California Code of Regulations
Title 10 - Investment
Chapter 12 - California Health Benefit Exchange
Article 2 - Abbreviations and Definitions
Section 6410 - Definitions
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
As used in this chapter, the following terms shall mean:
"Advance Payments of Premium Tax Credit" (APTC) means payment of the tax credits authorized by Section 36B of IRC (26 USC § 36B) and implementing regulations, which are provided on an advance basis to an eligible individual enrolled in a QHP through an Exchange in accordance with Section 1412 of the Affordable Care Act.
"Affordable Care Act" (ACA) means the federal Patient Protection and Affordable Care Act of 2010 (Pub.L. 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Pub.L. 111-152), and any amendments to, or regulations or guidance issued under, those acts, as defined in Government Code 100501(e).
"Annual Open Enrollment Period" means the period each year during which a qualified individual may enroll or change coverage in a QHP through the Exchange, as specified in Section 6502 of Article 5 of this chapter, Sections 1399.848(b) and 1399.849(c) of the Health and Safety Code, and Sections 10965.3(c) and 10965.4(b) of the Insurance Code.
"Applicable Children's Health Insurance Program (CHIP) MAGI-based Income Standard" means the applicable income standard as defined at 42 CFR Section 457.310(b)(1) (November 30, 2016), hereby incorporated by reference, as applied under the State plan adopted in accordance with title XXI of the Social Security Act, or waiver of such plan and as certified by the State CHIP Agency in accordance with 42 CFR Section 457.348(d) (November 30, 2016), hereby incorporated by reference, for determining eligibility for child health assistance and enrollment in a separate child health program.
"Applicable Medi-Cal Modified Adjusted Gross Income (MAGI)-based Income Standard" means the same standard as "applicable modified adjusted gross income standard," as defined in 42 CFR Section 435.911(b) (November 30, 2016), hereby incorporated by reference, and as specified in Sections 14005.60 and 14005.64 of the Welfare and Institutions Code.
"Applicant" means:
(a) An individual who is seeking eligibility for coverage for themselves through an application submitted to the Exchange (excluding those individuals seeking eligibility for an exemption from the shared responsibility payment) or transmitted to the Exchange by an agency administering an insurance affordability program for at least one of the following:
(b) For SHOP (CCSB):
"Application Filer" means an applicant; an adult who is in the applicant's household, as defined in 42 CFR Section 435.603(f) (November 30, 2016), hereby incorporated by reference, or family, as defined in 26 USC Section 36B(d) and 26 CFR Section 1.36B-1(d) (December 19, 2016), hereby incorporated by reference; an authorized representative; or if the applicant is a minor or incapacitated, someone acting responsibly for an applicant; excluding those individuals seeking eligibility for an exemption from the shared responsibility payment.
"Authorized Representative" means any person or entity that has been designated, in writing, by the applicant to act on his/her behalf or individuals who have appropriate power of attorney or legal conservatorship.
"Benefit Year" means a calendar year for which a health plan provides coverage for health benefits.
"Board" means the executive board that governs the California Health Benefit Exchange, established by Government Code Section 100500.
"California Health Benefit Exchange" or the "Exchange" means the entity established pursuant to Government Code Section 100500. The Exchange also does business as and may be referred to as "Covered California."
"California Healthcare Eligibility, Enrollment, and Retention System" (CalHEERS) means the California Healthcare Eligibility, Enrollment, and Retention System, created pursuant to Government Code Sections 100502 and 100503, as well as 42 USC Section 18031, to enable enrollees and prospective enrollees of QHPs to obtain standardized comparative information on the QHPs as well as apply for eligibility, enrollment, and reenrollment in the Exchange.
"Cancellation of Enrollment" means specific type of termination action that ends a qualified individual's enrollment on or before the coverage effective date resulting in enrollment through the Exchange never having been effective with the QHP.
"Captive Agent" means an insurance agent who is currently licensed in good standing by the California Department of Insurance to sell, solicit, and negotiate health insurance coverage and has a current and exclusive appointment with a single Issuer and may receive compensation on a salary or commission basis as an agent only from that Issuer.
