Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Certified Application Counselors shall perform
the following functions:
(1) Provide information
to individuals and employees about the full range of QHP options and insurance
affordability programs for which they are eligible, which includes providing fair,
impartial, and accurate information that assists consumers with submitting the
eligibility application; clarifying the distinctions among health coverage options,
including QHPs; and helping consumers make informed decisions during the health
coverage selection process;
(2) Assist
individuals and employees in applying for coverage in a QHP through the Exchange and
for insurance affordability programs;
(3) Help to facilitate enrollment of eligible
individuals into QHPs and insurance affordability programs;
(4) Comply with the privacy and security
requirements in 45 C.F.R. §
155.260;
(5) Act in the best interest of the applicants
assisted;
(6) Either directly or through
an appropriate referral to assist personnel certified pursuant to Article 8 of this
Chapter, provide information in a manner that is accessible to individuals with
disabilities, as defined by the Americans with Disabilities Act, as amended,
42 U.S.C. Section
12101 et seq. and Section 504 of the
Rehabilitation Act, as amended, 29 U.S.C. Section 794;
(7) Ensure that voter registration assistance is
available in compliance with Section
6462 of Article 4 of this
Chapter;
(8) Comply with any applicable
federal or state laws and regulations;
(9) Provide referrals to any applicable office of
health insurance Consumer Assistance or health insurance ombudsman established under
Section 2793 of the Public Health Service Act,
42 U.S.C. §
300gg-93, or any other appropriate state agency or
agencies, for any enrollee with a grievance, complaint, or question regarding their
health plan, coverage, or a determination under such plan or coverage; and
(10) Provide referrals to licensed tax advisers,
tax preparers, or other resources for assistance with tax preparation and tax advice
related to consumer questions about the Exchange application and enrollment process,
exemptions from the requirement to maintain minimum essential coverage and from the
individual shared responsibility payment, and premium tax credit
reconciliations.
(b) Prior to
receiving access to any consumer's personally identifiable information as defined in
Section 6650 of Article 8, the Certified
Application Counselor shall:
(1) Inform the
consumer that the Certified Application Counselor must obtain his or her
authorization prior to accessing any personally identifiable information;
(2) Inform each consumer of the roles and
responsibilities of the Certified Application Counselor as set forth in this
section;
(3) Inform each consumer that
Certified Application Counselors are not acting as tax advisers or attorneys when
providing assistance as Certified Application Counselors and cannot provide tax or
legal advice within their capacity as Certified Application Counselors;
(4) Obtain oral or written authorization from the
consumer to access the consumer's personally identifiable information;
(A) Written authorization shall contain a
consumer's signature and a written attestation completed by the Certified
Application Counselor affirming under penalty of perjury that the Certified
Application Counselor:
1. Is a Certified
Application Counselor affiliated with a Certified Application Entity;
2. Conveyed all the information required under
this subdivision to the consumer in a language and manner which he or she
understands; and
3. Obtained written
authorization from the consumer consenting to the release of his or her personally
identifiable information as defined in Article 8 in order to fulfill the duties as
described in this section.
(B)
Oral authorization shall be accompanied by a written attestation completed by the
Certified Application Counselor affirming under penalty of perjury that the
Certified Application Counselor:
1. Is a Certified
Application Counselor affiliated with a Certified Application Entity;
2. Conveyed all the information required under
this subdivision to the consumer in a language and manner which he or she
understands; and
3. Obtained oral
authorization from the consumer consenting to the release of his or her personally
identifiable information in order to fulfill the duties as described in this
section.
(5) Inform
the consumer that the Certified Application Counselor cannot choose a health
insurance plan on the consumer's behalf;
(6) Inform the consumer that the Certified
Application Counselor will provide the consumer with information regarding the
health insurance options and insurance affordability programs for which he or she
may be eligible;
(7) Inform the consumer
that his or her personally identifiable information will be kept private and secure
in accordance with the standards set forth in
45 C.F.R. §
155.260;
(8) Inform the consumer that if the Certified
Application Counselor cannot assist the consumer, he or she will refer the consumer
to another Certified Application Counselor or the Covered California Call
Center;
(9) Inform the consumer that the
Certified Application Counselor will not charge a fee in exchange for performing the
duties described in this section;
(10)
Inform the consumer that the assistance is based only on the information provided by
the consumer, and if the information given is inaccurate or incomplete, the
Certified Application Counselor may not be able to offer assistance;
(11) Inform the consumer that the authorization
set forth in subdivision (b)(4) of this section may be revoked at any time;
and
(12) Maintain a record of such
authorization for a minimum of ten (10) years.
