Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Certified Medi-Cal Managed Care Plans and
Certified Medi-Cal Managed Care Plan Enrollers shall perform the following
functions:
(1) Maintain expertise in eligibility,
enrollment, and Exchange program specifications;
(2) Provide information and services in a fair,
accurate, and impartial manner, which includes: providing 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. Such information must
acknowledge the existence of other health programs (i.e., Medi-Cal and Children's
Health Insurance Programs);
(3)
Facilitate selection of a QHP and/or insurance affordability programs;
(4) 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;
(5) Comply with the privacy and security
requirements in 45 C.F.R. §
155.260 (September 6, 2016), hereby incorporated
by reference;
(6) Ensure that voter
registration assistance is available in compliance with section
6462 of Article 4 of this Chapter;
and
(7) Comply with any applicable
federal or state laws and regulations.
(b) 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,
a Certified Medi-Cal Managed Care Plan and its affiliated Certified Medi-Cal Managed
Care Plan Enrollers shall comply with the requirements of section
6664(b)(1) through
(b)(6) of Article 8.
(c) To ensure that Consumer Assistance is
accessible to people with disabilities, Certified Medi-Cal Managed Care Plans and
affiliated Certified Medi-Cal Managed Care Plan Enrollers shall comply with the
requirements of section
6664(c)(1) through
(c)(5) of Article 8.
(d) To ensure that no consumer is discriminated
against, Certified Medi-Cal Managed Care Plans and Certified Medi-Cal Managed Care
Plan Enrollers shall provide the same level of service to all individuals regardless
of age, disability, culture, sexual orientation, or gender identity and seek advice
of experts when needed.
(e) Certified
Med-Cal Managed Care Plan Enrollers shall complete the Certified Enrollment
Counselor section of a consumer's application to the Exchange, including the
following:
(1) Name and certification number of
the Certified Medi-Cal Managed Care Plan Enroller.
(2) Name of the Certified Medi-Cal Managed Care
Plan and the Certified Medi-Cal Managed Care Plan Number: and
(3) Signature and date of signature by the
Certified Medi-Cal Managed Care Plan Enroller.
(f) If any of the information listed in
subdivision (e) of this section is not included on the consumer's original
application, it shall not be added at a later time.
(g) Certified Medi-Cal Managed Care Plan Enrollers
shall wear the badge issued by the Exchange at all times when providing assistance
pursuant to this Article.
(h) The
Certified Medi-Cal Managed Care Plan and Certified Medi-Cal Managed Care Plan
Enroller shall never:
(1) Have a conflict of
interest as defined in section
6907;
(2) Mail the paper application for the
consumer;
(3) Coach the consumer to
provide inaccurate information on the application regarding income, residency,
immigration status and other eligibility rules;
(4) Coach or recommend one plan or provider over
another;
(5) Accept and premium payments
from the consumer;
(6) Input any premium
payment information on behalf of the consumer;
(7) Pay any part of the premium or any other type
of consideration to or on behalf of the consumer;
(8) Induce or accept any type of direct or
indirect remuneration from the consumer;
(9) 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;
(10)
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 USC §
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;
(11) 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 consumer has a pre-existing relationship with the individual Certified
Medi-Cal Managed Care Plan Enroller or Certified Medi-Cal Managed Care Plan and
other applicable State and Federal laws are otherwise complied with; or
(12) Initiated 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 Medi-Cal Managed Care Plan Enroller
or Certified Medi-Cal Manged Care Plan has a relationship with the consumer and so
long as other applicable State and Federal laws are otherwise complied
with.
(i) Certified Medi-Cal
Managed Care Plan Enrollers shall report to the Exchange any subsequent arrests for
which they have been released on bail or personal recognizance and criminal
convictions, in accordance with section
6456(c) of Article 4,
and administrative actions taken by any other agency, within 30 calendar days of the
date of the arrest or final administrative action order.
(j) Certified Medi-Cal Managed Care Plans shall
notify the Exchange of any change in Contact information for the Certified Medi-Cal
Managed Care Plan or its Certified Medi-Cal Managed Care Plan Enrollers.
1. New section
filed 3-12-2020; operative 3-12-2020 pursuant to Government Code section
11343.4(b)(3)
(Register 2020, No. 11).
Note: Authority cited: Sections
100502 and
100504,
Government Code. Reference: Sections
100502 and
100503,
Government Code; and 26 C.F.R.
Section 1.36B-2; and
45 C.F.R. Section
155.260.
