Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(a) The Exchange shall use an exemption
application to collect the applicant's information necessary to determine the
applicant's eligibility for religious conscience and hardship
exemptions.
(b) To apply for a
religious conscience or hardship exemption, an applicant or an application
filer shall submit all information, documentation, and declarations required on
the application, as specified in subdivisions (c), (d), and (e) of this
section, and shall sign and date the application.
(c) An applicant or an application filer
shall provide the following information on the applicable exemption
application:
(1) The applicant's full name
(first, middle, if applicable, and last name).
(2) The applicant's home and mailing address,
if different from home address, the applicant's county of residence and
telephone number(s). For an applicant who does not have a home address, only a
mailing address shall be provided.
(3) The applicant's email address, if the
applicant chooses to get correspondence via email from the Exchange.
(4) The applicant's preferred written and
spoken language.
(5) The
applicant's date of birth.
(6) The
applicant's Social Security Number or Individual Taxpayer Identification
Number, if one has been issued to the applicant.
(7) The applicant's gender.
(8) For each individual included on the
applicant's state tax return, including the applicant and the applicant's
spouse or domestic partner, the individual's relationship to the applicant, the
individual's full name, date of birth, Social Security Number or Individual
Taxpayer Identification Number, if the individual has one, gender, and whether
the individual wants an exemption.
(d) For a religious conscience exemption, as
specified in Section
6914(b), an
applicant or an application filer shall provide the following information on
the religious conscience exemption application in addition to the information
specified in subdivision (c) of this section:
(1) The year for which the applicant or any
individual in the applicant's tax household is requesting the
exemption.
(2) Whether the
applicant or any individual in the applicant's tax household is a member of
recognized religious sect or division described in section
1402(g)(1) of the
Internal Revenue Code (26
USC §
1402(g)(1)) and
adheres to the established tenets or teachings of such sect or
division.
(3) Whether the applicant
or any individual in the applicant's tax household has an approved IRS Form
4029 ("Application for Exemption from Social Security and Medicare Taxes and
Waiver of Benefits") with required signatures. If so, a copy of the approved
form shall be submitted with the application.
(4) Whether the applicant or any individual
in the applicant's tax household is a member of a religious sect or division
that is not described in Section
1402(g)(1) of the
Internal Revenue Code (26
USC §
1402(g)(1)),
relies solely on a religious method of healing, and the acceptance of medical
health services would be inconsistent with the religious beliefs of the
individual. If so, an attestation signed by the applicant that the member has
not received medical health services during the preceding taxable year shall be
submitted with the application.
(5)
The full name and address of the religious sect or division the applicant or
any individual in the applicant's tax household is a member of and the date
they became a member.
(e)
For a general hardship exemption, as specified in Section
6914(c), an
applicant or an application filer shall provide the following information on
the general hardship exemption application in addition to the information
specified in subdivision (c) of this section:
(1) The type of hardship.
(2) The tax year for which the hardship
exemption is requested.
(3) The
start and end dates for the hardship.
(f) For an affordability hardship exemption,
as specified in Section
6914(d), an
applicant or an application filer shall provide the following information on
the affordability hardship exemption application in addition to the information
specified in subdivision (c) of this section:
(1) The year and months the applicant
requests the exemption.
(2) Whether
the applicant has been offered employer-sponsored health coverage.
(3) Documentation of the cost of the premium
for the employer-sponsored coverage for the applicant and any covered family
members and whether the employer-sponsored coverage meets the minimum value
standards, specified in 45
CFR Section 156.145 (February 27, 2015),
hereby incorporated by reference.
(4) The applicant's projected household
income from all sources for the year the applicant has requested the exemption,
including tax-exempt foreign earned income and tax-exempt income from interest
that the applicant receives or accrues during the taxable year, if any, and
proof of such income. If self-employed, the amount of net income. The projected
household income does not include income from child support payments, veteran's
payments, and Supplemental Security Income/State Supplementary Payment
(SSI/SSP).
(5) The applicant's
expected type and amount of the tax deductions that the applicant is allowed to
deduct from the applicant's taxable gross income when calculating the
applicant's adjusted gross income on the applicant's federal income tax
return.