(c) Certified Application Counselors shall include
the following in a consumer's application to the Exchange:
(1) Name and certification number of the Certified
Application Counselor;
(2) Name of the
Certified Application Entity and the Certified Application Entity Number;
and
(3) Signature and date of signature
by the Certified Application Counselor.
(d) If any of the information listed in
subdivision (c) of this section is not included on the consumer's original
application, it may not be added at a later time.
(e) Certified Application Counselors shall wear
the badge issued by the Exchange at all times when performing duties under this
section.
(f) Certified Application
Entities must maintain a physical presence in the state of California so that
face-to-face assistance can be provided to applicants and enrollees.
(g) Certified Application Entities shall maintain
a registration process and method to track the performance of Certified Application
Counselors.
(h) To ensure that
information provided as part of any Consumer Assistance is culturally and
linguistically appropriate to the needs of the population being served, including
individuals with limited English proficiency as required by
45 C.F.R. §§
155.205(c)(2) and
155.225, Certified Application Entities
and Certified Application Counselors shall:
(1)
Develop and maintain general knowledge about the racial, ethnic, and cultural groups
in their service area, including each group's diverse cultural health beliefs and
practices, preferred languages, health literacy, and other needs;
(2) Collect and maintain updated information to
help understand the composition of the communities in the service area, including
the primary languages spoken;
(3)
Provide consumers with information and assistance in the consumer's preferred
language, at no cost to the consumer, including the provision of oral interpretation
of non-English languages and the translation of written documents in non-English
languages when necessary to ensure meaningful access. Use of a consumer's family or
friends as oral interpreters can satisfy the requirement to provide linguistically
appropriate services only when requested by the consumer as the preferred
alternative to an offer of other interpretive services;
(4) Provide oral and written notice to consumers
with limited English proficiency informing them of their right to receive language
assistance services and how to obtain them;
(5) Receive ongoing education and training in
culturally and linguistically appropriate service delivery; and
(6) Implement strategies to recruit, support, and
promote a staff that is representative of the demographic characteristics, including
primary languages spoken, of the communities in their service
area.
(i) To ensure that
Consumer Assistance is accessible to people with disabilities, Certified Application
Entities and Certified Application Counselors shall:
(1) Ensure that any consumer education materials,
web sites, or other tools utilized for Consumer Assistance purposes are accessible
to people with disabilities, including those with sensory impairments, such as
visual or hearing impairments, and those with mental illness, addiction, and
physical, intellectual, and developmental disabilities;
(2) Provide auxiliary aids and services for
individuals with disabilities, at no cost, where necessary for effective
communication. Use of a consumer's family or friends as interpreters can satisfy the
requirement to provide auxiliary aids and services only when requested by the
consumer as the preferred alternative to an offer of other auxiliary aids and
services;
(3) Provide assistance to
consumers in a location and in a manner that is physically and otherwise accessible
to individuals with disabilities;
(4)
Ensure that legally authorized representatives are permitted to assist an individual
with a disability to make informed decisions; and
(5) Acquire sufficient knowledge to refer people
with disabilities to local, state, and federal long-term services and support
programs when appropriate.
(j)
To ensure that no consumer is discriminated against, Certified Application Entities
and Certified Application Counselors shall provide the same level of service to all
individuals regardless of age, disability, culture, sexual orientation, or gender
identity, and seek advice or experts when needed.
