Individual Market Clause Samples

Individual Market. QHP Issuers are solely responsible for compensating Agencies and Agents for plans sold in the Individual Exchange. Compensation rates are set by QHP Issuers and may vary depending on the terms and conditions established by agreement with Agent or Agency.

Individual Market i. The Exchange does not appoint Agents or Agencies in the Individual Market. QHPs are responsible for maintaining a reasonable appointment process for appointing agents to sell QHPs in the Individual Market. Agency and its Agents are responsible for contacting the QHP for any issues or inquiries related to the QHP's appointment process.

Individual Market. QHPs are solely responsible for compensating Agencies and Agents for plans sold in the Individual Exchange. Compensation rates are set by QHPs and may vary depending on the terms and conditions established by agreement with Agent or Agency.

Individual Market. (i) Premium charged to individuals includes the assessment of the participation fee, (see Section 5.03 Participation Fee). Contractor shall not pursue collection of any delinquent premiums from the Exchange for an Enrollee enrolled in the Individual Exchange who is responsible for directly paying for his/her premium to Contractor. (ii) Contractor shall not be entitled to collect from Enrollees and/or receive funds above the premium amounts except with respect to cost-sharing amounts or to the extent that such payment (i) is expressly authorized under the Certified QHPs, such as out-of-network services that comply with the notice requirements set forth at Section 3.15 above, or (ii) relates to a charge for non- sufficient funds or transaction fees initiated by Enrollee at rates that are reasonable and customary for such transactions; the Contractor shall not pursue collections of any said fees from the Exchange. (iii) Contractor shall review and reconcile information received from the Exchange on a monthly basis relating to the administration of premium payments, including information required under 45 C.F.R. § 155.705 and other applicable laws, rules and regulations necessary to the administration of premiums. Such reconciliation process will include the Contractor’s review of information relating to the receipt of premium amounts due to Contractor from each individual in the Individual Exchange including providing notices required under State and Federal laws. Contractor shall provide the Exchange notice of any reconciling enrollment information with premium payment information, which shall be evaluated by the Exchange in consultation with Contractor.

Individual Market. Broker/Agent Fees due hereunder shall be earned and payable monthly to Broker for Consumer Direct Market Benefit Contracts issued and for which the Premium has been paid to and earned by Insurer as long as this agreement is in effect and Broker is recognized by Insurer as Broker/Agent of Record.

Individual Market. (i) Premium charged to individuals includes the assessment of the participation fee, refer to Section 5.03 Participation Fee. Contractor shall not pursue collection of any delinquent premiums Covered California – Draft Health Plan Contract -- April 22, 2013April 298, 2013 from the Exchange for an Enrollee enrolled in the Individual Exchange who is responsible for directly paying for his/her premium to Contractor. (b) (ii) Contractor shall not be entitled to collect from Enrollees and/or receive from Employers any amounts or receive funds from the Employers above the premium amounts except with respect to cost-sharing amounts or to the extent that such payment (i) is expressly authorized under the Certified QHPs, such as out-of-network services that comply with the notice requirements set forth at Section 3.15 above, or (ii) relates to a charge for non-sufficient funds or transaction feestransactions initiated by Enrollee at rates that are reasonable and customary for such transactions and the Contractor shall not pursue collections of any said fees from the Exchange.

Individual Market a. The WAHBE Board will certify both QHPs and QDPs for plan year 2026. Health plans intended to be certified as QHPs must NOT include the pediatric dental Essential Health Benefit. b. The pediatric dental Essential Health Benefit must be offered in a stand-alone dental plan for QDP certification. A stand-alone QDP that offers the pediatric dental Essential Health Benefit may be offered as a pediatric-only plan or as a family plan that includes adult dental benefits. The WAHBE board will certify stand-alone family and pediatric- only QDPs to be offered both on the Exchange and in the outside market for plan year 2026.

Individual Market a. Agent shall complete all eligibility verification and enrollment applications for Consumers online through CalHEERS or via the paper application established by the Exchange. Agent shall provide substantial assistance to Consumers during the application process. Agent shall use this single streamlined application to determine eligibility and to collect information necessary for enrollment in a QHP, advance payments of the premium tax credit, cost-sharing reductions; and, where applicable, enrollment in Medi- Cal or CHIP. Agent will only be included on an application when Consumer has authorized the Agent to act as the Consumer’s agent of record and has authorized the Agent to access the Consumer’s personally identifiable information to complete the eligibility and enrollment process. For Agents using an online application, please see Subsection D of Exhibit E for further information; b. In the case that a Consumer is or may be eligible for Medi-Cal or CHIP, Agent shall facilitate the enrollment of interested Consumers without undue delay. c. Agent shall ensure that each application is fully and truthfully completed by the Consumer and the completed application fully and accurately reflects and discloses the circumstances of persons included in the application. d. To allow for the proper processing of Agent’s compensation, Agent must ensure the completion the following sections of each consumer’s application to the Exchange: i. Name and license number of the Certified Insurance Agent; and ii. Agent’s personal identification number for electronic applications or Agent’s signature and date of signature for paper applications.

Individual Market. Producer Fees due hereunder shall be earned and payable monthly to Contractor for Individual Market Benefit Contracts issued and for which the Premium has been paid to and earned by Insurer as long as this agreement is in effect and Contractor is recognized by Insurer as Producer of Record.