HIOS/Issuer ID 10 words. Corporate Office Address 10 words. City 10 State 10 Zip Code 10 Primary Contact Name 10 words. Contact Title 10 words. Contact Phone Number 10 words. Contact Email 10 words. Applicant Eligibility Single, list. 1: CCSB Market Contracted in 2019, 2: Individual Market Place Contracted in 2019, 3: New Entrant Applicant Indicate if Applicant has completed the Qualified Health Plan Application Plan Year 2019 Individual Single, list. 1: Yes, CCSB application completed, 2: Yes, Individual
8.1 Applicant must confirm it can provide certain detailed documentation as defined by the Exchange in the NOD 23 Gross to Network Report as specified in Appendix J Issuer Payment Discrepancy Resolution and Appendix K NOD 23 Report Glossary. No space for details provided. Single, Pull-down list. 1: Yes, confirmed, 2: No, not confirmed Attached Document(s): , 8.2 Applicant must confirm it can perform financial reconciliation at a member and group level for each monthly coverage period. No for details provided. Single, Pull-down list. 1: Yes, confirmed, 2: No, not confirmed 9 Fraud, Waste and Abuse Detection This section not required if Applicant has completed the Qualified Health Plan Application Plan Year 2019Individual Marketplace. 9.4.8 and 9.4.17 required for currently contracted Individual Market Applicants. Section not required for currently contracted CCSB Market Applicants. All questions required for new entrant Applicants. The Exchange is committed to working with its QHP issuers to minimize waste and abuse. The framework for managing fraud risks is detailed in Appendix O U.S. Government Accountability Office circular (available in Manage Documents). The Exchange expects QHP issuers to adopt leading practices outlined in the framework to the extent applicable. Fraud prevention is centered on integrity and expected behaviors from employees and others. All measures to detect, deter, and prevent fraud before it occurs are vital to all issuer and Exchange operations. Definitions: Fraud – Consists of an intentional misrepresentation, deceit, or concealment of a material fact known to the defendant with the intention on the part of the defendant of thereby depriving a person of property or legal rights or otherwise causing injury. (CA Civil Code §3294 (c)(3), CA Penal Code §§470-483.5). Prevention and early detection of fraudulent activities is crucial to ensuring affordable healthcare for all individuals. Examples of fraud include, but not limited to, false applications to obtain payment, false information to obtain insurance, billing for services that were not rendered. - Intentional or unintentional, extravagant careless or needless expenditures, consumption, mismanagement, use, or squandering of resources, to the detriment or potential detriment of entities, but without an intent to deceive or misrepresent. Waste includes incurring unnecessary costs as a result of inefficient or ineffective practices, systems, decisions, or controls.
list. 1: Daily, 2: Weekly, 3: Monthly, 4: Quarterly, 5: Other: 9.4.2 Based on the definition of internal audit in the introduction to this section, indicate how frequently internal auditing is performed for the following areas: No space for details provided. Response If other Audits of Claims Administration and Oversight Single, list. 1: Quarterly, 2: 3: Annually, 4: Biennially, 5: Other: 10 words. Audits of Network Providers Single, list. 1: Quarterly, 2: 3: Annually, 4: Biennially, 5: Other: 10 words. Audits of Eligibility and Enrollment Processes and Compliance with Requirements Single, list. 1: Quarterly, 2: 3: Annually, 4: 10
list. 1: Yes, 2: No Plan Paid Amount (Net Payment) Single, list. 1: Yes, 2: No 50 words. Nothing required Capitation Financials (per Provider / Facility) [1] If a portion of Applicant provider payments are capitated. If capitation does not check “No” and state “Not applicable, no provider payments are capitated” in the rightmost column. Single, list. 1: Yes, 2: No 50 Nothing required 12.4 Can Applicant provide member and subscriber IDs assigned by the Exchange on all records submitted? In the absence of other Personally Identifiable Information (PII), these elements are critical for the HEI Vendor to generate unique encrypted member identifiers linking eligibility to claims and encounter data, enabling the HEI Vendor to follow the health care experience of each de-identified member, even if he or she moves from one plan to another. If not, or if yes with deviation, explain. If unable or unwilling to provide all requested detail, elaborate on problematic data elements, estimating the number and percentage of affected enrollments, claims, and encounters. No space for details provided. Detail to be Provided Response If No or Yes with deviation, explain.
