Common use of External Quality Review Requirements Clause in Contracts

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an External Quality Review of Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860(d), Title 42, USC, Section 1396u- 2(c)(2), and 42 CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) contracted with DHCS in the conduct of this review. Contractor shall comply with the following requirements, as well as the activities specified in APL 17-014, including the external quality review protocol issued by CMS which provides detailed instructions on how to complete the activities. A. External Accountability Set (EAS) Performance Measures The EAS performance measures consist of a set of Healthcare Effectiveness Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Performance Improvement Projects (PIPs) 1) For this Contract, Contractor is required to conduct or participate in PIPs, including any PIP required by CMS, in accordance with 42 CFR 438.330. Contractor shall conduct or participate in, at a minimum, two (2) PIPs per year, as approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two PIPs for each contract. At its sole discretion, DHCS may require Contractor to conduct or participate in additional PIPs. 2) Contractor shall comply with APL 17-014, as well as any subsequent updates, and shall use the PIP reporting format as designated therein to request approval of proposed PIPs from DHCS and to report at least annually to DHCS on the status of each PIP.

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an External Quality Review of Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860(d), 53860 (d) and Title 42, USC, Section 1396u- 2(c)(21396u-2(c)(2), and 42 CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) contracted with DHCS in the conduct of this review. Contractor shall comply with the following requirements, as well as the activities specified in APL 17-014, including the external quality review protocol issued by CMS which provides detailed instructions on how to complete the activities. A. External Accountability Set (EAS) Performance Measures The EAS (EAS) performance measures consist of a set of Healthcare Effectiveness Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (previously referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS-developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i) The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii) Improvement plans are due to DHCS within 60 calendar days of DHCS’ notification that the Contractor has performed at or below the MPL for the period under review. iii) Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Performance Improvement Projects (PIPs) 1) For this Contract, Contractor is required to conduct or participate in PIPs, including any PIP required by CMS, in accordance with 42 CFR 438.330. Contractor shall conduct or participate in, at a minimum, two (2) PIPs per year, as approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two PIPs for each contract. At its sole discretion, DHCS may require Contractor to conduct or participate in additional PIPs. a) One PIP must be either an internal performance improvement project (PIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. The SGC must include a minimum of four (4) DHCS health plan contactors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One PIP must be a DHCS facilitated Statewide Collaborative. If the Contract Operation start date of this Contract is after the Statewide Collaborative has begun implementation, upon DHCS’s approval, Contractor may substitute a SGC and/or PIP in place of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a PIP unless otherwise approved by DHCS. 3) Contractor shall comply with APL 1716-014018, as well as any subsequent updates, and shall use the PIP reporting format as designated therein to request approval of proposed PIPs from DHCS and to report at least annually to DHCS on the status of each PIP. The required documentation for PIP proposals and for PIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the PIP.

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an External Quality Review of Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860(d), Title 42, USC, Section 1396u- 2(c)(21396u-2(c)(2), and 42 CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) contracted with DHCS in the conduct of this review. Contractor shall comply with the following requirements, as well as the activities specified in APL 17-014, including the external quality review protocol issued by CMS which provides detailed instructions on how to complete the activities. A. External Accountability Set (EAS) Performance Measures The EAS performance measures consist of a set of Healthcare Effectiveness Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (also referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. The EAS performance measures consists of a set of Healthcare Effectiveness Data Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 2) Contractor shall calculate and report all EAS performance measures at the county level unless otherwise approved by DHCS. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for DHCS- developed performance measures will be calculated by the EQRO. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. b) The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. c) Improvement plans are due to DHCS within 60 calendar days of DHCS’ notification that the Contractor has performed at or below the MPL for the period under review. d) Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, Audit and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Performance Improvement Projects (PIPs) 1) For this Contract, Contractor is required to conduct or participate in PIPs, including any PIP required by CMS, in accordance with 42 CFR 438.330. Contractor shall conduct or participate in, at a minimum, two (2) PIPs per year, as approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two (2) PIPs for each contract. At its sole discretion, DHCS may require Contractor to conduct or participate in additional PIPs. a) One PIP must be either an internal performance improvement project (IPIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. The SGC must include a minimum of two (2) DHCS health plan contractors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One PIP must be a DHCS facilitated Statewide Collaborative. If this Contract’s operation start date is after the Statewide Collaborative has begun implementation, upon DHCS’ approval, Contractor may substitute a SGC and/or IPIP in place of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a PIP unless otherwise approved by DHCS. 3) Contractor shall comply with APL 1716-014, as well as any subsequent updates, 018 and shall use the PIP reporting format as designated therein to request approval of proposed PIPs from DHCS and to report at least annually to DHCS on the status of each PIP. The required documentation for PIP proposals and for PIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the PIP.

