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§ 6530. Special Enrollment Periods for Qualified Employees and Dependents.

10 CA ADC § 6530BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS

Barclays Official California Code of Regulations Currentness
Title 10. Investment
Chapter 12. California Health Benefit Exchange
Article 6. Application, Eligibility, and Enrollment in the Shop Exchange
10 CCR § 6530
§ 6530. Special Enrollment Periods for Qualified Employees and Dependents.
(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.
(B) Loses pregnancy-related coverage described under Section 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)(IV), (a)(10)(A)(ii)(IX)) and Section 14005.18 of the Welfare and Institutions Code. The date of the loss of coverage is the last day the consumer would have pregnancy-related coverage; or
(C) Loses Medi-Cal coverage for the 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 Medi-Cal coverage is the last day the consumer would have medically needy coverage.
(2) A qualified employee gains a dependent or becomes a dependent through marriage or entry into domestic partnership, birth, adoption, placement for adoption, placement in foster care, assumption of a parent-child relationship, or through a child support order or other court order.
(3) The enrollee loses a dependent or is no longer considered a dependent through divorce or legal separation as defined by State law in the State in which the divorce or legal separation occurs, or if the enrollee, or his or her dependent, dies.
(4) The qualified employee'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, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities, as evaluated and determined by the Exchange. In such cases, the Exchange shall take necessary actions to correct or eliminate the effects of such error, misrepresentation, inaction, or misconduct. 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.
(5) An enrollee adequately demonstrates to the Exchange, with respect to QHPs offered through the Exchange, or to the applicable regulator, with respect to health plans offered outside the Exchange, that the Issuer of the health coverage or dental coverage in which he or she is enrolled, substantially violated a material provision of its contract in relation to the enrollee or his or her dependents.
(6) An enrollee, qualified employee, or his or her dependent, gains access to new QHPs as a result of a permanent move.
(7) The qualified employee, or his or her dependent, was released from incarceration.
(8) The qualified employee, or his or her dependent, is a member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service under Title 32 of the United States Code.
(9) A qualified employee who is an Indian, as defined by Section 4 of the Indian Health Care Improvement Act (25 U.S.C. Section 1603(c)), and his or her dependent who is enrolled or is enrolling in a QHP through an Exchange on the same application as the qualified employee, may enroll in a QHP or change from one QHP to another one time per month.
(10) A qualified employee, 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 may include, but are not limited to, the following:
(A) If a child who has been determined ineligible for Medi-Cal and CHIP, and for whom a party other than the party who expects to claim him or her as a tax dependent is required by court order to provide health coverage for the child, the child shall be eligible for a special enrollment period if otherwise eligible for enrollment in a QHP.
(11) A qualified employee or dependent demonstrates to the Exchange, with respect to health plans offered through the Exchange, or to the applicable regulator, with respect to health plans offered outside the Exchange, that he or she did not enroll in a health plan during the immediately preceding enrollment period available to the employee or dependent because he or she was misinformed that he or she was covered under MEC.
(12) A qualified employee, or his or her dependent, is receiving services from a contracting provider under a health plan, as defined in Section 1399.845(f) of the Health and Safety Code or Section 10965(f) of the Insurance Code, for one of the conditions described in Section 1373.96(c) of the Health and Safety Code or section 10133.56(a) of the Insurance Code, and that provider is no longer participating in the health plan.
(13) A qualified employee, or his or her dependent, loses eligibility for health coverage under a Medi-Cal plan under title XIX of the Social Security Act or a state child health plan under title XXI of the Social Security Act.
(14) A qualified employee, or his or her dependent, becomes eligible for assistance, with respect to health coverage under a SHOP, under a Medi-Cal plan (including any waiver or demonstration project conducted under or in relation to such a plan).
(15) A qualified employee, or his or her dependent, is a victim of domestic abuse or spousal abandonment, as specified in 26 CFR Section 1.36B-2 (b)(2)(ii) through (v) (July 26, 2017), hereby incorporated by reference, is enrolled in MEC, and seeks to enroll in a QHP 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 a QHP at the same time as the victim.
(16) A qualified employee or dependent -
(A) Applies for health 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 the Children's Health Insurance Program (CHIP), and is determined ineligible for Medi-Cal or CHIP by the State Medi-Cal or CHIP agency either after open enrollment has ended or more than 60 days after the qualifying event; or
(B) Applies for health 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 has ended.
(17) The qualified employee, or his or her dependent, adequately demonstrates to the Exchange that a material error related to plan benefits, service area, or premium influenced the qualified employee's or dependent's decision to purchase a QHP through the Exchange.
(18) The qualified employee or his or her dependent experiences any other triggering events identified in California Insurance Code section 10753.05(b)(3) and California Health and Safety Code section 1357.503(b).
(c) A qualified employee, or his or her dependent, who experiences one of the situations described in subdivision (b) of this section has:
(1) 30 days from the date of the event described in paragraphs (b)(1)-(11) and (b)(15)-(18) of that subdivision in this section to select a QHP through the SHOP.
(2) 30 days from the date of the event described in paragraphs (b)(12) or (g)(1) of this section to select a QDP through the SHOP.
(3) 60 days from the date of the event described in paragraphs (b)(13) and (b)(14) of that subdivision in this section to select a QHP through the SHOP.
(d) A dependent of a qualified employee is not eligible for a special enrollment period if the qualified employer does not extend the offer of health coverage or dental coverage to dependents.
