatives

Contractor agrees to work with the Exchange to develop or participate in initiatives to promote models of care that (i) target excessive costs, (ii) minimize unpredictable quality, (iii) reduce inefficiencies of the current system, and (iv) promote a culture of continuous quality and value improvement, health promotion, and the reduction of health disparities to the benefit of all Enrollees and, to the extent feasible, other health care consumers.

In order to further the mission of the Exchange with respect to these objectives and provide the Covered Services required by Enrollees, the Exchange and Contractor shall coordinate and cooperate with respect to quality activities conducted by the Exchange in accordance with the mutually agreeable terms set forth in this Section and in the Exchange’s Quality, Network Management and Delivery System Standards set forth at Attachment 7 (“Quality, Network Management and Delivery System Standards”).

ad)4.2 Quality Management Program

Contractor shall coordinate and cooperate with the Exchange in developing the Quality, Network Management and Delivery System Standards, including (i) participating in meetings and other programs as reasonably requested from time to time by the Exchange, and (ii) providing mutually agreed upon data and other information required under the Quality, Network Management and Delivery System Standards and/or (iii) as otherwise reasonably requested by the Exchange. The parties acknowledge and agree that quality related activities contemplated under this Article 4 will be subject to and conducted in compliance with any and all applicable laws, rules and regulations including those relating the confidentiality of medical information and will preserve all privileges set forth at Health and Safety Code 1370.

ae)4.3 Utilization Management

af)4.4 Transparency and Quality Reporting

b) Contractor shall timely respond to an Enrollee’s request for cost sharing information and shall make cost sharing information available to individuals through the internet and pursuant to other means for individuals without internet access in a timely manner.

ag)4.5 Quality Rating System

ah)4.6 Data Submission Requirements

Article 5 – Financial Provisions

ai)5.1 Individual Exchange

5.1.1 Rates and Payments

b) Updates. If the Term of this Agreement is longer than one year and Contractor’s QHPs are certified for another year, the Monthly Rates for each subsequent year of the Agreement will be established no more frequently than annually in accordance with the procedures set forth at and Section 3.5 and Attachment 9 (“Rate Updates - Individual Exchange”).

c) Collection and Remittance. Contractor understands that Contractor is responsible for collection and the Enrollee is responsible for remittance of the agreed-upon premium rates to Contractor in a timely manner. Contractor understands that individual Enrollees will remit their monthly premium payments directly to Contractor and the Exchange will not aggregate premiums. The failure by an Enrollee to timely pay premiums may result in a termination of coverage pursuant to the terms set forth at Sections 2.2.4 and 2.3.4. Contractor further understands that the premium payment collected by Contractor includes amounts allocated to the Participation Fee due to the Exchange. The Participation Fees shall be billed by the Exchange to Contractor and payable by Contractor to the Exchange in accordance with the requirements set forth at Section 5.1.3.

5.1.2 Financial Consequences of Non-Payment of Premium

b) Enrollee Terminations. In the event Contractor terminates an Enrollee’s coverage in a QHP due to non-payment of premiums, loss of eligibility, fraud or misrepresentation, change in Enrollees selection of QHP, decertification of Contractor’s QHP and/or as otherwise authorized under Sections 2.2.2 and 2.3.2, Contractor must include the Health Insurance Regulator-approved appeals language in its notice of termination of coverage to the Enrollee.

c) Grace Period. Contractor acknowledges and agrees that applicable laws, rules and regulations, including the Affordable Care Act and implementing regulations specify a grace period for individuals who receive advance payments of the premium tax credit through the Exchange and that the Knox-Keene Act and Insurance Code set a grace period for other individuals with respect to delinquent payments. Contractor agrees to abide by the requirements set forth at Section 2.2.2 and 2.3.2 and required under applicable laws, rules and regulations with respect to these grace periods.

5.1.3 Individual Exchange Participation Fees

b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost across the premiums charged to Contractor’s entire individual risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other enrollees of the respective risk pool.

c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month (“PMPM”) rate of $13.95 multiplied by the number of Enrollees 3.5 percent of the premium paid by each enrollee in Contractor’s QHPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment premiums paid by enrollees in Contractor's QHPs sold through the Individual Exchange for 20167 - 2019.

d) Participation Fee invoices will be issued by the Exchange prospectively to Contractor on the 15th of the month for the coming month. Contractor’s Participation Fee obligation will be determined and billed by evaluating Contractor’s then-current QHP confirmed enrollment and may be subject to adjustment to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollment). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QHP with Contractor in accordance with Billing Discrepancy Reporting requirement in Attachment 13. Participation Fee payments will be due on the 1st of the month the Participation Fee covers. For Participation Fees received after the 15th of the month in which the Participation Fee is due, the Exchange will charge, and Contractor shall owe, a 1% per month late fee on the unpaid balance as of that date.

e) In the event that Contractor disputes the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to the Exchange within thirty (30) days following receipt of such bill or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, reconciliation of any differences identified by Contractor in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.1.

f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.

g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.