Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Certified Enrollment Entities and Certified
Enrollment Counselors shall perform the following functions:
(1) Maintain expertise in eligibility, enrollment,
and program specifications. Individuals and entities registered under the Navigator
Program must also conduct outreach and education to raise awareness about the
Exchange;
(2) Provide information and
services in a fair, accurate and impartial manner, which includes providing
information that assists consumers with submitting the eligibility application,
clarifying the distinctions among health coverage options, including QHPs, and
helping consumers make informed decisions during the health coverage selection
process. Such information and services shall include assistance with all other
insurance affordability programs (e.g., Medicaid and Children's Health Insurance
Programs);
(3) Facilitate selection of a
QHP;
(4) Provide referrals to any
applicable office of health insurance Consumer Assistance or health insurance
ombudsman established under Section
2793 of the Public Health Service Act,
42 U.S.C. §
300gg-93, or any other appropriate State agency or
agencies, for any enrollee with a grievance, complaint, or question regarding their
health plan, coverage, or a determination under such plan or coverage;
(5) Comply with the privacy and security
requirements in 45 C.F.R. §
155.260;
(6) Prior to receiving access to any consumer's
personally identifiable information as defined in Section
6650 of Article 8, the Certified
Enrollment Counselor shall:
(A) Inform the
consumer that the Certified Enrollment Counselor must obtain his or her
authorization prior to accessing any personally identifiable information;
(B) Inform each consumer of the roles and
responsibilities of the Certified Enrollment Counselor as set forth in Section
6664, subdivisions (a)(1)-(5),
(7);
(C) Obtain oral or written
authorization from the consumer to access the consumer's personally identifiable
information;
1. Written authorization shall
contain a consumer's signature and a written attestation completed by the Certified
Enrollment Counselor affirming under penalty of perjury that the Certified
Enrollment Counselor:
i. Is a Certified Enrollment
Counselor affiliated with a Certified Enrollment Entity in the Navigator program as
defined in Section
6650;
ii. Conveyed all the information required under
this subdivision to the consumer in a language and manner which he or she
understands; and
iii. Obtained written
authorization from the consumer consenting to the release of his or her personally
identifiable information in order to fulfill the duties as described in Section
6664.
2. Oral authorization shall be accompanied by a
written attestation completed by the Certified Enrollment Counselor affirming under
penalty of perjury that the Certified Enrollment Counselor:
i. Is a Certified Enrollment Counselor affiliated
with a Certified Enrollment Entity in the Navigator program as defined in Section
6650;
ii. Conveyed all the information required under
this subdivision to the consumer in a language and manner which he or she
understands; and
iii. Obtained oral
authorization from the consumer consenting to the release of his or her personally
identifiable information in order to fulfill the duties as described in Section
6664.
(D) Inform the consumer that the Certified
Enrollment Counselor cannot choose a health insurance plan on the consumer's
behalf;
(E) Inform the consumer that the
Certified Enrollment Counselor will provide the consumer with information regarding
the health insurance options and insurance affordability programs for which he or
she may be eligible;
(F) Inform the
consumer that his or her personally identifiable information will be kept private
and secure in accordance with 45
C.F.R. §
155.260;
(G) Inform the consumer that if the Certified
Enrollment Counselor cannot assist the consumer, he or she will refer the consumer
to another Certified Enrollment Counselor or the Covered California call
center;
(H) Inform the consumer that the
Certified Enrollment Counselor will not charge a fee in exchange for performing the
duties described in Section
6664;
(I) Inform the consumer that the assistance is
based only on the information provided by the consumer, and if the information given
is inaccurate or incomplete, the Certified Enrollment Counselor may not be able to
offer assistance;
(J) Inform the
consumer that the authorization set forth in Section
6664, subdivision (a)(6)(C), may be
revoked at any time; and
(K) Maintain a
record of such authorization for a minimum of ten (10) years.
(7) Ensure that voter registration assistance is
available in compliance with Chapter 6 of the California Elections Code;
(8) For Certified Enrollment Entities only,
maintain a physical presence in the state of California so that face-to-face
assistance can be provided to applicants and enrollees;
(9) Provide information regarding the process of
filing Exchange eligibility appeals;
(10) Provide referrals to licensed tax advisers,
tax preparers, or other resources for assistance with tax preparation and tax advice
related to consumer questions about the Exchange application and enrollment process,
exemptions from the requirement to maintain minimum essential coverage and from the
individual shared responsibility payment, and premium tax credit
reconciliations;
(11) Inform each
consumer that Certified Enrollment Entities and Certified Enrollment Counselors are
not acting as tax advisors or attorneys when providing enrollment assistance and
cannot provide tax or legal advice within their capacity as a Certified Enrollment
Entity or Certified Enrollment Counselor;
(12) Provide targeted assistance to serve
underserved or vulnerable populations, as identified by the Exchange, within the
Exchange service area; and
(13) Comply
with any applicable federal or state laws and regulations.
