Recitals 2 Article 1 General Provisions 4 a 1 Purpose 4 b 2 Applicable Law and Regulation 4
aj)5.2 Covered California for Small Business Exchange
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- 5.2.2 Covered California for Small Business Participation Fees
aj)5.2 Covered California for Small Business Exchange5.2.1 Rates and Paymentsa) Schedule of Rates. The rates for the Covered California for Small Business pPlan yYear 20176 are set forth in Attachment 10 (“Monthly Rates - Covered California for Small Business”). The parties acknowledge and agree that the premium rates for Covered California for Small Business are actuarially determined to assure that premium revenues and cost sharing contributions will provide the total dollar amount necessary to support (i) the provision of Covered Services by Contractor through its QHPs, (ii) administrative expenses and reasonable reserves by Contractor to meet the requirements outlined in this Agreement and in accordance with applicable laws, rules and regulations, and (iii) the Contractor’s payment of the Participation Fee to the Exchange. The Participation Fee payable with respect to Enrollees in Covered California for Small Business includes a fee specified by the Exchange as necessary to support payment of agentAgent and Ggeneral agentAgent commissions, (set at $18.60TBD percent of premium paid by each enrollee per member per month for 20176). Contractor acknowledges and agrees that any Participation Fees due to the Exchange from Contractor shall be withheld by the Exchange before passing through any premium payments received by the Exchange from Employers and Employees to Contractor in accordance with paragraph (d) of this Section 5.2.1. b) Updates. The Monthly Rates shall be established in accordance with the procedures set forth at Section 3.5 and in Attachment 11 (“Rate Updates - Covered California for Small Business”). The Exchange may authorize an update of rates no more frequently than on a quarterly basis in the Covered California for Small Business in accordance with requirements and update schedules to be determined by the Exchange. c) Rate Determinations. Rates will be determined by the Exchange in accordance with applicable laws, rules and regulations. Rates for Employers and all covered Employees will be determined by the ZIP Code of the Employer’s primary business address. Rates for an Employer and all covered Employees will be determined and frozen at initial enrollment, or upon renewal, for twelve (12) months, until the next group renewal. Rates for all Employees including new Employees or Employees with qualifying events during the Employer pPlan yYear will be determined by the prevailing rates at group enrollment. d) Collection and Remittance. The Exchange agrees to perform collection and aggregation of monthly premiums with respect to Contractor’s QHPs in the small business exchange and will remit said premiums, net of (i) Participation Fees payable to the Exchange and (ii) the fee associated with agentAgent commissions paid by the Exchange pursuant to Section 2.3.6. e) The Exchange’s collection of premiums and remittance of net amounts to Contractor as described in this Section shall be made on a monthly basis. f) Grace Period. Contractor acknowledges and agrees that applicable laws, rules and regulations, including, the Knox-Keene Act and Insurance Code, set a grace period with respect to the delinquent payment of premiums for the small group market. Contractor agrees to comply with the requirements set forth at Section 2.3.2 and required under applicable laws, rules and regulations with respect to these grace periods. 5.2.2 Covered California for Small Business Participation Feesa) Contractor understands and agrees that (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QHPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange. 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 small employer risk pool (both inside and outside the Exchange) for Covered California for Small Business 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) With respect to Covered California for Small Business, Contractor acknowledges that (i) the Exchange is responsible for collecting premiums from Employers and Employees, and (ii) the Exchange will remit applicable Employer and Employee premiums collected by the Exchange to Contractor, net of (1) Participation Fees computed in accordance with the Participation Methodology - Covered California for Small Business, and (2) agentAgent commissions determined in accordance with the terms set forth at Section 2.3.6. The Exchange shall transfer funds to Contractor on a monthly basis or such other intervals as mutually agreed upon by the Exchange and Contractor and shall establish a process to resolve any disagreements on premium amounts due in a timely manner and prior to transfer of funds to Contractor as required under this Section. d) 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. e) 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 and follow up audits or examinations may be performed by the Exchange more frequently than annually to monitor Contractor’s implementation of such corrective actions. f) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange. Download 481.37 Kb. Share with your friends:
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