Cal. Code Regs. Tit. 10, § 6506 - Termination of Coverage in a QHP
(a)
Enrollee-initiated terminations shall be conducted in accordance with the
following process:
(1) An enrollee may
terminate his or her coverage in a QHP through the Exchange, including as a
result of the enrollee obtaining other MEC, by notifying the Exchange or the
QHP issuer.
(2) An enrollee may
choose to remain enrolled in a QHP at the time of plan selection if he or she
becomes eligible for other MEC and the enrollee does not request termination in
accordance with subdivision (a)(1) of this section. If the enrollee does not
choose to remain enrolled in a QHP in such a situation, the Exchange shall
initiate termination of his or her enrollment in the QHP upon completion of the
redetermination process specified in Section
6496.
(3) An individual, including an enrollee's
authorized representative, shall be permitted to report the death of an
enrollee to the Exchange for purposes of initiating termination of the
enrollee's coverage in accordance with the following requirements:
(A) The individual shall be at least 18 years
old.
(B) If the individual
reporting the death is the application filer, the enrollee's authorized
representative, or anyone in the household of the deceased who was included in
the initial application, he or she shall be permitted to initiate termination
of the deceased's coverage.
(C) If
the individual reporting the death is not the application filer, the enrollee's
authorized representative, or anyone in the household of the deceased who was
included in the initial application, he or she shall submit satisfactory
documentation of death to the Exchange before he or she can initiate
termination of the deceased's coverage. Satisfactory documentation may include
a copy of a death certificate, obituary, medical record, power of attorney,
proof of executor, or proof of estate. The documentation or an attached cover
note shall provide the following information:
1. Full name of the deceased;
2. Date of birth of the deceased;
3. The Exchange application ID or case number
(if known) of the deceased;
4.
Social Security Number (if known) of the deceased; and
5. Contact information for the person
submitting the documentation, including full name, address, and phone
number.
(4)
The Exchange shall permit an enrollee to retroactively terminate or cancel his
or her coverage or enrollment in a QHP if the enrollee demonstrates to the
Exchange that:
(A) He or she attempted to
terminate his or her coverage or enrollment in a QHP and experienced a
technical error that did not allow the enrollee to terminate his or her
coverage or enrollment through the Exchange, and requests retroactive
termination within 60 days after he or she discovered the technical
error;
(B) His or her enrollment in
a QHP through the Exchange was unintentional, inadvertent, or erroneous and was
the result of the error or misconduct of an officer, employee, or agent of the
Exchange or HHS, its instrumentalities, a QHP issuer, or a non-Exchange entity
providing enrollment assistance or conducting enrollment activities. Such
enrollee must request cancellation within 60 days of discovering the
unintentional, inadvertent, or erroneous enrollment. For purposes of this
provision, misconduct, as determined by the Exchange, includes the failure to
comply with applicable standards under this title, or other applicable Federal
or State laws; or
(C) He or she was
enrolled in a QHP without his or her knowledge or consent by any third party,
including third parties who have no connection with the Exchange, and requests
cancellation within 60 days of discovering of the enrollment.
(b) The Exchange may
initiate termination of an enrollee's coverage in a QHP, and shall permit a QHP
issuer to terminate such coverage, provided that the issuer makes reasonable
accommodations for all individuals with disabilities (as defined by the
Americans with Disabilities Act) before terminating coverage for such
individuals, under the following circumstances:
(1) The enrollee is no longer eligible for
coverage in a QHP through the Exchange;
(2) The enrollee fails to pay premiums for
coverage, as specified in subdivision (c) of this section, and:
(A) The three-month grace period required for
individuals receiving APTC specified in subdivision (c)(2) of this section has
been exhausted, as described in subdivision (c)(4) of this section;
or
(B) Any other grace period
required under the State law not described in subdivision (b)(2)(A) of this
section has been exhausted;
(3) The enrollee's coverage is rescinded by
the QHP issuer because the enrollee has made a fraudulent claim or an
intentional misrepresentation of a material fact in connection with the plan,
in accordance with Section
1389.21
of the Health and Safety Code and Section
10384.17
of the Insurance Code, after the QHP issuer demonstrates to the Exchange that
the rescission is appropriate due to the enrollee's fraudulent claim or
intentional misrepresentation of a material fact;
(4) The QHP terminates or is decertified as
described in
45 CFR Section
155.1080; or
(5) The enrollee changes from one QHP to
another during an annual open enrollment period or special enrollment period in
accordance with Sections
6502
and
6504.
