Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(b)
A qualified employee, or his or her dependent, may enroll in a QHP or change QHPs
during special enrollment periods outside of the initial and annual open enrollment
periods in the following situations:
(1) A
qualified employee, or his or her dependent, either:
(A) Loses Minimum Essential Coverage (MEC), as
specified in subdivision (e) of this section. The date of the loss of MEC shall be:
1. The date of the last day the qualified
employee, or his or her dependent, would have health coverage under his or her
previous plan or coverage; or
2. If a
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) Loses pregnancy-related coverage described
under Section 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Social Security
Act (42 U.S.C.
1396a(a)(10)(A)(i)(IV),
(a)(10)(A)(ii)(IX)) and Section
14005.18
of the Welfare and Institutions Code. The date of the loss of coverage is the last
day the consumer would have pregnancy-related coverage; or
(C) Loses Medi-Cal coverage for the 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 Medi-Cal coverage is the last day the consumer would have medically needy
coverage.
(2) A qualified
employee gains a dependent or becomes a dependent through marriage or entry into
domestic partnership, birth, adoption, placement for adoption, placement in foster
care, assumption of a parent-child relationship, or through a child support order or
other court order.
(3) The enrollee
loses a dependent or is no longer considered a dependent through divorce or legal
separation as defined by State law in the State in which the divorce or legal
separation occurs, or if the enrollee, or his or her dependent, dies.
(4) The qualified employee's, or his or her
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, or
a non-Exchange entity providing enrollment assistance or conducting enrollment
activities, as evaluated and determined by the Exchange. In such cases, the Exchange
shall take necessary actions to correct or eliminate the effects of such error,
misrepresentation, inaction, or misconduct. 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.
(5) An enrollee adequately
demonstrates to the Exchange, with respect to QHPs offered through the Exchange, or
to the applicable regulator, with respect to health plans offered outside the
Exchange, that the Issuer of the health coverage or dental coverage in which he or
she is enrolled, substantially violated a material provision of its contract in
relation to the enrollee or his or her dependents.
(6) An enrollee, qualified employee, or his or her
dependent, gains access to new QHPs as a result of a permanent move.
(7) The qualified employee, or his or her
dependent, was released from incarceration.
(8) The qualified employee, or his or her
dependent, is a member of the reserve forces of the United States military returning
from active duty or a member of the California National Guard returning from active
duty service under Title 32 of the United States Code.
(9) A qualified employee who is an Indian, as
defined by Section 4 of the Indian Health Care Improvement Act (25 U.S.C. Section
1603(c)), and his or her
dependent who is enrolled or is enrolling in a QHP through an Exchange on the same
application as the qualified employee, may enroll in a QHP or change from one QHP to
another one time per month.
(10) A
qualified employee, or his or her 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 may include, but are not limited to, the following:
(A) If a child who has been determined ineligible
for Medi-Cal and CHIP, and for whom a party other than the party who expects to
claim him or her as a tax dependent is required by court order to provide health
coverage for the child, the child shall be eligible for a special enrollment period
if otherwise eligible for enrollment in a QHP.
(11) A qualified employee or dependent
demonstrates to the Exchange, with respect to health plans offered through the
Exchange, or to the applicable regulator, with respect to health plans offered
outside the Exchange, that he or she did not enroll in a health plan during the
immediately preceding enrollment period available to the employee or dependent
because he or she was misinformed that he or she was covered under MEC.
(12) A qualified employee, or his or her
dependent, is receiving services from a contracting provider under a health plan, as
defined in Section
1399.845(f)
of the Health and Safety Code or Section
10965(f)
of the Insurance Code, for one of the conditions described in Section
1373.96(c)
of the Health and Safety Code or section
10133.56(a)
of the Insurance Code, and that provider is no longer participating in the health
plan.
(13) A qualified employee, or his
or her dependent, loses eligibility for health coverage under a Medi-Cal plan under
title XIX of the Social Security Act or a state child health plan under title XXI of
the Social Security Act.
(14) A
qualified employee, or his or her dependent, becomes eligible for assistance, with
respect to health coverage under a SHOP, under a Medi-Cal plan (including any waiver
or demonstration project conducted under or in relation to such a plan).
(15) A qualified employee, or his or her
dependent, is a victim of domestic abuse or spousal abandonment, as specified in
26 CFR Section
1.36B-2 (b)(2)(ii) through (v)
(July 26, 2017), hereby incorporated by reference, is enrolled in MEC, and seeks to
enroll in a QHP 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 a QHP at the same time as the
victim.
(16) A qualified employee or
dependent--
(A) Applies for health 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 the Children's
Health Insurance Program (CHIP), and is determined ineligible for Medi-Cal or CHIP
by the State Medi-Cal or CHIP agency either after open enrollment has ended or more
than 60 days after the qualifying event; or
(B) Applies for health 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 has ended.