Single, group. 1: Yes, describe: [ 50 words ] , 2: No 12.9 If data must be submitted by a party, can Applicant guarantee that the same information above will also be submitted by the third party? Single, Radio group. 1: Yes, describe: [ 50 words ] , 2: No, 3: Not Applicable 12.10 Can Applicant submit similar data listed above for other data feeds not yet requested, such as Disease Management or Lab data? If so, describe. Single, Radio group. 1: Yes, describe: [ 50 words ] , 2: No 13 Privacy and Security Requirements for Personally Identifiable Data This section not required if Applicant has completed the Qualified Health Plan Application Plan Year 2019 Individual Marketplace. Questions required only for new entrant Applicants. 13.1 HIPAA Privacy Rule Applicant must confirm that it complies with the following privacy-related requirements set forth within Subpart E of the Health Insurance Portability and Accountability Act [45 CFR §164.500 et. seq.]: 13.1.1 Individual access: Unless otherwise exempted by the HIPAA Privacy Rule, Applicant must confirm that it provides enrollees with the opportunity to access, inspect and obtain a copy of any PHI contained within their Designated Record Set [45 CFR §§164.501, 524]. No space for details provided. Single, Pull-down list. 1: Yes, confirmed, 2: No, not confirmed 13.1.2 Amendment: Applicant must confirm that it provides enrollees with the right to amend inaccurate or incomplete PHI contained within their Designated Record Set [45 CFR §§164.501, 526]. No space for details provided. Single, Pull-down list. 1: Yes, confirmed, 2: No, not confirmed 13.1.3 Restriction Requests: Applicant must confirm that it provides enrollees with the opportunity to request restrictions upon Applicant's use or disclosure of their PHI [45 CFR §164.522(a)].
Business Market - Commission Rate Business Direct Business Provide Commission Rate or Schedule Not applicable 10 words. Does the compensation level change as the business written by the agent matures? (i.e., Downgraded) Not applicable 50 words. Specify if the agent is compensated at a higher level as he or she attains certain levels or amounts of in-force business. Not applicable 50 words. Does the compensation level apply to all plans or does it vary by plan or tier? Not applicable 50 words. Does compensation level vary by product? Not applicable 50 words. Describe any business for which Applicant will not compensate Agents. Not applicable 50 words.
16 Provider Network 16.1 Network Offerings All questions are required for currently contracted Applicants and new entrant Applicants. 16.1.1 Applicant must indicate the different network products Applicant intends to offer on the Exchange Small Business market for coverage year 2019.If proposing plans with different networks within the same product type, respond for Network 1 under the appropriate product category and respond for Network 2 in the category “Other”. If any network has been proposed for products offered in the Individual Exchange, some sections are not required for that network. No space for details provided. Offered New or Existing Network? Has Network been Proposed for Individual Exchange Plan Year 2019? Has Network been Proposed for CCSB Exchange Plan Year2019? Network Name(s) HMO Single, list. 1: Yes, 2: No Single, list. 1: New Network, 2: New to Exchange, 3: Existing Individual Exchange 4: Existing CCSB Exchange Single, Pull-down list. 1: Yes, 2: No Single, Pull-down list. 1: Yes, 2: No 10 PPO Single, list. 1: Yes, 2: No Single, list. 1: New Network, 2: New to Exchange, 3: Existing Indivdual Exchange 4: Existing CCSB Exchange Single, Pull-down list. 1: Yes, 2: No Single, Pull-down list. 1: Yes, 2: No 10 words. EPO Single, list. 1: Yes, 2: No Single, list. 1: New Network, 2: New to Exchange, Single, Pull-down list. 1: Yes, 2: No Single, Pull-down list. 1: Yes, 2: No 10 words.
3: Existing Individual Exchange 4: Existing CCSB Exchange Other Single, list. 1: Yes, 2: No Single, list. 1: New Network, 2: New to Exchange, 3: Existing Individual Exchange 4: Existing CCSB Exchange Single, Pull-down list. 1: Yes, 2: No Single, Pull-down list. 1: Yes, 2: No 10 words. 16.1.2 Provider network data must be included in this submission for all geographic locations to which applicant is applying for certification as a QHP. Submit provider data according to the data file layout in Appendix I Covered California Provider Data Submission Guide. The provider network submission for 2019 must be consistent with what will be filed to the appropriate regulator for approval if Applicant is selected as a QHP. The Exchange requires the information, as requested, to allow cross-network comparisons and evaluations. No for details provided. Single, Pull-down list. Attachment required 1: Attached (confirming provider data is for plan year2019), 2: Not attached Attached Document(s): 16.1.3 Applicant must complete and upload through SERFF, the Network ID Template located https://www.cms.gov/ No space for details provided. Single, Pull-down list. 1: Confirmed, template will be completed and uploaded per Table 1.7 Key Action Dates, 2: Not confirmed, template will not be completed 16.2 HMO 16.2.1 Network Strategy All questions are required for Applicants that are new entrants or proposing new networks.