"Carrier" means either a private health insurer holding a valid outstanding certificate of authority from the Insurance Commissioner or a health care service plan, as defined under subdivision (f) of Section 1345 of the Health and Safety Code, licensed by the Department of Managed Health Care.
"Catastrophic Plan" means a health plan described in Section 1302(e) of the Affordable Care Act, Section 1367.008(c)(1) of the Health and Safety Code, and Section 10112.295(c)(1) of the Insurance Code.
"Certified Enrollment Counselor" (CEC) means an individual as defined in Section 6650 of Article 8 of this chapter.
"Certified Insurance Agent" means an agent certified by the Exchange to transact in the individual and Small Business Health Options Program (SHOP) Exchanges.
"Certified Plan-Based Enroller" (PBE) means an individual who provides Enrollment Assistance to Consumers, as defined in Section 6700(c) of Article 9 of this chapter, in the Individual Exchange through a Certified Plan-Based Enroller Program. Such an individual may be:
(a) A Captive Agent of a QHP issuer; or
(b) An Issuer Application Assister as defined in 45 CFR Section 155.20 (December 22, 2016), hereby incorporated by reference, provided that the issuer application assister is not employed or contracted by a PBEE to sell, solicit, or negotiate health insurance coverage licensed by the California Department of Insurance.
"Certified Plan-Based Enroller Program" (PBE Program) means the Program whereby a PBEE may provide Enrollment Assistance to Consumers in the Individual Exchange in a manner considered to be through the Exchange.
"Certified Plan-Based Enrollment Entity" (PBEE) means a QHP Issuer registered through the Exchange to provide Enrollment Assistance, as defined in Section 6700 of Article 9 of this chapter, to Consumers, as defined in Section 6700 of Article 9 of this chapter, in the Individual Exchange through a Certified Plan-Based Enroller Program sponsored by the Entity. A PBEE shall be registered by the Exchange only if it meets all of the training and certification requirements specified in Section 6706 of Article 9 of this chapter.
"Child" means a person as defined in Sections 1357.500(a) and 1399.845(a) of the Health and Safety Code and in Section 10753(d) of the Insurance Code.
"COBRA" and "COBRA Continuation Coverage" have the meanings provided for in 45 CFR Section 144.103 (December 22, 2016), hereby incorporated by reference. "COBRA Continuation Coverage" includes coverage under a similar State program.
"Cost-share" or "Cost-sharing" means any expenditure required by or on behalf of an enrollee with respect to receipt of Essential Health Benefits; such term includes deductibles, coinsurance, copayments, or similar charges, but excludes premiums, balance-billing amounts for non-network providers, if applicable, and spending for non-covered services.
"Cost-Sharing Reduction" (CSR) means reductions in cost-sharing for an eligible individual enrolled in a silver level plan in the Exchange or for an individual who is an Indian enrolled in a QHP in the Exchange.
"Day" means a calendar day unless a business day is specified.
"Dental Exclusive Provider Organization" (DEPO) means a managed care plan where services are covered if provided through doctors, specialists, and hospitals in the plan's network (except in an emergency).
"Dental Health Maintenance Organization" (DHMO) means a type of dental plan product that delivers dental services by requiring assignment to a primary dental care provider who is paid a capitated fee for providing all required dental services to the enrollee unless specialty care is needed. DHMOs require referral to specialty dental providers. These products do not include coverage of services provided by dental care providers outside the dental plan network.
"Dental Preferred Provider Organization" (DPPO) means a type of dental plan product that delivers dental services to members through a network of contracted dental care providers and includes limited coverage of out-of-network services.
"Dependent" means:
(a) In the Individual Exchange:
(b) In the SHOP Exchange, a dependent as defined in Section 1357.500(b) of the Health and Safety Code and in Section 10753(e) of the Insurance Code and also includes a non-registered domestic partner who meets the requirements established by the qualified employer for non-registered domestic partners and who is approved by the QHP issuer for coverage in the SHOP Exchange.
"Domestic Partner" means:
(a) For purposes of the Individual Exchange, a person as defined in Sections 297 and 299.2 of the Family Code.
