Covered California Certification of Qualified Health and Dental Plans

Introduction

Soon after the passage of national health care reform through the Patient Protection and Affordable Care Act of 2010 (ACA), California enacted legislation to establish a qualified health benefit exchange. (California Government Code § 100500 et seq.) The California state law is referred to as the California Patient Protection and Affordable Care Act (CA-ACA).

Covered California offers a statewide health insurance marketplace to make it easier for individuals and small businesses to compare plans and buy affordable, high quality health insurance in the private market.

Health and Dental Issuers interested in participating in Covered California are encouraged to review the application and model contract for Issuer participation requirements. Contract requirements can be found here.

All interested Health and Dental Issuers currently licensed must apply for certification and be selected by Covered California in order to participate. Covered California will exercise its statutory authority to selectively contract for health and dental care coverage offered through Covered California for the upcoming Plan Year (PY). Covered California reserves the right to select or reject any Applicant or to cancel the Application at any time.

Application Evaluation and Selection

The evaluation of Qualified Health Plan (QHP) and Qualified Dental Plan (QDP) Certification Applications is not based on a single, strict formula; instead, the evaluation will consider the mix of health plans for each region of California that best meet the needs of consumers in that region and the Covered California's goals. Covered California strives to provide an appropriate range of high quality health plans to participants in the individual and small group markets at the best available price that is balanced with the need for consumer stability and long-term affordability. In consideration of the mission and values of Covered California, the Board articulated guidelines for the selection and oversight of Qualified Health and Dental Plans which are used when reviewing the Applications. These guidelines are:

• Promote Affordability and Value for the Consumer – Both in Premiums and at Point of Care

• Encourage Competition Based upon Quality

• Encourage Competition Based upon the Populations Served

• Encourage Competition Based upon Meaningful QHP and QDP Choice and Product Differentiation: Patient-Centered Benefit Plan Designs

• Encourage Competition throughout the State

• Encourage Delivery System Improvement, Effective Prevention Programs and Payment Reform

• Demonstrate Administrative Capability and Financial Solvency

• Encourage Robust Customer Service 

Application Process

The application process shall consist of the following steps:

• Completion of Letter of Intent to Apply

• Release of the Final Application

• Submission of Applicant responses, including network and quality data

• Evaluation of Applicant responses

• Discussion and negotiation of final contract terms, conditions, and premium rates

• Execution of contracts with the selected QHP Issuers

Contact

QHPCertification@covered.ca.gov 

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Application Information, Notices, and Documents

September 16, 2024: Draft 2026 Certification Applications for Qualified Health and Qualified Dental Plan Individual and Covered California for Small Business Marketplaces

Covered California is accepting comments on the draft QHP and QDP Certification Applications until close of business Friday, October 11, 2024.

For each application, there is a clean and redline version along with a crosswalk explaining edits to assist with the review process. In addition, each application's appendices and attachments have been updated for clarity.

*Appendix M is pending Cal Hospital Compare's release of its updated infection rates data.

• PY2026 QHP-IND Certification Application

• PY2026 QHP-CCSB Certification Application

• PY2026 QDP-IND Certification Application

• PY2026 QDP-CCSB Certification Application

A comment template should be used for each application type and submitted to QHPCertification@covered.ca.gov. 

• PY2026 Comment Template

Please note: Applicants will ultimately complete the applications electronically.

February 1, 2024: Letter of Intent to Apply

Covered California will accept Letters of Intent to Apply until February 15, 2024, at 5:00 pm PST. Interested Applicants must use template provided. If Applicants are applying for multiple markets, a Letter of Intent is required for each application.

Letters of Intent are nonbinding but are required to obtain access to the electronic application submission portal. Questions and comments can be submitted to QHPCertification@covered.ca.gov.
 

Covered California has updated the QHP and QDP Certification Applications.

For each application, there is a clean and redline version along with each application's appendices and attachments. 

*Attachment J and K is pending further review and will be updated before applications are available for submission. 

• PY2025 Certification Application - Public Comment Summary

• PY2025 QHP-IND Certification Application - Final

• PY2025 QHP-CCSB Certification Application - Final

• PY2025 QDP-IND Certification Application - Final

• PY2025 QDP-CCSB Certification Application - Final

Please note: Applicants will ultimately complete the applications electronically. 

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