(b) To ensure that information provided as part of
any Consumer Assistance is culturally and linguistically appropriate to the needs of
the population being served, including individuals with limited English proficiency
as required by 45 C.F.R.
§§
155.205(c)(2) and
155.210(e)(5),
Certified Enrollment Entities and Certified Enrollment Counselors shall:
(1) Develop and maintain general knowledge about
the racial, ethnic, and cultural groups in their service area, including each
group's diverse cultural health beliefs and practices, preferred languages, health
literacy, and other needs;
(2) Collect
and maintain updated information to help understand the composition of the
communities in the service area, including the primary languages spoken;
(3) Provide consumers with information and
assistance in the consumer's preferred language, at no cost to the consumer,
including the provision of oral interpretation of non-English languages and the
translation of written documents in non-English languages when necessary to ensure
meaningful access. Use of a consumer's family or friends as oral interpreters can
satisfy the requirement to provide linguistically appropriate services only when
requested by the consumer as the preferred alternative to an offer of other
interpretive services;
(4) Provide oral
and written notice to consumers with limited English proficiency informing them of
their right to receive language assistance services and how to obtain
them;
(5) Receive ongoing education and
training in culturally and linguistically appropriate service delivery;
and
(6) Implement strategies to recruit,
support, and promote a staff that is representative of the demographic
characteristics, including primary languages spoken, of the communities in their
service area.
(c) To ensure
that Consumer Assistance is accessible to people with disabilities, Certified
Enrollment Entities and Certified Enrollment Counselors shall:
(1) Ensure that any consumer education materials,
websites, or other tools utilized for Consumer Assistance purposes are accessible to
people with disabilities, including those with sensory impairments, such as visual
or hearing impairments, and those with mental illness, addiction, and physical,
intellectual, and developmental disabilities;
(2) Provide auxiliary aids and services for
individuals with disabilities, at no cost, where necessary for effective
communication. Use of a consumer's family or friends as interpreters can satisfy the
requirement to provide auxiliary aids and services only when requested by the
consumer as the preferred alternative to an offer of other auxiliary aids and
services;
(3) Provide assistance to
consumers in a location and in a manner that is physically and otherwise accessible
to individuals with disabilities;
(4)
Ensure that legally authorized representatives are permitted to assist an individual
with a disability to make informed decisions; and
(5) Acquire sufficient knowledge to refer people
with disabilities to local, state, and federal long-term services and support
programs when appropriate.
(d)
To ensure that no consumer is discriminated against, Certified Enrollment Entities
and Certified Enrollment Counselors shall provide the same level of service to all
individuals regardless of age, disability, culture, sexual orientation, or gender
identity and seek advice or experts when needed.
(e) Certified Enrollment Counselors shall complete
the Certified Enrollment Entity and Certified Enrollment Counselor section of a
consumer's application to the Exchange, including the following:
(1) Name and certification number of the Certified
Enrollment Counselor;
(2) Name of the
Certified Enrollment Entity and the Certified Enrollment Entity Number;
and
(3) Signature and date of signature
by the Certified Enrollment Counselor;
(f) If any of the information listed in
subdivision (e) of this Section is not included on the consumer's original
application, it may not be added at a later time.
(g) Certified Enrollment Counselors shall wear the
badge issued by the Exchange at all times when providing Consumer
Assistance.
(h) The Certified Enrollment
Entity and Certified Enrollment Counselor shall never:
(1) Have a conflict of interest as defined in
Section 6666;
(2) Mail the paper application for the
consumer;
(3) Coach the consumer to
provide inaccurate information on the application regarding income, residency,
immigration status and other eligibility rules;
(4) Coach or recommend one plan or provider over
another;
(5) Accept any premium payments
from the consumer;
(6) Input any premium
payment information on behalf of the consumer;
(7) Pay any part of the premium or any other type
of consideration to or on behalf of the consumer;
(8) Induce or accept any type of direct or
indirect remuneration from the consumer;
(9) Intentionally create multiple applications
from the same household, as defined in
42 C.F.R. §
435.603(f);
(10) Invite, influence, or arrange for an
individual whose existing coverage through an eligible employer-sponsored plan is
affordable and provides minimum value, as described in
26 U.S.C. §
36B(c)(2)(C)) and in
26 C.F.R. §
1.36B-2(c)(3)(v) and (vi), to
separate from employer-based group health coverage;
(11) Provide gifts, including gift cards or cash
or provide promotional items that market or promote the products or services of a
third party, to any applicant or potential enrollee as an inducement for enrollment.