(6) The enrollee was enrolled in a QHP
without his or her knowledge or consent by a third party, including by a third
party with no connection with the Exchange.
(7) Any other reason for termination of
coverage described in
45 CFR Section
147.106 (December 22, 2016), hereby
incorporated by reference.
(c) In the case of termination of enrollee's
coverage due to non-payment of premium, as specified in subdivision (b)(2) of
this section, a QHP issuer shall:
(1) Provide
the enrollee, who is delinquent on premium payment, with notice of such payment
delinquency;
(2) Provide a grace
period of three consecutive months for an enrollee who, when first failing to
timely pay premiums, is receiving APTC;
(3) During the grace period specified in
subdivision (c)(2) of this section:
(A) Pay
all appropriate claims for services rendered to the enrollee during the first
month of the grace period;
(B)
Notify the Exchange and HHS of such non-payment;
(C) Continue to collect APTC on behalf of the
enrollee from the IRS; and
(D)
Comply with any other applicable State laws and regulations relating to the
grace period specified in subdivision (c)(2) of this section; and
(4) If an enrollee receiving APTC
exhausts the three-month grace period specified in subdivision (c)(2) of this
section without paying all outstanding premiums:
(A) Terminate the enrollee's coverage on the
effective date described in subdivision (d)(6) of this section, provided that
the QHP issuer meets the notice requirements specified in subdivision (e)(1)
and (2) of this section; and
(B)
Return APTC paid on behalf of such enrollee for the second and third months of
the grace period.
(d) If an enrollee's coverage in a QHP is
terminated for any reason, the following effective dates for termination of
coverage shall apply.
(1) For purposes of this
subdivision, reasonable notice is defined as 14 days before the requested
effective date of termination.
(2)
Changes in eligibility for APTC and CSR, including terminations, shall adhere
to the effective dates specified in subdivisions (j) through (1) of Section
6496.
(3) In the case of a termination in
accordance with subdivision (a)(1) through (3) of this section, the last day of
coverage shall be:
(A) The termination date
specified by the enrollee, if the enrollee provides reasonable
notice;
(B) Fourteen days after the
termination is requested by the enrollee, if the enrollee does not provide
reasonable notice;
(C) On a date on
or after the date on which the termination is requested by the enrollee if the
enrollee's QHP issuer agrees to effectuate termination in fewer than 14 days,
and the enrollee requests an earlier termination effective date;
(D) If the enrollee is newly eligible for
full-scope Medi-Cal or CHIP, the last day of the month during which the
enrollee is determined eligible for full-scope Medi-Cal or CHIP; or
(E) The retroactive termination date
requested by the enrollee, if specified by applicable State laws.
(4) In the case of a retroactive
termination in accordance with subdivision (a)(4) of this section, the
following termination dates apply:
(A) For a
termination in accordance with subdivision (a)(4)(A) of this section, the
termination date shall be no sooner than 14 days after the date that the
enrollee can demonstrate he or she contacted the Exchange to terminate his or
her coverage or enrollment through the Exchange, unless the QHP issuer agrees
to an earlier effective date as set forth in paragraph (d)(3)(C) of this
section.
(B) For a termination or
cancellation in accordance with subdivision (a)(4)(B) or (C) of this section,
the cancellation or termination date shall be the original coverage effective
date or a later date, as determined appropriate by the Exchange on a case by
case basis, based on the circumstances of the cancellation or
termination.
(5) In the
case of a termination in accordance with subdivision (b)(1) of this section,
the last day of QHP coverage shall be the last day of eligibility, as described
in Section
6496(k)
unless the individual requests an earlier termination effective date per
subdivision (a) of this section.
