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§ 6504. Special Enrollment Periods.

10 CA ADC § 6504BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS

Barclays Official California Code of Regulations Currentness
Title 10. Investment
Chapter 12. California Health Benefit Exchange
Article 5. Application, Eligibility, and Enrollment Process for the Individual Exchange
10 CCR § 6504
§ 6504. Special Enrollment Periods.
(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 his or her 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 his or her dependent would have coverage under his or her 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;
(B) Is enrolled in any non-calendar year group health plan or individual health insurance coverage, including both grandfathered and non-grandfathered health plans that expired or will expire, even if the qualified individual or his or her dependent has the option to renew such coverage. The date of the loss of coverage shall be the last day of the plan or policy year;
(C) Loses Medi-Cal coverage for pregnancy-related services, as described under Section 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Social Security Act (42 USC 1396a(a)(10)(A)(i)(IV), (a)(10)(A)(ii)(IX)) and Section 14005.18 of the Welfare and Institutions Code or loses access to healthcare services through coverage provided to a pregnant woman's unborn child, based on the definition of a child in 42 CFR Section 457.10, (November 30, 2016), hereby incorporated by reference. The date of the loss of coverage shall be the last day the consumer would have pregnancy-related coverage or access to healthcare services through unborn child coverage; or
(D) Loses Medi-Cal coverage for medically needy, as described under Section 1902(a)(10)(C) of the Social Security Act and Section 14005.21 of the Welfare and Institutions Code, only once per calendar year. The date of the loss of coverage shall be the last day the consumer would have medically needy coverage.
(2) A qualified individual gains a dependent or becomes a dependent through marriage or entry into domestic partnership, birth, adoption, placement for adoption, or placement in foster care, or through a child support order or other court order.
(3) An enrollee loses a dependent or is no longer considered a dependent through divorce, legal separation, or dissolution of domestic partnership as defined by State law in the State in which the divorce, legal separation, or dissolution of domestic partnership occurs, or if the enrollee, or his or her dependent, dies.
(4) A qualified individual, or his or her dependent, becomes newly eligible for enrollment in a QHP through the Exchange because he or she newly meets the requirements specified in Section 6472(c) or (d).
(5) A qualified individual's, or his or her dependent's, enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, a QHP issuer, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities. For purposes of this provision, misconduct, as determined by the Exchange, includes the failure to comply with applicable standards under this title, or other applicable Federal or State laws.
(6) An enrollee, or his or her dependent, adequately demonstrates to the Exchange, as determined by the Exchange on a case-by-case basis, that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee.
(7) An enrollee, or his or her dependent enrolled in the same QHP, is determined newly eligible or ineligible for APTC or has a change in eligibility for CSR.
(8) A qualified individual, or his or her dependent, who is enrolled in an eligible employer-sponsored plan is determined newly eligible for APTC because such individual is ineligible for qualifying coverage in an eligible employer-sponsored plan in accordance with 26 CFR Section 1.36B-2(c)(3), including as a result of his or her employer discontinuing or changing available coverage within the next 60 days, provided that such individual is allowed to terminate existing coverage.
(9) A qualified individual or enrollee, or his or her dependent, gains access to new QHPs as a result of a permanent move.
(10) A qualified individual who:
(A) Gains or maintains status as an Indian, as defined in Section 6410 of Article 2 of this chapter, may enroll in a QHP or change from one QHP to another one time per month; or
(B) Is or becomes a dependent of an Indian, as defined in Section 6410 of Article 2 of this chapter, and is enrolled or is enrolling in a QHP through the Exchange on the same application as the Indian, may change from one QHP to another one time per month, at the same time as the Indian.
(11) A qualified individual or enrollee, or his or her dependent, demonstrates to the Exchange, in accordance with guidelines issued by HHS and as determined by the Exchange on a case-by-case basis, that the individual meets other exceptional circumstances. Such circumstances include, but are not limited to, the following:
(A) If an individual receives a certificate of exemption for hardship based on the eligibility standards described in 45 CFR Section 155.605(g)(1) (April 17, 2018), hereby incorporated by reference, for a month or months during the coverage year, and based on the circumstances of the hardship attested to, he or she is no longer eligible for a hardship exemption within a coverage year but outside of an open enrollment period described in Section 6502, the individual and his or her dependents shall be eligible for a special enrollment period if otherwise eligible for enrollment in a QHP.
