reglab/statecodes huggingface dataset:
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 5 - Application, Eligibility, and Enrollment Process for the Individual Exchange › Section 6496 - Eligibility Redetermination During a Benefit Year

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Exchange shall redetermine the
				eligibility of an enrollee in a QHP through the Exchange during the benefit
				year if it receives and verifies new information reported by an enrollee or
				identifies updated information through the data matching described in
				subdivision (g) of this section.
(b) Except as specified in subdivisions (c)
				and (d) of this section, an enrollee, or an application filer on behalf of the
				enrollee, shall report any change of circumstances with respect to the
				eligibility standards specified in Sections
				6472 and
				6474 within 30 days of such
				change. Changes shall be reported through any of the channels available for the
				submission of an application, as described in Section
				6470(j).
(c) An enrollee who has not requested an
				eligibility determination for IAPs shall not be required to report changes that
				affect eligibility for IAPs.
(d) An
				enrollee who experiences a change in income that does not impact the amount of
				the enrollee's APTC or the level of CSR for which the enrollee is eligible
				shall not be required to report such a change.
(e) The Exchange shall verify any reported
				changes in accordance with the process specified in Sections
				6478 through
				6492 before using such information
				in an eligibility determination.
(f) The Exchange shall provide electronic
				notifications to an enrollee who has elected to receive electronic
				notifications, unless the enrollee has declined to receive notifications under
				this subdivision, regarding the requirements for reporting changes, as
				specified in subdivision (b) of this section, and the enrollee's opportunity
				not to report any changes described in subdivision (d) of this
				section.
(g) The Exchange shall
				examine available data sources at least twice in a calendar year to identify
				the following changes of circumstances:
(1)
				Death; and
(2) For an enrollee on
				whose behalf APTC or CSR are being provided, eligibility determination for or
				enrollment in:
(A) Medi-Cal or
				CHIP;
(B) Medicare; or
(C) Multiple overlapping QHPs through the
				Exchange.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 5 - Application, Eligibility, and Enrollment Process for the Individual Exchange › Section 6498 - Annual Eligibility Redetermination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Except as specified in subdivisions (d)
				and (m) of this section, the Exchange shall redetermine the eligibility of an
				enrollee or a qualified individual on an annual basis.
(b) To conduct an annual redetermination for
				an enrollee or a qualified individual who requested an eligibility
				determination for IAPs in accordance with Section
				6476(b), the
				Exchange shall have on file an active authorization from the qualified
				individual to obtain updated tax return information described in subdivision
				(c) of this section. This authorization shall be for a period of no more than
				five years based on a single authorization, provided that an individual may:
(1) Decline to authorize the Exchange to
				obtain updated tax return information; or
(2) Authorize the Exchange to obtain updated
				tax return information for fewer than five years; and
(3) Discontinue, change, or renew their
				authorization at any time.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 5 - Application, Eligibility, and Enrollment Process for the Individual Exchange › Section 6500 - Enrollment of Qualified Individuals into QHPs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A qualified individual may enroll in a
				QHP (and an enrollee may change QHPs) only during, and in accordance with the
				coverage effective dates related to, the following periods:
(1) The initial open enrollment period, as
				specified in Section
				6502;
(2) The annual open enrollment period, as
				specified in Section
				6502; or
(3) A special enrollment period, as specified
				in Section
				6504, for which the qualified
				individual has been determined eligible.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 5 - Application, Eligibility, and Enrollment Process for the Individual Exchange › Section 6502 - Initial and Annual Open Enrollment Periods

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A qualified individual may enroll in a
				QHP, or an enrollee may change QHPs, only during the initial open enrollment
				period, as specified in subdivision (b) of this section, the annual open
				enrollment period, as specified in subdivision (d) of this section, or a
				special enrollment period, as described in Section
				6504, for which the qualified
				individual has been determined eligible.
(b) The initial open enrollment period begins
				October 1, 2013 and extends through March 31, 2014.
(c) Regular coverage effective dates for
				initial open enrollment period for a QHP selection received by the Exchange
				from a qualified individual:
(1) On or before
				December 23, 2013, shall be January 1, 2014;
(2) On or between December 24, 2013 and
				December 31, 2013, shall be February 1, 2014;
(3) On or between the first and fifteenth day
				of the month for any month between January 2014 and March 31, 2014, shall be
				the first day of the following month; and
(4) On or between the sixteenth and last day
				of the month for any month between January 2014 and March 31, 2014, shall be
				the first day of the second following month.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 5 - Application, Eligibility, and Enrollment Process for the Individual Exchange › Section 6504 - Special Enrollment Periods