The value of gifts provided to applicants and potential enrollees for purposes other
than as an inducement for enrollment must not exceed nominal value, either
individually or in the aggregate, when provided to that individual during a single
encounter. The nominal value is equal to or less than $15. Gifts of nominal value
may not include beer, wine, liquor, cigarettes, tobacco, or lottery tickets. Gifts,
gift cards, or cash may be provided for the purpose of providing reimbursement for
legitimate expenses incurred by a consumer in effort to receive Exchange application
assistance, such as, but not limited to, travel or postage expenses;
(12) Use Exchange funds to purchase gifts or gift
cards, or promotional items that market or promote the products or services of a
third party, that would be provided to any applicant or potential
enrollee;
(13) Solicit any consumer for
application or enrollment assistance by going door-to-door or through other
unsolicited means of direct contact, including calling a consumer to provide
application or enrollment assistance without the consumer initiating the contact,
unless the consumer has a pre-existing relationship with the individual Certified
Enrollment Counselor or Certified Enrollment Entity and other applicable State and
Federal laws are otherwise complied with. Outreach and education activities may be
conducted by going door-to-door or through other unsolicited means of direct
contact, including calling a consumer; or
(14) Initiate any telephone call to a consumer
using an automatic telephone dialing system or an artificial or prerecorded voice,
except in cases where the individual Certified Enrollment Counselor or Certified
Enrollment Entity has a relationship with the consumer and so long as other
applicable State and Federal laws are otherwise complied with.
(i) Certified Enrollment Counselors shall report
to the Exchange any subsequent arrests for which they have been released on bail or
personal recognizance and criminal convictions, received by the Exchange in
accordance with Section
6456, subdivision (c), and
administrative actions taken by any other agency, within 30 calendar days of the
date of each occurrence.
1. New section
filed 7-15-2013 as an emergency; operative 7-15-2013 (Register 2013, No. 29). A
Certificate of Compliance must be transmitted to OAL by 1-13-2014 or emergency
language will be repealed by operation of law on the following day.
2.
Repealed by operation of Government Code section
11346.1(g)
(Register 2014, No. 7).
3. New section filed 2-10-2014 as an emergency
pursuant to Government Code section
11346.1,
subdivision (h); operative 2-10-2014 (Register 2014, No. 7). A Certificate of
Compliance must be transmitted to OAL by 5-12-2014 or emergency language will be
repealed by operation of law on the following day.
4. New section refiled
5-12-2014 as an emergency pursuant to Government Code section
11346.1,
subdivision (h); operative 5-12-2014 (Register 2014, No. 20). A Certificate of
Compliance must be transmitted to OAL by 8-11-2014 or emergency language will be
repealed by operation of law on the following day.
5. New section,
including new subsections (a)(6)-(a)(6)(K) and subsection renumbering, refiled
7-21-2014 as an emergency pursuant to Government Code section
100504(a)(6),
as modified by Senate Bill 857 (Stats 2014, c. 31); operative 7-21-2014 (Register
2014, No. 30). A Certificate of Compliance must be transmitted to OAL by 7-15-2015
pursuant to Government Code section
100504 or
emergency language will be repealed by operation of law on the following
day.
6. Refiling of 7-21-2014 action on 12-12-2014, including further
amendment of section and NOTE, as an emergency pursuant to Government Code section
100504(a)(6),
as modified by Senate Bill 857 (Stats 2014, c.31); operative 12-12-2014 (Register
2014, No. 50). A Certificate of Compliance must be transmitted to OAL by 7-15-2015
pursuant to Government Code section
100504 or
emergency language will be repealed by operation of law on the following
day.
7. 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 2-10-2017 or the language in the emergency order of
12-12-2014 will be repealed by operation of law on the following day (Register 2015,
No. 38).
8. Certificate of Compliance as to 7-21-2014 order, including
further amendment of section, transmitted to OAL 11-6-2015 and filed 12-23-2015
(Register 2015, No. 52).
9. Redesignation of former subsections
(a)(6)(K)(1)-(2) as subsections (a)(7)-(8), amendment of newly designated subsection
(a)(8), new subsections (a)(9)-(12), subsection renumbering and amendment of
subsection (h)(11) filed 12-12-2016 as an emergency; operative 12-12-2016 (Register
2016, No. 51). Pursuant to Government Code section
100504, this is
a deemed emergency. A Certificate of Compliance must be transmitted to OAL by
12-12-2021 pursuant to Government Code section
100504 or
emergency language will be repealed by operation of law on the following
day.
10. Amendment of subsections (a)(6) and (a)(6)(K) filed 3-7-2018;
operative 3-7-2018 pursuant to Government Code section
11343.4(b)(3)
(Register 2018, No. 10).
11. Editorial correction of HISTORY 9 (Register
2021, No. 13).
12. Certificate of Compliance as to 12-12-2016 order,
including amendment of subsections (a)(6)(F) and (a)(7), transmitted to OAL
8-27-2021 and filed 10-7-2021; amendments effective 10-7-2021 pursuant to Government
Code section
11343.4(b)(3)
(Register 2021, No. 41).
Note: Authority cited: Sections
100502 and
100504,
Government Code. Reference: Sections
1043,
100502 and
100503,
Government Code; and 45 C.F.R.
§§
155.205,
155.210,
155.215 and
155.260.
