Common use of Network Design Based on Quality Clause in Contracts

Network Design Based on Quality. Attachment 7, Article 1, Section 1.02 - 4% of total performance penalty for Group 3 Contractor shall include quality criteria into its Exchange network development, with a phased approach starting in plan year 2017 and continuing in plan years 2018,2019, and 2020. Measurement Year 2017 Expectation: Describe valid inclusion of quality criteria into Exchange network development and begin implementation of criteria Performance Levels: Contractor is unable to describe valid inclusion of quality criteria into Exchange network development by end of year 2017: 4% penalty Contractor reports strategy for inclusion of quality criteria in all networks offered to Exchange enrollees, and demonstrates implementation of criteria by end of year 2017: No penalty Contractor reports strategy for inclusion of quality criteria in all networks offered to Exchange enrollees, demonstrates Measurement Year 2018 Expectation: Describe valid inclusion of quality criteria into Exchange network development and begin implementation of criteria Performance Levels: Contractor is unable to describe valid inclusion of quality criteria into Exchange network development by end of year 2018: 4% penalty Contractor submits report showing that quality criteria for all provider types has been applied to at least part of each Exchange network offered to Exchange enrollees by end of 2018; report shows that providers have been reviewed against established quality metrics and providers not meeting metrics either have a corrective action plan Measurement Year 2019 Expectation: Describe valid inclusion of quality criteria into Exchange network development and begin implementation of criteria Performance Levels: Contractor is unable to describe valid inclusion of quality criteria into Exchange network development by end of year 2019: 4% penalty Contractor submits report showing that quality criteria for all provider types has been applied to at least part of each Exchange network offered to Exchange enrollees by end of 2019; report shows that those providers that have been reviewed against established quality metrics and providers not meeting metrics either have a corrective Measurement Year 2020 Expectation: Describe valid inclusion of quality criteria into Exchange network development and begin implementation of criteria Performance Levels: Contractor submits report and is unable to describe valid inclusion of quality criteria into Exchange network development for all provider types by the end of 2020 or has not reviewed any providers against established quality metrics: 4% penalty Contractor submits report showing that quality criteria for all provider types has been applied to at least part of each Exchange network offered to enrollees by the end of 2020; report shows that those Quality, Network Management and Delivery System Standards 48% of Total Performance Penalty or Credit1 for Measurement Year 2020 and Thereafter Covered California and Contractor shall work together to periodically review and adjust the specific measures consistent with any applicable Federal regulations. For Performance Standards 3.4a, 3.4b, 3.8, and 3.9, mutually agreed upon performance goals will be pre-determined and documented in Contractor’s Quality Improvement Strategy prior to the start of the performance year.

Network Design Based on Quality. Attachment 7, Article 1, Section 1.02 - 4% of total performance penalty for Group 3 Contractor shall include quality criteria into its Exchange network development, with a phased approach starting in plan year 2017 and continuing in plan years 2018,2019, 2018 and 20202019. Measurement Year 2017 Expectation: Describe valid inclusion of quality criteria into Exchange network development and begin implementation of criteria Performance Levels: Contractor is unable to describe valid inclusion of quality criteria into Exchange network development by end of year 2017: 4% penalty Contractor reports strategy for inclusion of quality criteria in all networks offered to Exchange enrollees, and demonstrates implementation of criteria by end of year 2017: No penalty Contractor reports strategy for inclusion of quality criteria in all networks offered to Exchange enrollees, demonstrates Measurement Year 2018 Expectation: Describe valid inclusion of quality criteria into Exchange network development and begin implementation of criteria Performance Levels: Contractor is unable to describe valid inclusion of quality criteria into Exchange network development by end of year 2018: 4% penalty Contractor submits report showing that quality criteria for all provider types has been applied to at least part of each Exchange network offered to Exchange enrollees by end of 2018; report shows that providers have been reviewed against established quality metrics and providers not meeting metrics either have a corrective action plan Measurement Year 2019 Expectation: Describe valid inclusion of quality criteria into Exchange network development and begin implementation of criteria Performance Levels: Contractor is unable to describe valid inclusion of quality criteria into Exchange network development by end of year 2019: 4% penalty Contractor submits report showing that quality criteria for all provider types has been applied to at least part of each Exchange network offered to Exchange enrollees by end of 2019; report shows that those providers that have been reviewed against established quality metrics and providers not meeting metrics either have a corrective Measurement Year 2020 Expectationaction plan to improve or have been removed from networks: Describe valid inclusion of quality criteria into Exchange network development and begin implementation of criteria Performance Levels: Contractor submits report and is unable to describe valid inclusion of quality criteria into Exchange network development for all provider types by the end of 2020 or has not reviewed any providers against established quality metrics: 4% No penalty Contractor submits a report showing that quality criteria for all provider types has been applied to at least part 100% of each Exchange network offered to Exchange enrollees by the end of 20202019; report shows that provider have been reviewed against established quality metrics and those not meeting metrics either have a corrective action plan to improve or have been removed from network: 4% credit Quality, Network Management and Delivery System Standards 4845% of Total Performance Penalty or Credit1 for Measurement Year 2020 2019 and Thereafter Covered California and Contractor shall work together to periodically review and adjust the specific measures consistent with any applicable Federal regulations. For Performance Standards 3.4a, 3.4b, 3.8, and 3.9, mutually agreed upon performance goals will be pre-determined and documented in Contractor’s Quality Improvement Strategy prior to the start of the performance year.