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A qualified individual may enroll in a
				QHP, or an enrollee may change from one QHP to another, during special
				enrollment periods only if one of the following triggering events occurs:
(1) A qualified individual or their dependent
				either:
(A) Loses MEC, as specified in
				subdivision (b) of this section. The date of the loss of MEC shall be:
1. Except as provided in subdivision
				(a)(1)(A)2 of this section, the last day the qualified individual or their
				dependent would have coverage under their previous plan or coverage;
2. If loss of MEC occurs due to a QHP
				decertification, the date of the notice of decertification as described in
				45 CFR Section
				155.1080(e)(2) (May 29,
				2012), hereby incorporated by reference;
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 5 - Application, Eligibility, and Enrollment Process for the Individual Exchange › Section 6508 - Authorized Representative

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Exchange shall permit an applicant or
				enrollee in the individual or small group market, subject to applicable privacy
				and security requirements, to designate an individual or organization to act on
				their behalf in applying for an eligibility determination or redetermination
				and in carrying out other ongoing communications with the Exchange.
(b) Designation of an authorized
				representative shall be in a written document signed by the applicant or
				enrollee, or through another legally binding format subject to applicable
				authentication and data security standards, as required by
				45 CFR Section
				155.270. If submitted, legal documentation of
				authority to act on behalf of an applicant or enrollee under State law, such as
				a court order establishing legal guardianship or a power of attorney, shall
				serve in the place of the applicant's or enrollee's signature.
(c) The authorized representative shall agree
				to maintain, or be legally bound to maintain, the confidentiality of any
				information regarding the applicant or enrollee provided by the
				Exchange.
(d) The authorized
				representative shall be responsible for fulfilling all responsibilities
				encompassed within the scope of the authorized representation, as described in
				subdivision (f) of this section, to the same extent as the applicant or
				enrollee they represent.
(e) The
				Exchange shall permit an applicant or enrollee to designate an authorized
				representative at the time of application or at other times and through methods
				described in Section
				6470(j).
(f) The Exchange shall permit an applicant or
				enrollee to authorize their representative to:
(1) Sign an application on the applicant's or
				enrollee's behalf;
(2) Submit an
				update or respond to a redetermination for the applicant or enrollee in
				accordance with Sections
				6496 and
				6498;
(3) Receive copies of the applicant's or
				enrollee's notices and other communications from the Exchange; and
(4) Act on behalf of the applicant or
				enrollee in all other matters with the Exchange.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6522 - Eligibility Requirements for Enrollment in the Shop

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An employer is a qualified employer and
				eligible to participate in the SHOP if such employer:
(1) Is a small employer as defined in Section
				6410;
(2) Elects to offer, at a minimum, all
				eligible full-time employees coverage in a QHP through the SHOP;
(3) Either --
(A) Has its principal business address in
				California and offers coverage to all its full-time employees through the SHOP
				in California or
(B) offers
				coverage to each eligible employee through the SHOP serving that employee's
				primary worksite;
(4)
				Meets the following minimum participation rules:
(A) A minimum of 70 percent of eligible
				employees of the qualified employer must enroll in health coverage through the
				SHOP, or a lesser minimum percent that may be determined by prevailing market
				practice through a SHOP survey of market practices. SHOP must provide QHP
				issuers notice of such a change, if any, at least 210 days prior to the
				effective date of the proposed change, unless the QHP issuers agree to an
				earlier effective date for the proposed change. The percentage will be
				published on the Covered California for Small Business (CCSB) website.
1. If the qualified employer pays 100 percent
				of the qualified employees' QHP premiums, then all eligible employees not
				waiving coverage per Section
				6522(a)(4)(B) of
				the qualified employer must enroll in health coverage through the
				SHOP.
(B) A qualified
				employee who waives employer offered health coverage because that qualified
				employee is enrolled in coverage through another employer, an employee's union,
				Medicaid pursuant to 42
				U.S.C. Section 1396 et seq., Medicare
				pursuant to 42 U.S.C.
				Section 1395 et seq., or any other federal or
				state health coverage program or any health coverage meeting the definition of
				minimum essential coverage pursuant to Health and Safety Code Section
				1345.5
				is not counted in calculating compliance with the group participation rules
				above.
(5) Meets the
				following group contribution rule:
(A) A
				qualified employer must contribute to each of its qualified employees' health
				plan premiums, a minimum of 50 percent of the lowest cost premium for
				employee-only health coverage in the level of coverage selected by the
				qualified employer pursuant to Section
				6520(a)(12)(C),
				or a lesser minimum percent that may be determined by prevailing market
				practice through a SHOP survey of market practices. The contribution rate will
				be published on the CCSB website.
(6) A qualified employer who wishes to offer
				infertility benefits to his/ her qualified employees must do so in accordance
				with Health and Safety Code Section
				1374.55
				and Insurance Code Section
				10119.6.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6524 - Verification Process for Enrollment in the Shop

