California Code of Regulations
Title 10 - Investment
Chapter 12 - California Health Benefit Exchange
Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange
Section 6542 - General Eligibility Appeals Requirements for Shop

Universal Citation: 10 CA Code of Regs 6542

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

(a) An employer shall have the right to appeal:

(1) An eligibility determination made by the SHOP in accordance with this Article;

(2) A failure by the SHOP to provide a timely eligibility determination in accordance with this Article; or

(3) A failure of the SHOP to provide written notice to an employer of the SHOP's eligibility determination as provided in Section 6524(c) within 15 calendar days of receiving a completed application from an employer.

(b) An employee shall have the right to appeal:

(1) An eligibility determination made by the SHOP in accordance with this Article;

(2) A failure by the SHOP to provide a timely eligibility determination in accordance with this Article; or

(3) A failure of the SHOP to provide written notice to an employee of the SHOP's eligibility determination as provided in Section 6524(c) within 15 calendar days of receiving a completed application from an employee.

(c) Notices of the right to appeal an eligibility determination pursuant to Section 6524(c) and (d) shall include:

(1) The reason for the eligibility determination, including a citation to the applicable regulations; and

(2) The procedure by which the employer or employee may request an appeal of the eligibility determination.

(d) The SHOP and appeals entity shall:

(1) Allow an employer or employee to request an appeal within 90 days of the date of the notice of the eligibility determination, unless the appeals entity determines that good cause exists for allowing a late appeal request.

(2) Accept appeal requests submitted in person or through an appeals representative, via telephone, facsimile, mail, electronic mail or, as soon as it becomes available, the SHOP's Internet Web Site;

(3) Comply with the accessibility requirements specified in 45 CFR 155.205(c);

(4) Assist the employer or employee with the submission and processing of the appeal request, if requested, and not limit or interfere with the employer's or employee's right to request an appeal; and

(5) Consider an appeal request valid if it is submitted in accordance with the requirements of this section.

(e) Upon receipt of an appeal request pursuant to this section, the SHOP shall transmit the appeal request to the appeals entity via secure electronic interface within three (3) business days.

(1) The appeal request, if the appeal was initially made to the SHOP; and

(2) All records concerning the eligibility of the employer or employee who is appealing.

(f) The appeals entity shall confirm receipt of the records transmitted pursuant to subdivision (e) of this section within three (3) business days.

(g) The appeals entity shall conduct all appeals on behalf of the SHOP pursuant to this Article.

(h) For purposes of this Article, an administrative law judge designated by the appeals entity shall determine, on a case-by-case basis, the validity of all appeals requests and all determinations of good cause.

(i) Upon receipt of a valid appeal request, the appeals entity shall send written acknowledgment to the appellant, or the employer and employee if the employee is the appellant, within five (5) business days from the date on which the valid appeal request is received. The written acknowledgment shall include:

(1) An explanation of the appeals process;

(2) Instructions for submitting additional evidence for consideration; and

(3) Information regarding the appellant's opportunity for informal resolution prior to the hearing pursuant to Section 6544.

(j) Upon receipt of an invalid appeal request because it fails to meet the requirements of this section, the appeals entity shall:

(1) Within five (5) business days from the date on which the invalid appeal request is received, send written notice to the appellant informing him or her:
(A) That the appeal request has not been accepted;

(B) Of the nature of the defect in the appeal request; and

(C) An explanation that the appellant may cure the defect, if curable, and resubmit the appeal request if it meets the timeliness requirements of subdivision (d)(1) of this section, or if the timeliness requirement in subdivision (d)(1) has lapsed, then within 10 calendar days from the date of the notice specified in subdivision (j)(1) of this section.

(2) Treat as valid an amended appeal request that meets the requirements of this section.

(k) The appellant has the right to be represented by an appeals representative.

(l) An appellant may seek judicial review to the extent it is available by law.

(m) The appeals entity shall ensure that all data exchanges that are part of the appeals process, comply 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.) and are in an electronic format that is consistent with 45 CFR Section 155.270.

(n) Both the SHOP and the appeals entity shall provide the appellant with the opportunity to review his or her entire eligibility file, including all papers, requests, documents, and relevant information in the SHOP's possession at any time from the date on which an appeal request is filed to the date on which the appeal decision is issued.

1. New section filed 12-3-2013 as an emergency; operative 12-3-2013 (Register 2013, No. 49). A Certificate of Compliance must be transmitted to OAL by 6-2-2014 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 6-2-2014 as an emergency; operative 6-2-2014 (Register 2014, No. 23). A Certificate of Compliance must be transmitted to OAL by 9-2-2014 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 9-2-2014 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 9-2-2014 (Register 2014, No. 36). A Certificate of Compliance must be transmitted to OAL by 12-3-2015 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
4. 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 12-5-2016 or the language in the emergency order of 9-2-2014 will be repealed by operation of law on the following day (Register 2015, No. 38).
5. Certificate of Compliance as to 9-2-2014 order, including amendments, transmitted to OAL 5-4-2016 and filed 6-14-2016; amendments effective 6-14-2016 pursuant to Government Code section 11343.4(b)(3) (Register 2016, No. 25).
6. Amendment of subsection (b)(2) 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: Section 100506, Government Code; and 45 CFR § 155.740.

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