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 6504 - Special Enrollment Periods
Universal Citation: 10 CA Code of Regs 6504
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) A qualified individual may enroll in a QHP, or an enrollee may change from one QHP to another, during special enrollment periods only if one of the following triggering events occurs:
(1) A qualified individual or their
dependent either:
(A) Loses MEC, as specified in
subdivision (b) of this section. The date of the loss of MEC shall be:
1. Except as provided in subdivision (a)(1)(A)2 of
this section, the last day the qualified individual or their dependent would have
coverage under their previous plan or coverage;
2. If loss of MEC occurs due to a QHP
decertification, the date of the notice of decertification as described in
45 CFR Section
155.1080(e)(2) (May 29, 2012),
hereby incorporated by reference;
(B) Is enrolled in any non-calendar year group
health plan or individual health insurance coverage, including both grandfathered
and non-grandfathered health plans that expired or will expire, even if the
qualified individual or their dependent has the option to renew such coverage. The
date of the loss of coverage shall be the last day of the plan or policy
year;
(C) Loses Medi-Cal coverage for
pregnancy-related services, as described under Section 1902(a)(10)(A)(i)(IV) and
(a)(10)(A)(ii)(IX) of the Social Security Act (42 USC 1396a(a)(10)(A)(i)(IV),
(a)(10)(A)(ii)(IX)) and Section
14005.18
of the Welfare and Institutions Code or loses access to healthcare services through
coverage provided to a pregnant woman's unborn child, based on the definition of a
child in 42 CFR Section
457.10, (November 30, 2016), hereby incorporated
by reference. The date of the loss of coverage shall be the last day the consumer
would have pregnancy-related coverage or access to healthcare services through
unborn child coverage; or
(D) Loses
Medi-Cal coverage for medically needy, as described under Section 1902(a)(10)(C) of
the Social Security Act and Section
14005.21
of the Welfare and Institutions Code, only once per calendar year. The date of the
loss of coverage shall be the last day the consumer would have medically needy
coverage.
(2) A qualified
individual gains a dependent or becomes a dependent through marriage or entry into
domestic partnership, birth, adoption, placement for adoption, or placement in
foster care, or through a child support order or other court order.
(3) An enrollee loses a dependent or is no longer
considered a dependent through divorce, legal separation, or dissolution of domestic
partnership as defined by State law in the State in which the divorce, legal
separation, or dissolution of domestic partnership occurs, or if the enrollee, or
their dependent, dies.
(4) A qualified
individual, or their dependent, becomes newly eligible for enrollment in a QHP
through the Exchange because they newly meet the requirements specified in Section
6472(c) or
(d).
(5) A qualified individual's, or their
dependent's, enrollment or non-enrollment in a QHP is unintentional, inadvertent, or
erroneous and is the result of the error, misrepresentation, misconduct, or inaction
of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, a
QHP issuer, or a non-Exchange entity providing enrollment assistance or conducting
enrollment activities. For purposes of this provision, misconduct, as determined by
the Exchange, includes the failure to comply with applicable standards under this
title, or other applicable Federal or State laws.
(6) An enrollee, or their dependent, adequately
demonstrates to the Exchange, as determined by the Exchange on a case-by-case basis,
that the QHP in which they are enrolled substantially violated a material provision
of its contract in relation to the enrollee.
(7) An enrollee, or their dependent enrolled in
the same QHP, is determined newly eligible or ineligible for APTC or has a change in
eligibility for CSR.
(8) A qualified
individual, or their dependent, who is enrolled in an eligible employer-sponsored
plan is determined newly eligible for APTC because such individual is ineligible for
qualifying coverage in an eligible employer-sponsored plan in accordance with
26 CFR Section
1.36B-2(c)(3), including as a
result of their employer discontinuing or changing available coverage within the
next 60 days, provided that such individual is allowed to terminate existing
coverage.
(9) A qualified individual or
enrollee, or their dependent, gains access to new QHPs as a result of a permanent
move.
