Individual Exchange. The following provision shall apply to the Individual Exchange.
(i) During the thirty (30) day period following the Exchange’s receipt of the Non- Recertification Election, Contractor shall (i) be removed from the enrollment and eligibility assignment process, and (ii) no longer receive assignment of new Enrollees;
(ii) Contractor will provide coverage for Enrollees assigned to Contractor as of the date of the Non-Recertification Election if coverage commences within the sixty (60) day period following the Notice of Non-Recertification. Contractor shall provide coverage for such Enrollees until the earlier of
(i) the end of the Contract Year, or (ii) the Enrollee’s transition to another QHP during the Special Enrollment Period;
(iii) Contractor shall provide coverage for Enrollees until the earlier of (i) the end of the Contract Year, or (ii) the Enrollee’s transition to another QHP during Special Enrollment Period.
Individual Exchange. The Exchange shall be responsible for the determination of eligibility and enrollment of individuals in the Exchange in accordance with the requirements set forth at 45 C.F.R. Part 155, and other applicable laws, rules and regulations. The Exchange will assume statutory obligations as required as part of initial enrollment that would otherwise be carried out by Contractor, such as assuring completion of agent attestation, if applicable. In addition, the Exchange shall issue certifications of individual exemption consistent with the Affordable Care Act standards in a timely manner. The enrollment of eligible individuals in the Exchange shall be made by the Exchange pursuant to its management and participation in CalHEERS, a project jointly sponsored by the Exchange and DHCS with the assistance of the Office of Systems Integration. The Exchange and CalHEERS shall develop, implement and maintain processes to make the eligibility and enrollment decisions regarding the Exchange and other California health care programs and submit that information to Contractor in a timely manner in accordance with Federal and State laws, rules and regulations and the terms set forth in this Agreement.
Individual Exchange. The following provision shall apply to the Individual Exchange.
(i) During the thirty (30) day period following the Exchange’s receipt of the Non Recertification Election, Contractor shall (i) be removed from the enrollment and eligibility assignment process, and (ii) no longer receive assignment of new Enrollees;
(ii) Contractor will provide coverage for Enrollees assigned to Contractor as of the date of the Non-Recertification Election if coverage commences within the sixty (60) day period following the Notice of Non-Recertification;
(iii) Contractor shall provide coverage for such Enrollees until the earlier of (i) the end of the Contract Year, or (ii) the Enrollee’s transition to another QDP during the Special Enrollment Period.
Individual Exchange. For the Individual Exchange, rates shall be established through an annual negotiation process between the Contractor and the Exchange and are set for the following calendar year. The parties acknowledge that (1) the Agreement does not contemplate any mid-year rate changes for the Individual Exchange in the ordinary course of business, and (2) the annual negotiation process must be supported by Contractor through the submission of information in such form and at such date as shall be established by the Exchange to provide Contractor with sufficient time for necessary analysis and actuarial certification.
Individual Exchange. The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month (“PMPM”) rate of $13.95 multiplied by the number of Enrollees in Contractor’s QHPs for such month. The Participation Fee is based on the Exchange’s estimates of the revenue required to support the transition of the Exchange to being self-sufficient beginning in 2015. The Participation Fee is based on a rate equivalent to approximately three percent (3%) of the estimated individual market premium of $465 per month, an amount which represents the Exchange’s planning estimate of total premium paid to plans for each Enrollee in the Individual Exchange, inclusive of Federal subsidies. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment in Contractor's QHPs sold through the Individual Exchange in 2014.
Individual Exchange. The Exchange through which Qualified Individuals may purchase Qualified Health Plans.
Individual Exchange. The provisions of this Section 3.21(a) shall apply with respect to the Individual Exchange.
