Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) A
qualified individual may enroll in a QHP (and an enrollee may change QHPs) only
during, and in accordance with the coverage effective dates related to, the
following periods:
(1) The initial open enrollment
period, as specified in Section
6502;
(2) The annual open enrollment period, as
specified in Section
6502; or
(3) A special enrollment period, as specified in
Section 6504, for which the qualified
individual has been determined eligible.
(b) The Exchange shall accept a QHP selection from
an applicant who is determined eligible for enrollment in a QHP in accordance with
Section 6472, and shall:
(1) Notify the applicant of her or his initial
premium payment method options and of the requirement that the applicant's initial
premium payment shall be received by the QHP issuer on or before the premium payment
due date, as defined in Section
6410 of Article 2 of this chapter, in
order for the applicant's coverage to be effectuated, as specified in Sections
6502(g) and
6504(i);
(2) Notify the QHP issuer that the individual is a
qualified individual and of the applicant's selected QHP and premium payment method
option;
(3) Transmit to the QHP issuer
information necessary to enable the issuer to enroll the applicant within three
business days from the date the Exchange obtains the information; and
(4) Transmit eligibility and enrollment
information to HHS promptly and without undue delay, in a manner and timeframe as
specified by HHS.
(c) The
Exchange shall maintain records of all enrollments in QHPs through the
Exchange.
(d) The Exchange shall
reconcile enrollment information with QHP issuers and HHS no less than once a
month.
(e) A QHP issuer shall accept
enrollment information specified in subdivision (b) of this section consistent with
the federal and State privacy and security standards specified in
45 CFR Section
155.260 (September 6, 2016), hereby incorporated
by reference, and the Information Practices Act of 1977 (Cal. Civ. Code, §
1798 et seq.) and in an electronic
format that is consistent with 45
CFR Section 155.270 (August 30, 2013), hereby
incorporated by reference, and shall:
(1)
Acknowledge receipt of enrollment information transmitted from the Exchange upon the
receipt of such information;
(2) Enroll
a qualified individual during the periods specified in subdivision (a) of this
section;
(3) Notify a qualified
individual of their premium payment due date;
(4) Abide by the effective dates of coverage
established by the Exchange in accordance with Section
6502(c) and (f) and
Section 6504(g) and
(h);
(5) Notify the Exchange of the issuer's timely
receipt of a qualified individual's initial premium payment and their effective date
of coverage;
(6) Notify a qualified
individual of their effective date of coverage upon the timely receipt of the
individual's initial premium payment; and
(7) Provide new enrollees an enrollment
information package that is compliant with accessibility and readability standards
specified in Section
6452 of Article 4 of this
chapter.
(f) If an applicant
requests assistance from a QHP issuer for enrollment through the Exchange, the QHP
issuer shall either:
(1) Direct the individual to
file an application with the Exchange, or
(2) Ensure the applicant received an eligibility
determination for coverage through the Exchange through the Exchange Internet Web
site by assisting the applicant to apply for and receive an eligibility
determination for coverage through the Exchange through CalHEERS, provided that the
QHP issuer:
(A) Complies with the federal and State
privacy and security standards specified in
45 CFR Section
155.260 and the Information Practices Act of 1977
(Cal. Civ. Code, §
1798 et seq.);
(B) Complies with the consumer assistance
standards specified in 45 CFR
Section 155.205(d) (December 22,
2016), hereby incorporated by reference;
(C) Informs the applicant of the availability of
other QHP products offered through the Exchange and displays the Web link to, and
describes how to access, the Exchange Web site; and
(D) Complies with the requirements of Article 9 of
this chapter.
(g) In
accordance with the following premium payment process established by the Exchange, a
QHP issuer shall:
(1) Accept, at a minimum, for
all payments, paper checks, cashier's checks, money orders, EFT, and all
general-purpose pre-paid debit cards as methods of payment and present all payment
method options equally for a consumer to select their preferred payment
method.