(10) A qualified individual who:
(A) Gains or maintains status as an Indian, as
defined in Section
6410 of Article 2 of this chapter, may
enroll in a QHP or change from one QHP to another one time per month; or
(B) Is or becomes a dependent of an Indian, as
defined in Section
6410 of Article 2 of this chapter, and
is enrolled or is enrolling in a QHP through the Exchange on the same application as
the Indian, may change from one QHP to another one time per month, at the same time
as the Indian.
(11) A
qualified individual or enrollee, or their dependent, demonstrates to the Exchange,
in accordance with guidelines issued by HHS and as determined by the Exchange on a
case-by-case basis, that the individual meets other exceptional circumstances. Such
circumstances include, but are not limited to, the following:
(A) If an individual receives a certificate of
exemption for hardship based on the eligibility standards described in
45 CFR Section
155.605(d)(1) (April 17, 2018),
hereby incorporated by reference, or the eligibility standards described in Section
6914 of Article 13 of this chapter for
a month or months during the coverage year, and based on the circumstances of the
hardship attested to, they are no longer eligible for a hardship exemption within a
coverage year but outside of an open enrollment period described in Section
6502, the individual and their
dependents shall be eligible for a special enrollment period if otherwise eligible
for enrollment in a QHP.
(B) If an
individual with a certificate of exemption reports a change regarding the
eligibility standards for an exemption, as required under
45 CFR Section
155.620(b) (July 1, 2013), hereby
incorporated by reference, or under Section
6920 of Article 13 of this chapter and
the change resulting from a redetermination is implemented, the certificate provided
for the month in which the redetermination occurs, and for prior months, remains
effective. If the individual is no longer eligible for an exemption, the individual
and their dependents shall be eligible for a special enrollment period if otherwise
eligible for enrollment in a QHP.
(C) If
an enrollee provides satisfactory documentary evidence to verify their eligibility
for an IAP or enrollment in a QHP through the Exchange within 30 days following
their termination of Exchange enrollment due to a failure to verify such status
within the 95-day period specified in Section
6492(a)(2)(B), the
enrollee shall be eligible for a special enrollment period if otherwise eligible for
enrollment in a QHP.
(D) If a qualified
individual or enrollee, or their dependent, experiences a fire, flood, or other
natural or human-caused disaster that results in the declaration of state of
emergency in California, the individual shall be eligible for a special enrollment
period if otherwise eligible for enrollment in a QHP. The date of the triggering
event shall be the date of the declaration of state of emergency.
(E) In case of a national public health emergency
or a pandemic that results in a declaration of a state of emergency at the state or
national level, a qualified individual or enrollee, or their dependent, shall be
eligible for a special enrollment period if otherwise eligible for enrollment in a
QHP. This triggering event shall be ongoing throughout the state of
emergency.
(12) A qualified
individual or enrollee is a victim of domestic abuse or spousal abandonment, as
specified in 26 CFR Section
1.36B-2 (b)(2)(ii) through (v),
or a dependent or unmarried victim within a household, is enrolled in MEC, and seeks
to enroll in coverage separate from the perpetrator of the abuse or abandonment. A
dependent of a victim of domestic abuse or spousal abandonment who is on the same
application as the victim may enroll in coverage at the same time as the
victim.
(13) A qualified individual, or
their dependent:
(A) Applies for coverage on the
Exchange during the annual open enrollment period or due to a qualifying event, is
assessed by the Exchange as potentially eligible for Medi-Cal or CHIP, and is
determined ineligible for Medi-Cal or CHIP by the State Medi-Cal or CHIP agency
either after open enrollment period has ended or more than 60 days after the
qualifying event; or
(B) Applies for
coverage at the State Medi-Cal or CHIP agency during the annual open enrollment
period and is determined ineligible for Medi-Cal or CHIP after open enrollment
period has ended.
(14) The
qualified individual's or enrollee's, or their dependent's, enrollment through the
Exchange was influenced by a material error related to plan benefits, service area,
cost-sharing, or premium. A material error is one that is likely to have influenced
a qualified individual's, enrollee's, or their dependent's enrollment in a QHP, as
determined by the Exchange on a case-by-case basis.