External Quality Review Requirements. At least annually or as designated by DHCSCDHS, DHCS CDHS shall arrange for an External Quality Review external quality of care review of the Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR 22, CCR, Section 53860(d), 53860 (d) and Title 42, USC, Section 1396u- 2(c)(21396a(30)(C), and 42 CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) contracted with DHCS designated by the State in the conduct of this review. Contractor shall comply with the following requirements, as well as the activities specified in APL 17-014, including the external quality review protocol issued by CMS which provides detailed instructions on how to complete the activities. A. External Accountability Set (EAS) Performance Measures The EAS performance measures consist External Accountability Set (EAS) consists of a set of Healthcare Effectiveness Health Plan Employer Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS ) and CDHS developed performance measures selected by DHCS CDHS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (also referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the CDHS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of CDHS-developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the CDHS-selected EQRO. Rates for CDHS-developed performance measures will be calculated by the EQRO. b) Contractor shall report audited results on the EAS performance measures to CDHS no later than June 15 of each year or such date as established by CDHS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the CDHS-established Minimum Performance Level (MPL) for each HEDIS measure. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i. The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii. Improvement plans are due to the CDHS within 60 calendar days of the CDHS’ notification that the Contractor has performed at or below the MPL for the period under review. iii. Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCSmeasures. These measures may will be audited as part of the EAS/HEDIS Compliance Audit, Audit and these rates shall be submitted with the EAS audited rates or separately as directed by DHCSrates. DHCS CDHS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS CDHS on an annual basis. By August 1 of each year, DHCS CDHS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Performance Quality Improvement Projects (PIPs) 1QIPs) For this Contract, Contractor is required to conduct or and/or participate in PIPsfour (4) Quality Improvement Projects. For Contractors holding multiple Medi-Cal managed care contracts, including any PIP each contracted entity will be required by CMS, to conduct and/or participate in accordance four QIPs. 1) Among the four QIPs: a) One must be plan-specific (“internal QIP”) b) One must be in collaboration with 42 CFR 438.330. Contractor shall conduct or participate in, at least one other health plan (“small -group collaborative”) Collaboratives must include a minimum, minimum of two (2) PIPs per yearCDHS health plan Contractors and must use standardized measures and clinical practice guidelines. Additionally, as approved by DHCSall health plans participating in a collaborative must agree to the same timelines for development, implementation, and measurement. If Contractor holds Health plans must also agree on the nature of health plan commitment of staff and other resources to the collaborative project. Contractors may include only one county in a collaborative regardless of whether the health plan’s contract covers multiple managed care contracts with DHCScounties. However, if multiple counties are to be included, Contractor is required shall demonstrate that the measurement strategies are adequate to conduct or participate in two PIPs assess the impact of the intervention within each county. CDHS must approve the Contractor’s proposal before the Contractor proceeds with their intended approach for each contract. At its sole discretion, DHCS may require Contractor to conduct or participate in additional PIPsmultiple county measurement. c) One must be the state-wide collaborative QIP (“Cal-QIP”) 2) Contractor shall comply with APL 17Among the above listed four QIPs: a) One must be non-014clinical (i.e., as well as any subsequent updatesavailability, accessibility or cultural competency of services; appeals, grievances, and complaints); and b) One must be clinical (i.e., to improve clinical services or clinical interventions). 3) Contractor shall use the PIP reporting format as designated therein NCQA Quality Improvement Activity form to request approval propose initiation of proposed PIPs from DHCS the project and to report at least annually to DHCS on the status of each PIPfor subsequent periodic reporting.