(i) The Exchange shall (i) notify Contractor regarding each eligible applicant who has completed an application for enrollment and designated Contractor as the Certified QHP, and (ii) transmit information required for Contractor to enroll the applicant within five (5) business days of verification of eligibility and selection of Contractor’s QHP. Contractor shall ensure a coverage effective date for the Enrollee as of (1) the first day of the next subsequent month for a QHP selection notice received by the Exchange between the first day and fifteenth (15) day of the month, or (2) the first day of the second following month for QHP selections received by the Exchange from the sixteenth day through the last day of a month, or (3) such other applicable dates specified in 45 C.F.R. 155. § 410 for the Open Enrollment Period and 45 C.F.R. § 155.420 for the Special Enrollment Period and/or as otherwise established by Contractor in accordance with applicable laws, rules and regulations. The Exchange shall require payment of one hundred percent (100%) of the entire first month premium to be received by the Exchange on or before the fourth (4th) remaining business day of the month in order to commence coverage as of the first (1st) day of the following month.
(ii) Contractor shall provide the Exchange with information necessary to confirm Contractor’s receipt of premium payment from Enrollee that is required to commence coverage. The specific terms and conditions relating to commencement of coverage, including, the administration of advance payments of the premium tax credit and cost sharing reductions and cancellation or postponement of the effective date of coverage in the event of nonpayment or partial payment of an initial premium, shall be established by the Exchange in accordance with applicable laws, rules and regulations.
(iii) Receipt of the first premium binder payment to be processed through a third- party administrator will be deposited into an account owned by the third-party administrator and settled by the third-party administrator to the Contractor’s own bank account.
Individual Exchange. The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month (“PMPM”) rate of $.83 multiplied by the number of Enrollees in Contractor’s SADPs for such month. The Participation Fee is based on the Exchange’s estimates of the revenue required to support the transition of the Exchange to being self-sufficient beginning in 2015. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment in Contractor's SADPs sold through the Individual Exchange in 2014.
Individual Exchange. The following provisions shall apply to the Individual Exchange:
i. Following the Exchange’s receipt of the Non-Recertification Election, Contractor must continue to participate in the enrollment and eligibility assignment process, and may be assigned new Enrollees through the end of the calendar year;
ii. Contractor will provide coverage for Enrollees assigned to Contractor until the earlier of
(i) the end of the calendar year, or (ii) the Enrollee’s transition to another QHP during a Special Enrollment Period.
Individual Exchange. The provisions of this Section 3.21(a) shall apply with respect to the Individual Exchange.
(i) The Exchange shall (i) notify Contractor regarding each eligible applicant who has completed an application for enrollment and designated Contractor as the SADP, and (ii) transmit information required for Contractor to enroll the applicant within five (5) business days of verification of eligibility and selection of Contractor’s SADP or its QHP partner as applicable. Contractor shall ensure a coverage effective date for the Enrollee as of (1) the first day of the next subsequent month for a SADP selection notice received by the Exchange between the first day and fifteenth (15) day of the month, or (2) the first day of the second following month for SADP selections received by the Exchange from the sixteenth day through the last day of a month, or (3) such other applicable dates specified in 45 C.F.R. 155. § 410 for the Open Enrollment Period and 45 C.F.R. § 155.420 for the Special Enrollment Period and/or as otherwise established by Contractor in accordance with applicable laws, rules and regulations. The Exchange shall require payment of one hundred percent (100%) of the entire first month premium to be received by the Exchange on or before the fourth (4th) remaining business day of the month in order to commence coverage as of the first (1st) day of the following month.
(ii) Contractor shall provide the Exchange with information necessary to confirm Contractor’s receipt of premium payment from Enrollee that is required to commence coverage. The specific terms and conditions relating to commencement of coverage, including, the administration of advance payments of the premium tax credit and cost sharing reductions and cancellation or postponement of the effective date of coverage in the event of nonpayment or partial payment of an initial premium, shall be established by the Exchange in accordance with applicable laws, rules and regulations.
(iii) Receipt of the first month’s full premium binder payment to be processed through a third-party administrator will be deposited into an account owned by the third- party administrator and settled by the third-party administrator to the Contractor’s own bank account.