(15) The qualified individual, enrollee, or
dependent newly gains access to an individual coverage HRA, as defined in
45 CFR Section
146.123(b) (August 19, 2019),
hereby incorporated by reference, or is newly provided a qualified small employer
health reimbursement arrangement (QSEHRA), as defined in Section
9831(d)(2) of the Internal
Revenue Code. The date of this triggering event shall be the first day on which
coverage for the qualified individual, enrollee, or dependent under the individual
coverage HRA can take effect, or the first day on which coverage under the QSEHRA
takes effect. An individual, enrollee, or dependent shall qualify for this special
enrollment period regardless of whether they were previously offered or enrolled in
an individual coverage HRA or previously provided a QSEHRA, so long as the
individual, enrollee, or dependent is not enrolled in the individual coverage HRA or
covered by the QSEHRA on the day immediately prior to the triggering
event.
(16) The qualified individual or
their dependent is enrolled in COBRA continuation coverage for which an employer is
paying all or part of the premiums, or for which a government entity is providing
subsidies, and the employer completely ceases its contributions to the qualified
individual's or dependent's COBRA continuation coverage or government subsidies
completely cease. The date of this event shall be the last day of the period for
which COBRA continuation coverage is paid for or subsidized, in whole or in part, by
an employer or government entity.
(17)
The qualified individual, enrollee, or dependent, who is eligible for APTC, whose
expected household income is at or below 150 percent of the FPL, and whose
applicable percentage for purposes of calculating the APTC amount, as defined in
section 36B(b)(3)(A) of the IRC
(26 USC §
36B(b)(3)(A)), is set at zero,
may enroll in a QHP or change from one QHP to another one time per month.
(18) Any other triggering events listed in the
Health and Safety Code Section
1399.849(d)(1)
and the Insurance Code Section
10965.3(d)(1).
(b) Loss of MEC, as specified in subdivision (a)(1)(A) of this section, includes:
(1) Loss of
eligibility for coverage, including but not limited to:
(A) Loss of eligibility for coverage as a result
of:
1. Legal separation,
2. Divorce or dissolution of domestic
partnership,
3. Cessation of dependent
status (such as attaining the maximum age to be eligible as a dependent child under
the plan),
4. Death of an
employee,
5. Termination of
employment,
6. Reduction in the number
of hours of employment, or
7. Any loss
of eligibility for coverage after a period that is measured by reference to any of
the foregoing;
(B) Loss of
eligibility for coverage through Medicare, Medi-Cal, or other government-sponsored
health care programs, other than programs specified as not MEC under
26 CFR Section
1.5000A-2(b)(2) (November 26,
2014), hereby incorporated by reference;
(C) In the case of coverage offered through an HMO
or similar program in the individual market that does not provide benefits to
individuals who no longer reside, live, or work in a service area, loss of coverage
because an individual no longer resides, lives, or works in the service area
(whether or not within the choice of the individual);
(D) In the case of coverage offered through an HMO
or similar program in the group market that does not provide benefits to individuals
who no longer reside, live, or work in a service area, loss of coverage because an
individual no longer resides, lives, or works in the service area (whether or not
within the choice of the individual), and no other benefit package is available to
the individual; and
(E) A situation in
which a plan no longer offers any benefits to the class of similarly situated
individuals that includes the individual.
(2) Termination of employer contributions toward
the employee's or dependent's coverage that is not COBRA continuation coverage,
including contributions by any current or former employer that was contributing to
coverage for the employee or dependent; and
(3) Exhaustion of COBRA continuation coverage,
meaning that such coverage ceases for any reason other than either failure of the
individual to pay premiums on a timely basis, or for cause, such as making a
fraudulent claim or an intentional misrepresentation of a material fact in
connection with the plan. An individual is considered to have exhausted COBRA
continuation coverage if such coverage ceases:
(A)
Due to the failure of the employer or other responsible entity to remit premiums on
a timely basis;
(B) When the individual
no longer resides, lives, or works in the service area of an HMO or similar program
(whether or not within the choice of the individual) and there is no other COBRA
continuation coverage available to the individual; or
(C) When the individual incurs a claim that would
meet or exceed a lifetime limit on all benefits and there is no other COBRA
continuation coverage available to the individual.
