Cal. Code Regs. Tit. 10, § 6498 - Annual Eligibility Redetermination

(a) Except as specified in subdivisions (d) and (m) of this section, the Exchange shall redetermine the eligibility of an enrollee or a qualified individual on an annual basis.
(b) To conduct an annual redetermination for an enrollee or a qualified individual who requested an eligibility determination for IAPs in accordance with Section 6476(b), the Exchange shall have on file an active authorization from the qualified individual to obtain updated tax return information described in subdivision (c) of this section. This authorization shall be for a period of no more than five years based on a single authorization, provided that an individual may:
(1) Decline to authorize the Exchange to obtain updated tax return information; or
(2) Authorize the Exchange to obtain updated tax return information for fewer than five years; and
(3) Discontinue, change, or renew his or her authorization at any time.
(c) If an enrollee or a qualified individual requested an eligibility determination for IAPs on the original application, in accordance with Section 6476(b), and the Exchange has an active authorization to obtain tax data as a part of the annual redetermination process, the Exchange shall request:
(1) Updated tax return information, as described in Section 6482(b);
(2) Data regarding Social Security benefits, as described in Section 6482(b); and
(3) Income data from available State data sources, such as Franchise Tax Board and Employment Development Department.
(d) If an enrollee or a qualified individual requested an eligibility determination for IAPs on the original application, in accordance with Section 6476(b), and the Exchange does not have an active authorization to obtain tax data as a part of the annual redetermination process, the Exchange:
(1) Shall notify the individual at least 30 days prior to the date of the notice of annual redetermination described in subdivision (f) of this section. This notice shall include an explanation that unless the individual authorizes the Exchange to obtain his or her updated tax return information to redetermine the individual's eligibility for coverage effective January first of the following benefit year:
(A) His or her APTC and CSR will end on the last day of the current benefit year; and
(B) His or her coverage in a QHP will be renewed for the following benefit year, in accordance with the process specified in subdivision (l) of this section, without APTC and CSR;
(2) Shall redetermine the enrollee's or the qualified individual's eligibility only for enrollment in a QHP; and
(3) Shall not proceed with a redetermination for IAPs until such authorization has been obtained or the qualified individual continues his or her request for an eligibility determination for IAPs in accordance with Section 6476(b).
(e) The Exchange shall provide an annual redetermination notice in accordance with the following process:
(1) For all qualified individuals who are not currently enrolled in a QHP through the Exchange, the notice shall include at least:
(A) A description of the annual redetermination and renewal process;
(B) The requirement to report changes to information affecting eligibility, as specified in Section 6496(b);
(C) The instructions on how to report a change to the Exchange; and
(D) The open enrollment date and the last day on which a plan selection may be made for coverage effective on January first of the following benefit year to avoid any coverage gap.
(2) For all current enrollees who have requested an eligibility determination for IAPs for the current benefit year, the notice shall include at least:
(A) All the information specified in subdivision (e)(1) of this section;
(B) An explanation that the premiums for the QHPs and the amount of APTC and the level of CSR, for which he or she may be eligible, may change each benefit year;
(C) A description of the reconciliation process for APTC;
(D) Data used in the enrollee's most recent eligibility determination and the amount of monthly APTC and the level of CSR the enrollee has been receiving during the current benefit year;
(E) An explanation that if he or she does not complete the Exchange's renewal process to obtain an updated eligibility determination by December 15 of the current benefit year for coverage effective January first of the following benefit year, the Exchange will redetermine the enrollee's eligibility and renew the enrollee's coverage for the following benefit year, in accordance with the process specified in subdivision (l) of this section, using information obtained from the electronic data sources specified in subdivision (c) of this section and the most recent information the enrollee provided to the Exchange; and
(F) An explanation that in order to obtain the most accurate eligibility determination from the Exchange, including APTC that may increase or decrease, or to change his or her QHP, the enrollee shall contact the Exchange and update his or her information, as required under subdivision (g) of this section, or make a plan selection by the end of the open enrollment period.
