Cal. Code Regs. Tit. 10, § 6472 - Eligibility Requirements for Enrollment in a QHP through the Exchange
(a) An
applicant who is seeking enrollment in a QHP that is not a catastrophic plan
shall meet the requirements of this section, except for the requirements
specified in subdivision (f) of this section, regardless of the applicant's
eligibility for APTC or CSR. For purposes of this section, an applicant
includes all individuals listed on the application who are seeking enrollment
in a QHP through the Exchange. An applicant who is seeking enrollment in a
catastrophic QHP shall also meet the requirements specified in subdivision (f)
of this section. An applicant who is seeking enrollment in a QDP shall also
meet the requirements specified in subdivision (g) of this section.
(b) An applicant who has a SSN shall provide
his or her SSN to the Exchange.
(c)
An applicant shall be a citizen or national of the United States, or a
non-citizen who is lawfully present in the United States, and is reasonably
expected to be a citizen, national, or a non-citizen who is lawfully present
for the entire period for which enrollment is sought.
(d) An applicant shall not be incarcerated,
other than incarceration pending the disposition (judgment) of
charges.
(e) An applicant shall
meet one of the following applicable residency standards:
(1) For an individual who is age 21 and over,
is not living in an institution as defined in
42 CFR Section
435.403(b) (March 23, 2012),
hereby incorporated by reference, is capable of indicating intent, and is not
receiving Supplemental Security Income/State Supplemental Program payments as
defined in Title 22, Division 3, Section 50095 of CCR, the service area of the
Exchange of the individual is the service areas of the Exchange in which he or
she is living and:
(A) Intends to reside,
including without a fixed address; or
(B) Has entered with a job commitment or is
seeking employment (whether or not currently employed).
(2) For an individual who is under the age of
21, is not living in an institution as defined in
42 CFR Section
435.403(b), is not eligible
for Medi-Cal based on receipt of assistance under title IV-E of the Social
Security Act, is not emancipated, and is not receiving Supplemental Security
Income/State Supplementary Payment (SSI/SSP) as defined in Title 22, Division
3, Section 50095 of CCR, the Exchange service area of the individual is:
(A) The service area of the Exchange in which
he or she resides, including without a fixed address; or
(B) The service area of the Exchange of a
parent or caretaker, established in accordance with subdivision (e)(1) of this
section, with whom the individual resides.
(3) For an individual who is not described in
subdivisions (e)(1) or (2) of this section, the Exchange shall apply the
residency requirements described in
42 CFR Section
435.403 with respect to the service area of
the Exchange.
(4) Special rule for
tax households with members in multiple Exchange service areas.
(A) Except as specified in subdivision
(e)(4)(B) of this section, if all of the members of a tax household are not
within the same Exchange service area, in accordance with the applicable
standards in subdivisions (e)(1), (2), and (3) of this section, any member of
the tax household may enroll in a QHP through any of the Exchanges for which
one of the tax filers meets the residency standard.
(B) If both spouses in a tax household enroll
in a QHP through the same Exchange, a tax dependent may choose to enroll in a
QHP either through that Exchange or through the Exchange that services the area
in which the dependent meets a residency standard described in subdivisions
(e)(1), (2), or (3) of this section.
(5) The Exchange shall not deny or terminate
an individual's eligibility for enrollment in a QHP through the Exchange if the
individual meets the standards in subdivision (e)(1)-(4) of this section but
for a temporary absence from the service area of the Exchange and intends to
return when the purpose of the absence has been accomplished.
(f) The eligibility standards
specified in this subdivision shall only apply to the eligibility determination
for enrollment through the Exchange in a QHP that is a catastrophic plan, as
defined in Section 1302(e) of the Affordable Care Act.
(1) The Exchange shall determine an applicant
eligible for enrollment in a catastrophic QHP through the Exchange if the
applicant:
(A) Has not attained the age of 30
before the beginning of the plan year; or
(B) Has a certification in effect for any
plan year that the applicant is exempt from the requirement to maintain MEC
under section
5000 A of
IRC (
26 USC §
5000A ) by reason of:
1. Section
5000
A(e)(1) of IRC (
26 USC §
5000A(e)(1) ) relating to
individuals without affordable coverage; or
(2) APTC shall not be available to support
enrollment in a catastrophic QHP through the Exchange.