(c) Loss of coverage, as specified in subdivision (a)(1) of this section, does not include voluntary termination of coverage or loss due to:
(1) Failure to pay premiums on a timely
basis, including COBRA premiums prior to exhaustion of COBRA coverage, except for
circumstances in which an employer completely ceases its contributions to COBRA
continuation coverage or government subsidies of COBRA continuation coverage
completely cease as described in subdivision (a)(16) of this section; or
(2) Termination of coverage for cause, such as
making a fraudulent claim or an intentional misrepresentation of a material fact in
connection with a plan.
(d) A qualified individual or an enrollee shall attest under penalty of perjury that they meet at least one of the triggering events specified in subdivision (a) of this section. The Exchange shall inform the qualified individual or the enrollee that pursuant to 45 CFR Section 155.285, (September 6, 2016), hereby incorporated by reference, HHS may impose civil money penalties of:
(1) Up to $25,000 on the qualified individual or
the enrollee who fails to provide the correct information requested by the Exchange,
subject to the exception specified in subdivision (e)(4) of this section, due to
their negligence or disregard of the federal or State rules or regulations related
to the Exchange with negligence and disregard defined as they are in section
6662 of IRC (26 USC §
6662), as
follows:
(A) "Negligence" includes any failure to
make a reasonable attempt to provide accurate, complete, and comprehensive
information; and
(B) "Disregard"
includes any careless, reckless, or intentional disregard for any federal or State
rules or regulations related to the Exchange; and
(2) Up to $250,000 on the qualified individual or
the enrollee who:
(A) Knowingly and willfully
provides false or fraudulent information requested by the Exchange, where knowingly
and willfully means intentionally providing information that the person knows to be
false or fraudulent; or
(B) Knowingly
and willfully uses or discloses information in violation of Section
1411(g) of the
Affordable Care Act (42 USC
§
18081(g)), where knowingly
and willfully means intentionally using or disclosing information in violation of
Section 1411(g).
(e) The Exchange shall accept the qualified individual's or the enrollee's attestation provided in accordance with subdivision (d) of this section, subject to the following statistically valid random sampling verification process:
(1) The Exchange may select
a statistically valid random sample of the qualified individuals or the enrollees
who, in accordance with subdivision (d) of this section, have attested that they met
at least one of the triggering events specified in subdivision (a) of this section
and request, in writing, that they provide documentation as proof of the triggering
event to which they attested or for which they qualify.
(2) The qualified individual or the enrollee shall
provide the requested document(s) within 30 days from the date of the Exchange's
written request, as specified in subdivision (e)(1) of this section, to the Exchange
for verification. The Exchange may extend this period if the Exchange determines on
a case-by-case basis that the qualified individual or the enrollee has demonstrated
that they have made a good-faith effort but was unable to obtain the requested
documentation during the 30-day time period.
(3) Except as specified in subdivision (e)(4) of
this section, if the qualified individual or the enrollee fails to submit the
requested document(s) by the end of the time period specified in subdivision (e)(2)
of this section or the Exchange is unable to verify the provided document(s), the
Exchange shall:
(A) Determine the qualified
individual or the enrollee ineligible for any special enrollment period;
(B) Notify the qualified individual or the
enrollee regarding the determination and their appeals rights, in accordance with
the requirements specified in Section
6476(h); and
(C) Implement such eligibility determination in
accordance with the dates specified in Section
6496(j) and (k), as
applicable.
(4) The Exchange
shall provide an exception, on a case-by-case basis, to accept a qualified
individual's or an enrollee's attestation as to their triggering event which cannot
otherwise be verified and their explanation of circumstances as to why they do not
have documentation if:
(A) The qualified
individual or the enrollee does not have the requested documentation with which to
prove a triggering event through the process described in subdivision (e)(1) through
(3) of this section because such documentation does not exist or is not reasonably
available;
(B) The Exchange is unable to
otherwise verify the triggering event for the qualified individual or the enrollee;
and
(C) The qualified individual or the
enrollee provides the Exchange with a signed written statement of their attestation
under penalty of perjury as to the triggering event and the explanation of
circumstances as to why they do not have the documentation.