(6) In the case of a termination in
accordance with subdivision (b)(2)(A) of this section, the last day of coverage
shall be the last day of the first month of the three-month grace
period.
(7) In the case of a
termination in accordance with subdivision (b)(2)(B) of this section, the last
day of coverage shall be consistent with existing California laws regarding
grace periods.
(8) In the case of a
termination in accordance with subdivision (b)(5) of this section, the last day
of coverage in an enrollee's prior QHP shall be the day before the effective
date of coverage in his or her new QHP, including any retroactive enrollments
effectuated under Section
6504(h)(4)
when an enrollee is granted a special enrollment period to change QHPs with a
retroactive coverage effective date.
(9) In the case of a cancellation of
enrollment in accordance with subdivision (b)(6) of this section, the Exchange
may cancel the enrollee's enrollment upon its determination that the enrollment
was performed without the enrollee's knowledge or consent. The cancellation
date shall be the original coverage effective date.
(10) In the case of a termination due to the
enrollee's death, the last day of coverage is the date of death.
(11) In cases of retroactive termination
dates, the Exchange shall ensure that:
(A)
The enrollee receives the APTC and CSR for which he or she is determined
eligible;
(B) The enrollee is
refunded any premiums owed to the enrollee by the QHP issuer after the
retroactive termination date;
(C)
If the enrollee enrolls in a new QHP:
1. The
enrollee's premium and cost sharing are adjusted to reflect the enrollee's
obligations under the new QHP; and
2. Consistent with
45
CFR Section 156.425(b)
(February 27, 2015), hereby incorporated by reference, in the case of a change
in the level of CSR (or a QHP without CSR) under the same QHP issuer during a
benefit year, any cost sharing paid by the enrollee under the previous level of
CSR (or a QHP without CSR) for that benefit year is taken into account in the
new level of CSR for purposes of calculating cost sharing based on aggregate
spending by the individual, such as for deductibles or for the annual
limitations on cost sharing.
(e) If an enrollee's coverage in a QHP is
terminated in accordance with subdivision (a)(1) or (b)(2) and (3) of this
section, the QHP issuer shall:
(1) Provide the
enrollee, within five business days from the date of the termination, with a
written notice of termination of coverage that includes:
(A) The termination effective date;
(B) The reason for termination; and
(C) The notice of appeals right, in
accordance with the requirements specified in Section
6604
of Article 7 of this chapter.
(2) Notify the Exchange of the termination
effective date and reason for termination;
(3) Abide by the termination of coverage
effective dates described in subdivision (d) of this section; and
(4) Maintain electronic records of
termination of coverage, including audit trails and reason codes for
termination, for a minimum of ten years.
(f) If an enrollee's coverage in a QHP is
terminated for any reason other than terminations pursuant to subdivision
(b)(2) and (3) of this section, the Exchange shall:
(1) Send termination information to the QHP
issuer within three business days from the date of the termination;
(2) Send termination information to HHS
promptly and without undue delay, in the manner and timeframe specified by HHS;
and
(3) Retain records of
termination of coverage for a minimum of ten years in order to facilitate audit
functions.
Notes
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; and 45 CFR Sections 147.106, 147.128, 155.430, 155.1080, 156.270 and 156.425.
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, including amendments, 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. Refiling of 6-30-2014 action on 9-30-2014, including further amendments, 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. Refiling of 9-30-2014 action on 12-12-2014, including further amendments, as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 ( Stats.
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, including amendment of subsections (f) and (f)(3), 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, including amendment of subsections (d)(2) and (f), 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 with amendments 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 (including amendment of subsections (d)(3)(C)-(D)) and (d)(11)(C)) 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 (including subsequent amendments and amendment of subsection (b)(3)) 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
17. Amendment of subsections (a)(1), (b)(3) and (d)(11)(B) and new subsections (d)(11)(C)-(d)(11)(C)2. filed 10-7-2019 as a deemed emergency pursuant to Government Code section 100504; operative
18. Amendment of subsections (a)(1), (b)(3) and (d)(11)(B) and new subsections (d)(11)(C)-(d)(11)(C)2. refiled 9-9-2022 as a deemed emergency pursuant to Government Code section 100504; operative
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