(3) For all current enrollees who have not requested an eligibility determination for IAPs for the current benefit year, the notice shall include at least:
(A) All the information specified in subdivision (e)(1) of this section;
(B) An explanation that the premiums for the QHPs may change each benefit year;
(C) An explanation that unless the enrollee completes the Exchange's renewal process to obtain an updated eligibility determination by December 15 of the current benefit year for coverage effective January first of the following benefit year, the Exchange will redetermine the enrollee's eligibility and renew the enrollee's coverage for the following benefit year, in accordance with the process specified in subdivision (l) of this section, using the most recent information the enrollee provided to the Exchange; and
(D) An explanation that in order to obtain the most accurate eligibility determination from the Exchange or to change his or her QHP, the enrollee shall contact the Exchange and update his or her information, as required under subdivision (g) of this section, or make a plan selection by the end of the open enrollment period.
(f) For eligibility redeterminations under this section, the Exchange shall provide the annual redetermination notice, as specified in subdivision (e) of this section, and the notice of annual open enrollment period, as specified in Section 6502(e), through a single, coordinated notice.
(g) Except as specified in Section 6496(c), an enrollee, a qualified individual, or an application filer on behalf of the qualified individual, shall report to the Exchange any changes with respect to the eligibility standards specified in Sections 6472 and 6474 within 30 days of such change, using any of the channels available for the submission of an application, as described in Section 6470(j).
(h) The Exchange shall verify any information reported by an enrollee or a qualified individual under subdivision (g) of this section using the processes specified in Sections 6478 through 6492, prior to using such information to determine eligibility.
(i) A current enrollee or a qualified individual who has selected a QHP through the Exchange during the current benefit year but his or her coverage has not been effectuated, shall complete the Exchange's renewal process, as specified in subdivision (i)(1) of this section, within 30 days from the date of the notice described in subdivision (e) of this section.
(1) To complete the Exchange's renewal process, the enrollee or the qualified individual shall:
(A) Check his or her application information for accuracy, and make any changes to the application information, as required under subdivision (g) of this section;
(B) If any changes made, provide a reason for the change and the date of the change;
(C) Declare under penalty of perjury that he or she:
1. Understands that he or she must report any changes to the information on the application that may affect his or her eligibility for enrollment in a QHP or for APTC and CSR, if applicable, to the Exchange within 30 days of such change;
2. Understands that if he or she, or someone in his or her household, has health insurance through Medi-Cal, he or she must report any changes to information on the application to his or her county social services office within 10 days of such change;
3. Provided true answers and correct information to the best of his or her knowledge during the renewal process;
4. Knows that if he or she does not tell the truth, there may be a civil or criminal penalty for perjury that may include up to four years in jail, pursuant to California Penal Code Section 126;
5. Understands that if he or she received premium tax credits for health coverage through the Exchange during the previous benefit year, he or she must have filed or will file a federal tax return for that benefit year;
6. Understands that, unless he or she has already provided authorization for the Exchange to use electronic data sources to obtain his or her updated tax return information to conduct the annual redetermination for all IAPs, except for Medi-Cal or CHIP, he or she is giving the Exchange authorization to obtain updated tax return information to provide him or her with an updated eligibility determination for the following benefit year; and
7. Understands that he or she must provide his or her electronic signature and PIN to complete the Exchange's renewal process for enrollment in a QHP or for APTC and CSR, if applicable;
(D) Provide his or her electronic signature and PIN;
(E) Submit any reported changes and the signed declarations, through any of the channels specified in subdivision (i)(2) of this section, to obtain an updated eligibility determination for the following benefit year; and
(F) If eligible to enroll in a QHP, make a plan selection for the following benefit year.
(2) The enrollee or the qualified individual may complete the renewal process described in subdivision (i)(1) of this section through the channels available for the submission of an application, as described in Section 6470(j), except mail and facsimile.