(e) Loss of MEC, as specified in subdivision (b)(1) of this section, includes:
(1) Loss of eligibility for health coverage, including but not limited to:
(A) Loss of eligibility for health coverage as a result of:
1. Legal separation;
2. Divorce;
3. Cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the health plan);
4. Death of an employee;
5. Termination of employment; and
6. Reduction in the number of hours of employment;
(B) Loss of eligibility for coverage through Medicare, Medicaid, or other government-sponsored health care programs, other than programs specified as not MEC under 26 CFR Section 1.5000A-2(b)(2) (November 26, 2014), hereby incorporated by reference;
(C) In the case of health coverage offered through an HMO or similar program in the individual market that does not provide health coverage to individuals who no longer reside, live, or work in a service area, loss of health 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 health coverage offered through an HMO or similar program in the group market that does not provide health coverage to individuals who no longer reside, live, or work in a service area, loss of health 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;
(E) A situation in which a health plan no longer offers any health coverage to the class of similarly situated individuals that includes the individual; and
(F) Loss of that coverage due to the circumstances described in Section 1163 of Title 29 of the United States Code. “Loss of minimum essential coverage” also includes loss of that coverage for a reason that is not due to the fault of the individual.
(2) Termination of qualified employer contributions toward the qualified employee's or dependent's health insurance coverage that is not COBRA continuation coverage, including contributions by any current or former employer that was contributing to health coverage for the qualified employee or dependent;
(3) Exhaustion of COBRA or Cal-COBRA continuation health coverage, meaning that such coverage ceases for any reason other than a reason specified in subdivision (e)(4) of this section. 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, but not of the employee or dependent receiving COBRA benefits, 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.
(4) Loss of MEC, as specified in subdivision (b)(1) of this section, does not include termination or loss due to:
(A) The employee's or dependent's failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; or
(B) Subject to Section 10384.17 of the Insurance Code and Section 1365 of the Health and Safety Code, termination of coverage due to a carrier demonstrating fraud or an intentional misrepresentation of material fact under the terms of the policy by the policyholder, contractholder, or employer.
(f) If requested by a QHP Issuer or SHOP, an employee or a dependent of an employee who experiences a triggering event that gives rise to a special enrollment period pursuant to this section must provide verification of the triggering event to SHOP for review.
(g) A qualified employee or his or her dependent may enroll in a QDP during a special enrollment period outside of the initial and annual open enrollment periods in the following situations:
(1) Loss of eligibility for dental coverage. Loss of eligibility for dental coverage shall be consistent with any of following situations specified in subdivisions (b)(11) or (e)(1)-(3) of this section. The date of the loss of dental coverage shall be the date of the last day the qualified employee, or his or her dependent, would have dental coverage under his or her previous plan or coverage.
(2) Loss of eligibility for dental coverage does not include termination or loss of dental coverage due to any of the situations specified in subdivisions (e)(4)(A)-(B).
(3) A qualified employee, or his or her dependent, loses eligibility for pediatric dental coverage subsequent to turning nineteen (19) years of age and wishes to continue dental coverage under a standalone dental plan offered by a QDP Issuer in the SHOP;
(h) The effective dates of coverage are determined using the provisions of Section 6534.
(i) Limitation. Qualified employees will not be able to enroll unless the employer group meets any applicable minimum participation rules under Section 6522(a)(4).
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 10503, Government Code; 26 CFR Sections 1.36B-2, 1.5000A-2 and 54.9801-2; 45 CFR Sections 147.104, 155.420, 155.725, 155.1080 and 156.285; Sections 1357.503 and 1399.849, Health and Safety Code; and Sections 10753.05, 10753.063.5 and 10965, Insurance Code.
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 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. New section refiled 6-30-2014 as a deemed emergency pursuant to Government Code section 100504 subdivision (a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 6-30-2014 (Register 2014, No. 27). 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.
4. New section, including amendment of subsections (a)(2) and (e), refiled 10-2-2014 as a deemed emergency pursuant to Government Code section 100504, subdivision (a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 10-2-2014 (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 3 and History 4 (Register 2014, No. 45).
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 9-30-2016 or the language in the emergency order of 10-2-2014 will be repealed by operation of law on the following day (Register 2015, No. 38).
7. 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 10-2-2014 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.
8. Refiling of 9-30-2016 order, including further amendment of section and amendment of Note, on 11-28-2016 as a deemed emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 833 (Stats. 2016, c. 30); operative 11-28-2016 (Register 2016, No. 49). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
9. Refiling of 11-28-2016 order, including further amendment of section, filed 4-20-2018 as a deemed emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 833 (Stats. 2016, c.30); operative 4-20-2018 (Register 2018, No. 16). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 4-20-2018 order, including amendment of section and Note, transmitted to OAL 8-3-2018 and filed 9-17-2018; amendments effective 9-17-2018 pursuant to Government Code section 11343.4(b)(3) (Register 2018, No. 38).
11. Amendment filed 9-7-2021 as an emergency; operative 9-7-2021 (Register 2021, No. 37). Pursuant to Government Code section 100504(a)(6)(A), a Certificate of Compliance must be transmitted to OAL by 9-7-2026 or emergency language will be repealed by operation of law on the following day.
This database is current through 11/12/21 Register 2021, No. 46
10 CCR § 6530, 10 CA ADC § 6530
End of Document