California Code of Regulations
Title 10 - Investment
Chapter 12 - California Health Benefit Exchange
Article 5 - Application, Eligibility, and Enrollment Process for the Individual Exchange
Section 6484 - Verification Process for Changes in Household Income Related to Eligibility Determination for APTC and CSR

Universal Citation: 10 CA Code of Regs 6484

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) Except as provided in subdivisions (b) and (c) of this section, the Exchange shall accept the applicant's attestation regarding the tax filer's annual household income without further verification if:

(1) An applicant attests, in accordance with Section 6482(e)(2), that a tax filer's annual household income has increased, or is reasonably expected to increase, from the income described in Section 6482(e)(1) for the benefit year for which the applicant(s) in the tax filer's family are requesting coverage; and

(2) The Exchange has not verified the applicant's MAGI-based income to be within the applicable Medi-Cal or CHIP MAGI-based income standard, in accordance with the process specified in Medicaid regulations at 42 CFR Sections 435.945 (November 30, 2016), hereby incorporated by reference, 435.948 (March 23, 2012), hereby incorporated by reference, and 435.952 (November 30, 2016), hereby incorporated by reference, and CHIP regulations at 42 CFR Section 457.380 (November 30, 2016), hereby incorporated by reference.

(b) If data available to the Exchange regarding the MAGI-based income in accordance with Section 6482(c) indicate that a tax filer's projected annual household income is above the tax filer's attestation by more than the income threshold specified in subdivision (f) of this section, the Exchange shall follow the inconsistency procedures specified in Section 6492(a)(1) through (4).

(c) If other information provided by the application filer indicates that a tax filer's projected annual household income is above the tax filer's attestation by more than the income threshold specified in subdivision (f) of this section, the Exchange shall utilize data available to the Exchange regarding the MAGI-based income in accordance with Section 6482(c) to verify the attestation. If such data are unavailable or not reasonably compatible with the applicant's attestation, the Exchange shall follow the inconsistency procedures specified in Section 6492(a)(1) through (4).

(d) If, at the conclusion of the 95-day period specified in Section 6492(a)(2)(B), the Exchange remains unable to verify the applicant's attestation, the Exchange shall:

(1) Determine the applicant's eligibility based on the information described in Section 6482(e)(1);

(2) Notify the applicant of such determination in accordance with the notice requirements specified in Section 6476(h); and

(3) Implement such determination in accordance with the effective dates specified in Section 6496(j) through (l).

(e) If, at the conclusion of the 95-day period specified in Section 6492(a)(2)(B), the Exchange remains unable to verify the applicant's attestation and the information described in Section 6482(e)(1) is unavailable, the Exchange shall:

(1) Determine the tax filer ineligible for APTC and CSR;

(2) Notify the applicant of such determination in accordance with the notice requirements specified in Section 6476(h); and

(3) Discontinue any APTC and CSR in accordance with the effective dates specified in Section 6496(j) through (l).

(f) For any benefit year for which the applicable percentages for purposes of calculating the APTC amount, as defined in Section 36B(b)(3)(A) of the IRC (26 USC § 36B(b)(3)(A)), are between zero and 8.5, inclusive, the income threshold shall be 50 percent or $12,000 (whichever is greater). Otherwise, the income threshold shall be 25 percent or $6,000 (whichever is greater).

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 26 USC Section 36B(b)(3)(A); 42 CFR Sections 435.945, 435.948, 435.952 and 457.380; and 45 CFR Section 155.320.

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 26 USC Section 36B(b)(3)(A); and 42 CFR Sections 435.945, 435.948, 435.952 and 457.380; 45 CFR Section 155.320.

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