(3) The enrollee or the qualified individual may seek assistance from a CEC, PBE, or a Certified Insurance Agent to complete the renewal process described in subdivision (i)(1) of this section.
(4) If the enrollee or the qualified individual does not complete the Exchange's renewal process specified in subdivision (i)(1) of this section within 30 days from the date of the notice described in subdivision (e) of this section, the Exchange shall proceed in accordance with the process specified in subdivision (j) of this section.
(j) After the 30-day period specified in subdivision (i) of this section has elapsed, the Exchange shall:
(1) Redetermine the enrollee's or the qualified individual's eligibility in accordance with the standards specified in Sections 6472 and 6474 using information obtained from the electronic data sources specified in subdivision (c) of this section and the most recent information the individual provided to the Exchange and renew the enrollee's coverage for the following benefit year, in accordance with the process specified in subdivision (l) of this section;
(2) Notify the enrollee or the qualified individual in accordance with the requirements specified in Section 6476(h); and
(3) If applicable, notify the enrollee's or the qualified individual's employer, in accordance with the requirements specified in Section 6476(i).
(k) A redetermination under this section shall be effective on the first day of the coverage year following the year in which the Exchange provided the notice in subdivision (e) of this section, or in accordance with the rules specified in Section 6496(j) through (l), whichever is later.
(l) If an enrollee remains eligible for enrollment in a QHP through the Exchange upon annual redetermination, and he or she does not terminate coverage, including termination of coverage in connection with voluntarily selecting a different QHP in accordance with Section 6506, the Exchange shall proceed in accordance with the following process:
(1) The enrollee shall be enrolled in the same QHP as the enrollee's current QHP, unless the enrollee's current QHP is not available.
(2) If the enrollee is not eligible for the same level of CSR as the enrollee's current level of CSR, he or she shall be enrolled in a silver-tier QHP offered by the same QHP issuer at the CSR level for which the enrollee is eligible. If the enrollee is not eligible for any level of CSR, he or she shall be enrolled in a standard silver-tier QHP offered by the same QHP issuer without CSR.
(3) If the enrollee's current QHP is not available and the current QHP is a HDHP as defined in Section 6410, the enrollee shall be enrolled in the lowest cost HDHP offered by the same QHP issuer at the same metal tier, as determined by the Exchange on a case-by-case basis. If there is no HDHP available, the enrollee shall be enrolled in the lowest cost QHP that is not a HDHP offered by the same QHP issuer at the same metal tier, as determined by the Exchange on a case-by-case basis.
(4) If the enrollee's current QHP is not available and the current QHP is not a HDHP, the enrollee shall be enrolled in the lowest cost QHP that is not a HDHP offered by the same QHP issuer at the same metal tier, as determined by the Exchange on a case-by-case basis.
(5) If the enrollee who is currently enrolled in a catastrophic QHP attains the age of 30 before the beginning of the following benefit year, the enrollee shall be enrolled in the lowest cost bronze-tier QHP that is not a HDHP offered by the same QHP issuer.
(6) Notwithstanding the process specified in subdivision (l)(1) through (5) of this section, an enrollee whose household income is at or below 150 percent of the FPL, who is determined by the Exchange to be eligible for APTC and CSR, and who is currently enrolled in a bronze-tier QHP shall be enrolled in a silver-tier QHP with the same provider network as the enrollee's current QHP offered by the same QHP issuer, provided that the enrollee's net monthly premium for the silver-tier QHP is $0.00.
(7) If the issuer of the QHP in which the enrollee is currently enrolled is no longer available, the enrollee shall be enrolled in the lowest cost QHP that is most similar to the enrollee's current QHP offered by a different QHP issuer that is available to the enrollee through the Exchange at the same metal tier and in accordance with the same hierarchy specified in subdivision (l)(3) through (5) of this section, as determined by the Exchange on a case-by-case basis.
