California Code of Regulations
Title 10 - Investment
Chapter 12 - California Health Benefit Exchange
Article 6 - Application, Eligibility, and Enrollment in the Shop Exchange
Section 6552 - Appeal Decisions

Universal Citation: 10 CA Code of Regs 6552

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

(a) The appeals decisions shall:

(1) Be based solely on the evidence referenced in Section 6548(e) and the eligibility requirements for SHOP under this Article.

(2) State the decision, including a plain language description of the effect of the decision on the appellant's eligibility;

(3) Identify the legal basis, including the regulations that support the decision;

(4) Summarize the facts relevant to the appeal;

(5) State the effective date of the decision; and

(6) Provide information about judicial review available to the appellant pursuant to Section 1094.5 of the California Code of Civil Procedure.

(b) The appeals entity shall issue and provide a written appeal decision to the employer, or to the employer and employee if an employee is appealing, and to the SHOP, within 90 calendar days of the date on which a valid appeal request is received, unless the appeal request was determined by the appeals entity to meet the criteria for an expedited appeal.

(c) If the appeal request was determined by the appeals entity to meet the criteria for an expedited appeal, the appeals entity shall issue and provide a written appeal decision to the employer, or to the employer and employee if an employee is appealing, and to the SHOP, as expeditiously as reasonably possible, but not later than five business days from the date of the conclusion of the hearing.

(d) Upon issuance of an appeal decision, the SHOP shall implement the appeal decision, which shall be effective as follows:

(1) If an employer is found eligible under the decision, then at the employer's option, the effective date of coverage or enrollment through the SHOP under the decision can either be made retroactive to the effective date of coverage or enrollment through the SHOP that the employer would have had if the employer had been correctly determined eligible, or prospective to the first day of the month following the date of notice of the appeal decision;

(2) For employee appeal decisions only, if an employee is found eligible under the decision, then at the employee's option, the effective date of coverage or enrollment through the SHOP under the decision can either be made effective retroactive to the effective date of coverage or enrollment through the SHOP that the employee would have had if the employee had been correctly deemed eligible, or prospective to the first day of the month following the date of notice of the appeal decision; or

(3) If the employer or employee is found ineligible under the decision, then the appeal decision is effective as of the date of the notice of the appeal decision.

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).

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

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