Recitals 2 Article 1 General Provisions 4 a 1 Purpose 4 b 2 Applicable Law and Regulation 4
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| 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
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
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
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
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
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
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
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
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
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). Download 481.37 Kb. Share with your friends:
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