Definition of Good Standing Agency. Verification that issuer holds a state health care service plan license or insurance certificate of authority. • Approved for lines of business sought in Covered California (e.g. commercial, small group, individual) DMHC and CDI • Approved to operate in what geographic service areas DMHC and CDI • Most recent financial exam and medical survey report reviewed DMHC •Most recent market conduct exam reviewed CDI Affirmation of no material1 statutory or regulatory violations, including penalties levied, during the year prior to the date of the Agreement or throughout the term of Agreement in relation to any of the following, where applicable: • Financial solvency and reserves reviewed DMHC and CDI • Administrative and organizational capacity acceptable DMHC • Benefit Design • State mandates (to cover and to offer) DMHC and CDI • Essential health benefits (State required) DMHC and CDI • Basic health care services DMHC and CDI • Copayments, deductibles, out-of-pocket maximums DMHC and CDI • Actuarial value confirmation (using the Federal Actuarial Value Calculator as applicable.) DMHC and CDI • Network adequacy and accessibility standards are met DMHC and CDI • Provider contracts DMHC and CDI • Language Access DMHC and CDI • Uniform disclosure (summary of benefits and coverage) DMHC and CDI • Claims payment policies and practices DMHC and CDI • Provider complaints DMHC and CDI • Utilization review policies and practices DMHC and CDI • Quality assurance/management policies and practices DMHC and CDI • Enrollee/Member grievances/complaints and appeals policies and practices DMHC and CDI • Independent medical review DMHC and CDI • Marketing and advertising DMHC and CDI • Guaranteed issue individual and small group DMHC and CDI • Rating Factors DMHC and CDI • Medical Loss Ratio DMHC and CDI • Premium rate review DMHC and CDI • Geographic rating regions • Rate development and justification is consistent with ACA requirements DMHC and CDI 1Covered California, in its sole discretion and in consultation with the appropriate health insurance regulator, determines what constitutes a material violation for this purpose.
Definition of Good Standing Agency. Verification that issuer holds a state health care service plan license or insurance certificate of authority.
Definition of Good Standing Agency. Verification that issuer holds a state health care service plan license or insurance certificate of authority. • Approved for lines of business sought in Covered California (e.g. commercial, small group, individual) DMHC and CDI • Approved to operate in what geographic service areas DMHC and CDI • Most recent financial exam and medical survey report reviewed DMHC • Most recent market conduct exam reviewed CDI Affirmation of no material1 statutory or regulatory violations, including penalties levied, during the year prior to the date of the Agreement or throughout the term of Agreement in relation to any of the following, where applicable: • Financial solvency and reserves reviewed DMHC and CDI • Administrative and organizational capacity acceptable DMHC • Benefit Design • State mandates (to cover and to offer) DMHC and CDI • Essential health benefits (State required) DMHC and CDI • Basic health care services DMHC and CDI • Copayments, deductibles, out-of-pocket maximums DMHC and CDI • Actuarial value confirmation (using the Federal Actuarial Value Calculator as applicable.) DMHC and CDI • Language Access DMHC and CDI • Rating Factors DMHC and CDI • Dental Loss Ratio DMHC and CDI • Premium rate review DMHC and CDI • Geographic rating regions • Rate development and justification is consistent with ACA requirements DMHC and CDI 1Covered California, in its sole discretion and in consultation with the appropriate health insurance regulator, determines what constitutes a material violation for this purpose.
Definition of Good Standing Agency. Verification that issuer holds a state health care service plan license or insurance certificate of authority. • Approved for lines of business sought in the Exchange (e.g., commercial, small group, individual) • Approved to operate in what geographic service areas • Most recent financial exam and medical survey report reviewed • Most recent market conduct exam reviewed DMHC and CDI DMHC and CDI DMHC CDI Affirmation of no material1 statutory or regulatory violations, including penalties levied, in the past two years in relation to any of the following, where applicable: • Financial solvency and reserves reviewed • Administrative and organizational capacity acceptable • Benefit Design • State mandates (to cover and to offer) • Essential health benefits (State required) • Basic health care services • Copayments, deductibles, out-of-pocket maximums • Actuarial value confirmation (using 2017 Federal Actuarial Value Calculator) • Network adequacy and accessibility standards are met • Provider contracts • Language Access • Uniform disclosure (summary of benefits and coverage) • Claims payment policies and practices • Provider complaints • Utilization review policies and practices • Quality assurance/management policies and practices • Enrollee/Member grievances/complaints and appeals policies and practices • Independent medical review • Marketing and advertising • Guaranteed issue individual and small group • Rating Factors • Medical Loss Ratio • Premium rate review • Geographic rating regions • Rate development and justification is consistent with ACA requirements DMHC and CDI DMHC DMHC and CDI DMHC and CDI DMHC and CDI DMHC and