(g) The eligibility standards specified in
this subdivision shall only apply to the eligibility determination for
enrollment in a QDP through the Exchange. The Exchange shall determine an
applicant eligible for enrollment in a QDP if the applicant meets both of the
following requirements:
(1) At least one
adult in the applicant's family who is enrolled in a non-catastrophic QHP
through the Exchange is enrolled in the QDP. The family may continue enrollment
in the QDP even if the adult later ceases enrollment in the non-catastrophic
QHP through the Exchange.
(2) To
enroll one child in a family in a QDP, all children in the family under 19
years of age shall also enroll in the same QDP.
Notes
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 42 CFR 435.403; and 45 CFR Section 155.305.
2. New section refiled 4-1-2014 as a deemed emergency pursuant to Government Code section 100504(a)(6); 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 6-30-2014 as a deemed emergency pursuant to Government Code section 100504(a)(6); operative 6-30-2014 (Register 2014, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-29-2014 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 9-30-2014 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 ( Stats.
5. Editorial correction of History 4 (Register 2014, No. 45).
6. Editorial correction of History 4 (Register 2014, No. 50).
7. New section refiled 12-12-2014 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 ( Stats.
8. New section refiled 5-11-2015 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 5-11-2015 (Register 2015, No. 20). 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.
9. 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 5-11-2015 will be repealed by operation of law on the following day (Register 2015, No. 38).
10. New section refiled 9-17-2015 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31) and Senate Bill 75 (Stats. 2015, Ch. 18); operative 9-17-2015 (Register 2015, No. 38). A Certificate of Compliance must be transmitted to OAL by 9-30-2016 pursuant to Government Code section 100504 or the language in the emergency order of 9-17-2015 will be repealed by operation of law on the following day.
11. New section refiled 12-14-2015 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31) and Senate Bill 75 (Stats. 2015, Ch. 18); operative 12-14-2015 (Register 2015, No. 51). A Certificate of Compliance must be transmitted to OAL by 9-30-2016 pursuant to Government Code section 100504 or the language in the emergency order of 12-14-2015 will be repealed by operation of law on the following day.
12. New section refiled (including amendment of subsection (a) and new subsections (g)-(g)(2)) on 6-6-2016 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31) and Senate Bill 75 (Stats. 2015, Ch. 18); operative 6-6-2016 (Register 2016, No. 24). A Certificate of Compliance must be transmitted to OAL by 9-30-2016 pursuant to Government Code section 100504 or the language in the emergency order of 6-6-2016 will be repealed by operation of law on the following day.
13. Senate Bill 833 (Stats. 2016, c. 30) modified Government Code section 100504(a)(6) to extend the date upon which a Certificate of Compliance must be transmitted to OAL. Refiling of 6-6-2016 order on 9-30-2016 as a deemed emergency pursuant to Government Code section 100504(a)(6); operative 9-30-2016 (Register 2016, No. 40). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504(a)(6) or emergency language will be repealed by operation of law on the following day.
14. New section refiled on 2-16-2017 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 833 (Stats. 2016, c. 30), Senate Bill 75 (Stats. 2015, c. 18) and Senate Bill 857 (Stats. 2014, c. 31); operative 2-16-2017 (Register 2017, No. 7). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504(a)(6) or the language in the emergency order of 2-16-2017 will be repealed by operation of law on the following day.
15. New section refiled on 10-26-2017 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 833 (Stats. 2016, c. 30), Senate Bill 75 (Stats. 2015, c. 18) and Senate Bill 857 (Stats. 2014, c. 31); operative 10-26-2017 (Register 2017, No. 43). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504(a)(6) or the language in the emergency order of 10-26-2017 will be repealed by operation of law on the following day.
16. Certificate of Compliance as to 10-26-2017 order, including further amendment of section and Note, transmitted to OAL 8-10-2018 and filed 9-24-2018; amendments effective
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