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The SHOP shall verify or obtain
				information as provided in this section to determine whether an employer,
				employee or dependent meets the eligibility requirements specified in Section
				6522 prior to allowing an employer
				to offer health coverage or dental coverage to its employees or a qualified
				employee to select a QHP through the SHOP.
(b) For purposes of verifying employee
				eligibility, the SHOP must:
(1) Verify that
				the employee has been identified by the qualified employer as an employee being
				offered health coverage or dental coverage by the qualified employer;
(2) Accept the information attested to by the
				employee under Section
				6520 unless the information is
				inconsistent with the qualified employer-provided information; and
(3) Collect only the minimum information
				necessary for verification of eligibility and enrollment in accordance with the
				eligibility requirements in Section
				6522.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6526 - Qualified Employer Election of Coverage Periods

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Subject to subdivision (b) of this
				section, a qualified employer who is not already participating in the SHOP may
				elect to offer health coverage or dental coverage through the SHOP for its
				eligible employees at any time during the calendar year by submitting the
				information required in Section
				6520.
(b) If a qualified employer fails to meet the
				minimum participation or the group contribution requirements in Section
				6522(a)(4) and
				(5) or Section
				6522(h)(3), but
				satisfies the remaining eligibility criteria in Section
				6522, the qualified employer may
				only elect to offer health coverage of dental coverage through SHOP for its
				eligible employees in an annual enrollment period from November 15 through
				December 15 of each year.
(c) A
				qualified employer's plan year is a 12-month period beginning on the coverage
				effective date for its qualified employees as described in Section
				6536. All qualified employees of a
				qualified employer will have the same plan year as their qualified
				employer.
(d) A qualified employer
				may only change its offer of health coverage or dental coverage, including
				making changes to the reference plan, to its qualified employees, as described
				in Section
				6520(a)(12),
				during the qualified employer's annual election period. The qualified
				employer's annual election period is at least 20 days, beginning on the day the
				SHOP sends written notice of the annual employer election period, which the
				SHOP must send at least 60 days prior to the completion of the employer's plan
				year.
(e) If a qualified employer's
				reference plan is no longer available at renewal, a qualified employer must
				select a new reference plan during the employer's annual election
				period.
(f) If the qualified
				employer's reference plan is no longer available at renewal and the qualified
				employer does not select a new reference plan prior to renewal quote creation,
				a default alternative reference plan will be auto-selected for the group.
(1) An auto-selected reference plan will be
				the lowest cost plan in qualified employer's selected metal tier.
(2) The contribution rate applied to the new
				reference plan will remain as the previous employer contribution rate
				selected.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6528 - Initial and Annual Enrollment Periods for Qualified Employees

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A qualified
				employee may enroll in a QHP or change his or her QHP only during the initial
				employee open enrollment period and annual employee open enrollment period
				described in this section or during a special enrollment period as described in
				Section 6530.
(b) Subject to subdivision (e) of this
				section, a qualified employee's initial employee open enrollment period begins
				the day his or her employer submits all of the information required in Section
				6520 and the SHOP has determined
				that the employer is a qualified employer.
(c) Subject to subdivision (e) of this
				section, the annual employee open enrollment period begins the day after his or
				her qualified employer's annual election period has ended.
(d) The initial and annual employee open
				enrollment period is at least 20 days.
(e) Beginning January 1, 2014, the SHOP shall
				provide to qualified employers, a written annual employee open enrollment
				period notification for each qualified employee 60 days prior to the end of the
				qualified employer's plan year and after that employer's annual election
				period.
(f) Qualified employers may
				allow qualified employees to make a change to their selected QHP after the
				effective date of coverage during the first thirty (30) days of the new plan
				year, provided that the newly selected QHP is offered by the same QHP issuer.
(1) Requests to the SHOP to make changes to
				QHP selection received on the first through the fifteenth day of the month
				after the effective date shall become retroactively effective to the first day
				of the month, unless the employer requests an effective date of the first of
				the following month.
(2) Requests
				to the SHOP to make changes to QHP selection received on the sixteenth day of
				the month up to the thirtieth day of the month after the effective date shall
				become effective on the first day of the following month, unless an earlier
				effective date is requested due to exceptional circumstances and is permitted
				by the SHOP and QHP Issuer, as determined on a case-by-case
				basis.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6530 - Special Enrollment Periods for Qualified Employees and Dependents

