California Code of Regulations › Title 10 - Investment › Chapter 12 - California Health Benefit Exchange › Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange › Section 6540 - Definitions for the Small Business Health Options Program (SHOP) Appeals Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
In addition to the definitions in Section
				  6410 of Article 2 of this chapter,
				  for purposes of the SHOP Appeals Process, the following terms shall
				  mean:
Appeal record: The appeal decision, all papers and requests
				  filed in the proceeding, and, if a hearing was held, the transcript or
				  recording of hearing testimony or an official report containing the substance
				  of what happened at the hearing and any exhibits introduced at the
				  hearing.
Appeals Representative: an authorized representative, an
				  agent or broker of the employer, legal counsel, a relative, a friend, an
				  employer filing for its employee or another spokesperson designated by the
				  appellant.
Appeal request: A clear expression, either orally or in
				  writing, by an applicant, enrollee, employer, or employee to have any SHOP
				  eligibility determination reviewed by an appeals entity.
Appeals entity: A body designated to conduct appeals hearings
				  of any SHOP eligibility determinations. The California Department of Social
				  Services shall be the designated appeals entity for the SHOP.
Appellant: The applicant or enrollee, the employer, or
				  employee who is requesting an appeal.
De novo review: A review of an appeal without deference to
				  prior decisions in the case.
Eligibility determination: A determination that an applicant,
				  enrollee, employer, or employee is eligible or not eligible for enrollment in a
				  QHP pursuant to this Article.
Evidentiary hearing: A hearing conducted where evidence may
				  be presented.
Good Cause: Cause as defined in Section
				  10951(b)(2)
				  of the Welfare and Institutions Code.
Statement of Position: A writing submitted by the Appellant
				  or SHOP that describes the Appellant's or SHOP's position regarding an appeal,
				  as specified in Section
				  10952.5 of the Welfare and
				  Institution Code.
Vacate: To set aside a previous action.
1. New section
				  filed 12-3-2013 as an emergency; operative 12-3-2013 (Register 2013, No. 49). A
				  Certificate of Compliance must be transmitted to OAL by 6-2-2014 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. New section refiled 6-2-2014 as an emergency; operative
				  6-2-2014 (Register 2014, No. 23). A Certificate of Compliance must be
				  transmitted to OAL by 9-2-2014 or emergency language will be repealed by
				  operation of law on the following day.
3. New section refiled
				  9-2-2014 as an emergency pursuant to Government Code section
				  100504(a)(6),
				  as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 9-2-2014
				  (Register 2014, No. 36). A Certificate of Compliance must be transmitted to OAL
				  by 12-3-2015 pursuant to Government Code section
				  100504 or
				  emergency language will be repealed by operation of law on the following
				  day.
4. 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 12-5-2016 or the language in the
				  emergency order of 9-2-2014 will be repealed by operation of law on the
				  following day (Register 2015, No. 38).
5. Certificate of Compliance
				  as to 9-2-2014 order, including amendment of definitions of "Eligibility
				  determination" and "Statement of Position," transmitted to OAL 5-4-2016 and
				  filed 6-14-2016; amendments effective 6-14-2016 pursuant to Government Code
				  section
				  11343.4(b)(3)
				  (Register 2016, No. 25).
Note: Authority cited: Section
					 100504,
					 Government Code. Reference: Section
					 100506,
					 Government Code; and 45 CFR
					 §
												155.740.