Covered California Certification of Qualified Health Plans

Introduction

Soon after the passage of national health care reform through the Patient Protection and Affordable Care Act of 2010 (ACA), California enacted legislation to establish a qualified health benefit exchange. (California Government Code § 100500 et seq.) The California state law is referred to as the California Patient Protection and Affordable Care Act (CA-ACA).

The Exchange offers a statewide health insurance marketplace to make it easier for individuals and small businesses to compare plans and buy affordable, high quality health insurance in the private market. Health and Dental issuers interested in participating in the Exchange are encouraged to review the application and model contract for issuer participation requirements. Interested issuers must apply for certification and be selected by the Exchange in order to participate.

Application Evaluation and Selection

The evaluation of QHP Certification Applications is not based on a single, strict formula; instead, the evaluation will consider the mix of health plans for each region of California that best meet the needs of consumers in that region and the Exchange's goals. The Exchange strives to provide an appropriate range of high quality health plans to participants in the individual and small group markets at the best available price that is balanced with the need for consumer stability and long-term affordability. In consideration of the mission and values of the Exchange, the Board of the Exchange articulated guidelines for the selection and oversight of Qualified Health Plans which are used when reviewing the Applications. These guidelines are:

  • Promote affordability for the consumer– both in terms of premium and at point of care
  • Encourage "Value" Competition Based upon Quality, Service, and Price
  • Encourage Competition Based upon Meaningful QHP Choice and Product Differentiation: Patient-Centered Benefit Plan Designs
  • Encourage Competition throughout the State
  • Encourage Alignment with Providers and Delivery Systems that Serve the Low-Income Population
  • Encourage Delivery System Improvement, Effective Prevention Programs and Payment Reform
  • Demonstrate Administrative Capability and Financial Solvency
  • Encourage Robust Customer Service

March 4, 2021: 2023 Certification Application Qualified Health Plan Individual Marketplace

Covered California has updated the QHP Individual Application. Please submit comments to QHPCertification@covered.ca.gov.

Please note the following changes to the application from the February 18, 2022 posting:

  1. Added language to Section 1.2 – “To this end, Covered California only certifies those Applicants who demonstrate a clear value proposition to its consumers, both in terms of quality and price; in addition, QHPs already operating on the Exchange must maintain quality scores that meet or exceed established benchmarks and reduce health disparities, or risk being removed from the Exchange.”
  2. Added language to Section 1.3 – “In addition, supplemental contracted provider network data will be used to predict the likely quality of new entrant QHPs to ensure that new entrants are held to the same quality standards as existing QHPs. Proposed provider networks will be evaluated using provider organization quality data, hospital quality data, and health plan quality results including NCQA commercial and Medicaid HEDIS measure results and QRS Marketplace measure results from other states.”
  3. Added language to Section 1.5 – “…including provider network and quality data.”
  4. Added question 17.7 (IND) / 16.7 (CCSB) – “Applicant must complete all tabs in Attachment L – Contracted Provider Organizations to indicate the contracted provider organizations (POs) in-network for each of the prospective QHP’s proposed products (HMO, PPO, EPO, Other). Attachment L includes the Integrated Healthcare Association’s (IHA) list of POs, with their associated unique IDs, as well as their county and region locations.”
  5. Added Attachment L - Contracted Provider Organizations
  6. Added Appendix M - CAUTI, CLABSI, CDI, MRSA Rates, and SSI Colon Rates

Additions #1-5 have been made to ensure new entrant QHPs are held to the same quality standards as existing QHPs. Covered California will be evaluating the proposed provider networks of new entrant QHPs using provider organization quality data, hospital quality data, and health plan quality results.

March 4, 2021: 2023 Qualified Health Plan Covered California for Small Business Marketplace

    Covered California has updated the QHP Individual Application. Please submit comments to QHPCertification@covered.ca.gov.

    Please note the following changes to the application from the February 18, 2022 posting:

  1. Added language to Section 1.2 – “To this end, Covered California only certifies those Applicants who demonstrate a clear value proposition to its consumers, both in terms of quality and price; in addition, QHPs already operating on the Exchange must maintain quality scores that meet or exceed established benchmarks and reduce health disparities, or risk being removed from the Exchange.”
  2. Added language to Section 1.3 – “In addition, supplemental contracted provider network data will be used to predict the likely quality of new entrant QHPs to ensure that new entrants are held to the same quality standards as existing QHPs. Proposed provider networks will be evaluated using provider organization quality data, hospital quality data, and health plan quality results including NCQA commercial and Medicaid HEDIS measure results and QRS Marketplace measure results from other states.”
  3. Added language to Section 1.5 – “…including provider network and quality data.”
  4. Added question 17.7 (IND) / 16.7 (CCSB) – “Applicant must complete all tabs in Attachment L – Contracted Provider Organizations to indicate the contracted provider organizations (POs) in-network for each of the prospective QHP’s proposed products (HMO, PPO, EPO, Other). Attachment L includes the Integrated Healthcare Association’s (IHA) list of POs, with their associated unique IDs, as well as their county and region locations.”
  5. Added Attachment L - Contracted Provider Organizations
  6. Added Appendix M - CAUTI, CLABSI, CDI, MRSA Rates, and SSI Colon Rates

Additions #1-5 have been made to ensure new entrant QHPs are held to the same quality standards as existing QHPs. Covered California will be evaluating the proposed provider networks of new entrant QHPs using provider organization quality data, hospital quality data, and health plan quality results.