(B) If an individual with a certificate of exemption reports a change regarding the eligibility standards for an exemption, as required under 45 CFR Section 155.620(b), (July 1, 2013), hereby incorporated by reference, and the change resulting from a redetermination is implemented, the certificate provided for the month in which the redetermination occurs, and for prior months, remains effective. If the individual is no longer eligible for an exemption, the individual and his or her dependents shall be eligible for a special enrollment period if otherwise eligible for enrollment in a QHP.
(C) If an enrollee provides satisfactory documentary evidence to verify his or her eligibility for an IAP or enrollment in a QHP through the Exchange within 30 days following his or her termination of Exchange enrollment due to a failure to verify such status within the 95-day period specified in Section 6492(a)(2)(B), the enrollee shall be eligible for a special enrollment period if otherwise eligible for enrollment in a QHP.
(12) A qualified individual or enrollee is a victim of domestic abuse or spousal abandonment, as specified in 26 CFR Section 1.36B-2 (b)(2)(ii) through (v), or a dependent or unmarried victim within a household, is enrolled in MEC, and seeks to enroll in coverage separate from the perpetrator of the abuse or abandonment. A dependent of a victim of domestic abuse or spousal abandonment who is on the same application as the victim may enroll in coverage at the same time as the victim.
(13) A qualified individual, or his or her dependent:
(A) Applies for coverage on the Exchange during the annual open enrollment period or due to a qualifying event, is assessed by the Exchange as potentially eligible for Medi-Cal or CHIP, and is determined ineligible for Medi-Cal or CHIP by the State Medi-Cal or CHIP agency either after open enrollment period has ended or more than 60 days after the qualifying event; or
(B) Applies for coverage at the State Medi-Cal or CHIP agency during the annual open enrollment period, and is determined ineligible for Medi-Cal or CHIP after open enrollment period has ended.
(14) The qualified individual or enrollee, or his or her dependent, adequately demonstrates to the Exchange, as determined by the Exchange on a case-by-case basis, that a material error related to plan benefits, service area, or premium influenced the qualified individual's or enrollee's decision to purchase a QHP through the Exchange.
(15) Any other triggering events listed in the Health and Safety Code Section 1399.849(d)(1) and the Insurance Code Section 10965.3(d)(1).
(b) Loss of MEC, as specified in subdivision (a)(1)(A) of this section, includes:
(1) Loss of eligibility for coverage, including but not limited to:
(A) Loss of eligibility for coverage as a result of:
1. Legal separation,
2. Divorce or dissolution of domestic partnership,
3. Cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the plan),
4. Death of an employee,
5. Termination of employment,
6. Reduction in the number of hours of employment, or
7. Any loss of eligibility for coverage after a period that is measured by reference to any of the foregoing;
(B) Loss of eligibility for coverage through Medicare, Medi-Cal, or other government-sponsored health care programs, other than programs specified as not MEC under 26 CFR Section 1.5000A-2(b)(1)(ii) (November 26, 2014), hereby incorporated by reference;
(C) In the case of coverage offered through an HMO or similar program in the individual market that does not provide benefits to individuals who no longer reside, live, or work in a service area, loss of coverage because an individual no longer resides, lives, or works in the service area (whether or not within the choice of the individual);
(D) In the case of coverage offered through an HMO or similar program in the group market that does not provide benefits to individuals who no longer reside, live, or work in a service area, loss of coverage because an individual no longer resides, lives, or works in the service area (whether or not within the choice of the individual), and no other benefit package is available to the individual; and
(E) A situation in which a plan no longer offers any benefits to the class of similarly situated individuals that includes the individual.
(2) Termination of employer contributions toward the employee's or dependent's coverage that is not COBRA continuation coverage, including contributions by any current or former employer that was contributing to coverage for the employee or dependent; and
(3) Exhaustion of COBRA continuation coverage, meaning that such coverage ceases for any reason other than either failure of the individual to pay premiums on a timely basis, or for cause, such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan. An individual is considered to have exhausted COBRA continuation coverage if such coverage ceases:
(A) Due to the failure of the employer or other responsible entity to remit premiums on a timely basis;
(B) When the individual no longer resides, lives, or works in the service area of an HMO or similar program (whether or not within the choice of the individual) and there is no other COBRA continuation coverage available to the individual; or
(C) When the individual incurs a claim that would meet or exceed a lifetime limit on all benefits and there is no other COBRA continuation coverage available to the individual.
