QUALIFIED HEALTH PLAN CONTRACT THROUGH 2015Qualified Health Plan Contract • June 2nd, 2015 • California
QUALIFIED HEALTH PLAN CONTRACT FOR 2014 betweenQualified Health Plan Contract • September 3rd, 2013 • California
Attachment 1 Contractor’s Qualified Health Plan List Attachment 2 Benefit Plan Designs Attachment 3 Good Standing Attachment 4 Service Area Listing Attachment 5 Provider Agreement - Standard Terms Attachment 6 Customer Service Standards Attachment 7 Quality, Network Management and Delivery System Standards Attachment 8 2014 Rates - Individual Exchange Attachment 9 Reserved Attachment 10 Monthly Rates - SHOP Attachment 11 Rate Updates - SHOP Attachment 12 Reserved Attachment 13 Reserved
Covered California, the California Health Benefit Exchange andQualified Health Plan Contract • April 30th, 2013
Attachment 1 Contractor’s QHP List Attachment 2 Benefit Plan Designs Attachment 3 Good Standing Attachment 4 Service Area Listing
QUALIFIED HEALTH PLAN CONTRACT THROUGH 2015Qualified Health Plan Contract • February 18th, 2015
Member Cost Share amounts describe the Enrollee's out of pocket costs.Actuarial Value - AV Calculator PlatinumCoinsurance Plan PlatinumCopay Plan 88.10% 88.00% Individual Overall deductible $0 $0 Other individual deductibles for specific services Medical $0 $0 Brand Drugs $0 $0 Dental $0 $0 Individual Out–of–pocket maximum $4,000 $4,000 Common Medical Event Service Type Member Cost Share Deductible Applies Member Cost Share Deductible Applies Health care provider’s office or clinic visit Primary care visit or non-specialist practitioner visit to treat an injury or illness $20 $20 Specialist visit $40 $40 Preventive care/ screening/ immunization No cost share No cost share Tests Laboratory Tests $20 $20 X-rays and Diagnostic Imaging $40 $40 Imaging (CT/PET scans, MRIs) 10% $150 Drugs to treat illness or condition Generic drugs $5 $5 Preferred brand drugs $15 $15 Non-preferred brand drugs $25 $25 Specialty drugs 10% 10% Outpatien
List of Attachments to QHP Model Contract, 2nd Revised Draft Draft, April 22, 2013Qualified Health Plan Contract • April 22nd, 2013 • California
Attachment 1 Contractor’s QHP List Attachment 2 Benefit Plan Designs Attachment 3 Good Standing Attachment 4 Service Area Listing
Contractor”)Qualified Health Plan Contract • April 28th, 2013 • California
Attachment 1 Contractor’s QHP List Attachment 2 Benefit Plan Designs Attachment 3 Good Standing Attachment 4 Service Area Listing
QUALIFIED HEALTH PLAN CONTRACT FOR 2014 betweenQualified Health Plan Contract • May 22nd, 2013 • California
Attachment 7 Quality, Network Management and Delivery System Standards Attachment 8 Monthly Rates - Individual Exchange