(2) Effectuate coverage upon
receipt of an initial premium payment from the applicant on or before the premium
payment due date. In cases of retroactive enrollment dates, the initial premium
shall consist of the premium due for all months of retroactive coverage through the
first month of coverage following the plan selection date. If only partial premium
for less than all months of retroactive coverage is paid, only prospective coverage
shall be effectuated, in accordance with the regular coverage effective date
specified in Section
6504(g).
(3) Acknowledge receipt of qualified individuals'
premium payments by transmitting to the Exchange information regarding all received
payments.
(4) Initiate cancellation of
enrollment if the issuer does not receive the initial premium payment by the due
date.
(5) Transmit to the Exchange the
notice of cancellation of enrollment no earlier than the first day of the month when
coverage is effectuated.
(6) Send a
written notice of the cancellation to the enrollee within five business days from
the date of cancellation of enrollment due to nonpayment of
premiums.
(h) A QHP issuer
shall reconcile enrollment and premium payment files with the Exchange no less than
once a month.
(i) The premium for
coverage lasting less than one month shall equal the product of:
(1) The premium for one month of coverage divided
by the number of days in the month; and
(2) The number of days for which coverage is being
provided in the month described in subdivision (i)(1) of this section.
(j) If individuals in the tax filers'
tax households are enrolled in more than one QHP, and one or more APTC are to be
made on behalf of a tax filer (or two tax filers covered by the same plan(s)), that
portion of the APTC that is less than or equal to the aggregate adjusted monthly
premiums, as defined in 26 CFR
Section 1.36B-3(e), properly
allocated to the essential health benefits (EHB) for the QHP policies, shall be
allocated among the QHP policies as follows:
(1)
The APTC shall be apportioned based on the number of enrollees covered under the
QHP, weighted by the age of the enrollees, using the default uniform age rating
curve established by the Secretary of HHS under
45 CFR Section
147.102(e) (April 17, 2018),
hereby incorporated by reference;
(2)
The portion allocated to any single QHP policy shall not exceed the portion of the
QHP's adjusted monthly premium properly allocated to EHB; and
(3) If the portion of the APTC allocated to a QHP
under this subdivision exceeds the portion of the same QHP's adjusted monthly
premium properly allocated to EHB, the remainder shall be allocated evenly among all
other QHPs in which individuals in the tax filers' tax households are
enrolled.
(k) In accordance
with Section
100503.4 of the
Government Code, the Exchange shall:
(1)
Automatically enroll qualified individuals, whose Medi-Cal or CHIP coverage is being
discontinued, in the lowest-cost silver QHP available or any other appropriate QHP,
as specified in subdivision (a) of Section
100503.4 of the
Government Code, before the termination date of their Medi-Cal or CHIP
coverage;
(2) Provide a written notice
to the qualified individuals who are automatically enrolled in a QHP in accordance
with subdivision (d) of Section
100503.4 of the
Government Code;
(3) Ensure that the QHP
coverage is effective on the first day of the month following the qualified
individual's loss of Medi-Cal or CHIP coverage with no gap in coverage;
(4) Require the qualified individuals who are
automatically enrolled in a QHP with $0 monthly premium to actively opt in and
accept the enrollment; and
(5) Allow the
qualified individuals, whose Medi-Cal or CHIP coverage is being discontinued, to opt
out of the automatic enrollment through the Exchange.
Note: Authority cited: Section 100504, Government Code.
Reference: Sections 100502, 100503 and 100503.4, Government Code;
45 CFR Sections
147.102,
155.205,
155.240,
155.270,
155.340,
155.400,
156.260,
156.265,
156.1230 and
156.1240; and
26 CFR Section
1.36B-3(e).
Note: Authority cited: Section
100504,
Government Code. Reference: Sections
100502,
100503 and
100503.4,
Government Code; 45 CFR Sections
147.102,
155.205,
155.240,
155.270,
155.340,
155.400,
156.260,
156.265,
156.1230 and
156.1240; and
26 CFR Section
1.36B-3(e).