Name of Terminated Hospital Terminated by: Reason Reinstated 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 Nothing required 10 words. Nothing required 10 Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required
group, 3: N/A 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 words. Nothing required
16.3.2.4 If yes to 16.3.2.3, provide the following details: Methodology for patient identification and selection, such as consideration of patient residence, language proficiency Referral procedure for identified patients Accommodations for patients not residing in close proximity to a recognized higher volume provider 200 words. 16.3.3 Network Stability All questions are required for existing Exchange networks and newly-proposed networks. If network has been proposed for products offered in the Individual Exchange, this section is not required for that network. 16.3.3.1 Total Number of Contracted Hospitals: No space for details provided. Integer. 16.3.3.2 Identify network hospitals terminated between January 1, 2017 and December 31, 2017 , including any hospitals that had a break in maintaining a continuous contract during this period. Indicate reason for hospital termination: non-agreement on rates, non-compliance with contract provisions, and redesign of network or other (explain). Applicants with no prior California presence must use out of state experience. No for details provided. Name of Terminated Hospital Terminated by: Reason Reinstated 10 Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required
10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 Nothing required 16.3.3.3 Identify the number of participating providers who have terminated from the provider network between January 1, 2017 and December 31, 2017, by rating region. Indicate reason for termination: on rates, non-compliance with contract provisions, re-design of network or other (explain). No space for details provided. Terminated by Issuer Terminated by Provider Reason Region 1 Integer. Integer. 20 Region 2 Integer. Integer. 20 words. Region 3 Integer. Integer. 20 words. Region 4 Integer. Integer. 20 words. Region 5 Integer. Integer. 20 words. Region 6 Integer. Integer. 20 Region 7 Integer. Integer. 20 words. Region 8 Integer. Integer. 20 words.
2: IPA/Medical group, 3: N/A Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 Nothing required 16.3.3.6 Describe any plans for network additions, by product, including any new medical groups or hospital systems that Applicant would like to highlight for Exchange attention. 100 words. 16.3.3.7 Provide information on any known or anticipated potential network disruption that may affect Applicant's 2019provider networks. For example: list any pending terminations of general acute care hospitals or medical groups which can include Independent Practice Associations. 100 words. 16.4 EPO
Name of Terminated Hospital Terminated by: Reason Reinstated 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 Nothing required 10 Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required
3: N/A 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical 3: N/A 20 Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 Nothing required Single, list. 1: Applicant, 2: IPA/Medical group, 3: N/A 20 words. Nothing required 10 words. Nothing required
16.5.2.4 If yes to 16.5.2.3, provide the following details: Methodology for patient identification and selection, such as consideration of patient residence, language proficiency Referral procedure for identified patients Accommodations for patients not residing in close proximity to a recognized higher volume provider 200 words. 16.5.3 Network Stability All questions required for existing Exchange networks and newly proposed networks. If network has been proposed for products offered in the Individual Exchange, this section is not required for that network. 16.5.3.1 Total Number of Contracted Hospitals: No space for details provided. Integer. 16.5.3.2 Identify network hospitals terminated between January 1, 2017 and December 31, 2017 , including any hospitals that had a break in maintaining a continuous contract during this period. Indicate reason for hospital termination: non-agreement on rates, non-compliance with contract provisions, and redesign of network or other (explain). Applicants with no prior California presence must use out of state experience. No space for details provided. Name of Terminated Hospital Terminated by: Reason Reinstated 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required
10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 words. Nothing required 10 words. Nothing required Single, list. 1: Applicant, 2: Hospital, 3: N/A 20 words. Nothing required 10 Nothing required 16.5.3.3 Identify the number of participating providers who have terminated from the provider network betweenJanuary 1, 2017 and December 31, 2017, by rating region. Indicate reason for provider termination: non-agreement on rates, non-compliance with contract provisions, re-design of network or other (explain). No space for details provided. Terminated by Issuer Terminated by Provider Reason Region 1 Integer. Integer. 20 words. Region 2 Integer. Integer. 20 Region 3 Integer. Integer. 20 Region 4 Integer. Integer. 20 Region 5 Integer. Integer. 20 Region 6 Integer. Integer. 20 words. Region 7 Integer. Integer. 20 words. Region 8 Integer. Integer. 20 words.