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an External Quality Review of Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860(d), Title 42, USC, Section 1396u- 2(c)(21396u-2(c)(2), and 42 CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) contracted with DHCS in the conduct of this review. Contractor shall comply with the following requirements, as well as the activities specified in APL 17-014, including the external quality review protocol issued by CMS which provides detailed instructions on how to complete the activities. A. External Accountability Set (EAS) Performance Measures The EAS performance measures consist of a set of Healthcare Effectiveness Health Plan Employer Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (also referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. b) The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. c) Improvement plans are due to DHCS within 60 calendar days of DHCS notification that the Contractor has performed at or below the MPL for the period under review. d) Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, Audit and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Participation in LHD Sponsored QI Contractors in San Diego GMC shall participate in an LHD sponsored Quality Improvement committee review of quality issues, including but not limited to, Grievance trends and patterns in the Healthy San Diego GMC pilot project. D. Performance Improvement Projects (PIPs) 1) For this Contract, Contractor is required to conduct or participate in PIPs, including any PIP required by CMS, in accordance with 42 CFR 438.330. Contractor shall conduct or participate in, at a minimum, two (2) PIPs per year, as approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two PIPs for each contract. At its sole discretion, DHCS may require Contractor to conduct or participate in additional PIPs. a) One PIP must be either an internal performance improvement project (IPIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. The SGC must include a minimum of four (4) DHCS health plan contractors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One PIP must be a DHCS facilitated Statewide Collaborative. If this Contract’s operation start date is after the Statewide Collaborative has begun implementation, upon DHCS’ approval, Contractor may substitute a SGC and/or an IPIP in place of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a PIP unless otherwise approved by DHCS. 3) Contractor shall comply with APL 1716-014018, as well as any subsequent updates, and shall use the PIP reporting format as designated therein to request approval of proposed PIPs from DHCS and to report at least annually to DHCS on the status of each PIP. The required documentation for PIP proposals and for PIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the PIP.

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an External Quality Review external quality of care review of the Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860(d), 53860 (d) and Title 42, USC, Section 1396u- 2(c)(21396u-2(c)(2), and 42 CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) contracted with DHCS designated by the State in the conduct of this review. Contractor shall comply with the following requirements, as well as the activities specified in APL 17-014, including the external quality review protocol issued by CMS which provides detailed instructions on how to complete the activities. A. External Accountability Set (EAS) Performance Measures The EAS (EAS) performance measures consist of a set of Healthcare Effectiveness Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (previously referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS-developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS-established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i. The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii. Improvement plans are due to the DHCS within 60 calendar days of the DHCS’ notification that the Contractor has performed at or below the MPL for the period under review. iii. Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Performance Quality Improvement Projects (PIPsQIPs) 1) For this Contract, Contractor is required to conduct or participate in PIPs, including any PIP required by CMS, in accordance with 42 CFR 438.330. Contractor shall conduct or participate in, at a minimum, two Quality Improvement Projects (2QIPS) PIPs per year, as approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two PIPs QIPS for each contract. a) One QIP must be either an internal quality improvement project (IQIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. At its sole discretionThe SGC must include a minimum of four (4) DHCS health plan contactors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One QIP must be a DHCS facilitated Statewide Collaborative. If the Contract Operation start date of this Contract is after the Statewide Collaborative has begun implementation, upon DHCS’s approval, Contractor may require Contractor to conduct substitute a SGC or participate and IQIP in additional PIPsplace of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a QIP unless otherwise approved by DHCS. 3) Contractor shall comply with APL 17MMCD All Plan letter 11-014002, as well as any subsequent updates, and shall use the PIP QIP reporting format as designated therein to request approval of proposed PIPs QIPs from DHCS and to report at least annually to DHCS on the status of each PIPQIP. The required documentation for QIP proposals and for QIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the QIP.