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The SHOP must
				provide special enrollment periods consistent with this section, during which
				certain qualified employees or a dependent of a qualified employee may enroll
				in QHPs and enrollees may change QHPs.
(b) A qualified employee, or his or her
				dependent, may enroll in a QHP or change QHPs during special enrollment periods
				outside of the initial and annual open enrollment periods in the following
				situations:
(1) A qualified employee, or his
				or her dependent, either:
(A) Loses Minimum
				Essential Coverage (MEC), as specified in subdivision (e) of this section. The
				date of the loss of MEC shall be:
1. The date
				of the last day the qualified employee, or his or her dependent, would have
				health coverage under his or her previous plan or coverage; or
2. If a loss of MEC occurs due to a QHP
				decertification, the date of the notice of decertification as described in
				45 CFR Section
				155.1080(e)(2) (May 29,
				2012), hereby incorporated by reference.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6532 - Employer Payment of Premiums

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				Upon completion of the initial employee open enrollment period by all of the
				qualified employees of a qualified employer, the SHOP will send an invoice to
				the qualified employer for the total premium amount due for all of that
				qualified employer's qualified employees.
(1)
				A qualified employer's first premium payment shall be paid in full and must be
				delivered to the SHOP or postmarked by the due date indicated on the invoice,
				for effectuation to occur on the date requested on the employer's
				application.
(2) If a qualified
				employer's first payment does not meet the requirements in subdivision (a)(1),
				the SHOP will cancel the application of that qualified employer and the
				applications of that employer's qualified employees.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6534 - Coverage Effective Dates for Special Enrollment Periods

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Except as specified in subdivision (b) of
				this section, coverage effective dates for special enrollment periods for a QHP
				selection received by the Exchange from a qualified employee:
(1) Shall be no later than the first day of
				the following month for applications received between the first and fifteenth
				day of any month, or
(2) Shall be
				no later than the first day of the second following month for applications
				received between the sixteenth and last day of any month.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6538 - Disenrollment and Termination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				A qualified employer may terminate coverage during the plan year for all its
				qualified employees and their dependents covered by the employer group health
				plan at the end of each month, in accordance with subdivision (e) of this
				section. If a qualified employer terminates coverage through the SHOP, the SHOP
				must:
(1) Ensure that each QHP Issuer
				terminates the coverage of the qualified employer's qualified employees and
				their dependents enrolled in the QHP through the SHOP; and
(2) Send a notice to each of the qualified
				employer's qualified employees enrolled in a QHP through the SHOP within 15
				days of receiving notice from the employer in subdivision (a) of this section.
				Such notification must provide information about other potential sources of
				coverage, including access to individual market coverage through the
				Exchange.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6542 - General Eligibility Appeals Requirements for Shop

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An employer shall have the right to
				appeal:
(1) An eligibility determination made
				by the SHOP in accordance with this Article;
(2) A failure by the SHOP to provide a timely
				eligibility determination in accordance with this Article; or
(3) A failure of the SHOP to provide written
				notice to an employer of the SHOP's eligibility determination as provided in
				Section 6524(c) within 15
				calendar days of receiving a completed application from an
				employer.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6544 - Informal Resolution

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				An appellant shall have an opportunity for informal resolution prior to a
				hearing in accordance with the requirements of this section.
(b) Upon receipt of a valid appeal request,
				the SHOP shall:
(1) Contact the appellant to
				attempt to informally resolve the appeal; and
(2) Provide the appellant the opportunity to
				submit relevant evidence to assist in the informal resolution of the
				appeal.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6546 - Dismissals of Appeals