NCQA Case Management Accreditation Single, Radio group. 1: Accredited - 3 years, 2: Accredited - 2 years, 3: No accreditation To the day. 50 words. NCQA PHQ Certification Single, list. 1: Certified, 2: No PHQ Certification To the day. 50 words. NCQA Multicultural Health Care Distinction Single, Radio group. 1: Distinction, 2: No MHC Distinction To the day. URAC Accreditations Single, Radio group. 1: URAC used, 2: URAC not used URAC Accreditations - Health Plan Single, Radio group. 1: URAC Accredited, 2: Not URAC Accredited To the day. URAC Accreditation - Comprehensive Wellness Single, Radio group. 1: URAC Accredited, 2: Not URAC Accredited To the day. URAC Accreditations - Disease Management Single, Radio group. 1: URAC Accredited, 2: Not URAC Accredited To the day. URAC Accreditations Single, Radio To the day.
- Health Utilization Management group. 1: URAC Accredited, 2: Not URAC Accredited URAC Accreditations - Case Management Single, Radio group. 1: URAC Accredited, 2: Not URAC Accredited To the day. URAC Accreditations - Pharmacy Benefit Management Single, group. 1: URAC Accredited, 2: Not URAC Accredited To the day. 18.1.3 If Applicant indicated any accreditations above, provide a copy of the accrediting agency's certificate, and upload as a file titled “Accreditation 1a” and including question number 18.1.3. No space for details provided. Single, Pull-down list. 1: Yes, Accreditation 1a attached, 2: Not attached 18.1.4 Applicant must provide the NCQA accreditation status and expiration date of the accreditation achieved for the PPO product identified in this response. Indicate all that apply. For the URAC Accreditation option, enter each expiration date in the detail box if Applicant has earned multiple URAC accreditations. Details limited to 50 words. Answer Expiration date MM/DD/YYYY Programs Reviewed NCQA PPO Single, list. 1: Excellent, 2: Commendable, 3: Accredited, 4: Provisional, 5: Denied, 6: In Process, 7: Scheduled, 8: Expired, 9: NCQA not used or product not eligible To the day. NCQA Exchange Single, list. To the day.
NCQA Exchange Single, list. 1: Completed Health Plan Add-On Application, 2: Interim, 3: First, 4: Renewal, 5: NCQA Exchange not used To the day. NCQA Wellness & Health Promotion Accreditation Single, group. 1: Accredited and Reporting Measures to NCQA, 2: Accredited and NOT reporting measures, 3: Did not participate To the day. 50 words. NCQA Managed Behavioral Healthcare Single, Radio group. 1: Full Accreditation, 2: Accredited – 1 Year, 3: Provisional Accreditation, 4: Denied Accreditation, 5: NCQA not used To the day. 50 words. NCQA Disease Management – Accreditation Multi, Checkboxes. 1: Patient and practitioner oriented, 2: Patient oriented, 3: Plan Oriented, 4: NCQA not used To the day. 50 words. NCQA Disease Management – Certification Multi, Checkboxes. 1: Program Design, 2: Systems, To the day. 50 words.
