Health Plan Performance Report:
How Covered California as an ActivePurchaser Drives Clinical Quality, Equity, and Value
Covered California is committed to holding insurers accountable for ensuring that people get the right care at the right time and that care is individualized for their specific needs, while seeking to improve how care is delivered and promoting care that is increasingly high-quality, equitable, and cost-effective.
Through its annual contract requirements, Covered California requires every health insurance issuer (commonly referred to as a health insurance company) that sell plans through the Exchange to submit data on how their plans perform every year. This report, the Plan Performance Report, will publicly display the information Covered California requires plans to submit when that data relates to disparities reduction, cost reduction, or quality improvement.
The Plan Performance Report is required under California law as amended by AB 929, which confirms Covered California's access to plan performance data in its capacity as a health oversight agency. The performance metrics reported here will fall into one or more of the following reporting categories outlined in the language of AB 929: Disparities Reduction, Cost Reduction, or Quality Improvement.
Sources of Data
Plan Performance on Contract Requirements
Covered California requires plans to report annually on their performance of the contractual requirements outlined in Attachment 7 to the Covered California Individual Market QHP Issuer Contract: Quality, Network Management, Delivery System Standards and Improvement Strategy (referred to as Attachment 7). Responses are evaluated to confirm ongoing compliance and quality.
Quality Rating System (QRS) Measure Results
All plans that participate in the Exchange are required to submit data directly to CMS, which in turn calculates quality ratings in order to assist consumers, inform regulators, and drive quality improvement. There are three reporting categories: clinical quality management; enrollee experience; and plan efficiency, affordability, and management.
Healthcare Evidence Initiative (HEI) Data
Covered California requires all contracted health plan issuers to submit claims and utilization data into its own claims database, called the Covered California Healthcare Evidence Initiative, or HEI. The goal of HEI is to both inform Covered California's policy choices and requirements as an active purchaser and inform public and private policy more broadly.