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
				appeals entity shall dismiss an appeal if the appellant:
(1) Withdraws the request in writing prior to
				the hearing date; or
(2) Fails to
				submit an appeal request meeting the standards specified in Section
				6542(d);
(3) Fails to appear at a scheduled hearing
				without good cause.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6548 - Hearing Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				An appellant shall have an opportunity for a hearing in accordance with the
				requirements of this section.
(b)
				The appeals entity shall send written notice to the appellant of the date,
				time, and location or format of the hearing no later than 15 business days
				prior to the hearing date.
(c) The
				hearing shall be conducted:
(1) After notice
				of the hearing, pursuant to subdivision (b) of this section;
(2) As an evidentiary hearing, consistent
				with subdivision (e) of this section;
(3) By an administrative law judge not
				directly involved in the eligibility determination implicated in the appeal;
				and
(4) By telephone, video
				conference, or in person, in accordance with the California Department of
				Social Services' Manual of Policies and Procedures Section
				22-045.1.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6550 - Expedited Appeal Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An
				appellant shall have the right to request an expedited appeals process from the
				appeals entity where there is an immediate need for health coverage or dental
				coverage because a standard appeal could jeopardize the appellant's life or
				health, or ability to attain, maintain, or regain maximum function.
(b) If the appeals entity denies a request
				for an expedited appeal, it shall:
(1) Handle
				the appeal request under the standard appeals process and issue the appeal
				decision in accordance with Section
				6552; and
(2) Inform the appellant, within three (3)
				business days from the date of the denial of a request for an expedited appeal,
				through electronic, or oral notification if possible, of the denial and, if
				notification is oral, follow up with the appellant by written notice within
				five (5) business days of the denial. Written notice of the denial shall
				include:
(A) The reason for the
				denial;
(B) An explanation that the
				appeal request will be administered pursuant to the standard appeals process;
				and
(C) An explanation of the
				appellant's rights under the standard appeals
				process.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6552 - Appeal Decisions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				The appeals decisions shall:
(1) Be based
				solely on the evidence referenced in Section
				6548(e) and the
				eligibility requirements for SHOP under this Article.
(2) State the decision, including a plain
				language description of the effect of the decision on the appellant's
				eligibility;
(3) Identify the legal
				basis, including the regulations that support the decision;
(4) Summarize the facts relevant to the
				appeal;
(5) State the effective
				date of the decision; and
(6)
				Provide information about judicial review available to the appellant pursuant
				to Section
				1094.5
				of the California Code of Civil Procedure.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 7 - Appeals Process for the Individual Exchange › Section 6602 - General Eligibility Appeals Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) In accordance with Section
				6510 of Article 5, an applicant or
				enrollee shall have the right to appeal:
(1)
				An eligibility determination made in accordance with Article 5 of this chapter,
				including:
(A) An initial determination of
				eligibility, including the amount of APTC and level of CSR, made in accordance
				with the standards specified in Sections
				6472 and
				6474 of Article 5 of this
				chapter;
(B) A redetermination of
				eligibility, including the amount of APTC and level of CSR, made in accordance
				with Sections
				6496 and
				6498 of Article 5 of this chapter;
				and
(C) A determination of
				eligibility for an enrollment period, made in accordance with Section
				6476(c) of
				Article 5 of this chapter;
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 7 - Appeals Process for the Individual Exchange › Section 6604 - Notice of Appeal Procedures

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				The Exchange shall provide notice of appeal procedures at the time that the:
(1) Applicant submits an application;
				and
(2) Notice of eligibility
				determination and redetermination is sent in accordance with Sections
				6476(h),
				6496(h)(2), or
				6498(j)(2) of
				Article 5 of this chapter.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 7 - Appeals Process for the Individual Exchange › Section 6606 - Appeal Requests

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
				Exchange and the appeals entity shall:
(1)
				Accept appeal requests submitted through any of the following channels, in
				accordance with Section
				6470(j) of
				Article 5 of this chapter:
(A) The Exchange's
				Internet Web site;
(B)
				Telephone;
(C) Facsimile;
(D) Mail; or
(E) In person.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 7 - Appeals Process for the Individual Exchange › Section 6610 - Dismissals