(b) For purposes of the SHOP, a person who has established a domestic partnership as described in Sections 297 and 299.2 of the Family Code and also includes a person that has not established a domestic partnership pursuant to Sections 297 and 299.2 of the Family Code, but who meets the requirements established by their employer for non-registered domestic partners and who is approved by the QHP issuer for coverage in the SHOP Exchange.
"Eligible Employee" means an employee as defined in Section 1357.500(c) of the Health and Safety Code and in Section 10753(f) of the Insurance Code.
"Eligible Employer-Sponsored Plan" means a plan as defined in Section 5000 A(f)(2) of IRC (26 USC § 5000A(f)(2)).
"Employee" means an individual as defined in Section 2791 of the Public Health Service Act (42 USC § 300gg-91).
"Employer" means a person as defined in Section 2791 of the Public Health Service Act (42 USC § 300gg-91), except that such term includes employers with one or more employees. All persons treated as a single employer under subsection (b), (c), or (m) of Section 414 of IRC (26 USC § 414) are treated as one employer.
"Employer Contributions" means any financial contributions towards an employer sponsored health plan, or other eligible employer-sponsored benefit made by the employer including those made by salary reduction agreement that is excluded from gross income.
"Enrollee" means a person who is enrolled in a QHP. It also means the dependent of a qualified employee enrolled in a QHP through the SHOP, and any other person who is enrolled in a QHP through the SHOP, consistent with applicable law and the terms of the group health plan. If at least one employee enrolls in a QHP through the SHOP, "enrollee" also means a business owner enrolled in a QHP through the SHOP, or the dependent of a business owner enrolled in a QHP through the SHOP.
"Essential Community Providers" means providers that serve predominantly low-income, medically underserved individuals, as defined in 45 CFR Section 156.235 (December 22, 2016), hereby incorporated by reference.
"Essential Health Benefits" means the benefits listed in 42 USC Section 18022, Health and Safety Code Section 1367.005, and Insurance Code Section 10112.27.
"Exchange Service Area" means the entire geographic area of the State of California.
"Exclusive Provider Organization" (EPO) means a health insurance issuer's or carrier's insurance policy that limits coverage to health care services provided by a network of providers who are contracted with the issuer or carrier.
"Executive Director" means the Executive Director of the Exchange.
"Federal Poverty Level" (FPL) means the most recently published federal poverty level, updated periodically in the Federal Register by the Secretary of Health and Human Services pursuant to 42 USC Section 9902(2), as of the first day of the annual open enrollment period for coverage in a QHP through the Exchange, as specified in Section 6502 of Article 5 of this chapter.
"Full-time employee" means a permanent employee with a normal workweek of an average of 30 hours per week over the course of a month.
"Geographic Service Area" or "Service Area" means an area as defined in Section 1345(k) of the Health and Safety Code.
"Group Contribution Rule" means the requirement that a qualified employer pays a specified percentage or fixed dollar amount of the premiums for coverage of eligible employees.
"Group Dental Plan" means a plan certified by the Exchange for offer in the small group marketplace that provides the pediatric dental benefits required in Health and Safety Code Section 1367.005(a)(5) and Insurance Code Section 10122.27(a)(5), and also includes coverage for certain benefits for adult enrollees and is available to qualified employers meeting the requirements of Section 6522(a)(5)(B) of Article 6 of this chapter.
"Group Participation Rate" means the minimum percentage of all eligible individuals or employees of an employer that must be enrolled.
"Health Insurance Coverage" means coverage as defined in 45 CFR Section 144.103.
"Health Insurance Issuer" has the same meaning as the term is defined in 42 USC Section 300gg-91 and 45 CFR Section 144.103. Also referred to as "Carrier," "Health Issuer," or "Issuer."
"Health Maintenance Organization" (HMO) means an organization as defined in Section 1373.10(b) of the Health and Safety Code.
"Health plan" means a plan as defined in Section 1301(b)(1) of the Affordable Care Act (42 USC § 18021(b)(1)).
"High deductible health plan" (HDHP) has the same meaning as the term is defined in Section 223(c)(2) of IRC (26 USC § 223(c)(2)).
"Incarcerated" means confined, after the disposition of charges, in a jail, prison, or similar penal institution or correctional facility.
