Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Except as
specified in subdivisions (d) and (m) of this section, the Exchange shall
redetermine the eligibility of an enrollee or a qualified individual on an annual
basis.
(b) To conduct an annual
redetermination for an enrollee or a qualified individual who requested an
eligibility determination for IAPs in accordance with Section
6476(b), the Exchange
shall have on file an active authorization from the qualified individual to obtain
updated tax return information described in subdivision (c) of this section. This
authorization shall be for a period of no more than five years based on a single
authorization, provided that an individual may:
(1) Decline to authorize the Exchange to obtain
updated tax return information; or
(2)
Authorize the Exchange to obtain updated tax return information for fewer than five
years; and
(3) Discontinue, change, or
renew their authorization at any time.
(c) If an enrollee or a qualified individual
requested an eligibility determination for IAPs on the original application, in
accordance with Section
6476(b), and the
Exchange has an active authorization to obtain tax data as a part of the annual
redetermination process, the Exchange shall request:
(1) Updated tax return information, as described
in Section 6482(b);
(2) Data regarding Social Security benefits, as
described in Section
6482(b); and
(3) Income data from available State data sources,
such as Franchise Tax Board and Employment Development Department.
(d) If an enrollee or a qualified
individual requested an eligibility determination for IAPs on the original
application, in accordance with Section
6476(b), and the
Exchange does not have an active authorization to obtain tax data as a part of the
annual redetermination process, the Exchange:
(1)
Shall notify the individual at least 30 days prior to the date of the notice of
annual redetermination described in subdivision (f) of this section. This notice
shall include an explanation that unless the individual authorizes the Exchange to
obtain their updated tax return information to redetermine the individual's
eligibility for coverage effective January first of the following benefit year:
(A) The individual's APTC and CSR will end on the
last day of the current benefit year; and
(B) The individual's coverage in a QHP will be
renewed for the following benefit year, in accordance with the process specified in
subdivision (l) of this section, without APTC and CSR;
(2) Shall redetermine the enrollee's or
the qualified individual's eligibility only for enrollment in a QHP; and
(3) Shall not proceed with a redetermination for
IAPs until such authorization has been obtained or the qualified individual
continues their request for an eligibility determination for IAPs in accordance with
Section 6476(b).
(e) The Exchange shall provide an annual
redetermination notice in accordance with the following process:
(1) For all qualified individuals who are not
currently enrolled in a QHP through the Exchange, the notice shall include at least:
(A) A description of the annual redetermination
and renewal process;
(B) The requirement
to report changes to information affecting eligibility, as specified in Section
6496(b);
(C) The instructions on how to report a change to
the Exchange; and
(D) The open
enrollment date and the last day on which a plan selection may be made for coverage
effective on January first of the following benefit year to avoid any coverage
gap.
(2) For all current
enrollees who have requested an eligibility determination for IAPs for the current
benefit year, the notice shall include at least:
(A) All the information specified in subdivision
(e)(1) of this section;
(B) An
explanation that the premiums for the QHPs and the amount of APTC and the level of
CSR, for which the enrollee may be eligible, may change each benefit year;
(C) A description of the reconciliation process
for APTC;
(D) Data used in the
enrollee's most recent eligibility determination and the amount of monthly APTC and
the level of CSR the enrollee has been receiving during the current benefit
year;
(E) An explanation that if the
enrollee does not complete the Exchange's renewal process to obtain an updated
eligibility determination by December 15 of the current benefit year for coverage
effective January first of the following benefit year, the Exchange will redetermine
the enrollee's eligibility and renew the enrollee's coverage for the following
benefit year, in accordance with the process specified in subdivision
(l) of this section, using information obtained from the electronic
data sources specified in subdivision (c) of this section and the most recent
information the enrollee provided to the Exchange; and
(F) An explanation that in order to obtain the
most accurate eligibility determination from the Exchange, including APTC that may
increase or decrease, or to change their QHP, the enrollee shall contact the
Exchange and update their information, as required under subdivision (g) of this
section, or make a plan selection by the end of the open enrollment
period.
(3) For all current
enrollees who have not requested an eligibility determination for IAPs for the
current benefit year, the notice shall include at least:
(A) All the information specified in subdivision
(e)(1) of this section;
(B) An
explanation that the premiums for the QHPs may change each benefit year;
(C) An explanation that unless the enrollee
completes the Exchange's renewal process to obtain an updated eligibility
determination by December 15 of the current benefit year for coverage effective
January first of the following benefit year, the Exchange will redetermine the
enrollee's eligibility and renew the enrollee's coverage for the following benefit
year, in accordance with the process specified in subdivision (l)
of this section, using the most recent information the enrollee provided to the
Exchange; and
(D) An explanation that in
order to obtain the most accurate eligibility determination from the Exchange or to
change their QHP, the enrollee shall contact the Exchange and update their
information, as required under subdivision (g) of this section or make a plan
selection by the end of the open enrollment period.