(5) The sampling described in this subdivision
shall not be based on the qualified individual's or the enrollee's claims costs,
diagnosis code, or demographic information. For purposes of this subdivision (e)(5),
demographic information does not include geographic factors.
(f) Except as provided in subdivision (f)(1), (2), (3), (4), (5), (6), (7), and (8) of this section, a qualified individual, enrollee, or their dependent shall have 60 days from the date of a triggering event to select a QHP.
(1) Except as provided in subdivision (f)(6)
of this section, a qualified individual or their dependent who loses coverage, as
described in subdivision (a)(1) of this section shall have 60 days before and after
the date of the loss of coverage to select a QHP.
(2) A qualified individual who is enrolled in an
eligible employer-sponsored plan and will lose eligibility for qualifying coverage
in an eligible employer-sponsored plan within the next 60 days, as described in
subdivision (a)(8) of this section, shall have 60 days before and after the loss of
eligibility for qualifying coverage in an eligible employer-sponsored plan to select
a QHP.
(3) A qualified individual,
enrollee, or their dependent who is described in subdivision (a)(15) of this section
shall have 60 days before the triggering event to select a QHP, unless the HRA or
QSEHRA was not required to provide the notice setting forth its terms to such
individual or enrollee at least 90 days before the beginning of the plan year, as
specified in 45 CFR Section
146.123(c)(6),
26 CFR Section
54.9802-4(c)(6) (August 19,
2019), hereby incorporated by reference, and
29 CFR Section
2590.702-2(c)(6) (August 19,
2019), hereby incorporated by reference, or Section
9831(d)(4) of the Internal
Revenue Code, as applicable, in which case the qualified individual, enrollee, or
their dependent shall have 60 days before or after the triggering event to select a
QHP.
(4) A qualified individual or their
dependent who is described in subdivision (a)(16) of this section shall have 60 days
before and after the date of the triggering event to select a QHP.
(5) If a qualified individual, enrollee, or their
dependent did not receive timely notice of an event that triggers eligibility for a
special enrollment period under this section, and otherwise was reasonably unaware
that a triggering event described in subdivision (a) of this section occurred, the
Exchange shall allow the qualified individual, enrollee, or when applicable, their
dependent to select a new plan within 60 days of the date that they knew, or
reasonably should have known, of the occurrence of the triggering event.
(6) Beginning January 1, 2024, a qualified
individual or their dependent who loses Medi-Cal or CHIP coverage shall have 90 days
after the date of the loss of coverage to select a QHP.
(7) Beginning January 1, 2025, the following
individuals shall have 60 days before and after the triggering event to select a
QHP:
(A) A qualified individual or their dependent
who becomes newly eligible for enrollment in a QHP through the Exchange because they
newly meet the requirements specified in Section
6472(d) as described
in subdivision (a)(4) of this section.
(B) A qualified individual or their dependent who
gains access to new QHPs as a result of a permanent move as described in subdivision
(a)(9) of this section.
(g) Except as specified in subdivision (h) of this section, the regular coverage effective date for a special enrollment period shall be the first day of the month following plan selection.
(h) Special coverage effective dates shall apply to the following situations.
(1) In the case of
birth, adoption, placement for adoption, or placement in foster care, the coverage
shall be effective either:
(A) On the date of
birth, adoption, placement for adoption, or placement in foster care; or
(B) On the first day of the month following birth,
adoption, placement for adoption, or placement in foster care; or
(C) On the first day of the month following plan
selection, at the option of the qualified individual or the enrollee.