"Indian" has the same meaning as the term is defined in Section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub.L. 93-638; 25 USC § 450b(d)), referring to a person who is a member of an Indian tribe.
"Indian Tribe" has the same meaning as the term is defined in Section 4(e) of the Indian Self-Determination and Education Assistance Act (Pub.L. 93-638; 25 USC § 450b(e)), referring to any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688) [43 USC § 1601 et seq.], which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.
"Individual and Small Business Health Options Program (SHOP) Exchange" means the program administered by the Exchange pursuant to the Government Code Section 100500 et seq. (2010 Cal. Stat. 655 (AB 1602) and 2010 Cal. Stat. 659 (SB 900)), 42 USC Section 18031(b) of the federal Patient Protection Affordable Care Act and other applicable laws to furnish and to pay for health insurance plans for Qualified Individuals and Qualified Employers.
"Individual Market" means a market as defined in Section 1304(a)(2) of the Affordable Care Act (42 USC § 18024(a)(2)).
"Initial Open Enrollment Period" means the initial period in which Qualified Individuals may enroll in QHPs, from October 1, 2013 to March 31, 2014, subject to 45 CFR Section 155.410(b), (April 18, 2017), hereby incorporated by reference, Section 1399.849(c)(1) of the Health and Safety Code, and Section 10965.3(c)(1) of the Insurance Code.
"Insurance Affordability Program" (IAP) means a program that is one of the following:
(a) The Medi-Cal program under title XIX of the federal Social Security Act (42 USC § 1396 et seq.).
(b) The State children's health insurance program (CHIP) under title XXI of the federal Social Security Act (42 USC § 1397aa et seq.).
(c) A program that makes available to qualified individuals coverage in a QHP through the Exchange with APTC established under Section 36B of the Internal Revenue Code (26 USC § 36B).
(d) A program that makes available coverage in a QHP through the Exchange with CSR established under section 1402 of the Affordable Care Act.
"Lawfully Present" means a non-citizen individual as defined in 45 CFR Section 152.2 (August 30, 2012), hereby incorporated by reference.
"Level of Coverage" or "Metal Tier" means one of four standardized actuarial values and the catastrophic level of coverage as defined in 42 USC Section 18022(d) and (e), Sections 1367.008(a) and (c)(1) and 1367.009 of the Health and Safety Code, and Sections 10112.295(a) and (c)(1) and 10112.297 of the Insurance Code.
"Minimum Essential Coverage" (MEC) means coverage as defined in Section 5000 A(f) of IRC (26 USC § 5000A(f)) and in 26 CFR Section 1.36B-2(c) (July 26, 2017), hereby incorporated by reference.
"Minimum Value" when used to describe coverage in an eligible employer-sponsored plan, means that the plan meets the requirements with respect to coverage of the total allowed costs of benefits set forth in Section 36B(c)(2)(C)(ii) of IRC (26 USC § 36B(c)(2)(C)(ii)) and in 26 CFR Section 1.36B-6 (December 18, 2015), hereby incorporated by reference.
"Modified Adjusted Gross Income" (MAGI) means income as defined in Section 36B(d)(2)(B) of IRC (26 USC § 36B(d)(2)(B)) and in 26 CFR Section 1.36B-1(e)(2).
"Modified Adjusted Gross Income (MAGI)-based income" means income as defined in 42 CFR Section 435.603(e) for purposes of determining eligibility for Medi-Cal.
"Non-citizen" means an individual who is not a citizen or national of the United States, in accordance with Section 101(a)(3) of the Immigration and Nationality Act (8 USC § 1101(a)(3)).
"Part-time Eligible Employee" means a permanent employee who works at least 20 hours per week but not more than 29 hours per week and who otherwise meets the definition of an eligible employee except for the number of hours worked.
"Plan Year" means:
(a) For purposes of the Individual Exchange, a calendar year.
(b) For purposes of the SHOP, a period of time as defined in 45 CFR Section 144.103.
"Plain Language" means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-organized, uses simple vocabulary, avoids excessive acronyms and technical language, and follows other best practices of plain language writing.
"Preferred Provider Organization" (PPO) means a health insurance issuer's or carrier's insurance policy that offers covered health care services provided by a network of providers who are contracted with the issuer or carrier ("in-network") and providers who are not part of the provider network ("out-of-network").