(c) Loss of coverage, as specified in subdivision (a)(1) of this section, does not include voluntary termination of coverage or loss due to:
(1) Failure to pay premiums on a timely basis, including COBRA premiums prior to exhaustion of COBRA coverage; or
(2) Termination of coverage for cause, such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with a plan.
(d) A qualified individual or an enrollee shall attest under penalty of perjury that he or she meets at least one of the triggering events specified in subdivision (a) of this section. The Exchange shall inform the qualified individual or the enrollee that pursuant to 45 CFR Section 155.285, (September 6, 2016), hereby incorporated by reference, HHS may impose civil money penalties of:
(1) Up to $25,000 on the qualified individual or the enrollee who fails to provide the correct information requested by the Exchange, subject to the exception specified in subdivision (e)(4) of this section, due to his or her negligence or disregard of the federal or State rules or regulations related to the Exchange with negligence and disregard defined as they are in section 6662 of IRC (26 USC § 6662), as follows:
(A) “Negligence” includes any failure to make a reasonable attempt to provide accurate, complete, and comprehensive information; and
(B) “Disregard” includes any careless, reckless, or intentional disregard for any federal or State rules or regulations related to the Exchange; and
(2) Up to $250,000 on the qualified individual or the enrollee who:
(A) Knowingly and willfully provides false or fraudulent information requested by the Exchange, where knowingly and willfully means intentionally providing information that the person knows to be false or fraudulent; or
(B) Knowingly and willfully uses or discloses information in violation of Section 1411(g) of the Affordable Care Act (42 USC § 18081(g)), where knowingly and willfully means intentionally using or disclosing information in violation of Section 1411(g).
(e) The Exchange shall accept the qualified individual's or the enrollee's attestation provided in accordance with subdivision (d) of this section, subject to the following statistically valid random sampling verification process:
(1) The Exchange may select a statistically valid random sample of the qualified individuals or the enrollees who, in accordance with subdivision (d) of this section, have attested that they met at least one of the triggering events specified in subdivision (a) of this section and request, in writing, that they provide documentation as proof of the triggering event to which they attested or for which they qualify.
(2) The qualified individual or the enrollee shall provide the requested document(s) within 30 days from the date of the Exchange's written request, as specified in subdivision (e)(1) of this section, to the Exchange for verification. The Exchange may extend this period if the Exchange determines on a case-by-case basis that the qualified individual or the enrollee has demonstrated that he or she has made a good-faith effort but was unable to obtain the requested documentation during the 30-day time period.
(3) Except as specified in subdivision (e)(4) of this section, if the qualified individual or the enrollee fails to submit the requested document(s) by the end of the time period specified in subdivision (e)(2) of this section or the Exchange is unable to verify the provided document(s), the Exchange shall:
(A) Determine the qualified individual or the enrollee ineligible for any special enrollment period;
(B) Notify the qualified individual or the enrollee regarding the determination and his or her appeals rights, in accordance with the requirements specified in Section 6476(h); and
(C) Implement such eligibility determination in accordance with the dates specified in Section 6496(j) and (k), as applicable.
(4) The Exchange shall provide an exception, on a case-by-case basis, to accept a qualified individual's or an enrollee's attestation as to his or her triggering event which cannot otherwise be verified and his or her explanation of circumstances as to why he or she does not have documentation if:
(A) The qualified individual or the enrollee does not have the requested documentation with which to prove a triggering event through the process described in subdivision (e)(1) through (3) of this section because such documentation does not exist or is not reasonably available;
(B) The Exchange is unable to otherwise verify the triggering event for the qualified individual or the enrollee; and
(C) The qualified individual or the enrollee provides the Exchange with a signed written statement of his or her attestation under penalty of perjury as to the triggering event and the explanation of circumstances as to why he or she does not have the documentation.
(5) The sampling described in this subdivision shall not be based on the qualified individual's or the enrollee's claims costs, diagnosis code, or demographic information. For purposes of this subdivision (e)(5), demographic information does not include geographic factors.