Note that Applicants selecting “Plan does not offer or allow web or telehealth consultations” will not complete the responses for all rows and columns in this question. Details limited to 100 Response Answer Technology Details Applicant ability to support web/telehealth consultations, either through a contractor or provided by the medical group/provider Multi, Checkboxes. 1: Plan does not offer/allow web or telehealth consultations, 2: Web visit using instant messaging, 3: Telehealth with interactive face to face dialogue (video) over the Web, 4: Telehealth with interactive dialogue over the phone, 5: Telehealth via email, 6: Other (specify) 20 Indicate availability of web/telehealth consultations, either through a contractor or provided by a medical group/provider, by book of business Multi, Checkboxes. 1: Exchange, 2: All large group, 3: Large group buy-up option only, 4: Medicaid, 5: Medicare, 6: Other 20 words. Indicate availability of web/telehealth consultations, either through a contractor or provided by a Multi, Checkboxes. 1: HMO, 2: PPO, 3: EPO, 4: Other 20
medical group/provider, by product type Applicant uses a vendor for web/telehealth consultations (indicate vendor and average wait time in the answer section) 50 words. N/A OK. Multi, Checkboxes. N/A OK. 1: Telehealth via web (video), 2: Telehealth via phone, 3: Combination of web (video) and phone, 4: Instant messaging, 5: Email, 6: Other (specify) 20 words. Applicant contracts with medical groups/providers that offer web/telehealth consultations (yes/no with details) 50 words. N/A OK. Multi, Checkboxes. N/A OK. 1: Telehealth via web (video), 2: Telehealth via phone, 3: Combination of web (video) and phone, 4: Instant messaging, 5: Email, 6: Other (specify) 20 words. If physicians and/or physician groups/practices are designated in provider directory as having web/telehealth consultation services available, provide percentage of physicians in the Percent. Multi, Checkboxes. N/A OK. 1: Telehealth via web (video), 2: Telehealth via phone, 3: Combination of web (video) and phone, 4: Instant messaging, 5: Email, 6: Other (specify) 20 words.
attributed to those physicians offering web/telehealth consultations) (use as denominator total membership across all lines of business). If Applicant has and tracks use by Medi-Cal members as well, number here should include Medi-Cal numbers.) via phone, 3: Combination of web (video) and phone, 4: Instant messaging, 5: Email, 6: Other (specify) What percentage of the current total membership has access to web/telehealth consultations as a covered core benefit (no required)? (use as denominator total membership across all lines of business). Percent. N/A OK. Multi, Checkboxes. N/A OK. 1: Telehealth via web (video), 2: Telehealth via phone, 3: Combination of web (video) and phone, 4: Instant messaging, 5: Email, 6: Other (specify) 20 words. Percentage of unique members with a web/telehealth consultation in 2017 Percent. N/A OK. Multi, Checkboxes. N/A OK. 1: Telehealth via web (video), 2: Telehealth via phone, 3: Combination of web (video) and phone, 4: Instant messaging, 20 words. up
5: Email, 6: Other (specify) If Applicant had Exchange business in 2017: Percentage of unique Exchange enrollees with a web/telehealth consultation in 2017 Percent. N/A OK. Multi, Checkboxes. N/A OK. 1: Telehealth via web (video), 2: Telehealth via phone, 3: Combination of web (video) and phone, 4: Instant messaging, 5: Email, 6: Other (specify) 20 words. Applicant reimburses for web/telehealth consultations Single, Radio group. 1: Yes, 2: No Multi, Checkboxes. N/A OK. 1: Telehealth via web (video), 2: Telehealth via phone, 3: Combination of web (video) and phone, 4: Instant messaging, 5: Email, 6: Other (specify) 20 Among members in plans with available web/telehealth consultation, what is the member cost share? Multi, Checkboxes. 1: No cost share, 2: Same cost as a primary care visit, 3: Same cost as a specialist visit, 4: Telehealth visit cost share (please explain):, 5: Other (explain): Checkboxes. N/A OK. 1: Telehealth via web (video), 2: Telehealth via phone, 3: Combination of web (video) and phone, 4: Instant messaging, 5: Email, 6: Other (specify) 20 words.
ABSENCE of a service) Breast Cancer Screening Single, Radio group. 1: Yes, 2: No Single, group. 1: Available to > 75% of members, 2: Available to < 75% of members, 3: Not Available Single, Radio group. 1: Available to > 75% of members, 2: Available to < 75% of members, 3: Not Available Cervical Cancer Screening Single, Radio group. 1: Yes, 2: No Single, Radio group. 1: Available to > 75% of members, 2: Available to < 75% of members, 3: Not Available Single, group. 1: Available to > 75% of members, 2: Available to < 75% of members, 3: Not Available Colorectal Cancer Screening Single, Radio group. 1: Yes, 2: No Single, group. 1: Available to > 75% of members, 2: Available to < 75% of members, 3: Not Available Single, Radio group. 1: Available to > 75% of members, 2: Available to < 75% of members, 3: Not Available 18.9.5 Report selected measures below for the two most recently uploaded years of HEDIS/CAHPS (QC 2017 and QC 2016) results for HMO Applicant. If Applicant did not report a certain measure to Quality Compass (QC), or NCQA chose to exclude a certain value, instead of a rate, QC may have codes such as NR (not reported), EXC (Excluded), etc. To reflect this result in a numeric form for uploading, the following coding was devised: -1 means 'NR', -2 means 'NA', -3 means 'ND', -4 means 'EXC', and -5 means 'NB'. Childhood Immunization Status and Immunizations for Adolescents were eligible for rotation in HEDIS 2015. No space for details provided. QC 2016, or most current year’s HMO result QC 2015, or prior year’s HMO QC result Childhood Immunization Percent. Percent.