(k) Certified Application Entities and Certified
Application Counselors may not:
(1) Impose or
induce any fee, charge, or remuneration on applicants for application or other
assistance related to the Exchange;
(2)
Be a QHP;
(3) Receive any direct or
indirect consideration from any health insurance issuer or issuer of stop-loss
insurance in connection with the enrollment of any individuals in a QHP or a
non-QHP;
(4) Refer consumers to a
specific insurance agent or specific set of insurance agents;
(5) Provide gifts, including gift cards or cash or
provide promotional items that market or promote the products or services of a third
party, to any applicant or potential enrollee as an inducement for enrollment. The
value of gifts provided to applicants and potential enrollees for purposes other
than as an inducement for enrollment must not exceed nominal value, either
individually or in the aggregate, when provided to that individual during a single
encounter. The nominal value is equal to or less than $15. Gifts of nominal value
may not include beer, wine, liquor, cigarettes, tobacco, or lottery tickets. Gifts,
gift cards, or cash may be provided for the purpose of providing reimbursement for
legitimate expenses incurred by a consumer in an effort to receive Exchange
application assistance, such as, but not limited to, travel or postage
expenses;
(6) Solicit any consumer for
application or enrollment assistance by going door to door or through other
unsolicited means of direct contact, including calling a consumer to provide
application or enrollment assistance without the consumer initiating the contact,
unless the individual has a pre-existing relationship with the individual Certified
Application Counselor or designated organization and other applicable state and
federal laws are otherwise complied with. Outreach and education activities may be
conducted by going door to door or through other unsolicited means of direct
contact, including calling a consumer;
(7) Initiate any telephone call to a consumer
using an automatic telephone dialing system or an artificial or prerecorded voice,
except in cases where the individual Certified Application Counselor or designated
organization has a relationship with the consumer and so long as other applicable
state and federal laws are otherwise complied with;
(8) Mail the paper application for the
consumer;
(9) Coach the consumer to
provide inaccurate information on the application regarding income, residency,
immigration status, and other eligibility criteria;
(10) Coach or recommend one plan or provider over
another;
(11) Accept any premium
payments from the consumer;
(12) Input
any premium payment information on behalf of the consumer;
(13) Pay any part of the premium or provide any
form of consideration to the consumer on behalf of the consumer;
(14) Intentionally create multiple applications
from the same household, as defined in
42 C.F.R. §
435.603(f) (November 30, 2016),
hereby incorporated by reference; or
(15) Invite, influence, or arrange for an
individual whose existing coverage through an eligible employer-sponsored plan is
affordable and provides minimum value, as described in
26 U.S.C. §
36B(c)(2)(C) and in
26 C.F.R. §
1.36B-2(c)(3)(v) and (vi) (July
26, 2017), hereby incorporated by reference, to separate from employer-based group
health coverage.
(l) Certified
Application Counselors shall report to the Exchange any subsequent arrests for which
they have been released on bail or personal recognizance, criminal convictions, and
administrative actions taken by any other agency within 30 calendar days of the date
of the arrest or final administrative action order.
1. New section
filed 7-6-2015 as an emergency pursuant to Government Code section
100504(a)(6),
as modified by Senate Bill (Stats. 2015, c. 18); operative 7-6-2015 (Register 2015,
No. 28). A Certificate of Compliance must be transmitted to OAL by 7-6-2018 pursuant
to Government Code section
100504(a)(6)
or emergency language will be repealed by operation of law on the following
day.
2. Refiling of 7-6-2015 order on 9-1-2016, including new subsections
(a)(9)-(10) and (b)(3) and subsection renumbering, as a deemed emergency pursuant to
Government Code section
100504(a)(6);
operative 9-1-2016 (Register 2016, No. 36). 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; a Certificate of Compliance must be transmitted to OAL by 7-6-2020 pursuant to
Government Code section
100504(a)(6)
or emergency language will be repealed by operation of law on the following
day.
3. Editorial correction of HISTORY 2 (Register 2016, No.
40).
4. Refiling of 7-6-2015 order on 9-21-2017, including amendment of
subsections (b)(10)-(11) and (k)(5) and amendment of NOTE, as a deemed emergency
pursuant to Government Code section
100504(a)(6);
operative 9-21-2017 (Register 2017, No. 38). A Certificate of Compliance must be
transmitted to OAL by 7-6-2020 pursuant to Government Code section
100504(a)(6)
or emergency language will be repealed by operation of law on the following
day.
5. Certificate of Compliance as to 7-6-2015 order, including
amendment of section and NOTE, transmitted to OAL 4-25-2019 and filed 6-7-2019;
amendments operative 6-7-2019 pursuant to Government Code section
11343.4(b)(3)
(Register 2019, No. 23).
6. Editorial correction of HISTORY 1 (Register
2019, No. 39).
Note: Authority cited: Section
100504,
Government Code. Reference: Section
100502,
Government Code; 26 C.F.R.
Section 1.36B-2; 42 C.F.R. Section 436.603 ; and
45 C.F.R. Sections
155.205,
155.215,
155.225 and
155.260.
