California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 9 - Plan-Based Enrollers › Section 6710 - Roles and Responsibilities

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A Certified Plan-Based Enrollment Entity
				(PBEE) and its Certified Plan-Based Enrollers (PBEs) shall perform the
				following functions:
(1) Maintain expertise
				in eligibility, enrollment, and PBE Program specifications.
(2) Provide enrollment assistance to
				consumers in a manner considered to be through the Exchange pursuant to
				45 C.F.R. §
											156.265(b)(2) and Section
				6500(f) of
				Article 5 of this chapter.
(3)
				Provide information and services in a fair and accurate manner. Such
				information and services shall include assistance with other Insurance
				Affordability Programs (e.g., Medi-Cal).
(4) Provide referrals to any applicable
				office of health insurance consumer assistance or health insurance ombudsman
				established under Section
				2793 of the Public Health Service
				(PHS) Act, 42 U.S.C. §
											300gg-93, or any other appropriate State
				agency or agencies, for any enrollee with a grievance, complaint, or question
				regarding their health plan, coverage, or a determination under such plan or
				coverage.
(5) Comply with the
				privacy and security requirements in
				45 CFR §
											155.260.
(6) Comply with any applicable federal or
				state laws and regulations.
(7)
				Inform all applicants of the availability of other QHP products or stand-alone
				dental plans offered through the Exchange through an HHS-approved universal
				disclaimer and display the Web link to access the Exchange Web Site on the
				PBEE's Web Site, and describe how to access the Exchange Web Site or the
				Service Center of the Exchange. The PBE can refer an applicant to any
				individual or entity certified through Articles 8, 11, 12 of this chapter, or
				to any Agents certified by the Exchange.
(8) Facilitate enrollment and renewal in a
				QHP offered in the Individual Exchange by the PBEE affiliated with the PBE.
(A) The QHP Issuer must be able to provide
				applicants standardized information for its available QHPs in the Individual
				Exchange, including at a minimum the following data elements:
(i) Premium and cost-sharing
				information;
(ii) The summary of
				benefits and coverage established under Section
				2715 of the PHS Act;
(iii) Identification of whether the QHP is a
				bronze, silver, gold or platinum level plan as defined by Section
				1302(d) of the
				Affordable Care Act (ACA), 42 U.S.C. §
													18022(d), or a catastrophic
				plan as defined by Section
				1302(e) of the
				ACA, 42 U.S.C. §
													18022(e);
(iv) The results of the enrollee satisfaction
				survey, as described in Section
				1311(c)(4) of the
				ACA, 42 U.S.C.
				18031, when available;
(v) Quality ratings assigned in accordance
				with Section
				1311(c)(3) of the
				ACA, 42 U.S.C.
				18031;
(vi) Medical loss ratio information as
				reported to HHS in accordance with
				45 C.F.R. §
													158;
(vii) Transparency of coverage measures
				reported to the Exchange during certification with
				45 C.F.R. §
													155.1040;
(viii) The provider directory made available
				to the Exchange in accordance with
				45 C.F.R. §
													156.230;
(ix) Potential total cost, including premium
				and out-of-pocket expenses; and
(x)
				Participation of the preferred provider of the consumer in the QHP Issuer's
				available QHPs.
(9) Clearly distinguish between QHPs for
				which the consumer is eligible and other non-QHPs that the Issuer may offer,
				and indicate that advance payments of the premium tax credit and cost sharing
				reductions apply only to QHPs offered through the Exchange.
(10) Allow applicants to select and attest to
				an APTC amount, if applicable, in accordance with
				45 C.F.R. §
											155.310(d)(2) and Section
				6476(c) of
				Article 5 of this chapter.
(11) If
				the consumer is determined to be eligible for Medi-Cal, the PBE shall either
				transfer the consumer to the county of residence for enrollment in Medi-Cal or
				transmit all eligibility information to DHCS consistent with
				45 C.F.R. §
											155.310 and Section
				6476(e) of
				Article 5 of this chapter. A PBE shall not facilitate Medi-Cal plan selection
				until the California Healthcare Eligibility, Enrollment, and Retention System
				(CalHEERS) has been programmed to allow a beneficiary to select a Medi-Cal
				managed care plan, as defined in Section
				6410 of Article 2 of this chapter,
				pursuant to subdivision (p) of Section
				14016.5
				of the Welfare and Institutions Code.
(12) Advise all consumers found ineligible
				for Insurance Affordability Programs of their appeal rights, including the time
				limits and methods for filing appeals, in accordance with Sections
				6604 and
				6606 of Article 7 of this
				chapter.
(13) Advise all consumers
				found ineligible for Insurance Affordability Programs that there may be other
				health insurance products outside of the Individual Exchange that may be
				suitable to their needs. The PBE shall offer to transfer the consumer to a
				Captive Agent or Solicitor, as defined in Health and Safety Code Section
				1345(m),
				affiliated with the PBEE capable of offering the consumer the full range of
				health plans offered by the Issuer in the Individual Market and Individual
				Exchange.