California Code of Regulations
Title 10 - Investment
Chapter 12 - California Health Benefit Exchange
Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange
Section 6524 - Verification Process for Enrollment in the Shop

Universal Citation: 10 CA Code of Regs 6524

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) The SHOP shall verify or obtain information as provided in this section to determine whether an employer, employee or dependent meets the eligibility requirements specified in Section 6522 prior to allowing an employer to offer health coverage or dental coverage to its employees or a qualified employee to select a QHP through the SHOP.

(b) For purposes of verifying employee eligibility, the SHOP must:

(1) Verify that the employee has been identified by the qualified employer as an employee being offered health coverage or dental coverage by the qualified employer;

(2) Accept the information attested to by the employee under Section 6520 unless the information is inconsistent with the qualified employer-provided information; and

(3) Collect only the minimum information necessary for verification of eligibility and enrollment in accordance with the eligibility requirements in Section 6522.

(c) Inconsistencies

(1) When the information submitted to the SHOP by an employer, or an agent or authorized representative on behalf of the employer, is inconsistent with the eligibility requirements in Section 6522, the SHOP must:
(A) Make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors;

(B) Provide written notice to the employer of the inconsistency; and

(C) Provide the employer with a period of 30 days from the date on which the notice described in subdivision (c)(1)(B) of this section is sent to the employer to either present satisfactory documentary evidence to support the employer's application or resolve the inconsistency.

(D) If, after the 30-day period described in subdivision (c)(1)(C) of this section, the SHOP has not received satisfactory documentary evidence to support the employer's application or resolve the inconsistency, the SHOP must provide written notice to the employer of its denial of eligibility in accordance with subdivision (d) of this section and of the employer's right to appeal such determination pursuant to Section 6542(c).

(2) When the information submitted to the SHOP by an employee is inconsistent with the information provided by the employee's employer, the SHOP must:
(A) Make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors;

(B) Provide written notice to the employee of the inability to substantiate his or her employee status and;

(C) Provide the employee with a period of 30 days from the date on which the notice described in subdivision (c)(2)(B) of this section is sent to the employee to either present satisfactory documentary evidence to support the employee's application or resolve the inconsistency.

(D) If, after the 30-day period described in subdivision (c)(2)(C) of this section, the SHOP has not received satisfactory documentary evidence to support the employee's application or resolve the inconsistency, the SHOP must provide written notice to the employee of its denial of eligibility in accordance with subdivision (e) of this section.

(d) Notification of Employer Eligibility The SHOP must provide written notice to an employer applying to participate in the SHOP whether the employer is eligible in accordance with Section 6522 and the employer's right to appeal such determination pursuant to Section 6542(c).

(e) Notification of Employee Eligibility

The SHOP must provide written notice to an employee seeking to enroll in a QHP offered through the SHOP of the determination by the SHOP whether the employee is eligible in accordance with Section 6522(d) and the employee's right to appeal such eligibility determination pursuant to Section 6542(c).

1. New section filed 9-30-2013 as a deemed emergency pursuant to Government Code section 100504(a)(6); operative 9-30-2013 (Register 2013, No. 40). A Certificate of Compliance must be transmitted to OAL by 4-1-2014 or emergency language will be repealed by operation of law on the following day.
2. New section, including amendment of subsection (b)(1)(B), refiled 4-1-2014 as a deemed emergency pursuant to Government Code section 100504(a)(6); operative 4-1-2014 (Register 2014, No. 14). A Certificate of Compliance must be transmitted to OAL by 6-30-2014 or emergency language will be repealed by operation of law on the following day.
3. Refiling of 4-1-2014 action on 6-30-2014 as a deemed emergency pursuant to Government Code section 100504 subdivision (a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 6-30-2014 (Register 2014, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-30-2015 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
4. Refiling of 6-30-2014 order, including amendment of subsections (a)(1), (a)(3), (b)(1), (b)(1)(D) (c)(1) and (d)(1), on 10-2-2014 as a deemed emergency pursuant to Government Code section 100504, subdivision (a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 10-2-2014 (Register 2014, No. 40). A Certificate of Compliance must be transmitted to OAL by 9-30-2015 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
5. Editorial correction of HISTORY 3 and HISTORY 4 (Register 2014, No. 45).
6. Senate Bill 75 (Stats. 2015, Ch. 18) modified Government Code section 100504(a)(6) to change the date upon which a Certificate of Compliance must be transmitted to OAL. Pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 75 (Stats. 2015, Ch. 18), a Certificate of Compliance must be transmitted to OAL by 9-30-2016 or the language in the emergency order of 10-2-2014 will be repealed by operation of law on the following day (Register 2015, No. 38).
7. Senate Bill 833 (Stats. 2016, c. 30) modified Government Code section 100504(a)(6) to extend the date upon which a Certificate of Compliance must be transmitted to OAL. Refiling of 10-2-2014 order on 9-30-2016 as a deemed emergency pursuant to Government Code section 100504(a)(6); operative 9-30-2016 (Register 2016, No. 40). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504(a)(6) or emergency language will be repealed by operation of law on the following day.
8. Refiling of 9-30-2016 order, including amendment of section heading, on 11-28-2016 as a deemed emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 833 (Stats. 2016, c. 30); operative 11-28-2016 (Register 2016, No. 49). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
9. Refiling of 11-28-2016 order, including further amendment of section, filed 4-20-2018 as a deemed emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 833 (Stats. 2016, c.30); operative 4-20-2018 (Register 2018, No. 16). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 4-20-2018 order, including amendment of subsections (c)(1)(C)-(D) and (c)(2)(C)-(D) and amendment of NOTE, transmitted to OAL 8-3-2018 and filed 9-17-2018 (Register 2018, No. 38).
11. Amendment of subsections (a) and (b)(1) filed 9-7-2021 as an emergency; operative 9-7-2021 (Register 2021, No. 37). Pursuant to Government Code section 100504(a)(6)(A), a Certificate of Compliance must be transmitted to OAL by 9-7-2026 or emergency language will be repealed by operation of law on the following day.

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; and 45 CFR Sections 155.715 and 155.720.

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