(f) For eligibility redeterminations under this
section, the Exchange shall provide the annual redetermination notice, as specified
in subdivision (e) of this section, and the notice of annual open enrollment period,
as specified in Section
6502(e), through a
single, coordinated notice.
(g) Except
as specified in Section
6496(c), an enrollee,
a qualified individual, or an application filer on behalf of the qualified
individual, shall report to the Exchange any changes with respect to the eligibility
standards specified in Sections
6472 and
6474 within 30 days of such change,
using any of the channels available for the submission of an application, as
described in Section
6470(j).
(h) The Exchange shall verify any information
reported by an enrollee or a qualified individual under subdivision (g) of this
section using the processes specified in Sections
6478 through
6492, prior to using such information
to determine eligibility.
(i) A current
enrollee or a qualified individual who has selected a QHP through the Exchange
during the current benefit year but their coverage has not been effectuated, shall
complete the Exchange's renewal process, as specified in subdivision (i)(1) of this
section, within 30 days from the date of the notice described in subdivision (e) of
this section.
(1) To complete the Exchange's
renewal process, the enrollee or the qualified individual shall:
(A) Check their application information for
accuracy, and make any changes to the application information, as required under
subdivision (g) of this section;
(B) If
any changes made, provide a reason for the change and the date of the
change;
(C) Declare under penalty of
perjury that the enrollee or the qualified individual:
1. Understands that they must report any changes
to the information on the application that may affect their eligibility for
enrollment in a QHP or for APTC and CSR, if applicable, to the Exchange within 30
days of such change;
2. Understands that
if they, or someone in their household, have health insurance through Medi-Cal, they
must report any changes to information on the application to their county social
services office within 10 days of such change;
3. Provided true answers and correct information
to the best of their knowledge during the renewal process;
4. Knows that if they do not tell the truth, there
may be a civil or criminal penalty for perjury that may include up to four years in
jail, pursuant to California Penal Code Section
126;
5. Understands that if they received premium tax
credits for health coverage through the Exchange during the previous benefit year,
they must have filed or will file a federal tax return for that benefit
year;
6. Understands that, unless they
have already provided authorization for the Exchange to use electronic data sources
to obtain their updated tax return information to conduct the annual redetermination
for all IAPs, except for Medi-Cal or CHIP, they are giving the Exchange
authorization to obtain updated tax return information to provide him or her with an
updated eligibility determination for the following benefit year; and
7. Understands that they must provide their
electronic signature and PIN to complete the Exchange's renewal process for
enrollment in a QHP or for APTC and CSR, if applicable;
(D) Provide their electronic signature and
PIN;
(E) Submit any reported changes and
the signed declarations, through any of the channels specified in subdivision (i)(2)
of this section, to obtain an updated eligibility determination for the following
benefit year; and
(F) If eligible to
enroll in a QHP, make a plan selection for the following benefit
year.
(2) The enrollee or the
qualified individual may complete the renewal process described in subdivision
(i)(1) of this section through the channels available for the submission of an
application, as described in Section
6470(j), except mail
and facsimile.
(3) The enrollee or the
qualified individual may seek assistance from a CEC, PBE, or a Certified Insurance
Agent to complete the renewal process described in subdivision (i)(1) of this
section.
(4) If the enrollee or the
qualified individual does not complete the Exchange's renewal process specified in
subdivision (i)(1) of this section within 30 days from the date of the notice
described in subdivision (e) of this section, the Exchange shall proceed in
accordance with the process specified in subdivision (j) of this
section.
(j) After the 30-day
period specified in subdivision (i) of this section has elapsed, the Exchange shall:
(1) Redetermine the enrollee's or the qualified
individual's eligibility in accordance with the standards specified in Sections
6472 and
6474 using information obtained from
the electronic data sources specified in subdivision (c) of this section and the
most recent information the individual provided to the Exchange and renew the
enrollee's coverage for the following benefit year, in accordance with the process
specified in subdivision (l) of this section;
(2) Notify the enrollee or the qualified
individual in accordance with the requirements specified in Section
6476(h); and
(3) If applicable, notify the enrollee's or the
qualified individual's employer, in accordance with the requirements specified in
Section 6476(i).
(k) A redetermination under this section shall be
effective on the first day of the coverage year following the year in which the
Exchange provided the notice in subdivision (e) of this section, or in accordance
with the rules specified in Section
6496(j) through
(l), whichever is later.
