California Code of Regulations
Title 10 - Investment
Chapter 12 - California Health Benefit Exchange
Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange
Section 6544 - Informal Resolution

Universal Citation: 10 CA Code of Regs 6544

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

(a) An appellant shall have an opportunity for informal resolution prior to a hearing in accordance with the requirements of this section.

(b) Upon receipt of a valid appeal request, the SHOP shall:

(1) Contact the appellant to attempt to informally resolve the appeal; and

(2) Provide the appellant the opportunity to submit relevant evidence to assist in the informal resolution of the appeal.

(c) An appellant's right to a hearing shall be preserved in any case notwithstanding the outcome of the informal resolution process, unless the appellant withdraws his or her appeal request prior to the hearing date, in accordance with the procedure set forth in Section 6546(a).

(d) If the appeal advances to hearing:

(1) The appellant shall not be asked to provide information or documentation that he or she previously provided during the application or informal resolution process.

(2) The SHOP shall issue a statement of position and transmit via secure electronic interface, the statement of position and all papers, requests, and documents the SHOP obtained during the informal resolution process, to the appeals entity no less than two (2) business days before the date of the hearing.

(3) The SHOP shall make the statement of position available to the appellant no less than two (2) business days before the date of the hearing.

(e) If the appellant is satisfied with the outcome of the informal resolution process and withdraws his or her appeal request in accordance with Section 6546(a) and the appeal does not advance to hearing:

(1) The SHOP shall, within five (5) business days from the date of the outcome of the informal resolution, send the appellant notice, which shall:
(A) State the outcome of the informal resolution, including a plain language description of the effect of such outcome on the appellant's appeal and eligibility;

(B) State the effective date of such outcome, if applicable; and

(2) Within three (3) business days from the date of the outcome of the informal resolution, send notice of the informal resolution outcome to the appeals entity via secure electronic interface.

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 transmitted to OAL 5-4-2016 and filed 6-14-2016 (Register 2016, No. 25).

Note: Authority cited: Section 100504, Government Code. Reference: Section 100506, Government Code; and 45 CFR § 155.740.

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