Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) A Certified Plan-Based Enrollment Entity
(PBEE) and its Certified Plan-Based Enrollers (PBEs) shall perform the following
functions:
(1) Maintain expertise in eligibility,
enrollment, and PBE Program specifications.
(2) Provide enrollment assistance to consumers in
a manner considered to be through the Exchange pursuant to
45 C.F.R. §
156.265(b)(2) and Section
6500(f) of Article 5
of this chapter.
(3) Provide information
and services in a fair and accurate manner. Such information and services shall
include assistance with other Insurance Affordability Programs (e.g.,
Medi-Cal).
(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 (PHS)
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 CFR §
155.260.
(6) Comply with any applicable federal or state
laws and regulations.
(7) Inform all
applicants of the availability of other QHP products or stand-alone dental plans
offered through the Exchange through an HHS-approved universal disclaimer and
display the Web link to access the Exchange Web Site on the PBEE's Web Site, and
describe how to access the Exchange Web Site or the Service Center of the Exchange.
The PBE can refer an applicant to any individual or entity certified through
Articles 8, 11, 12 of this chapter, or to any Agents certified by the
Exchange.
(8) Facilitate enrollment and
renewal in a QHP offered in the Individual Exchange by the PBEE affiliated with the
PBE.
(A) The QHP Issuer must be able to provide
applicants standardized information for its available QHPs in the Individual
Exchange, including at a minimum the following data elements:
(i) Premium and cost-sharing
information;
(ii) The summary of
benefits and coverage established under Section
2715 of the PHS Act;
(iii) Identification of whether the QHP is a
bronze, silver, gold or platinum level plan as defined by Section 1302(d) of the
Affordable Care Act (ACA), 42
U.S.C. §
18022(d), or a
catastrophic plan as defined by Section 1302(e) of the ACA,
42 U.S.C. §
18022(e);
(iv) The results of the enrollee satisfaction
survey, as described in Section 1311(c)(4) of the ACA,
42 U.S.C.
18031, when available;
(v) Quality ratings assigned in accordance with
Section 1311(c)(3) of the ACA, 42
U.S.C. 18031;
(vi) Medical loss ratio information as reported to
HHS in accordance with 45 C.F.R. § 158 ;
(vii) Transparency of coverage measures reported
to the Exchange during certification with
45 C.F.R. §
155.1040;
(viii) The provider directory made available to
the Exchange in accordance with 45 C.F.R. §
156.230;
(ix) Potential total cost, including premium and
out-of-pocket expenses; and
(x)
Participation of the preferred provider of the consumer in the QHP Issuer's
available QHPs.
(9)
Clearly distinguish between QHPs for which the consumer is eligible and other
non-QHPs that the Issuer may offer, and indicate that advance payments of the
premium tax credit and cost sharing reductions apply only to QHPs offered through
the Exchange.
(10) Allow applicants to
select and attest to an APTC amount, if applicable, in accordance with
45 C.F.R. §
155.310(d)(2) and Section
6476(c) of Article 5
of this chapter.
(11) If the consumer is
determined to be eligible for Medi-Cal, the PBE shall either transfer the consumer
to the county of residence for enrollment in Medi-Cal or transmit all eligibility
information to DHCS consistent with
45 C.F.R. §
155.310 and Section
6476(e) of Article 5
of this chapter. A PBE shall not facilitate Medi-Cal plan selection until the
California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) has
been programmed to allow a beneficiary to select a Medi-Cal managed care plan, as
defined in Section
6410 of Article 2 of this chapter,
pursuant to subdivision (p) of Section
14016.5
of the Welfare and Institutions Code.
(12) Advise all consumers found ineligible for
Insurance Affordability Programs of their appeal rights, including the time limits
and methods for filing appeals, in accordance with Sections
6604 and
6606 of Article 7 of this
chapter.
(13) Advise all consumers found
ineligible for Insurance Affordability Programs that there may be other health
insurance products outside of the Individual Exchange that may be suitable to their
needs. The PBE shall offer to transfer the consumer to a Captive Agent or Solicitor,
as defined in Health and Safety Code Section
1345(m),
affiliated with the PBEE capable of offering the consumer the full range of health
plans offered by the Issuer in the Individual Market and Individual
Exchange.
(b) To ensure that
information provided as part of any enrollment assistance is culturally and
linguistically appropriate to the needs of the population being served, including
individuals with limited English proficiency, all PBEEs and PBEs 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 enrollment assistance is accessible to people with disabilities, all PBEEs and
PBEs shall:
(1) Ensure that any consumer education
materials, Web sites, 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 supports
programs when appropriate.
(d)
All PBEEs and PBEs shall provide the same level of service to all individuals
regardless of age, disability, culture, race, ethnicity, income, sexual orientation,
or gender identity and seek advice or experts when needed.
(e) If capacity necessitates, for those culturally
and linguistically appropriate services in this Section which are not otherwise
required of the PBEE in federal or state law, a PBE may transfer consumers seeking
those services under this Section to other Exchange resources including the Exchange
Service Center and describe how to access Exchange-provided services.