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The appeals
				entity shall dismiss an appeal if the appellant:
(1) Unconditionally or conditionally
				withdraws the appeal request in writing prior to the hearing date, in
				accordance with the following procedure:
(A)
				Except as provided in subdivision (a)(1)(B) of this section, if the withdrawal
				is unconditional, the appeal request shall be immediately dismissed.
(B) If the appellant has verbally withdrawn
				their appeal request prior to the hearing, and such withdrawal is
				unconditional, the following process shall apply:
1. The appeals entity shall send the
				appellant a written confirmation of the withdrawal within five business days
				from the date on which the appellant's verbal withdrawal request is received by
				the appeals entity. The written confirmation shall serve as the appellant's
				written withdrawal and the appeal shall be dismissed unless the appellant
				notifies the appeals entity, in writing or verbally, within 15 days of the date
				of the written confirmation, that the appellant has not withdrawn their appeal
				request.
2. If the appellant makes
				the verbal unconditional withdrawal request to the Exchange, the Exchange shall
				notify the appeals entity of the appellant's verbal unconditional withdrawal
				request within three business days from the date of the request.
(C) If the withdrawal is
				conditional:
1. The withdrawal shall be
				accompanied by an agreement signed by the appellant and by the Exchange as part
				of the informal resolution process specified in Section
				6612;
2. Upon receipt of the signed conditional
				withdrawal, the hearing date, if any, shall be vacated;
3. The actions of both parties under the
				agreement specified in subdivision (a)(1)(C)1 of this section shall be
				completed within 30 calendar days of the date on the agreement; and
4. Upon the satisfactory completion of the
				actions of the appellant and the Exchange under the agreement specified in
				subdivision (a)(1)(C)1 of this section, the appeals entity shall dismiss the
				appeals request unless the hearing request is reinstated within the time limits
				set forth in Section
				6606(c);
(D) Both unconditional and
				conditional withdrawals shall be accepted by telephone if the following
				requirements are met:
1. The appellant's
				statement and telephonic signature made under penalty of perjury shall be
				recorded in full; and
2. The
				appeals entity shall provide the appellant with a written confirmation
				documenting the telephonic interaction.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 7 - Appeals Process for the Individual Exchange › Section 6612 - Informal Resolution

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				An appellant shall have an opportunity for informal resolution prior to a
				hearing in accordance with the requirements of this section.
(b) Upon receipt of an appeal request, which
				has been determined to be valid in accordance with Section
				6602(c), or upon
				receipt of the notice under Section
				6606(e)(2), the
				Exchange shall contact the appellant to resolve the appeal informally and to
				request additional information or documentation, if applicable, prior to the
				hearing date.
(c) The informal
				resolution process shall comply with the scope of review specified in Section
				6614(e).
(d) An appellant's right to a hearing shall
				be preserved in any case notwithstanding the outcome of the informal resolution
				process unless the appellant unconditionally or conditionally withdraws their
				appeal request prior to the hearing date, in accordance with the procedure set
				forth in Section
				6610(a)(1).
(e) If the appeal advances to hearing:
(1) The appellant shall not be asked to
				provide duplicative information or documentation that they previously provided
				during the application or informal resolution process; and
(2) The Exchange shall:
(A) Issue a Statement of Position;
				and
(B) Transmit via secure
				electronic interface the Statement of Position and all papers, requests, and
				documents, including printouts from an appeal record, which the Exchange
				obtained during the informal resolution process to the appeals entity, the
				appellant, and, if applicable, the appellant's representative, at least two
				business days before the date of the hearing.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 7 - Appeals Process for the Individual Exchange › Section 6614 - Hearing Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				An appellant shall have an opportunity for a hearing in accordance with the
				requirements of this section.
(b)
				When a hearing is scheduled, the appeals entity shall send written notice to
				the appellant and the appellant's authorized representative, if any, of the
				date, time, location, and format of the hearing no later than 15 days prior to
				the hearing date unless:
(1) The appellant
				requests an earlier hearing date; or
(2) A hearing date sooner than 15 days is
				necessary to process an expedited appeal, as described in Section
				6616(a), and the
				appeals entity has contacted the appellant to schedule a hearing on a mutually
				agreed upon date, time, and location or format.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 7 - Appeals Process for the Individual Exchange › Section 6616 - Expedited Appeals

