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 their
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 their updated tax
return information to redetermine the individual's eligibility for coverage
effective January first of the following benefit year:
(A) The individual's APTC and CSR will end on
the last day of the current benefit year; and
(B) The individual's 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 their 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 the enrollee 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 the enrollee 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
their QHP, the enrollee shall contact the Exchange and update their
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
their QHP, the enrollee shall contact the Exchange and update their
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 their 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 their 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 the
enrollee or the qualified individual:
1.
Understands that they must report any changes to the information on the
application that may affect their 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
they, or someone in their household, have health insurance through Medi-Cal,
they must report any changes to information on the application to their county
social services office within 10 days of such change;
3. Provided true answers and correct
information to the best of their knowledge during the renewal
process;
4. Knows that if they do
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 they received premium
tax credits for health coverage through the Exchange during the previous
benefit year, they must have filed or will file a federal tax return for that
benefit year;
6. Understands that,
unless they have already provided authorization for the Exchange to use
electronic data sources to obtain their updated tax return information to
conduct the annual redetermination for all IAPs, except for Medi-Cal or CHIP,
they are 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 they must provide their 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 their 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 the
enrollee 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, they 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, they 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 250 percent of the
FPL and who upon annual redetermination is determined eligible for CSR, in
accordance with Section
6474(d), shall be
enrolled as follows:
(A) An enrollee 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 if the silver-tier QHP has a $0.00 net monthly
premium.
(B) An enrollee who is
currently enrolled in a gold-tier or platinum-tier QHP shall be enrolled in a
silver-tier QHP with the same or higher actuarial value and the same provider
network as the enrollee's current QHP offered by the same QHP issuer if the
silver-tier QHP has the same or lower net monthly premium.
(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 (6) 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 their 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
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; and 45 CFR Section 155.335.
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; and 45 CFR Section 155.335.
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.
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.
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
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
17. New subsection (l)(9) filed 6-14-2021 as an emergency; operative
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
19. Amendment of subsection (l)(6) filed 2-11-2022 as a deemed emergency pursuant to Government Code section 100504; operative
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
21. Amendment refiled 10-13-2023 as a deemed emergency pursuant to Government Code section 100504, including further amendment of section; operative
22. Certificate of Compliance as to 10-13-2023 order, including amendment of subsections (l)(6)(A)-(B) and (l)(7), transmitted to OAL 6-11-2024 and filed 7-24-2024; amendments effective
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