Recitals 2 Article 1 General Provisions 4 a 1 Purpose 4 b 2 Applicable Law and Regulation 4
f)1.6 Transition between Exchange and Other Coverage
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f)1.6 Transition between Exchange and Other CoverageIn order to further the Exchange’s mission regarding continued access to health insurance coverage, Contractor shall establish policies and practices to maximize smooth transitions and continuous coverage for enrollees to and from the Medi-Cal program and other governmental health care programs and coverage provided by employers, including, coverage required by the Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”) and the California Continuation Benefits Replacement Act, or Health and Safety Code § 1366.20 et seq. (“Cal-COBRA”). g)1.7 Coordination with Other ProgramsContractor and the Exchange recognize that the performance of Services under this Agreement depends upon the joint effort of the Exchange, Contractor, Participating Providers and other authorized subcontractors of Contractor. Contractor shall coordinate and cooperate with Participating Providers and such subcontractors to the extent necessary and as applicable to promote compliance by Participating Providers and such subcontractors with the terms set forth in this Agreement. Contractor shall also coordinate and comply with requirements of other State agencies that affect its Enrollees, including, the Department of Health Care Services (“DHCS”) (and the Medi-Cal program) regarding the development and implementation of CalHEERS with respect to eligibility and enrollment considerations or as may be required under inter-governmental agency agreements or other laws, rules, regulations or program instructions. The Contractor shall cooperate with the Exchange and DHCS to implement coverage or subsidy programs to complement existing programs that are administered by DHCS. Such programs may provide State and/or Federal funding for all or a portion of enrollee premiums or subsidies to reduce or eliminate cost-sharing charges. These programs may require special authorization and coverage of certain health benefits for individuals enrolled under these special programs, which may not otherwise be covered by a QHP. h)1.8 Changes in RequirementsThe parties agree that the Exchange may make prospective changes to benefits and services during a contract year to incorporate changes in State or Federal laws, requirements imposed by regulators or as mutually agreed by the Exchange and Contractor. The projected cost of any such benefit or service change will be included in the cost of health care projections and changes to the Monthly Rates will be implemented after Contractor has demonstrated the cost impact of the benefit or service change in accordance with the requirements set forth in Article 5. i)1.9 Evaluation of Contractor PerformanceThe Exchange shall evaluate Contractor’s performance with respect to fulfillment of its obligations under this Agreement on an ongoing basis, including, but not limited to, during the 90-day period prior to each anniversary of the Agreement Effective Date set forth in Section 7.1 so long as the Agreement remains in effect. In the event evaluations conducted by the Exchange reveal a significant problem or pattern of non-compliance with terms of this Agreement as reasonably determined and documented by the Exchange, the Exchange shall have the right, without limitation, to conduct reasonable additional reviews of Contractor’s compliance and operational performance. Such evaluations shall also be considered in connection with decisions relating to re-certification and de-certification in accordance with the terms set forth at Article 7. j)1.10 Required Notice of Contractor ChangesExcept as set forth below, notices pursuant to this section shall be provided by Contractor promptly within ten (10) days following Contractor’s knowledge of such occurrence; provided, however, (i) such notice shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Enrollees and (ii) in no event shall notice be provided by Contractor beyond the thirty (30) day period following the date of occurrence. All written notices from Contractor pursuant to this section shall contain sufficient information to permit the Exchange to evaluate the events under the same criteria that were used by the Exchange in its award of this Agreement to Contractor. Contractor agrees to provide the Exchange with such additional information as the Exchange may request. If Contractor requests confidential treatment for any information it provides, the Exchange shall treat the information as confidential, consistent with Section 1.4.1. Contractor shall notify the Exchange in writing upon the occurrence of any of the following events: a) Contractor is in breach of any of its obligations under this Agreement; b) Change in the majority ownership, control, or business structure of Contractor; c) Change in Contractor’s business, partnership or corporate organization that may reasonably be expected to have a material impact on Contractor’s performance of this Agreement or on the Exchange’s rights under this Agreement; d) Breach by Contractor of any term set forth in this Agreement and/or Contractor otherwise ceases to meet the requirements for a QHP Issuer, including, those set forth at and 45 C.F.R. § 156.200 et seq. (Subpart C Article 3—Qualified Health Plan Minimum Certification Standards); e) Immediate notice in the event that Contractor files any federal bankruptcy action or state receivership action, any federal bankruptcy or state receivership action is commenced against Contractor, Contractor is adjudicated bankrupt, or a receiver is appointed and qualifies; f) Changes in Contractor’s Provider Network by notice consistent with Section 3.3. i. Contractor shall notify the Exchange with respect to any material changes to its Essential Community Provider (ECP) contracting arrangements consistent with Section 3.3; and ii. Significant changes in operations of Contractor that may reasonably be expected to significantly impair Contractor’s operation of QHPs and/or delivery of Covered Services to Enrollees.
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