Quality and Network Management Sample Clauses

Quality and Network Management. Health Assessment Year 1- Track only; Year 2-3 performance measure based on Year 1 determined performance with preliminary target of exceeding QHP 50th percentile to avoid penaltyExpectation: Completion of Health Assessment annually- 5% of total performance penalty at risk. Performance Level: <30%- 5% performance penalty. 30-50%- no penalty. 50% or greater- 5% performance credit.

Quality and Network Management. New Care Models Year 1- Track only; Year 2-3 performance measure based on Year 1 determined performance with preliminary target of exceeding QHP 50th percentile to avoid penaltyExpectation: Increase in Covered California enrollees obtaining care through new care models- 5% of total performance penalty at risk. Performance Level: 0-5% increase- 5% performance. 5-10% increase- no penalty. 10% percent increase- 5% performance credit Attachment 165 Business Associate Agreement This Business Associate Agreement (this “Agreement”) dated , 2013 between the California Health Benefit Exchange (“Covered Entity”) and (“Business Associate”) is entered into in accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as codified at 42 U.S.C. §1320d-d8, and its implementing regulations at 45 C.F.R. Parts 160, 162 and 164 (the “HIPAA Regulations”) and attendant guidance; and the Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009, and its attendant regulations and guidance (the “HITECH Act”). HIPAA, the HIPAA Regulations and the HITECH Act are sometimes referred to collectively herein as “HIPAA Requirements.”

Quality and Network Management. Quality Reporting System (QRS)- Getting the Right Care; related to Attachment 7, Section 3.01. Specific measures noted in Appendix 1 to this Attachment 14. Expectation: Getting the Right Care- HEDIS/CAHPS Clinical Effectiveness measure set summary (Product type reporting)- 106.255% of total performance requirement expected. Performance Level: <50th PCT:105% penalty;51-75th PCT: no penalty; >75th PCT: 105% performance credit (vs. national HMO benchmark). 3.32 Quality and Network Management –Quality Reporting System (QRS)- Access to Care; related to Attachment 7, Section 3.01. Specific measures noted in Appendix 1 to this Attachment 14. Expectation: Access to Care- HEDIS/CAHPS measure set summary (Product type reporting): 106.255% of total performance requirement expected. Performance Level: <50th PCT:105% penalty;51-75th PCT: no penalty; >75th PCT: 105% performance credit (vs. national HMO benchmark). 3.43

Quality and Network Management. At Risk Enrollees; Attachment 7, Section 5.04 Performance expectation to be determined in collaboration with QHPs based on 2014 measurement with preliminary target of exceeding QHP 50th percentile to avoid penalty NOTE: for 2014 measurement year/2015 penalty/credit assessment, track and report to QHPs only;5% penalty at risk thereafter (2015 measurement and beyond) 4.1 Call Answer Timeliness for Covered California Expectation: 80% of calls answered 30 seconds. 6.25% of total performance penalty at risk. Performance Level: <80%- 6.25% performance penalty. 80%- 90%: no penalty. >90%: 5% performance credit.

Quality and Network Management. Preventive Health and Wellness; Attachment 7, Section 4.01. Performance expectation to be determined in collaboration with QHPs based on 2014 measurement with preliminary target of exceeding QHP 50th percentile to avoid penalty NOTE: for 2014 measurement year/2015 penalty/credit assessment, track and report to QHPs only;5% penalty at risk thereafter (2015 measurement and beyond) Year 1- Track only; Year 2-3 performance measure based on Year 1 determined performance with preliminary target of exceeding QHP 50th percentile to avoid penalty

Quality and Network Management. Quality Reporting System -– (QRS) - Access to Care- HEDIS/CAHPS measure set summary Expectation: Access to Care - HEDIS/CAHPS measure set summary (product type reporting) - 10% of total performance requirement expected. Getting Care Quickly Composite (CAHPS) Getting Needed Care Composite (CAHPS) Child and Adolescent Access to Primary Care Practitioners (12-14, 25mo-6yr, 7-11, 12-19) HEDIS Adults' Access to Preventive/Ambulatory Health Services (20 to 44 years and 45 to 64 years) HEDIS *certain CAHPS measures may not be available for all Product Types