February 18, 2022: Final Certification Applications - Qualified Health Plan and Qualified Dental Plan Individual Marketplace Plan Year 2023

February 18, 2022: Final Certification Applications - Qualified Health Plan and Qualified Dental Plan Small Business Marketplace Plan Year 2023

Qualified Health Plan Certification Application for Plan Year 2023 Individual Marketplace

Covered California will accept Letters of Intent to Apply until February 15, 2022 at 5:00 pm PST. Interested Applicants must use template provided. Letters of Intent are nonbinding but are required to obtain access to the electronic application submission portal. Questions and comments can be submitted to QHPCertification@covered.ca.gov.

Qualified Dental Plan Certification Application for Plan Year 2023 Individual Marketplace

Covered California will accept Letters of Intent to Apply until February 15, 2022 at 5:00 pm PST. Interested Applicants must use template provided. Letters of Intent are nonbinding but are required to obtain access to the electronic application submission portal. Questions and comments can be submitted to QHPCertification@covered.ca.gov.

Qualified Health Plan Certification Application for Plan Year 2023 Covered California Small Business Marketplace

Covered California will accept Letters of Intent to Apply until 5:00 pm PST by the following dates for the applicable Quarter:

Action: Due dates for Currently Contracted Small Business Applicant: Due dates for Currently Contracted Individual-New Small Business Entrant Applicant: Due dates for New Entrant Applicant:
Letter of Intent to Apply due to Covered California
  • Q1: February 11, 2022
  • Q2: June 3, 2022
  • Q3: September 2, 2022
  • Q4: December 2, 2022
  • Q1: February 11, 2022
  • Q2: June 3, 2022
  • Q3: September 2, 2022
  • Q4: December 2, 2022
  • Q1: February 11, 2022
  • Q2: June 3, 2022
  • Q3: September 2, 2022
  • Q4: December 2, 2022

Interested Applicants must use template provided. Letters of Intent are nonbinding but are required to obtain access to the electronic application submission portal. Questions and comments can be submitted to QHPCertification@covered.ca.gov.

Qualified Dental Plan Certification Application for Plan Year 2023 Covered California Small Business Marketplace

Covered California will accept Letters of Intent to Apply until February 15, 2022 at 5:00 pm PST. Interested applicants must use template provided. Letters of Intent are nonbinding but are required to obtain access to the electronic application submission portal. Questions and comments can be submitted to QHPCertification@covered.ca.gov.

January 20, 2021: Draft 2023 Certification Application Qualified Health Plan and Qualified Dental Plan Individual Marketplace

Covered California has updated the draft QHP and QDP Individual Applications reflecting changes from Public Comment. Covered California is accepting a second round of public comment on the draft QHP and QDP Certification Applications until close of business Friday, February 4, 2021. Please use the comment template and submit to QHPCertification@covered.ca.gov. Please note: Applicants will ultimately complete the applications electronically.

Here are the application changes from the December 2, 2021 posting:

  1. Question 8.4 (QHP) / 15.4 (QDP) – Reduced the marketing spend requirement from 0.6% to 0.4%. (QHP/QDP)
  2. Question 16.7.2.3 – New question regarding CMS Hospital Price Transparency rule. (QHP)
  3. Added clarifying sentences for Covered California Quality Improvement Strategies (QIS). (QHP)
  4. Revised the application to stay consistent with the proposed 2023-2025 Attachment 1. (QHP)
  5. Changes resulting in public comment, such as adding clarification or additional instructions. (QHP/QDP)
  6. Inserted and clarified definitions for terms. (QHP)

* Appendix M is pending Cal Hospital Compare’s release of its updated infection rates data.


January 20, 2021: Draft 2023 Qualified Health Plan and Qualified Dental Plan Applications Covered California for Small Business Marketplace

Covered California has updated the draft QHP and QDP Individual Applications reflecting changes from public comment. Covered California is accepting a second round of public comment on the draft QHP and QDP Certification Application until close of business Friday, February 4, 2021. Please use the comment template and submit to QHPCertification@covered.ca.gov. Please note: Applicants will ultimately complete the applications electronically.

Here are the application changes from the December 2, 2021 posting:

  1. Question 15.7.2.3 – New question regarding CMS Hospital Price Transparency rule. (QHP)
  2. Added clarifying sentences for Covered California Quality Improvement Strategies (QIS). (QHP)
  3. Revised the application to stay consistent with the proposed 2023-2025 Attachment 1. (QHP)
  4. Changes resulting in public comment, such as adding clarification or additional instructions. (QHP/QDP)
  5. Inserted and clarified definitions for terms. (QHP)

*Appendix M is pending Cal Hospital Compare’s release of its updated infection rates data.