Recitals 2 Article 1 General Provisions 4 a 1 Purpose 4 b 2 Applicable Law and Regulation 4



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TABLE OF CONTENTS


RECITALS 2

Article 1 -- General Provisions 4

a)1.1 Purpose 4

b)1.2 Applicable Law and Regulation 4

c)1.3 Relationship of the Parties 5

d)1.4 General Duties of the Exchange 5

1.4.1 Confidentiality of Contractor Documents 7



e)1.5 General Duties of the Contractor 7

f)1.6 Transition between Exchange and Other Coverage 8

g)1.7 Coordination with Other Programs 8

h)1.8 Changes in Requirements 8

i)1.9 Evaluation of Contractor Performance 9

j)1.10 Required Notice of Contractor Changes 9

k)1.11 Nondiscrimination 10

l)1.12 Conflict of Interest; Integrity 11

m)1.13 Other Financial Information 12

n)1.14 Other Laws 12

o)1.15 Contractor’s Representations and Warranties 12

p)1.16 Fraud, Waste and Abuse; Ethical Conduct 13

q)1.17 Current Enrollee Notification 14

Article 2 -- Eligibility And Enrollment 14

r)2.1 Eligibility and Enrollment Responsibilities 14

2.1.1 Exchange Responsibilities 14

2.1.2 Contractor Responsibilities 14

2.1.3 Collection Practices 15



s)2.2 Individual Exchange 16

2.2.1 Enrollment and Enrollment Periods 16

2.2.2 Individual Exchange Coverage Effective Dates 16

2.2.3 Premiums for Coverage in the Individual Exchange 17

2.2.4 Terminations of Coverage 17

2.2.5 Notice to Provider Regarding Enrollee’s Grace Period Status 17

2.2.6 Agents in the Individual Exchange 18

t)2.3 Covered California for Small Business Exchange 20

2.3.1 Covered California for Small Business Enrollment Periods 21

2.3.2 Covered California for Small Business Coverage Effective Dates 21

2.3.3 Covered California for Small Business Premiums 22

2.3.4 Covered California for Small Business Terminations of Coverage 22

2.3.5 Covered California for Small Business Minimum Participation Rates 23

2.3.6 Agents in the Covered California for Small Business Exchange 23

u)2.4 Enrollment and Marketing Coordination and Cooperation 25

v)2.5 Enrollee Materials and Branding Documents 27

Article 3 – QHP Issuer Program Requirements 29



w)3.1 Basic Requirements 29

3.1.1 Licensed in Good Standing 29

3.1.2 Certification 30

3.1.3 Accreditation 31

3.1.4 Plan Naming Conventions 32

3.1.5 Operational Requirements and Liquidated Damages 32

3.1.6 Additional Operational Requirements 33

x)3.2 Benefit Standards 33

3.2.1 Essential Health Benefits 33

3.2.2 Standard Benefit Designs 34

3.2.3 Offerings Outside of the Exchange 34

3.2.4 Pediatric Dental Benefits 34

3.2.5 Segregation of Funds 35

3.2.6 Prescription Drugs 35

y)3.3 Network Requirements 36

3.3.1 Service Areas 36

3.3.2 Network Adequacy 37

3.3.3 Essential Community Providers 38

3.3.4 Special Rules Governing American Indians and Alaskan Natives 39

3.3.5 Network Stability 40



z)3.4 Participating Providers 40

3.4.1 Provider Contracts 40

3.4.2 Provider Credentialing 42

3.4.3 Enrollee costs; Disclosure 42

3.4.4 Provider Directory 43

aa)3.5 Premium Rate Setting 43

3.5.1 Rating Variations 43

3.5.2 Individual Exchange Rates 43

3.5.3 Covered California for Small Business Exchange Rates 44

3.5.4 Rate Methodology 44

3.5.5 Provider Rates 44



ab)3.6 Customer Service Standards 45

3.6.1 Basic Customer Service Requirements 45

3.6.2 Enrollee Appeals and Grievances 45

3.6.3 Applications and Notices 45

3.6.4 Customer Service Call Center 46

3.6.5 Customer Service Transfers 47

3.6.6 Customer Care 47

3.6.7 Notices 47

3.6.8 Issuer-Specific Information 48

3.6.9 Enrollee Materials: Basic Requirements 48

3.6.10 New Enrollee Enrollment Packets 49

3.6.11 Summary of Benefits and Coverage. 50

3.6.12 Electronic Listing of Participating Providers 50

3.6.13 Access to Medical Services Pending ID Card Receipt 50

3.6.14 Explanation of Benefits 50

3.6.15 Secure Plan Website for Enrollees and Providers 50

3.6.16 Standard Reports 51

3.6.17 Contractor Staff Training about the Exchange 51

3.6.18 Customer Service Training Process 51

Article 4 – Quality, Network Management and Delivery System Standards 52

ac)4.1 Exchange Quality Initiatives 52

ad)4.2 Quality Management Program 52

ae)4.3 Utilization Management 53

af)4.4 Transparency and Quality Reporting 53

ag)4.5 Quality Rating System 53

ah)4.6 Data Submission Requirements 53

Article 5 – Financial Provisions 53

ai)5.1 Individual Exchange 54

5.1.1 Rates and Payments 54

5.1.2 Financial Consequences of Non-Payment of Premium 54

5.1.3 Individual Exchange Participation Fees 55



aj)5.2 Covered California for Small Business Exchange 56

