Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Except as
otherwise specified in this Article, for an applicant or enrollee for whom the
Exchange cannot verify information required to determine eligibility for enrollment
in a QHP, or for APTC and CSR, including when electronic data is required in
accordance with this section but data for individuals relevant to the eligibility
determination are not included in such data sources or when electronic data from
IRS, DHS, or SSA is required but it is not reasonably expected that data sources
will be available within one day of the initial request to the data source, the
Exchange:
(1) Shall make a reasonable effort to
identify and address the causes of such inconsistency, including through
typographical or other clerical errors, by contacting the application filer or
enrollee to confirm the accuracy of the information submitted by the application
filer or enrollee;
(2) If unable to
resolve the inconsistency through the process described in subdivision (a)(1) of
this section, shall:
(A) Provide notice to the
applicant or enrollee regarding the inconsistency; and
(B) Provide the applicant or enrollee with a
period of 95 days from the date of the notice described in subdivision (a)(2)(A) of
this section to either present satisfactory documentary evidence through the
channels available for the submission of an application, as described in Section
6470(j), except by
telephone, or otherwise resolve the inconsistency.
(3) May extend the period described in subdivision
(a)(2)(B) of this section for an applicant or enrollee if the Exchange determines on
a case-by-case basis that the applicant or enrollee has demonstrated that they have
made a good-faith effort to obtain the required documentation during the
period.
(4) During the periods described
in subdivisions (a)(1) and (a)(2)(B) of this section, shall:
(A) Proceed with all other elements of eligibility
determination using the applicant's or enrollee's attestation, and provide
eligibility for enrollment in a QHP if an applicant or enrollee is otherwise
qualified;
(B) Ensure that APTC and CSR
are provided within this period on behalf of an applicant or enrollee who is
otherwise qualified for such payments and reductions, as described in Section
6474, provided that the tax filer
attests to the Exchange that the tax filer understands that any APTC paid on their
behalf are subject to reconciliation; and
(C) Clear the inconsistencies for which the
Exchange receives satisfactory documentary evidence from the applicant or the
enrollee. For income inconsistencies, the Exchange shall clear the inconsistency if
the income shown on the documents provided by the applicant or enrollee is within
10% of the applicant's or enrollee's attestation.
(5) If, after the period described in subdivision
(a)(2)(B) of this section, the Exchange remains unable to verify the attestation,
shall:
(A) Determine the applicant's or enrollee's
eligibility based on the information available from the data sources specified in
Sections 6478 through
6492, unless such applicant or enrollee
qualifies for the exception provided under subdivision (b) of this section;
and
(B) Notify the applicant or enrollee
of such determination in accordance with the notice requirements specified in
Section 6476(h), including
notice that the Exchange is unable to verify the attestation.
(6) When electronic data to support the
verifications specified in Section
6478(d) or Section
6480 is required but it is not
reasonably expected that data sources will be available within one day of the
initial request to the data source, the Exchange shall accept the applicant's or
enrollee's attestation regarding the factor of eligibility for which the unavailable
data source is relevant.
(7) The
Exchange shall extend the period described in subdivision (a)(2)(B) of this section
by a period of 60 days for an applicant or enrollee with an income inconsistency who
is required to present satisfactory documentary evidence to verify household
income.
(b) The Exchange shall
provide an exception, on a case-by-case basis, to accept an applicant's or
enrollee's attestation as to the information which cannot otherwise be verified and
the applicant's explanation of circumstances as to why the applicant or enrollee
does not have documentation if:
(1) An applicant
or enrollee does not have documentation with which to resolve the inconsistency
through the process described in subdivision (a)(2) of this section because such
documentation does not exist or is not reasonably available;
(2) The Exchange is unable to otherwise resolve
the inconsistency for the applicant or enrollee; and
(3) The inconsistency is not related to
citizenship or immigration status.
(c) An applicant or enrollee shall not be required
to provide information beyond the minimum necessary to support the eligibility and
enrollment processes of the Exchange, Medi-Cal, and CHIP.
Note: Authority cited: Section 100504, Government Code.
Reference: Sections 100502, 100503 and 100504, Government Code; and
45 CFR Section
155.315.
Note: Authority cited: Section
100504,
Government Code. Reference: Sections
100502,
100503 and
100504,
Government Code; and 45 CFR
Section
155.315.
