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 6494 - Special Eligibility Standards and Verification Process for Indians
Universal Citation: 10 CA Code of Regs 6494
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) An Indian applicant's eligibility for CSR shall be determined based on the following procedures.
(1) An Indian applicant shall be
eligible for CSR if the applicant:
(A) Meets the
eligibility requirements specified in Sections
6472 and
6474(c);
(B) Is expected to have a household income, as
defined in section 36B(d)(2) of IRC (26 USC §
36B(d)(2)) and in
26 CFR Section
1.36B-1(e), that does not exceed
300 percent of the FPL for the benefit year for which coverage is requested;
and
(C) Is enrolled in a QHP through the
Exchange.
(2) If an Indian
applicant meets the eligibility requirements of subdivision (a)(1):
(A) Such applicant shall be treated as an eligible
insured; and
(B) The QHP issuer shall
eliminate any cost-sharing under the plan.
(3) Regardless of an Indian applicant's income and
the requirement of Section
6476(b) to request an
eligibility determination for all IAPs, such applicant shall be eligible for CSR if
the individual is:
(A) Enrolled in a QHP through
the Exchange; and
(B) Furnished an item
or service directly by the Indian Health Service, an Indian Tribe, Tribal
Organization, or Urban Indian Organization, or through referral under contract
health services.
(4) If an
Indian applicant meets the requirements of subdivision (a)(3) of this section, the
QHP issuer:
(A) Shall eliminate any cost-sharing
under the plan for the item or service specified in subdivision (a)(3)(B);
and
(B) Shall not reduce the payment to
any such entity for the item or service specified in subdivision (a)(3)(B) by the
amount of any cost-sharing that would be due from the Indian but for subdivision
(A).
(b) An Indian applicant's attestation that the applicant is an Indian shall be verified by:
(1) Using any relevant documentation verified in
accordance with Section
6492;
(2) Relying on any HHS-approved electronic data
sources that are available to the Exchange; or
(3) If HHS-approved data sources are unavailable,
an individual is not represented in available data sources, or data sources are not
reasonably compatible with an applicant's attestation:
(A) Following the procedures specified in Section
6492; and
(B) Verifying documentation provided by the
applicant that meets the following requirements for satisfactory documentary
evidence of citizenship or nationality:
1. Except
as provided in subdivision (b)(3)(B)2 of this section, a document issued by a
federally recognized Indian tribe evidencing membership or enrollment in, or
affiliation with, such tribe (such as a tribal enrollment card or certificate of
degree of Indian blood).
2. With respect
to those federally recognized Indian tribes located within States having an
international border whose membership includes individuals who are not citizens of
the United States, such other forms of documentation (including tribal
documentation, if appropriate) that HHS has determined to be satisfactory
documentary evidence of citizenship or
nationality.
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 26 CFR Section 1.36B-1; and 45 CFR Section 155.350.
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 26 CFR Section 1.36B-1; and 45 CFR Section 155.350.
Disclaimer: These regulations may not be the most recent version. California may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