(6) Whether the applicant
intends to file federal and state income tax returns for the year for which the
applicant is requesting coverage, and if so, the applicant's expected
tax-filing status.
(7) Whether the
applicant is enrolled in minimum essential coverage through any government
sponsored programs, as defined in Section
5000 A(f)(1)(A) of the Internal
Revenue Code (26 USC §
5000A(f)(1)(A)), or is
eligible for full-scope Medi-Cal or free Medicare Part A.
(8) The applicant's status as a U.S. Citizen
or U.S. National, or the following information if the applicant is not a U.S.
Citizen or U.S. National and attests to having lawful presence status:
(A) The applicant's immigration
status;
(B) The applicant's
immigration document type, identification number, country of issuance,
expiration date, and the applicant's name as it appears on the
document;
(C) Whether the applicant
has lived in the U.S. since 1996; and
(D) Whether the applicant, or the applicant's
spouse or parent, is a veteran or an active-duty member of the U.S.
military.
(9) Whether the
applicant is pregnant, and if so, the number of babies expected and the
expected delivery date.
(10)
Whether the applicant is 18 to 20 years old and a full-time student.
(11) Whether the applicant is 18 to 26 years
old and lived in foster care on the applicant's 18th birthday or whether the
applicant was in foster care and enrolled in Medicaid in any state.
(12) Whether the applicant is 18 years old or
younger, and if so, the number of parents living with the applicant.
(13) Whether the applicant lives with at
least one child under the age of 19 and is the primary person taking care of
this child.
(14) Whether the
applicant is incarcerated.
(15)
Whether the applicant is a primary tax filer or a tax dependent. If the
applicant is a tax dependent, the non-applicant primary tax filer shall provide
the information in subdivision (f)(1) through (14) of this section, except for
the information in subdivision (f)(8).
(16) For any other individuals seeking an
exemption on the applicant's exemption application, all of the information in
subdivision (f)(1) through (15) of this section.
(g) If the applicant designates an authorized
representative, the applicant shall provide the authorized representative's
name and address, and the applicant's signature authorizing the designated
representative to act on the applicant's behalf for the exemption application,
eligibility and enrollment, and appeals process, if applicable.
(h) An applicant or an application filer
shall declare under penalty of perjury that the applicant or application filer:
(1) Understood all questions on the
application and gave true and correct answers to the best of the applicant's or
application filer's personal knowledge.
(2) Knows that if the applicant or
application filer does not tell the truth on the exemption application, there
may be a civil or criminal penalty for perjury pursuant to Penal Code Section
126.
(3) Knows that the information provided on
the exemption application shall only be used for the purpose of determining
exemption eligibility for the individuals listed on the application who are
requesting an exemption, and that the Exchange shall keep such information
private in accordance with the applicable federal and State privacy and
security laws.
(4) Understands that
the Exchange shall not discriminate against the applicant or anyone on the
application because of race, color, national origin, religion, age, sex, sexual
orientation, gender identity, or disability, and that the applicant may make a
complaint of discrimination through the U.S. Department of Health and Human
Services, Office for Civil Rights.
1. New section
filed 10-7-2019 as a deemed emergency pursuant to Government Code section
100725(c);
operative 1-1-2020 (Register 2019, No. 41). A Certificate of Compliance must be
transmitted to OAL by 1-1-2025 pursuant to Government Code section
100725 or
emergency language will be repealed by operation of law on the following
day.
2. New section refiled 5-11-2020 as a deemed emergency pursuant
to Government Code section
100725(c),
including amendment of section and NOTE; operative 5-11-2020 (Register 2020,
No. 20). A Certificate of Compliance must be transmitted to OAL by 1-1-2025
pursuant to Government Code section
100725 or
emergency language will be repealed by operation of law on the following
day.
Note: Authority cited: Sections
100504 and
100725,
Government Code. Reference: Sections
100502 and
100715,
Government Code; 26 USC
Section 5000A;
45 CFR Sections
155.605,
155.610 and
156.145.
