Removal from Covered California.
a) The clinical performance of Contractor’s products offered by Covered California must meet or exceed the national 25th percentile benchmark for the Quality Rating System (QRS) Clinical Quality Management Summary Indicator or face removal from Covered California if not met.
b) Contractor’s products with a minimum of two years of QRS reportable scores will be subject to this Section.
c) For each year that a product meets CMS eligibility criteria to report QRS measure scores and receive QRS star ratings, Covered California will calculate each product’s composite score using the reportable measure scores on the QRS Clinical Quality Management Summary Indicator measures and compare it with the applicable 25th percentile composite benchmark.
d) Covered California sets the 25th percentile composite benchmark using a simple average of available QRS Clinical Quality Management Summary Indicator national measure scores. The benchmark year will be Measurement Year 2024 and will not change during the contract term. However, if new clinical measures with benchmarks after 2024 are introduced, Covered California may revise the 2024 benchmark to include these measures.
e) The 25th percentile composite benchmark and each product's clinical composite score are calculated by averaging measure scores. Reportable measure scores are summed and divided by the count of reportable measure scores. The product’s clinical composite score is compared to the matched QRS 25th percentile composite benchmark score to determine if the 25th percentile composite benchmark is achieved.
f) Consistent with CMS QRS scoring methodology, a minimum of 50% of the measures from the QRS 25th national percentile benchmark measures set must be reportable for a composite score to be calculated.
g) If Contractor’s products fall below the Measurement Year 2024 25th percentile composite benchmark for the Quality Rating System (QRS) Clinical Quality Management Summary Indicator measures for two (2) consecutive years (the Monitoring Period), Covered California will notify Contractor and specify the Remediation Period (the two years following the final year of the monitoring period) within which Contractor must raise the quality of those products above the 25th percentile composite benchmark. If the quality of those products does not improve within the remediation period, those products will not be certified for the Plan Year two years following the final year of the remediation period.
h) Once notified of...