If Applicant did not report a certain measure to Quality Compass (QC), or NCQA chose to exclude a certain value, instead of a rate, QC may have codes such as NR (not reported), EXC (Excluded), etc. To reflect this result in a numeric form for uploading, the following coding was devised: -1 means 'NR', -2 means 'NA', -3 means 'ND', -4 means 'EXC', and -5 means 'NB' Childhood Immunization Status and Immunizations for Adolescents were eligible for rotation in HEDIS 2015. No for details provided. QC 2017, or most current year’s EPO result QC 2016, or prior year’s EPO QC result Childhood Immunization Status - Combo 2 Percent. Percent. Immunizations for Adolescents - Combination Percent. Percent. CAHPS Flu Shots for Adults (50-64) (report rolling average) Percent. Percent. 18.9.8 Identify member interventions used in calendar year 2018 to improve immunization rates. Check all that apply. No for details provided. Response reminders (electronic or written, etc.) sent to members for needed care based on general eligibility (age/gender) reminders for gaps in services based on administrative or clinical information (mail, email/text, automated phone or live outbound
the tobacco users identified in each of the ways identified in this row with the recognition that this may result in some duplication or over counting in response to row below on number of commercial members individually identified as tobacco dependent in2017. Management, 6: Wellness Vendor, 7: Other (describe in box in cell) Indicate ability to track identification of members. Select only ONE of response options 1-4 and include response option 5 if applicable Multi, Checkboxes. 1: Identification tracked statewide & regionally, 2: Identification only tracked statewide, 3: Identification only tracked regionally, 4: Identification not tracked regionally/statewide, 5: Identification can be tracked at Covered California level Indicate ability to track participation of Multi, Checkboxes. 1: Participation tracked statewide & regionally, 2: Participation only tracked statewide, dependent dependent
members in cessation activities. Select only ONE of response options 1-4 and include response option 5 if applicable 3: Participation only tracked regionally, 4: Participation not tracked regionally/statewide, 5: Participation can be tracked at Covered California level Number of California members individually identified as tobacco in 2017. (If Applicant has and tracks use by Medi-Cal members as well, number here should include Medi-Cal numbers.) Decimal. % of California members identified as tobacco Percent. Number of Exchange enrollees individually identified as tobacco dependent in 2017. Decimal. % of Exchange enrollees Percent.
result in some duplication or over counting in response to row below on Number of commercial members individually identified as obese in 2017 as of December 2017 Indicate ability to track identification of obese members. Select only ONE of response options 1-4 and include response option 5 if applicable Multi, Checkboxes. 1: Identification tracked statewide & regionally, 2: Identification only tracked statewide, 3: Identification only tracked regionally, 4: Identification not tracked regionally/statewide, 5: Identification can be tracked at Covered California level Indicate ability to track participation of obese members in weight management programs. Select only ONE of response options 1-4 and include response Multi, Checkboxes. 1: Participation tracked statewide & regionally, 2: Participation tracked only statewide, 3: Participation only tracked regionally, 4: Participation not tracked regionally/statewide, 5: Participation can be tracked at Covered California level
tracks use by Medi-Cal members as well, number here should include Medi-Cal numbers.) % of California members identified as obese who are participating in weight management program (# program participants divided by # of identified obese) Percent. Number of Exchange members identified as obese who participated in weight management program during 2017. Decimal. % of Exchange members identified as obese who are participating in weight management program (# program participants divided by # Percent.
members as well, number here should include Medi-Cal numbers.) Percent HA completion (Health plan HA completion number divided by total enrollment) Percent. Number of completed HAs resulting in referral to health plan case management staff or assigned provider Decimal. Percent completed HAs resulting in referral to health plan case management staff or assigned provider (Referral number divided by number of completed HAs) Percent. 18.9.15 Does Applicant collect information, at both individual and aggregate levels, on changes in enrollees' health status? Describe Applicant's process to monitor and changes in enrollees' health status, which may include its process for identifying individuals who show a decline in health status, and referral of such enrollees to care management and chronic condition program(s). Include in the answer how many members, across all