(8) If the enrollee who is currently enrolled in a QHP as a dependent attains the age of 26 before the beginning of the following benefit year, the enrollee shall be enrolled in his or her own individual QHP through the Exchange in accordance with the process specified in subdivision (l)(1) through (7) of this section.
(9) Notwithstanding the process specified in subdivision (l)(1) through (8) of this section, a federally-recognized American Indian or Alaska Native enrollee who is currently enrolled in a zero cost sharing QHP shall be enrolled in the lowest cost zero cost sharing QHP that offers the same benefits and provider network offered by the same QHP issuer. If the issuer of the QHP in which the enrollee is currently enrolled is no longer available, the enrollee shall be enrolled in the lowest cost zero cost sharing QHP offered by a different QHP issuer that is available to the enrollee through the Exchange, as determined by the Exchange on a case-by-case basis.
(10) Notwithstanding the process specified in subdivision (l)(1) through (9) of this section, if the enrollee's current QDP is not available, the enrollee shall be enrolled in the lowest cost QDP that is most similar to the enrollee's current QDP offered by the same or different QDP issuer that is available to the enrollee through the Exchange, as determined by the Exchange on a case-by-case basis.
(m) The Exchange shall not redetermine a qualified individual's eligibility in accordance with this section if the qualified individual's eligibility was redetermined under this section during the prior year, and the qualified individual was not enrolled in a QHP through the Exchange at the time of such redetermination, and has not enrolled in a QHP through the Exchange since such redetermination.

Notes

Cal. Code Regs. Tit. 10, § 6498

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; and 45 CFR Section 155.335.

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 (g), 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 6-30-2014 action on 9-30-2014, including further 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 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.
4. Editorial correction of History 4 (Register 2014, No. 45).
5. Editorial correction of History 4 (Register 2014, No. 50).
6. 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.
7. 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.
8. 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).
9. New section, including amendment of subsection (d)(1), 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.
10. New section, including new subsection (i)(1)(D)5., subsection renumbering and amendment of subsection (k), 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.
11. New section refiled (including amendment of subsections (i), (i)(4) and (j)) 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.
12. 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.
13. New section refiled 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.
14. New section refiled, including amendment of subsections within subsection (l), 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.
15. 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).
16. Amendment of subsections (c)(1)-(2), (l)(3) and (l)(6) filed 10-7-2019 as a deemed emergency pursuant to Government Code section 100504; operative 10-7-2019 (Register 2019, No. 41). A Certificate of Compliance must be transmitted to OAL by 10-7-2024 pursuant to Government Code section 100504or emergency language will be repealed by operation of law on the following day.
17. New subsection (l)(9) filed 6-14-2021 as an emergency; operative 6-14-2021 (Register 2021, No. 25). Pursuant to Government Code section 100504, this is a deemed emergency. A Certificate of Compliance must be transmitted to OAL by 6-14-2026 pursuant to Government Code section 100504or emergency language will be repealed by operation of law on the following day.
18. New subsection (l)(6), subsection renumbering and amendment of newly designated subsections (l)(8)-(10) refiled 10-4-2021 as a deemed emergency pursuant to Government Code section 100504; operative 10-4-2021 (Register 2021, 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.
19. Amendment of subsection (l)(6) filed 2-11-2022 as a deemed emergency pursuant to Government Code section 100504; operative 2-11-2022 (Register 2022, No. 6). A Certificate of Compliance must be transmitted to OAL by 10-7-2024 pursuant to Government Code section 100504(a)(6)or emergency language in the emergency order of 10-7-2019 will be repealed by operation of law on the following day.
20. Amendment of subsections (c)(1)-(2), (l)(3) and (l)(6) refiled 9-9-2022 as a deemed emergency pursuant to Government Code section 100504; operative 9/9/2022 (Register 2022, No. 36). 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.

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