(f) Except as provided in subdivision (f)(1) and (2) of this section, a qualified individual or an enrollee shall have 60 days from the date of a triggering event to select a QHP.
(1) A qualified individual or his or her dependent who loses coverage, as described in subdivision (a)(1) of this section shall have 60 days before and after the date of the loss of coverage to select a QHP.
(2) A qualified individual who is enrolled in an eligible employer-sponsored plan and will lose eligibility for qualifying coverage in an eligible employer-sponsored plan within the next 60 days, as described in subdivision (a)(8) of this section, shall have 60 days before and after the loss of eligibility for qualifying coverage in an eligible employer-sponsored plan to select a QHP.
(g) Except as specified in subdivision (h) of this section, regular coverage effective dates for a special enrollment period for a QHP selection received by the Exchange from a qualified individual:
(1) Between the first and fifteenth day of any month, shall be the first day of the following month; and
(2) Between the sixteenth and last day of any month, shall be the first day of the second following month.
(h) Special coverage effective dates shall apply to the following situations.
(1) In the case of birth, adoption, placement for adoption, or placement in foster care, the coverage shall be effective either:
(A) On the date of birth, adoption, placement for adoption, or placement in foster care; or
(B) On the first day of the month following plan selection; or
(C) In accordance with the regular coverage effective dates specified in subdivision (g) of this section, at the option of the qualified individual or the enrollee.
(2) In the case of marriage or entry into domestic partnership, the coverage and APTC and CSR, if applicable, shall be effective on the first day of the month following plan selection.
(3) In the case where a qualified individual, or his or her dependent, loses coverage, as described in subdivisions (a)(1) and (a)(8) of this section, the coverage and APTC and CSR, if applicable, shall be effective:
(A) On the first day of the month following the loss of coverage if the plan selection is made on or before the date of the loss of coverage; or
(B) On the first day of the month following plan selection if the plan selection is made after the date of the loss of coverage.
(4) In the case of a qualified individual or enrollee eligible for a special enrollment period described in subdivisions (a)(5), (a)(6), (a)(11), (a)(13), or (a)(14) of this section, the coverage shall be effective on an appropriate date, including a retroactive date, determined by the Exchange on a case-by-case basis based on the circumstances of the special enrollment period.
(5) In the case of a court order described in subdivision (a)(2) of this section, the coverage shall be effective either:
(A) On the date the court order is effective;
(B) On the first day of the month following plan selection; or
(C) In accordance with the regular coverage effective dates specified in subdivision (g) of this section, at the option of the qualified individual or the enrollee.
(6) If an enrollee or his or her dependent dies, as described in subdivision (a)(3) of this section, the coverage shall be effective on the first day of the month following the plan selection.
(i) A qualified individual's coverage shall be effectuated in accordance with the coverage effective dates specified in subdivisions (g) and (h) of this section if:
(1) The individual makes his or her initial premium payment, reduced by the APTC amount he or she is determined eligible for by the Exchange, by the premium payment due date, as defined in Section 6410 of Article 2 of this chapter. In cases of retroactive enrollment dates, the initial premium shall consist of the premium due for all months of retroactive coverage through the first month of coverage following the plan selection date. If only partial premium for less than all months of retroactive coverage is paid, only prospective coverage shall be effectuated, in accordance with the regular coverage effective dates specified in subdivision (g) of this section; and
(2) The applicable QHP issuer receives such payment on or before such due date.
(j) Notwithstanding the standards of this section, APTC and CSR shall adhere to the effective dates specified in subdivisions (j) through (l) of Section 6496.
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 26 CFR Sections 1.36B-2 and 1.5000A-2; 42 CFR Section 457.10; and 45 CFR Sections 155.420, 155.605, 155.620 and 155.1080.
HISTORY
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, with amendments, 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 further amendments, 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 further amendment of subsection (d) and new subsection (j), 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, including new subsection (a)(10)(D), 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 subsections (i)(1) and (j), 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 with amendments on 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 833 (Stats. 2016, c. 30), Senate Bill 75 (Stats. 2015, c. 18) and 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 repealer of subsection (a)(11)(C), subsection relettering and amendment of subsections (a)(12) and (i)(1)) 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).
This database is current through 7/5/19 Register 2019, No. 27
10 CCR § 6504, 10 CA ADC § 6504
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