"Premium Payment Due Date" means:
(a) For purposes of the initial premium or binder payment for qualified individuals who are enrolled in a QHP by the Exchange in accordance with Section 100503.4 of the Government Code, a date no earlier than the last day of the first month of coverage.
(b) For purposes of the initial premium or binder payment for qualified individuals other than those specified under paragraph (a), and for purposes of the premium payment for the subsequent months of coverage, a date no earlier than the last day of the month prior to the prospective coverage month, and no later than the last day of the prospective coverage month.
"QHP Issuer" means a licensed health care service plan or insurer who has been selected and certified by the Exchange to be offered to Qualified Individuals and Qualified Employers purchasing health insurance coverage through the Exchange. For purposes of Section 6498 (l), licensed health care service plans or insurers that are subsidiaries of the same parent company are considered to be the same QHP issuer.
"Qualified Dental Plan" (QDP) means a plan providing limited scope dental benefits as defined in 26 USC Section 9832(c)(2)(A), including the pediatric dental benefits meeting the requirements of 42 USC Section 18022(b)(1)(J).
"Qualified Employee" means any employee or former employee of a qualified employer who has been offered health insurance coverage by such qualified employer through the SHOP for themselves and, if the qualified employer offers dependent coverage through the SHOP, for their dependents.
"Qualified Employer" has the same meaning as the term is defined in 42 USC Section 8032(f)(2) and 45 CFR Section 155.710 (February 27, 2015), hereby incorporated by reference.
"Qualified Health Plan" (QHP) has the same meaning as the term is defined in Patient Protection and Affordable Care Act Section 1301 (42 USC § 18021) and Government Code Section 100501(g) and includes QDP.
"Qualified Individual" means an individual who has been determined eligible to enroll through the Exchange in a QHP in the individual market.
"Qualifying Coverage in an Eligible Employer-Sponsored Plan" means coverage in an eligible employer-sponsored plan that meets the affordability and minimum value standards specified in Section 36B(c)(2)(C) of IRC (26 USC § 36B(c)(2)(C)) and in 26 CFR Sections 1.36B-2(c)(3) and 1.36B-6.
"Rating Region" means the geographic regions for purposes of rating defined in Sections 1357.512(a)(2)(A) and 1399.855(a)(2)(A) of the Health and Safety Code and Sections 10753.14(a)(2)(A) and 10965.9(a)(2)(A) of the Insurance Code.
"Reasonably Compatible" has the same meaning as the term is defined in 45 CFR Section 155.300(d) (July 15, 2013), hereby incorporated by reference, providing that information the Exchange obtained through electronic data sources, information provided by the applicant, or other information in the records of the Exchange shall be considered to be reasonably compatible with an applicant's attestation if the difference or discrepancy does not impact the applicant's eligibility, including the amount of APTC or the category of CSR.
"Reconciliation" means coordination of premium tax credit with advance payments of premium tax credit (APTC), as described in Section 36B(f) of IRC (26 USC § 36B(f)) and 26 CFR Section 1.36B-4(a) (July 26, 2017), hereby incorporated by reference.
"Reference Plan" means a QHP that is selected by an employer, which is used by the SHOP to determine the contribution amount the employer will be making towards its employees' premiums.
"Reinstatement of Enrollment" means a correction of an erroneous termination of coverage or cancellation of enrollment action and results in restoration of an enrollment with no break in coverage.
"Self-only Coverage" means a health care service plan contract or an insurance policy that covers one individual.
"SHOP" means a Small Business Health Options Program operated by the Exchange through which a qualified employer can provide its employees and their dependents with access to one or more QHPs. The SHOP also does business as and may be referred to as "Covered California for Small Business" or "CCSB."
"SHOP Application Filer" means an applicant, an authorized representative, an agent or broker of the employer, or an employer filing for its employees where not prohibited by law.
"SHOP Plan Year" means a 12-month period beginning with the Qualified Employer's effective date of coverage.
"Small Employer" means an employer as defined in Section 1357.500(k)(3) of the Health and Safety Code and in Section 10753(q)(3) of the Insurance Code.