Network Design Based on Quality. Attachment 7, Article 1, Section 1.02 - 4% of total performance penalty for Group 3 Contractor shall include quality criteria into its Exchange Covered California network development, with a phased approach starting in plan year 2017 and continuing in plan years 2018,20192018, 2019, 2020 and 20202021. Measurement Year 2017 Expectation: Describe valid inclusion of quality criteria into Exchange Covered California network development and begin implementation of criteria Performance Levels: Contractor is unable to describe valid inclusion of quality criteria into Exchange Covered California network development by end of year 2017: 4% penalty Contractor reports strategy for inclusion of quality criteria in all networks offered to Exchange Covered California enrollees, and demonstrates implementation of criteria by end of year 2017: No penalty Contractor reports strategy for inclusion of quality criteria in all networks offered to Exchange enrollees, demonstrates Measurement Year 2018 Expectation: Describe valid inclusion of quality criteria into Exchange Covered California network development and begin implementation of criteria Performance Levels: Contractor is unable to describe valid inclusion of quality criteria into Exchange Covered California network development by end of year 2018: 4% penalty Contractor submits report showing that quality criteria for all provider types has been applied to at least part of each Exchange Covered California network offered to Exchange enrollees by end of 2018; report shows that providers have been reviewed against established quality metrics and providers not meeting metrics either have a corrective action plan Measurement Year 2019 Expectation: Describe valid inclusion of quality criteria into Exchange Covered California network development and begin implementation of criteria Performance Levels: Contractor is unable to describe valid inclusion of quality criteria into Exchange Covered California network development by end of year 2019: 4% penalty Contractor submits report showing that quality criteria for all provider types has been applied to at least part of each Exchange Covered California network offered to Exchange Covered Measurement Year 2020 Expectation: Describe valid inclusion of quality criteria into Covered California network development and begin implementation of criteria Performance Levels: Contractor submits report and is unable to describe valid inclusion of quality criteria into Covered California network development for all provider types by the end of 2020 or has not reviewed any providers against established quality metrics: 4% penalty Measurement Year 2021 Expectation: Describe valid inclusion of quality criteria into Covered California network development and evaluation and make progress on implementation of criteria including the exclusion of outlier poor performing hospitals as defined by Covered California in Attachment 7 Performance Levels: Contractor submits report that demonstrates that no action has been taken on addressing outlier poor performing hospitals: 4% penalty Quality, Network Management and Delivery System Standards 45% of Total Performance Penalty or Credit1 for Measurement Year 2021 and Thereafter Covered California and Contractor shall work together to periodically review and adjust the specific measures consistent with any applicable Federal regulations. For Performance Standards 3.4a, 3.4b, 3.8, and 3.9, mutually agreed upon performance goals will be pre-determined and documented in Contractor’s Quality Improvement Strategy prior to the start of the performance year. Measurement Year 2017 Performance Levels: implementation of criteria by end of year 2017: No penalty Contractor reports strategy for inclusion of quality criteria in all networks offered to Covered California enrollees, demonstrates implementation of criteria by end of 2017, and submits documentation that contracted hospitals have been notified in 2017 of expectation to meet targets for appropriate use of C-Section and reduction in Hospital Acquired Conditions by the end of 2019: 4% credit Measurement Year 2018 Performance Levels: Covered California enrollees by end of 2018; report shows that providers have been reviewed against established quality metrics and providers not meeting metrics either have a corrective action plan to improve or have been removed from networks: No penalty Contractor submits a report showing that quality criteria for all provider types has been applied to 100% of each Covered California network offered to Covered California enrollees by the end of 2018; report shows Measurement Year 2019 Performance Levels: California enrollees by end of 2019; report shows that those providers that have been reviewed against established quality metrics and providers not meeting metrics either have a corrective Measurement Year 2020 Expectationaction plan to improve or have been removed from networks: Describe valid inclusion of No penalty Contractor submits a report showing that quality criteria into Exchange network development and begin implementation of criteria Performance Levels: Contractor submits report and is unable to describe valid inclusion of quality criteria into Exchange network development for all provider types has been applied to 100% of each Covered California network offered to Covered California enrollees by the end of 2019; report shows that provider have been Measurement Year 2020 or has not reviewed any providers against established quality metricsPerformance Levels: 4% penalty Contractor submits report showing that quality criteria for all provider types has been applied to at least part of each Exchange Covered California network offered to enrollees by the end of 2020; report shows that those providers that have been reviewed against established quality metrics and providers not meeting metrics either have a corrective action plan to improve or have been removed from networks: No penalty Contractor submits a report showing that quality criteria for all provider types has been applied to 100% of each Covered California network offered to enrollees by the end of 2020; report Measurement Year 2021 Performance Levels: Contractor submits a report showing that outlier poor performing hospitals that have not demonstrated improvement, despite a corrective action plan or other documented improvement process,have been removed from network or Contractor has provided justification for continued inclusion of outlier poor performing hospitals in network: 4% credit Quality, Network Management and Delivery System Standards 4845% of Total Performance Penalty or Credit1 for Measurement Year 2020 2021 and Thereafter Covered California and Contractor shall work together to periodically review and adjust the specific measures consistent with any applicable Federal regulations. For Performance Standards 3.4a, 3.4b, 3.8, and 3.9, mutually agreed upon performance goals will be pre-determined and documented in Contractor’s Quality Improvement Strategy prior to the start of the performance year.