Covered California, the state health insurance marketplace, has adopted strengthened quality reporting and improvement requirements for qualified health plans (QHPs) seeking to sell health insurance through the California marketplace for 2017 through 2019.   The contractual requirements include:

  • QHPs will ensure all consumers either select or are provisionally assigned a primary care clinician within 30 days of effectuation into their plan, so they have an established source of care.
  • Covered California will encourage QHPs to promote enrollment in advanced models of primary care, including patient-centered medical homes and integrated health care models, such as accountable care organizations.
  • QHPs will develop programs to proactively identify and manage at-risk enrollees, with requirements to improve in targeted areas.
  • QHPs will exchange data with providers so that physicians can be notified if their patients are hospitalized and can track trends and improve performance on chronic conditions, such as hypertension or diabetes.
  • QHPs will be required to identify hospitals and providers that are outliers and deliver either poor-quality care or unwarranted high-cost care. Once these providers are identified, health plans will be expected to work with them to improve their care or to lower their costs, and, if they do not and do not provide justification, plans will exclude those hospitals from Covered California networks as early as 2019.
  • Covered California will adopt a payment system for hospitals, such as the one employed by the Centers for Medicare and Medicaid Services (CMS), which, over time, will put at least 6 percent of reimbursement at risk or subject to a bonus payment based on quality performance.
  • QHPs will be required to track health disparities among all their patients receiving care, identify trends in those disparities and reduce the disparities, beginning with four major conditions: diabetes, hypertension, asthma and depression.
  • QHPs will be required to help consumers be active participants in their health care by providing tools to help consumers better understand their diagnoses and treatment options and understand their share of costs for medical services — based on the contracted costs of their plan.

Link to Original Source

Covered California staff prepared a slide presentation for the Covered California board of directors outlining the quality improvement strategy requirements.

Link to Original Source

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