"Small Group Market" means a group market as defined in Section 1304(a)(3) of the Affordable Care Act.
"Special Enrollment Period" means a period during which a qualified individual or enrollee who experiences certain qualifying events, as specified in Section 6504(a) of Article 5 of this chapter, Section 1399.849(d) of the Health and Safety Code, and Section 10965.3(d) of the Insurance Code, may enroll in, or change enrollment in, a QHP through the Exchange outside of the initial and annual open enrollment periods.
"State Health Insurance Regulator" or "State Health Insurance Regulators" means the Department of Managed Health Care and the Department of Insurance.
"Tax Filer" means an individual, or a married couple, who attests that he, she, or the couple expects:
(a) To file an income tax return for the benefit year, in accordance with Sections 6011 and 6012 of IRC (26 USC §§ 6011, 6012), and implementing regulations;
(b) If married (within the meaning of 26 CFR Section 1.7703-1 (January 16, 1997), hereby incorporated by reference), to file a joint tax return for the benefit year, unless the tax filer satisfies one of the exceptions specified in 26 CFR Section 1.36B-2(b)(2)(ii)-(v);
(c) That no other taxpayer will be able to claim him, her, or the couple as a tax dependent for the benefit year; and
(d) That he, she, or the couple expects to claim a personal exemption deduction under Section 151 of IRC (26 USC § 151) on their tax return for one or more applicants, who may or may not include themselves and their spouse.
"Termination of Coverage" or "Termination of Enrollment" means an action taken after a coverage effective date that ends an enrollee's coverage through the Exchange for a date after the original coverage effective date, resulting in a period during which the individual was enrolled in coverage through the Exchange.
"TIN" means an identification number used by the IRS in the administration of tax laws. It is issued either by the SSA or by the IRS. TINs include SSN, Employer Identification Number (EIN), Individual Taxpayer Identification Number (ITIN), Taxpayer Identification Number for Pending U.S. Adoptions (ATIN), and Preparer Taxpayer Identification Number (PTIN). A SSN is issued by the SSA whereas all other TINs are issued by the IRS.
Note: Authority cited: Sections 100502, 100503, 100503.4, 100504 and 100505, Government Code. Reference: Sections 100501, 100502, 100503, 100503.4 and 100505, Government Code; Sections 1345, 1357.500, 1357.512, 1367.005, 1367.008, 1367.009, 1373, 1373.10, 1374.1, 1399.845, 1399.848, 1399.849 and 1399.855, Health and Safety Code; Sections 10112.27, 10112.295, 10112.297, 10122.27, 10278.1, 10753, 10753.14, 10965, 10965.3, 10965.4 and 10965.9, Insurance Code; 42 CFR Sections 435.603, 435.911, 457.310 and 457.348; 45 CFR Sections 144.103, 152.2, 155.20, 155.300, 155.305, 155.410, 155.415, 155.430, 155.700, 155.705, 155.710, 155.725, 156.235 and 156.1230; and 26 CFR Sections 1.36B-1, 1.36B-2, 1.36B-4, 1.36B-6, 1.5000A-1(d) and 1.7703-1.
Note: Authority cited: Sections 100502, 100503, 100503.4, 100504 and 100505, Government Code. Reference: Sections 100501, 100502, 100503, 100503.4 and 100505, Government Code; Sections 1345, 1357.500, 1357.512, 1367.005, 1367.008, 1367.009, 1373, 1373.10, 1374.1, 1399.845, 1399.848, 1399.849 and 1399.855, Health and Safety Code; Sections 10112.27, 10112.295, 10112.297, 10122.27, 10278.1, 10753, 10753.14, 10965, 10965.3, 10965.4 and 10965.9, Insurance Code; 42 CFR Sections 435.603, 435.911, 457.310 and 457.348; 45 CFR Sections 144.103, 152.2, 155.20, 155.300, 155.305, 155.410, 155.415, 155.430, 155.700, 155.705, 155.710, 155.725, 156.235 and 156.1230; and 26 CFR Sections 1.36B-1, 1.36B-2, 1.36B-4, 1.36B-6, 1.5000A-1(d) and 1.7703-1.
