QHP Certification and Recertification Applications for Plan Year 2016

This is a model contract governing the relationship between Covered California and a Qualified Health Plan (QHP) issuer for the 2015 plan year. It outlines the issuer’s obligations to provide ACA‑compliant benefit designs, maintain network adequacy, submit rates, and meet performance‑measurement standards, while paying a per‑member‑per‑month participation fee. The agreement also details reporting, data‑privacy, fraud‑waste‑abuse controls, and termination provisions, with penalties and credits tied to performance. • Participation fee: $13.95 PMPM (individual) / $18.60 PMPM (SHOP) with late‑fee provisions. • Benefit design must include all ten Essential Health Benefits and follow the 2015 Standard Benefit Plan Designs. • Network adequacy, Essential Community Provider (ECP) requirements, and quarterly provider‑directory updates are mandatory. • Performance‑Measurement Standards impose call‑center, enrollment, quality, and eValue8 reporting thresholds; penalties up to 10 % of the participation fee may be applied. • No automatic contract renewal; any extension must be formalized via amendment.