5.2.1 Rates and Payments 56

5.2.2 Covered California for Small Business Participation Fees 58

Article 6 – Performance measures 59

ak)6.1 Standards 59

al)6.2 Penalties and Credits 59

am)6.3 No Waiver 59

Article 7 – Contract Term; Recertification and Decertification 60

an)7.1 Agreement Term 60

ao)7.2 Agreement Termination 60

7.2.1 Exchange Termination 60

7.2.2 Contractor Termination 61

7.2.3 Notice of Termination 61

7.2.4 Remedies in Case of Contractor Default or Breach Non-Compliance 62

7.2.5 Contractor Insolvency 63



ap)7.3 Recertification 63

7.3.1 Recertification Process 63

7.3.2 Non-Recertification Election 63

aq)7.4 Decertification 65

ar)Notwithstanding any other language set forth in this Section 7.4, the Agreement shall expire on the Expiration Date set forth in Section 7.1 in the event that the Exchange elects to decertify Contractor’s QHP based on the Exchange’s evaluation of Contractor’s QHP during the recertification process that shall be conducted by Exchange pursuant to Section 7.2. 65

as)7.5 Effect of Termination 65

1)Mid-Month Termination: For a termination of this Agreement that occurs during the middle of any month, the premium for that month shall be apportioned on a pro rata basis. Contractor shall be entitled to premiums from Enrollees for the period of time prior to the date of termination and Enrollees shall be entitled to a refund of the balance of the month. 67

2)Responsibility to Complete Contractual Obligations: Contractor is responsible for completing submission and corrections to Encounter Data for Covered Services received by Enrollees during the period of the Agreement. Contractor is responsible for submitting any outstanding financial or other reports required for Covered Services rendered or Claims paid during the term of the Agreement. 68

at)7.6 Coverage Following Termination and Decertification 68

au)7.7 Termination Due to Contractor Merger 69

Article 8 –Insurance and Indemnification 69

av)8.1 Contractor Insurance 69

8.1.1 Required Coverage 69

8.1.2 Workers’ Compensation 70

8.1.3 Subcontractor Coverage 70

8.1.4 Continuation of Required Coverage 70

8.1.5 Premium Payments and Disclosure 70



aw)8.2 Indemnification 71

Article 9 – Privacy and Security 71

ax)9.1 Privacy and Security Requirements for Personally Identifiable Data 71

ay)9.2 Protection of Information Assets 79

Article 10 – Recordkeeping 81

az)10.1 Clinical Records 81

ba) 81

bb)10.2 Financial Records 81

bc) 82

bd)10.3 Storage 82

be) 82

bf)10.4 Back-Up 83

bg) 83

bh)10.5 Examination and Audit Results 83

bi) 83

bj)10.6 Notice 84

bk) 84

bl)10.7 Confidentiality 84

bm) 84

bn)10.8 Tax Reporting 85

bo) 85

bp)10.9 Electronic Commerce 85

bq) 85

Article 11 – Intellectual Property 85

br)11.1 Warranties 85

bs)11.2 Intellectual Property Indemnity 86

bt)11.3 Federal Funding 87

bu)11.4 Ownership and Cross-Licenses 88

bv)11.5 Survival 89

Article 12 – Special Terms and Conditions 89

bw)12.1 Dispute Resolution 89

by)12.2 Attorneys’ Fees 90

ca)12.3 Notices 90

cb) 90

cc)12.4 Amendments 91

cd)12.5 Time is of the Essence 91

ce) 91

cf)12.6 Publicity 91

cg) 91

ch)12.7 Force Majeure 92

ci) 92

cj)12.8 Further Assurances 92

ck) 92

cl)12.9 Binding Effect 92

cm) 92

cn)12.10 Titles/Section Headings 92

co) 92

cp)12.11 Severability 92

cq) 92

cr)12.12 Entire Agreement/Incorporated Documents/Order of Precedence 93

cs) 93

ct)12.13 Waivers 93

cv)12.14 Incorporation of Amendments to Applicable Laws 93

cx)12.15 Choice of Law, Jurisdiction, and Venue 94

cy) 94

cz)12.16 Counterparts 94

db)12.17 Days 94

dc) 94

dd)12.18 Ambiguities Not Held Against Drafter 94

df)12.19 Clerical Error 94

dh)12.20 Administration of Agreement 94

di) 94

dj)12.21 Performance of Requirements 95

Article 13 – Definitions 95


COVERED CALIFORNIA
QUALIFIED HEALTH PLAN ISSUER CONTRACT
between
Covered California, California Health Benefit Exchange
(the “Exchange”)
and
____________________ (“Contractor”)

THIS QUALIFIED HEALTH PLAN ISSUER CONTRACT (this or the “Agreement”) is entered into by and between the California Health Benefit Exchange, an independent entity established within the government of the State of California doing business as Covered California (the “Exchange”), and _______________ , a [California] corporation and a health insurance issuer as defined in Title 10 California Code of Regulations (“CCR”) § 6410 (“Contractor”). (Except as otherwise expressly defined, capitalized terms shall have the meaning set forth at Article 13 Definitions).




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