(2) In the case where a qualified
individual, or their dependent, loses coverage as described in subdivisions (a)(1)
and (a)(8) of this section, or is enrolled in COBRA continuation coverage and
employer contributions to or government subsidies of this coverage completely cease
as described in subdivision (a)(16) of this section, the coverage and APTC and CSR,
if applicable, shall be effective:
(A) On the
first day of the month following the loss of coverage or the date of the triggering
event if the plan selection is made on or before the date of the loss of coverage or
the triggering event;
(B) On the first
day of the month following plan selection if the plan selection is made after the
date of the loss of coverage or the triggering event; or
(C) Beginning January 1, 2025, at the option of
the qualified individual or the enrollee, on the first day of the month in which the
loss of coverage or the triggering event occurs if the plan selection is made on or
before the last day of the month prior to the month of the loss of coverage or the
triggering event.
(3)
Beginning January 1, 2025, in the case of a qualified individual or their dependent
who becomes newly eligible for enrollment in a QHP through the Exchange because they
newly meet the requirements specified in Section
6472(d), as described
in subdivision (a)(4) of this section, or gains access to new QHPs as a result of a
permanent move, as described in subdivision (a)(9) of this section, the coverage and
APTC and CSR, if applicable, shall be effective:
(A) On the first day of the month following the
date of the triggering event if the plan selection is made on or before the date of
the event; or
(B) On the first day of
the month following plan selection if the plan selection is made after the date of
the triggering event.
(4) In
the case of a qualified individual or enrollee eligible for a special enrollment
period described in subdivisions (a)(5), (a)(6), (a)(11), (a)(13), or (a)(14) of
this section, the coverage shall be effective on an appropriate date, including a
retroactive date, determined by the Exchange on a case-by-case basis based on the
circumstances of the special enrollment period.
(5) In the case of a court order described in
subdivision (a)(2) of this section, the coverage shall be effective either:
(A) On the date the court order is effective;
or
(B) On the first day of the month
following plan selection, at the option of the qualified individual or the
enrollee.
(6) If a qualified
individual, enrollee, or dependent newly gains access to an individual coverage HRA
or is newly provided a QSEHRA, each as described in subdivision (a)(15) of this
section, and if the plan selection is made before the day of the triggering event,
the coverage shall be effective on the first day of the month following the date of
the triggering event or, if the triggering event is on the first day of a month, on
the date of the triggering event. If the plan selection is made on or after the day
of the triggering event, the coverage shall be effective on the first day of the
month following plan selection.
(7) At
the option of a qualified individual, enrollee, or their dependent who is eligible
to select a plan during a period provided for under subdivision (f)(5) of this
section, the Exchange shall provide the earliest effective date that would have been
available under subdivisions (g) and (h) of this section, based on the applicable
triggering event under subdivisions (a) of this section.
(i) A qualified individual's coverage shall be effectuated in accordance with the coverage effective dates specified in subdivisions (g) and (h) of this section if:
(1)
The individual makes their initial premium payment, reduced by the APTC amount they
are determined eligible for by the Exchange, by the premium payment due date, as
defined in Section
6410 of Article 2 of this chapter. 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
subdivision (g) of this section; and
(2)
The applicable QHP issuer receives such payment on or before such due
date.
(j) Notwithstanding the standards of this section, APTC and CSR shall adhere to the effective dates specified in subdivisions (j) through (l) of Section 6496.
(k) For purposes of this section, references to eligibility for APTC refer to being eligible for such advance payments in an amount greater than zero dollars per month. References to ineligibility for APTC refer to being ineligible for such payments or being eligible for such payments but being eligible for a maximum of zero dollars per month of such payments.
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 26 USC Sections 36B(b)(3)(A) and 9831(d)(4); 26 CFR Sections 1.36B-2, 1.5000A-2 and 54.9802-4; 29 CFR Section 2590.702-2; 42 CFR Section 457.10; and 45 CFR Sections 146.123, 155.420, 155.605, 155.620 and 155.1080.
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 26 USC Sections 36B(b)(3)(A) and 9831(d)(4); 26 CFR Sections 1.36B-2, 1.5000A-2 and 54.9802-4; 29 CFR Section 2590.702-2; 42 CFR Section 457.10; and 45 CFR Sections 146.123, 155.420, 155.605, 155.620 and 155.1080.
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