(17) The qualified employee, or his or her
dependent, adequately demonstrates to the Exchange that a material error related to
plan benefits, service area, or premium influenced the qualified employee's or
dependent's decision to purchase a QHP through the Exchange.
(18) The qualified employee or his or her
dependent experiences any other triggering events identified in California Insurance
Code section
10753.05(b)(3)
and California Health and Safety Code section
1357.503(b).
(c) A qualified employee, or his or her dependent,
who experiences one of the situations described in subdivision (b) of this section
has:
(1) 30 days from the date of the event
described in paragraphs (b)(1)-(11) and (b)(15)-(18) of that subdivision in this
section to select a QHP through the SHOP.
(2) 30 days from the date of the event described
in paragraphs (b)(12) or (g)(1) of this section to select a QDP through the
SHOP.
(3) 60 days from the date of the
event described in paragraphs (b)(13) and (b)(14) of that subdivision in this
section to select a QHP through the SHOP.
(e) Loss of MEC, as specified in subdivision
(b)(1) of this section, includes:
(1) Loss of
eligibility for health coverage, including but not limited to:
(A) Loss of eligibility for health coverage as a
result of:
1. Legal separation;
2. Divorce;
3. Cessation of dependent status (such as
attaining the maximum age to be eligible as a dependent child under the health
plan);
4. Death of an
employee;
5. Termination of employment;
and
6. Reduction in the number of hours
of employment;
(B) Loss of
eligibility for coverage through Medicare, Medicaid, 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 health coverage offered through
an HMO or similar program in the individual market that does not provide health
coverage to individuals who no longer reside, live, or work in a service area, loss
of health 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 health coverage offered through
an HMO or similar program in the group market that does not provide health coverage
to individuals who no longer reside, live, or work in a service area, loss of health
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;
(E) A situation in which a health plan no longer
offers any health coverage to the class of similarly situated individuals that
includes the individual; and
(F) Loss of
that coverage due to the circumstances described in Section 1163 of Title 29 of the
United States Code. "Loss of minimum essential coverage" also includes loss of that
coverage for a reason that is not due to the fault of the
individual.
(2) Termination of
qualified employer contributions toward the qualified employee's or dependent's
health insurance coverage that is not COBRA continuation coverage, including
contributions by any current or former employer that was contributing to health
coverage for the qualified employee or dependent;
(3) Exhaustion of COBRA or Cal-COBRA continuation
health coverage, meaning that such coverage ceases for any reason other than a
reason specified in subdivision (e)(4) of this section. 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, but not of the employee or dependent receiving COBRA benefits,
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.
(4) Loss of MEC, as specified in subdivision
(b)(1) of this section, does not include termination or loss due to:
(A) The employee's or dependent's failure to pay
premiums on a timely basis, including COBRA premiums prior to expiration of COBRA
coverage; or
(B) Subject to Section
10384.17 of the
Insurance Code and Section
1365 of
the Health and Safety Code, termination of coverage due to a carrier demonstrating
fraud or an intentional misrepresentation of material fact under the terms of the
policy by the policyholder, contractholder, or
employer.
(g) A qualified employee or
his or her dependent may enroll in a QDP during a special enrollment period outside
of the initial and annual open enrollment periods in the following situations:
(1) Loss of eligibility for dental coverage. Loss
of eligibility for dental coverage shall be consistent with any of following
situations specified in subdivisions (b)(11) or (e)(1)-(3) of this section. The date
of the loss of dental coverage shall be the date of the last day the qualified
employee, or his or her dependent, would have dental coverage under his or her
previous plan or coverage.
(2) Loss of
eligibility for dental coverage does not include termination or loss of dental
coverage due to any of the situations specified in subdivisions
(e)(4)(A)-(B).
(3) A qualified employee,
or his or her dependent, loses eligibility for pediatric dental coverage subsequent
to turning nineteen (19) years of age and wishes to continue dental coverage under a
standalone dental plan offered by a QDP Issuer in the SHOP;
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 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. New section refiled 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. New section, including amendment of subsections (a)(2) and (e),
refiled 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 further amendment of
section and amendment of NOTE, 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 section and NOTE, transmitted to OAL 8-3-2018 and filed 9-17-2018;
amendments effective 9-17-2018 pursuant to Government Code section
11343.4(b)(3)
(Register 2018, No. 38).
11. Amendment 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
10503,
Government Code; 26 CFR Sections
1.36B-2,
1.5000A-2 and
54.9801-2;
45 CFR Sections
147.104,
155.420,
155.725,
155.1080 and
156.285; Sections 1357.503 and
1399.849, Health and Safety Code; and Sections
10753.05,
10753.063.5 and
10965, Insurance
Code.
