Cal. Code Regs. tit. 10 § 6496

Current through Register 2024 Notice Reg. No. 44, November 1, 2024

Section 6496 - Eligibility Redetermination During a Benefit Year

(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.

(h) If the Exchange verifies updated information reported by an enrollee, the Exchange shall:

(1) Redetermine the enrollee's eligibility in accordance with the standards specified in Sections 6472 and 6474;

(2) Notify the enrollee regarding the determination, in accordance with the requirements specified in Section 6476(h); and

(3) Notify the enrollee's employer, as applicable, in accordance with the requirements specified in Section 6476(i).

(i) If the Exchange identifies updated information through the data matching specified in subdivision (g) of this section regarding death or eligibility for or enrollment in Medicare, Medi-Cal, CHIP, or multiple overlapping QHPs, the Exchange shall:

(1) Notify the enrollee regarding the updated information, as well as the enrollee's projected eligibility determination after considering such information;

(2) Allow an enrollee 30 days from the date of the notice described in subdivision (i)(1) to notify the Exchange that such information is inaccurate;

(3) If the enrollee responds contesting the updated information, proceed in accordance with Section 6492; and

(4) If the enrollee does not respond within the 30-day period specified in subdivision (i)(2), proceed in accordance with subdivisions (h)(1) and (2) of this section, provided:

(A) The enrollee has not directed the Exchange to terminate their coverage under such circumstances, in which case the Exchange shall terminate the enrollee's coverage in accordance with Section 6506(a)(2) and (d)(3); and

(B) The enrollee has not been determined to be deceased, in which case the Exchange shall terminate the enrollee's coverage in accordance with Section 6506(d)(10).

(j) The Exchange shall implement changes resulting from an appeal decision, on the date specified in the appeal decision or consistent with the effective dates specified in Section 6618(c)(1) of Article 7 of this chapter.

(k) Except as specified in subdivision (j) or (l) of this section, the Exchange shall implement changes on the first day of the month following the month of the notice of eligibility redetermination described in subdivision (h)(2) of this section.

(l) The Exchange shall implement a change associated with the events described in Section 6504(h)(1), (2), (3), (4), (5), (6), and (7) on the coverage effective dates described in Section 6504(h)(1), (2), (3), (4), (5), (6), and (7) respectively.

(m) When an eligibility redetermination in accordance with this section results in a change in the amount of APTC for the benefit year, the Exchange shall recalculate the amount of APTC in such a manner as to:

(1) Account for any APTC already made on behalf of the tax filer for the benefit year for which information is available to the Exchange, such that the recalculated APTC amount is projected to result in total APTC for the benefit year that correspond to the tax filer's total projected premium tax credit for the benefit year, calculated in accordance with Section 36B of IRC (26 USC § 36B) and 26 CFR Section 1.36B-3; and

(2) If the recalculated APTC amount is less than zero, set the APTC provided on the tax filer's behalf to zero.

(n) In the case of a redetermination that results in a change in CSR, the Exchange shall determine an individual eligible for the category of CSR that corresponds to their expected annual household income for the benefit year, subject to the special rule for family policies set forth in Section 6474(d)(4).

Cal. Code Regs. Tit. 10, § 6496

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 26 CFR Section 1.36B-3; and 45 CFR Section 155.330.

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 26 CFR 1.36B-3; and 45 CFR Section 155.330.

