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 6492 - Inconsistencies

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Except as
				otherwise specified in this Article, for an applicant for whom the Exchange
				cannot verify information required to determine eligibility for enrollment in a
				QHP, or for APTC and CSR, including when electronic data is required in
				accordance with this section but data for individuals relevant to the
				eligibility determination are not included in such data sources or when
				electronic data from IRS, DHS, or SSA is required but it is not reasonably
				expected that data sources will be available within one day of the initial
				request to the data source, the Exchange:
(1)
				Shall make a reasonable effort to identify and address the causes of such
				inconsistency, including through typographical or other clerical errors, by
				contacting the application filer to confirm the accuracy of the information
				submitted by the application filer;
(2) If unable to resolve the inconsistency
				through the process described in subdivision (a)(1) of this section, shall:
(A) Provide notice to the applicant regarding
				the inconsistency; and
(B) Provide
				the applicant with a period of 95 days from the date of the notice described in
				subdivision (a)(2)(A) of this section to either present satisfactory
				documentary evidence through the channels available for the submission of an
				application, as described in Section
				6470(j), except
				by telephone, or otherwise resolve the inconsistency.
(3) May extend the period described in
				subdivision (a)(2)(B) of this section for an applicant if the Exchange
				determines on a case-by-case basis that the applicant has demonstrated that
				they have made a good-faith effort to obtain the required documentation during
				the period.
(4) During the periods
				described in subdivisions (a)(1) and (a)(2)(B) of this section, shall:
(A) Proceed with all other elements of
				eligibility determination using the applicant's attestation, and provide
				eligibility for enrollment in a QHP if an applicant is otherwise
				qualified;
(B) Ensure that APTC and
				CSR are provided within this period on behalf of an applicant who is otherwise
				qualified for such payments and reductions, as described in Section
				6474, provided that the tax filer
				attests to the Exchange that the tax filer understands that any APTC paid on
				their behalf are subject to reconciliation; and
(C) Clear the inconsistencies for which the
				Exchange receives satisfactory documentary evidence from the applicant or the
				enrollee. For income inconsistencies, the Exchange shall clear the
				inconsistency if the income shown on the documents provided by the applicant or
				enrollee is within 10% of the applicant's or enrollee's attestation.
(5) If, after the period described
				in subdivision (a)(2)(B) of this section, the Exchange remains unable to verify
				the attestation, shall:
(A) Determine the
				applicant's eligibility based on the information available from the data
				sources specified in Sections
				6478 through
				6492, unless such applicant
				qualifies for the exception provided under subdivision (b) of this section;
				and
(B) Notify the applicant of
				such determination in accordance with the notice requirements specified in
				Section 6476(h),
				including notice that the Exchange is unable to verify the
				attestation.
(6) When
				electronic data to support the verifications specified in Section
				6478(d) or
				Section 6480 is required but it is not
				reasonably expected that data sources will be available within one day of the
				initial request to the data source, the Exchange shall accept the applicant's
				attestation regarding the factor of eligibility for which the unavailable data
				source is relevant.
(7) The
				Exchange shall extend the period described in subdivision (a)(2)(B) of this
				section by a period of 60 days for an applicant with an income inconsistency
				who is required to present satisfactory documentary evidence to verify
				household income.