(f) All PBEs shall complete the PBEE and PBE
Section of a consumer's application to the Exchange, including the following:
(1) Name, certification number of the PBE,
signature or electronic signature, date, and PBE PIN number, if applicable;
and
(2) Name of the
PBEE.
(g) PBEs that do not
meet the definition of a Captive Agent, as defined in Section
6410 of Article 2 of this chapter,
shall report to the Exchange any criminal convictions, administrative actions taken
by any other agency, and arrests for which the individual is out on bail or his or
her own recognizance, within 30 days of the date of the conviction, action, or
arrest.
(h) PBEs that are Captive Agents
shall be licensed in good standing through the California Department of
Insurance.
(i) Prohibited Activities for
PBEEs and PBEs.
(1) All PBEEs and their
Contractors and Employees that are PBEs may not:
(A) Conduct door-to-door marketing;
(B) Employ marketing practices or offer
information and assistance only to certain members in a manner that will have the
effect of enrolling a disproportionate number of the Issuer's non-QHP members with
significant health needs in QHPs offered in the Individual Exchange;
(C) Cold-call non-member target
populations;
(D) Mail the paper
application for the consumer;
(E) Advise
the consumer to provide inaccurate information on the application regarding income,
residency, immigration status and other eligibility criteria;
(F) Select a QHP for the potential applicant while
providing application assistance;
(G)
Solicit or accept any consideration from an applicant in exchange for application
assistance;
(H) Pay any part of the
premium or any other type of consideration to or on behalf of the
consumer;
(I) Sponsor a person eligible
for the program by paying family contribution amounts or co-payments;
(J) Offer applicants any inducements such as gifts
or monetary payments to apply for coverage in a QHP or Medi-Cal Managed Care Plan
represented by the PBE;
(K)
Intentionally create multiple applications from the same household, as defined in 45
C.F.R § 435.603(f);
(L) 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;
(M) Request, view or obtain claims data
information while providing application assistance;
(N) Request, view or obtain health status
information including any pre-existing conditions for purposes other than connecting
the consumer to the appropriate IAP;
(O)
Violate conflict of interest standards in Section
6712;
(P) Be a Certified Insurance Agent through the
Exchange pursuant to Section
6800 of Article 10 of this chapter, or
any other enrollment assistance function of the Exchange, including those certified
through Article 8 of this chapter; or
(Q) Retain any information related to income,
citizenship, immigration status, or disability.
(R) Employ, be employed by, be in partnership
with, or receive any remuneration arising out of the functions performed under this
Article, from any individual or entity certified through Article 8 or Article 11 of
this chapter or from any Agents certified by the
Exchange.
1. New section
filed 9-30-2013 as an emergency; operative 9-30-2013 (Register 2013, No. 40). A
Certificate of Compliance must be transmitted to OAL by 4-1-2014 or emergency
language will be repealed by operation of law on the following day.
2.
New section, including amendment of subsection (a)(8)(A)(iii), repealer of
subsection (a)(8)(A)(iv), subsection renumbering and amendment of subsections
(f)(1)-(2), refiled 4-1-2014 as an emergency; operative 4-1-2014 (Register 2014, No.
14). A Certificate of Compliance must be transmitted to OAL by 6-30-2014 or
emergency language will be repealed by operation of law on the following
day.
3. New section refiled 6-26-2014 as an emergency pursuant to
Government Code section
100504(a)(6),
as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 7-1-2014 (Register
2014, No. 26). A Certificate of Compliance must be transmitted to OAL by 9-30-2015
pursuant to Government Code section
100504 or
emergency language will be repealed by operation of law on the following
day.
4. New section refiled with amendments 10-2-2014 as an emergency
pursuant to Government Code section
100504(a)(6),
as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 10-2-2014 (Register
2014, No. 40). A Certificate of Compliance must be transmitted to OAL by 9-30-2015
pursuant to Government Code section
100504 or
emergency language will be repealed by operation of law on the following
day.
5. Editorial correction of HISTORY 3 (Register 2014, No.
51).
6. 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 9-30-2016 or the language in the emergency order of
10-2-2014 will be repealed by operation of law on the following day (Register 2015,
No. 38).
7. Certificate of Compliance as to 10-2-2014 order, including
further amendment of subsections (a)(5), (a)(8), (a)(11), (f)(1) and (i)(1)(P),
transmitted to OAL 4-12-2016 and filed 5-23-2016; amendments effective 5-23-2016
pursuant to Government Code section
11343.4(b)(3)
(Register 2016, No. 22).
8. Amendment of subsection (a)(7) and new
subsection (i)(1)(R) filed 1-29-2018; operative 1-29-2018 pursuant to Government
Code section
11343.4(b)(3)
(Register 2018, No. 5).
Note: Authority cited: Section
100504,
Government Code. Reference: Section
100503,
Government Code; and 45 Code of Federal Regulations, Sections 155.205(d), 155.260,
155.415, 156.265 and 156.1230.