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				Pursuant to 45 CFR Section
				155.540(a) (December 22,
				2016), hereby incorporated by reference, the appeals entity shall establish and
				maintain an expedited appeals process for an appellant to request an expedited
				process where there is an immediate need for health services because a standard
				appeal could jeopardize the appellant's life or health or ability to attain,
				maintain, or regain maximum function.
(b) If the appeals entity denies a request
				for an expedited appeal, it shall:
(1)
				Conduct the appeal under the standard appeals process and issue the appeal
				decision in accordance with Section
				6618(b)(1);
				and
(2) Inform the appellant,
				within three business days from the date of the denial of a request for an
				expedited appeal, through electronic or verbal notification, if possible, of
				the denial and, if notification is verbal, follow up with the appellant by
				written notice within five business days of the denial. The written notice of
				the denial shall include:
(A) The reason for
				the denial;
(B) An explanation that
				the appeal will be conducted under the standard appeals process; and
(C) An explanation of the appellant's rights
				under the standard appeals process.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 7 - Appeals Process for the Individual Exchange › Section 6618 - Appeal Decisions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				Appeal decisions shall:
(1) Be based
				exclusively on the information and evidence specified in Section
				6614(e) and the
				eligibility requirements under Article 5 of this chapter;
(2) State the decision, including a plain
				language description of the effect of the decision on the appellant's
				eligibility;
(3) Include a summary
				of the facts relevant to the appeal;
(4) Identify the legal basis, including the
				regulations that support the decision;
(5) State the effective date of the decision,
				if applicable; and
(6) Explain the
				appellant's right to pursue the appeal before the HHS appeals entity, including
				the applicable timeframe and instructions to file, if the appellant remains
				dissatisfied with the eligibility determination;
(7) Indicate that the decision of the
				Exchange appeals entity is final, unless the appellant pursues the appeal
				before the HHS appeals entity; and
(8) Provide information about judicial review
				available to the appellant pursuant to Section
				1094.5
				of the California Code of Civil Procedure.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 8 - Enrollment Assistance › Section 6652 - Certified Enrollment Entities

