California Code of Regulations
Title 10 - Investment
Chapter 12 - California Health Benefit Exchange
Article 7 - Appeals Process for the Individual Exchange
Section 6612 - Informal Resolution

Universal Citation: 10 CA Code of Regs 6612

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 an appeal request, which has been determined to be valid in accordance with Section 6602(c), or upon receipt of the notice under Section 6606(e)(2), the Exchange shall contact the appellant to resolve the appeal informally and to request additional information or documentation, if applicable, prior to the hearing date.

(c) The informal resolution process shall comply with the scope of review specified in Section 6614(e).

(d) An appellant's right to a hearing shall be preserved in any case notwithstanding the outcome of the informal resolution process unless the appellant unconditionally or conditionally withdraws their appeal request prior to the hearing date, in accordance with the procedure set forth in Section 6610(a)(1).

(e) If the appeal advances to hearing:

(1) The appellant shall not be asked to provide duplicative information or documentation that they previously provided during the application or informal resolution process; and

(2) The Exchange shall:
(A) Issue a Statement of Position; and

(B) Transmit via secure electronic interface the Statement of Position and all papers, requests, and documents, including printouts from an appeal record, which the Exchange obtained during the informal resolution process to the appeals entity, the appellant, and, if applicable, the appellant's representative, at least two business days before the date of the hearing.

(f) If the appellant is satisfied with the outcome of the informal resolution process and conditionally withdraws their appeal request, in accordance with Section 6610(a)(1)(C), and the appeal does not advance to hearing:

(1) Within five business days from the date of the outcome of the informal resolution, the Exchange shall:
(A) Notify the appellant of:
1. The outcome of the informal resolution, including a plain language description of the effect of such outcome on the appellant's appeal and eligibility; and

2. The effective date of such outcome, if applicable; and

(B) Provide a copy of the conditional withdrawal agreement signed by the appellant, or the appellant's authorized representative, and the Exchange and instructions on how to submit their conditional withdrawal request to the appeals entity, in accordance with the procedure set forth in Section 6610(a)(1)(C).

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

(3) If the appeal is dismissed in accordance with Section 6610, the informal resolution decision shall be final and binding.

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100503 and 100506, Government Code; and 45 CFR Section 155.535.

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100503 and 100506, Government Code; and 45 CFR Section 155.535.

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