1. New section filed 9-30-2013 as a deemed emergency pursuant to Government Code section 100504(a)(6); operative 9-30-2013 (Register 2013, No. 40). A Certificate of Compliance must be transmitted to OAL by 4-1-2014 or emergency language will be repealed by operation of law on the following day.
2. New section, including amendment of subsections (b) and (l), refiled 4-1-2014 as a deemed emergency pursuant to Government Code section 100504(a)(6); operative 4-1-2014 (Register 2014, No. 14). A Certificate of Compliance must be transmitted to OAL by 6-30-2014 or emergency language will be repealed by operation of law on the following day.
3. Refiling of 4-1-2014 action on 6-30-2014, including amendment of subsections (e), (g)(2), (h), (i), (j) and (m) and repealer of subsections (g)(2)(A)-(B), as a deemed emergency pursuant to Government Code section 100504(a)(6); operative 6-30-2014 (Register 2014, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-29-2014 or emergency language will be repealed by operation of law on the following day.
4. Refiling of 6-30-2014 action on 9-30-2014, including amendment of subsection (n)(2), as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31 ); operative 9-30-2014 (Register 2014, No. 40). A Certificate of Compliance must be transmitted to OAL by 9-30-2015 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
5. Editorial correction of History 4 (Register 2014, No. 45).
6. Editorial correction of History 4 (Register 2014, No. 50).
7. Refiling of 9-30-2014 action on 12-12-2014, including further amendments, as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31 ); operative 12/12/2014 (Register 2014, No. 50). A Certificate of Compliance must be transmitted to OAL by 9-30-2015 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
8. Refiling of 12-12-2014 action on 5-11-2015, including amendment of section, as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 5-11-2015 (Register 2015, No. 20). A Certificate of Compliance must be transmitted to OAL by 9-30-2015 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
9. 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 9-30-2016 or the language in the emergency order of 5-11-2015 will be repealed by operation of law on the following day (Register 2015, No. 38).
10. New section refiled 9-17-2015 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31) and Senate Bill 75 (Stats. 2015, Ch. 18); operative 9-17-2015 (Register 2015, No. 38). A Certificate of Compliance must be transmitted to OAL by 9-30-2016 pursuant to Government Code section 100504 or the language in the emergency order of 9-17-2015 will be repealed by operation of law on the following day.
11. New section, including amendment of subsection (i), repealer of subsections (j)-(j)(4), subsection relettering and amendment of newly designated subsections (j) and (k), refiled 12-14-2015 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31) and Senate Bill 75 (Stats. 2015, Ch. 18); operative 12-14-2015 (Register 2015, No. 51). A Certificate of Compliance must be transmitted to OAL by 9-30-2016 pursuant to Government Code section 100504 or the language in the emergency order of 12-14-2015 will be repealed by operation of law on the following day.
12. New section refiled 6-6-2016 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31) and Senate Bill 75 (Stats. 2015, Ch. 18); operative 6-6-2016 (Register 2016, No. 24). A Certificate of Compliance must be transmitted to OAL by 9-30-2016 pursuant to Government Code section 100504 or the language in the emergency order of 6-6-2016 will be repealed by operation of law on the following day.
13. Senate Bill 833 (Stats. 2016, c. 30) modified Government Code section 100504(a)(6) to extend the date upon which a Certificate of Compliance must be transmitted to OAL. Refiling of 6-6-2016 order on 9-30-2016 as a deemed emergency pursuant to Government Code section 100504(a)(6); operative 9-30-2016 (Register 2016, No. 40). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504(a)(6) or emergency language will be repealed by operation of law on the following day.
14. New section refiled with amendments on 2-16-2017 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 2-16-2017 (Register 2017, No. 7). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504(a)(6) or the language in the emergency order of 2-16-2017 will be repealed by operation of law on the following day.
15. New section refiled (including subsequent amendments and amendment of subsections (j) and (k) and repealer of subsections (j)(1)-(2)) on 10-26-2017 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 833 (Stats. 2016, c. 30), Senate Bill 75 (Stats. 2015, c. 18) and Senate Bill 857 (Stats. 2014, c. 31); operative 10-26-2017 (Register 2017, No. 43). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504(a)(6) or the language in the emergency order of 10-26-2017 will be repealed by operation of law on the following day.
16. Certificate of Compliance as to 10-26-2017 order, including further amendment of section and Note, transmitted to OAL 8-10-2018 and filed 9-24-2018; amendments effective 9/24/2018 pursuant to Government Code section 11343.4(b)(3) (Register 2018, No. 39).
17. Amendment of subsections (g) and (g)(2), repealer of subsections (g)(2)(A)-(B) and amendment of subsections (i) and (k)(1)-(2) filed 10-7-2019 as a deemed emergency pursuant to Government Code section 100504; operative 10/7/2019 (Register 2019, No. 41). A Certificate of Compliance must be transmitted to OAL by 10-7-2024 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
18. Amendment of subsections (g) and (g)(2), new subsections (g)(2)(A)-(B), amendment of subsections (i) and (i)(4), new subsections (i)(4)(A)-(B), amendment of subsection (k), repealer of subsections (k)(1)-(2) and amendment of subsection (l) filed 6-14-2021 as an emergency; operative 6/14/2021 (Register 2021, No. 25). Pursuant to Government Code section 100504, this is a deemed emergency. A Certificate of Compliance must be transmitted to OAL by 6-14-2026 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
19. Refiling of 10-7-2019 emergency order, including amendment of subsections (g) and (g)(2)(A)-(B), new subsection (g)(2)(C) and amendment of subsection (i), on 9-9-2022 as a deemed emergency pursuant to Government Code section 100504; operative 9/9/2022 (Register 2022, No. 36). A Certificate of Compliance must be transmitted to OAL by 10-7-2024 pursuant to Government Code section 100504(a)(6) or the language in the emergency order of 10-7-2019 will be repealed by operation of law on the following day.
20. Amendment refiled 10-13-2023 as a deemed emergency pursuant to Government Code section 100504, including further amendment of subsections (d), (f), (i)(4)(A) and (n); operative 10/13/2023 (Register 2023, No. 41). A Certificate of Compliance must be transmitted to OAL by 10-7-2024 pursuant to Government Code section 100504(a)(6)or the language in the emergency order of 10-7-2019 will be repealed by operation of law on the following day.
21. Certificate of Compliance as to 10-13-2023 order, including amendment of NOTE, transmitted to OAL 6-11-2024 and filed 7-24-2024; amendments effective 7/24/2024 pursuant to Government Code section 11343.4(b)(3) (Register 2024, No. 30).