Cal. Code Regs. Tit. 10, § 6492 - Inconsistencies

(a) Except as otherwise specified in this Article, for an applicant or enrollee for whom the Exchange cannot verify information required to determine eligibility for enrollment in a QHP, or for APTC and CSR, including when electronic data is required in accordance with this section but data for individuals relevant to the eligibility determination are not included in such data sources or when electronic data from IRS, DHS, or SSA is required but it is not reasonably expected that data sources will be available within one day of the initial request to the data source, the Exchange:

(1) Shall make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors, by contacting the application filer or enrollee to confirm the accuracy of the information submitted by the application filer or enrollee;

(2) If unable to resolve the inconsistency through the process described in subdivision (a)(1) of this section, shall:

(A) Provide notice to the applicant or enrollee regarding the inconsistency; and

(B) Provide the applicant or enrollee with a period of 95 days from the date of the notice described in subdivision (a)(2)(A) of this section to either present satisfactory documentary evidence through the channels available for the submission of an application, as described in Section 6470(j), except by telephone, or otherwise resolve the inconsistency.

(3) May extend the period described in subdivision (a)(2)(B) of this section for an applicant or enrollee if the Exchange determines on a case-by-case basis that the applicant or enrollee has demonstrated that they have made a good-faith effort to obtain the required documentation during the period.

(4) During the periods described in subdivisions (a)(1) and (a)(2)(B) of this section, shall:

(A) Proceed with all other elements of eligibility determination using the applicant's or enrollee's attestation, and provide eligibility for enrollment in a QHP if an applicant or enrollee is otherwise qualified;

(B) Ensure that APTC and CSR are provided within this period on behalf of an applicant or enrollee who is otherwise qualified for such payments and reductions, as described in Section 6474, provided that the tax filer attests to the Exchange that the tax filer understands that any APTC paid on their behalf are subject to reconciliation; and

(C) Clear the inconsistencies for which the Exchange receives satisfactory documentary evidence from the applicant or the enrollee. For income inconsistencies, the Exchange shall clear the inconsistency if the income shown on the documents provided by the applicant or enrollee is within 10% of the applicant's or enrollee's attestation.

(5) If, after the period described in subdivision (a)(2)(B) of this section, the Exchange remains unable to verify the attestation, shall:

(A) Determine the applicant's or enrollee's eligibility based on the information available from the data sources specified in Sections 6478 through 6492, unless such applicant or enrollee qualifies for the exception provided under subdivision (b) of this section; and

(B) Notify the applicant or enrollee of such determination in accordance with the notice requirements specified in Section 6476(h), including notice that the Exchange is unable to verify the attestation.

(6) When electronic data to support the verifications specified in Section 6478(d) or Section 6480 is required but it is not reasonably expected that data sources will be available within one day of the initial request to the data source, the Exchange shall accept the applicant's or enrollee's attestation regarding the factor of eligibility for which the unavailable data source is relevant.

(7) The Exchange shall extend the period described in subdivision (a)(2)(B) of this section by a period of 60 days for an applicant or enrollee with an income inconsistency who is required to present satisfactory documentary evidence to verify household income.

(b) The Exchange shall provide an exception, on a case-by-case basis, to accept an applicant's or enrollee's attestation as to the information which cannot otherwise be verified and the applicant's explanation of circumstances as to why the applicant or enrollee does not have documentation if:

(1) An applicant or enrollee does not have documentation with which to resolve the inconsistency through the process described in subdivision (a)(2) of this section because such documentation does not exist or is not reasonably available;

(2) The Exchange is unable to otherwise resolve the inconsistency for the applicant or enrollee; and

(3) The inconsistency is not related to citizenship or immigration status.

(c) An applicant or enrollee shall not be required to provide information beyond the minimum necessary to support the eligibility and enrollment processes of the Exchange, Medi-Cal, and CHIP.

Notes

Cal. Code Regs. Tit. 10, § 6492

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502, 100503 and 100504, Government Code; and 45 CFR Section 155.315.

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502, 100503 and 100504, Government Code; and 45 CFR Section 155.315.

1. New section filed 9-30-2013 as a deemed emergency pursuant to Government Code section 100504(a)(6); 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)(2)(B), 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. Refiling of 4-1-2014 action on 6-30-2014, including amendment of subsection (a)(5)(B) and repealer of subsection (a)(5)(C), 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. 2014, c. 31 ); operative 9-30-2014 (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 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. 2014, c. 31 ); operative 12/12/2014 (Register 2014, No. 50). 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.
8. Refiling of 12-12-2014 action on 5-11-2015, including amendment of section, 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 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 2-16-2017 as an emergency pursuant to Government Code section 100504(a)(6), as modified by 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, including amendment of subsection (a)(4)(B) and new subsection (a)(4)(C), 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, transmitted to OAL 8-10-2018 and filed 9-24-2018; amendments effective 9/24/2018 pursuant to Government Code section 11343.4(b)(3) (Register 2018, No. 39).
17. Amendment refiled 10-13-2023 as a deemed emergency pursuant to Government Code section 100504, including further amendment of subsections (a)(3) and (a)(4)(B) and new subsection (a)(7); operative 10/13/2023 (Register 2023, No. 41). A Certificate of Compliance must be transmitted to OAL by 10-7-2024 pursuant to Government Code section 100504(a)(6)or the language in the emergency order of 10-7-2019 will be repealed by operation of law on the following day.
18. Certificate of Compliance as to 10-13-2023 order, including further amendment of section, transmitted to OAL 6-11-2024 and filed 7-24-2024; amendments effective 7/24/2024 pursuant to Government Code section 11343.4(b)(3) (Register 2024, No. 30).