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an External Quality Review of Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860(d), Title 42, USC, Section 1396u- 2(c)(2), and 42 CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) contracted with DHCS in the conduct of this review. Contractor shall comply with the following requirements, as well as the activities specified in APL 17-014, including the external quality review protocol issued by CMS which provides detailed instructions on how to complete the activities. A. External Accountability Set (EAS) Performance Measures The EAS performance measures consist of a set of Healthcare Effectiveness Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (previously referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS-developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS-established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. b) The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. c) Improvement plans are due to DHCS within 60 calendar days of DHCS’ notification that the Contractor has performed at or below the MPL for the period under review. d) Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Performance Improvement Projects (PIPs) 1) For this Contract, Contractor is required to conduct or participate in PIPs, including any PIP required by CMS, in accordance with 42 CFR 438.330. Contractor shall conduct or participate in, at a minimum, two (2) PIPs per year, as approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two PIPs for each contract. At its sole discretion, DHCS may require Contractor to conduct or participate in additional PIPs. a) One PIP must be either an internal performance improvement project (IPIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. The SGC must include a minimum of four (4) DHCS health plan contactors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One PIP must be a DHCS facilitated Statewide Collaborative. If the Contract operation start date of this Contract is after the Statewide Collaborative has begun implementation, upon DHCS’s approval, Contractor may substitute a SGC and/or IPIP in place of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a PIP unless otherwise approved by DHCS. 3) Contractor shall comply with APL 1716-014018, as well as any subsequent updates, and shall use the PIP reporting format as designated therein to request approval of proposed PIPs from DHCS and to report at least annually to DHCS on the status of each PIP. The required documentation for PIP proposals and for PIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the PIP.

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an External Quality Review external quality of care review of the Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860(d), Title 42, USC, Section 1396u- 2(c)(2), and 42 CFR 438.350, 438.358, and 438.364reviews. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) contracted with DHCS designated by the State in the conduct of this review. Contractor shall comply with the following requirements, as well as the activities specified in APL 17-014, including the external quality review protocol issued by CMS which provides detailed instructions on how to complete the activities. A. External Accountability Set (EAS) Performance Measures The EAS performance measures consist of a set of Healthcare Effectiveness Health Plan Employer Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (also referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i. The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii. Improvement plans are due to the DHCS within 60 calendar days of the DHCS notification that the Contractor has performed at or below the MPL for the period under review. iii. Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, Audit and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Performance Participation in LHD Sponsored QI Contractors in San Diego GMC shall participate in an LHD sponsored Quality Improvement committee review of quality issues, including but not limited to, Grievance trends and patterns in the Healthy San Diego GMC pilot project. D. Quality Improvement Projects (PIPsQIPs) 1) For this Contract, Contractor is required to conduct or participate in PIPs, including any PIP required by CMS, in accordance with 42 CFR 438.330. Contractor shall conduct or participate in, at a minimum, two Quality Improvement Projects (2QIPs) PIPs per year, as approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two PIPs QIPs for each contract. a) One QIP must be either an internal quality improvement project (IQIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. At its sole discretionThe SGC must include a minimum of four (4) DHCS health plan contractors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One QIP must be a DHCS facilitated Statewide Collaborative. If this Contract’s operation start date is after the Statewide Collaborative has begun implementation, upon DHCS’ approval, Contractor may require Contractor to conduct substitute a SGC or participate an IQIP in additional PIPsplace of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a QIP unless otherwise approved by DHCS. 3) Contractor shall comply with APL 17All Plan Letter 11-014002, as well as any subsequent updates, and shall use the PIP QIP reporting format as designated therein to request approval of proposed PIPs QIPs from DHCS and to report at least annually to DHCS on the status of each PIPQIP. The required documentation for QIP proposals and for QIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the QIP.