(l) If an enrollee remains eligible for enrollment
in a QHP through the Exchange upon annual redetermination, and the enrollee does not
terminate coverage, including termination of coverage in connection with voluntarily
selecting a different QHP in accordance with Section
6506, the Exchange shall proceed in
accordance with the following process:
(1) The
enrollee shall be enrolled in the same QHP as the enrollee's current QHP, unless the
enrollee's current QHP is not available.
(2) If the enrollee is not eligible for the same
level of CSR as the enrollee's current level of CSR, they shall be enrolled in a
silver-tier QHP offered by the same QHP issuer at the CSR level for which the
enrollee is eligible. If the enrollee is not eligible for any level of CSR, they
shall be enrolled in a standard silver-tier QHP offered by the same QHP issuer
without CSR.
(3) If the enrollee's
current QHP is not available and the current QHP is a HDHP as defined in Section
6410, the enrollee shall be enrolled in
the lowest cost HDHP offered by the same QHP issuer at the same metal tier, as
determined by the Exchange on a case-by-case basis. If there is no HDHP available,
the enrollee shall be enrolled in the lowest cost QHP that is not a HDHP offered by
the same QHP issuer at the same metal tier, as determined by the Exchange on a
case-by-case basis.
(4) If the
enrollee's current QHP is not available and the current QHP is not a HDHP, the
enrollee shall be enrolled in the lowest cost QHP that is not a HDHP offered by the
same QHP issuer at the same metal tier, as determined by the Exchange on a
case-by-case basis.
(5) If the enrollee
who is currently enrolled in a catastrophic QHP attains the age of 30 before the
beginning of the following benefit year, the enrollee shall be enrolled in the
lowest cost bronze-tier QHP that is not a HDHP offered by the same QHP
issuer.
(6) Notwithstanding the process
specified in subdivision (
l)(1) through (5) of this section, an
enrollee whose household income is at or below 250 percent of the FPL and who upon
annual redetermination is determined eligible for CSR, in accordance with Section
6474(d), shall be
enrolled as follows:
(A) An enrollee who is
currently enrolled in a bronze-tier QHP shall be enrolled in a silver-tier QHP with
the same provider network as the enrollee's current QHP offered by the same QHP
issuer if the silver-tier QHP has a $0.00 net monthly premium.
(B) An enrollee who is currently enrolled in a
gold-tier or platinum-tier QHP shall be enrolled in a silver-tier QHP with the same
or higher actuarial value and the same provider network as the enrollee's current
QHP offered by the same QHP issuer if the silver-tier QHP has the same or lower net
monthly premium.
(7) If the
issuer of the QHP in which the enrollee is currently enrolled is no longer
available, the enrollee shall be enrolled in the lowest cost QHP that is most
similar to the enrollee's current QHP offered by a different QHP issuer that is
available to the enrollee through the Exchange at the same metal tier and in
accordance with the same hierarchy specified in subdivision (l)(3)
through (6) of this section, as determined by the Exchange on a case-by-case
basis.
(8) If the enrollee who is
currently enrolled in a QHP as a dependent attains the age of 26 before the
beginning of the following benefit year, the enrollee shall be enrolled in their own
individual QHP through the Exchange in accordance with the process specified in
subdivision (l)(1) through (7) of this section.
(9) Notwithstanding the process specified in
subdivision (l)(1) through (8) of this section, a
federally-recognized American Indian or Alaska Native enrollee who is currently
enrolled in a zero cost sharing QHP shall be enrolled in the lowest cost zero cost
sharing QHP that offers the same benefits and provider network offered by the same
QHP issuer. If the issuer of the QHP in which the enrollee is currently enrolled is
no longer available, the enrollee shall be enrolled in the lowest cost zero cost
sharing QHP offered by a different QHP issuer that is available to the enrollee
through the Exchange, as determined by the Exchange on a case-by-case
basis.
(10) Notwithstanding the process
specified in subdivision (l)(1) through (9) of this section, if the
enrollee's current QDP is not available, the enrollee shall be enrolled in the
lowest cost QDP that is most similar to the enrollee's current QDP offered by the
same or different QDP issuer that is available to the enrollee through the Exchange,
as determined by the Exchange on a case-by-case basis.
(m) The Exchange shall not redetermine a qualified
individual's eligibility in accordance with this section if the qualified
individual's eligibility was redetermined under this section during the prior year,
and the qualified individual was not enrolled in a QHP through the Exchange at the
time of such redetermination, and has not enrolled in a QHP through the Exchange
since such redetermination.
Note: Authority cited: Section 100504, Government Code.
Reference: Sections 100502 and 100503, Government Code; and
45 CFR Section
155.335.
Note: Authority cited: Section
100504,
Government Code. Reference: Sections
100502 and
100503,
Government Code; and 45 CFR
Section
155.335.