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The following entities and individuals
				are eligible to apply to become a Certified Enrollment Entity in the Navigator
				Program pursuant to Section
				6656:
(1) American Indian Tribes or Tribal
				Organizations;
(2) Chambers of
				Commerce;
(3) Cities, Counties, and
				Local Government Agencies;
(4)
				Commercial fishing, industry organizations;
(5) Community Colleges and
				Universities;
(6) Faith-Based
				Organizations;
(7) Indian Health
				Services Facilities;
(8) Labor
				Unions;
(9) Licensed attorneys
				(e.g., family law attorneys who have clients that are experiencing life
				transitions);
(10) Non-Profit
				Community Organizations;
(11)
				Ranching and farming organizations;
(12) Resource partners of the Small
				Businesses Administration;
(13)
				School Districts;
(14) Tax
				preparers as defined in Business and Professions Code Section
				22251,
				subdivision (a)(1)(A);
(15) Trade,
				industry, and professional organizations;
(16) Safety Net Clinics:
(A) Community Clinics as defined in Health
				and Safety Code Section
				1204,
				subdivision (a)(1)(A);
(B) Free
				Clinics as defined in Health and Safety Code Section
				1204,
				subdivision (a)(1)(B);
(C)
				Federally Qualified Health Centers (FQHCs) under Section
				330 of the Public Health Service
				Act, 42 U.S.C. §
												254b;
(D) FQHC Look-Alikes designated by the U.S.
				Department of Health and Human Services, Health Resources and Services
				Administration, 42 U.S.C.
				§§
												1395x and
				1396d;
(E) Health care facilities directly managed
				and funded by the Indian Health Services under the Indian Self-Determination
				and Education Assistance Act of 1975,
				25 U.S.C. §
												450 et seq.;
(F) 638 Contracting or Compacting Clinics
				funded by the Indian Health Services under the Indian Self-Determination and
				Education Assistance Act of 1975,
				25 U.S.C. §
												450 et seq.; and
(G) Urban Indian Health Centers under Title V
				of the Indian Health Care Improvement Act,
				25 U.S.C. §
												1601 et seq.
(17) Other public or private entities or
				individuals who meet the requirements of this Article except for:
(A) Entities and individuals who are licensed
				by the Department of Insurance;
(B)
				Health insurance issuers or stop loss insurance issuers;
(C) Except for the Safety Net Clinics listed
				in subdivision (a)(16) above, Licensed Health Care Clinics;
(D) Licensed Health Care Institutions;
				and
(E) Licensed Health Care
				Providers.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 8 - Enrollment Assistance › Section 6654 - In-Person Assistance Program Application. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New section
				  filed 7-15-2013 as an emergency; operative 7-15-2013 (Register 2013, No. 29). A
				  Certificate of Compliance must be transmitted to OAL by 1-13-2014 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Repealed by operation of Government Code section
				  11346.1(g)
				  (Register 2014, No. 7).
3. New section filed 2-10-2014 as an
				  emergency pursuant to Government Code section
				  11346.1,
				  subdivision (h); operative 2-10-2014 (Register 2014, No. 7). A Certificate of
				  Compliance must be transmitted to OAL by 5-12-2014 or emergency language will
				  be repealed by operation of law on the following day.
4. New section
				  refiled 5-12-2014 as an emergency pursuant to Government Code section
				  11346.1,
				  subdivision (h); operative 5-12-2014 (Register 2014, No. 20). A Certificate of
				  Compliance must be transmitted to OAL by 8-11-2014 or emergency language will
				  be repealed by operation of law on the following day.
5. New
				  section, including amendment of subsection (b)(25)(B), refiled 7-21-2014 as an
				  emergency pursuant to Government Code section
				  100504(a)(6),
				  as modified by Senate Bill 857 (Stats 2014, c. 31); operative 7-21-2014
				  (Register 2014, No. 30). A Certificate of Compliance must be transmitted to OAL
				  by 7-15-2015 pursuant to Government Code section
				  100504 or
				  emergency language will be repealed by operation of law on the following
				  day.
6. Senate Bill 75 (Stats. 2015, Ch. 18) modified Government
				  Code section
				  100504(a)(6)
				  to change the date upon which a Certificate of Compliance must be transmitted
				  to OAL. Pursuant to Government Code section
				  100504(a)(6),
				  as modified by Senate Bill 75 (Stats. 2015, Ch. 18), a Certificate of
				  Compliance must be transmitted to OAL by 2-10-2017 or the language in the
				  emergency order of 7-21-2014 will be repealed by operation of law on the
				  following day (Register 2015, No. 38).
7. Certificate of Compliance
				  as to 7-21-2014 order, including repealer of section, transmitted to OAL
				  11-6-2015 and filed 12-23-2015 (Register 2015, No.
				  52).
Note: Authority cited: Sections
					 100502 and
					 100504,
					 Government Code. Reference: Sections
					 100502 and
					 100503,
					 Government Code; and 45
					 C.F.R. §§
												155.205,
					 155.210,
					 155.215 and
					 155.260.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 8 - Enrollment Assistance › Section 6657 - Certified Enrollment Counselor Application

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An individual may become a Certified
				Enrollment Counselor according to the following process:
(1) The Certified Enrollment Entity shall
				notify the Exchange of the individual to be affiliated according to the process
				described in subdivision (c) of this Section.
(2) The individual shall:
(A) Submit the following:
1. All information, documentation, and
				declarations required in subdivision (b) of this Section; and
2. An executed agreement conforming to the
				Roles and Responsibilities defined in Section
				6664;
(B) Within 30 calendar days of completing the
				requirements in subdivision (a)(2)(A) of this Section:
1. Submit fingerprinting images in accordance
				with Section
				6658;
2. Disclose to the Exchange all criminal
				convictions and administrative actions taken against the applicant;
3. Complete the required training established
				in Section
				6660; and
4. Pass the required certification exam
				pursuant to Section
				6660.
(3) Individuals who complete the above
				requirements, pass the Certified Enrollment Counselor Fingerprinting and
				Criminal Record Check described in Section
				6658, and have no administrative
				actions taken against them which are substantially related to the
				qualifications, functions, or duties of the specific position sought, shall be
				certified as Certified Enrollment Counselors by the Exchange.
(4) Applicants who have been denied for
				reasons other than failure to pass the Certified Enrollment Counselor
				Fingerprinting and Criminal Record Check may appeal the denial of their
				Certified Enrollment Counselor Application through the process established by
				Section 6662.
California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 8 - Enrollment Assistance › Section 6658 - Certified Enrollment Counselor Fingerprinting and Criminal Record Checks

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Individuals
				Required To Submit Fingerprinting Images.
(1)
				Individuals seeking certification under this Article shall submit fingerprint
				images and associated criminal history information pursuant to Government Code
				Section
				1043 and
				Section 6456, subdivision (c), of these
				regulations.