Cal. Code Regs. Tit. 10, § 6520 - Employer and Employee Application Requirements
(a) A
small employer who is eligible to purchase coverage from a Qualified Health
Plan (QHP) Issuer for its eligible employees through the Small Business Health
Options Program (SHOP) pursuant to Section
6522, may apply to participate in
the SHOP by submitting the following information to the SHOP:
(1) General employer information: business
legal name and whether the employer is doing business under a fictitious name,
Federal Employer Identification Number, State Employer Identification Number,
organization type (private, nonprofit, government, church/church affiliated),
Standard Industry Classification (SIC) code, principal business address, and
mailing address;
(2) The number of
eligible employees being offered enrollment in SHOP and the total number of
full-time equivalent (FTE) employees employed by the qualified employer, as
calculated in accordance with Health and Safety Code Section
1357.500(k)(3)
and Insurance Code Section
10753(q)(3);
(3) Whether you have employed 20 or more
employees for 20 or more weeks in the current or preceding calendar
year;
(4) Whether the qualified
employer is offering dependent health coverage or dental coverage for spouses,
registered or non-registered domestic partners and/or dependent
children;
(5) The qualified
employer's desired health coverage or dental coverage effective date;
(6) Whether the qualified employer is subject
to COBRA or Cal-COBRA continuation coverage regulations;
(7) Whether the qualified employer is
currently offering health coverage or dental coverage, and if so, through which
issuer;
(8) Whether the qualified
employer intends to claim the Small Business Health Care Tax Credit with the
IRS;
(9) The name, primary phone
number, and email address for the primary contact and business owner/authorized
company officer for the qualified employer and the preferred method of
communication;
(10) Whether the
qualified employer used an insurance agent and if so, the agent's name, general
agency name (if applicable), CA insurance license number, the agency Federal
Employer Identification Number if applicable, and whether the agent is an
insurance agent certified by Covered California. If the qualified employer uses
an insurance agent, the qualified employer must have that agent certify that
they understand they may be subject to a civil penalty for providing false
information under Health and Safety Code Section
1389.8
and Insurance Code Section
10119.3.
(11) Information about the qualified
employer's qualified employees, in the employee application in subdivision
(d);
(12) The employer's offer of
health coverage or dental coverage and the reference plan or dental reference
plan, which includes:
(A) The employer's
contribution rate to each of its qualified employee's health plan premiums
pursuant to Section
6522(a)(5)(A);
(B) The employer's health plan premium
contribution rate for spouse or non-registered domestic partner, or dependent
children health coverage, if applicable; and
(C) The employer's selection for one, two
contiguous, three contiguous, or four contiguous tiers of health coverage,
pursuant to 45 CFR Section
156.140(b) (bronze, silver,
gold, or platinum) (February 25, 2013), hereby incorporated by
reference;
(D) Whether the
qualified employer wishes to include infertility benefits to qualified
employees;
(E) Effective August 1,
2021, if the qualified employer is offering dental coverage to qualified
employees, the employer must select a dental reference plan. The qualified
employer must indicate its contribution rate for qualified employees' QDP
premiums pursuant to Section
6522(h)(3). The
qualified employer must indicate its QDP premium contribution rate for spouse's
or non-registered domestic partner's, or dependent children's coverage, if
applicable;
(13) New
qualified employer application submissions are due five days prior to the
requested effective date. Completed submissions received after this date will
carry an effective date no earlier than the first of the following month unless
the qualified employer submits a signed CCSB New Business Late Submission
Acknowledgement Form (Rev. 1/4/2024), hereby incorporated by reference. The
CCSB New Business Late Submission Acknowledgement Form must be submitted by the
7th day of the month to retroactively effectuate enrollment to the 1st of the
month. Exceptions for exceptional circumstances will be considered on a
case-by-case basis.
(b)
To participate in the SHOP, an employer must attest to the following:
(1) That the business has 100 or fewer
full-time or FTE employees and has a principal business address in
California;
(2) That all eligible
full-time employees of this business will be offered SHOP coverage;
(3) That the business has at least one
employee who is not the owner or business partner, or the spouse of the owner
or business partner;
(4) That the
employer is signing the application under penalty of perjury, which means all
information contained in the qualified employer application is true and correct
to the best of the qualified employer's knowledge;
(5) That the employer knows that they may be
subject to penalties under federal law if they intentionally provide false or
untrue information pursuant to
45 CFR Section
155.285 (September 6, 2016), hereby
incorporated by reference;
(6) That
the employer knows that the information will only be used to determine
eligibility and facilitate enrollment in health coverage or dental coverage and
will otherwise be kept private as required by federal and state law;
(7) That any waiting period established by
the qualified employer complies with
42 U.S.C. Section
300gg-7,
45 CFR Section
155.725 (April 18, 2017), hereby incorporated
by reference, and applicable state law, and all qualified employees have
complied with the qualified employer's waiting period;
(8) That the employer has the consent from
every qualified employee listed on the application to include their personally
identifiable information such as dates of birth, addresses, social security
numbers or tax identification numbers, phone numbers, and email
addresses;
(9) That the employer
understands that discrimination is prohibited on the basis of race, color,
national origin, religion, sex, age, sexual orientation, marital status, gender
identity, veteran status, disability, or any other type of discrimination
prohibited in the Health and Safety Code and Insurance Code;
(10) That the qualified employer understands
that the SHOP will not consider the qualified employer approved for health
coverage or dental coverage until the SHOP has received the qualified
employer's first month's total premium payment;
(11) That the qualified employer agrees to
continue to make the total required monthly premium payment by the due date,
and which at no time shall be less than 100 dollars less than the total amount
due each month, including any premium amounts past due, to maintain eligibility
for coverage in the SHOP;
(12) That
the qualified employer agrees to inform its eligible employees of the
availability of health coverage and dental coverage and that those declining
coverage must wait until the next open enrollment period, pursuant to Section
6528, to sign up for coverage,
unless that employee experiences an event that would entitle them to a special
enrollment period pursuant to Section
6530;
(13) That the qualified employer understands
that once coverage in a QHP is approved by the SHOP, changes to the coverage
cannot be implemented until the qualified employer's annual election of
coverage period pursuant to Section
6526, except to the extent the
qualified employer exercises the right to change coverage with the same QHP
issuer within the first 30 days of the effective date of coverage pursuant to
Section
6528(f),
Health and Safety Code 1357.504(d), and Insurance Code Section
10753.06.5(d);
(14) That the qualified employer understands
that health coverage and dental coverage through the SHOP is subject to the
applicable terms and conditions of the QHP issuer contract or policy and
applicable state law, which will determine the procedures, exclusions and
limitations relating to the coverage and will govern in the event of any
conflict with SHOP or QHP issuer benefits comparison, summary or other
description of the coverage;
(15)
That the qualified employer understands that once employer and employee
information is transmitted to the selected QHP Issuers, the qualified
employer's coverage effective date cannot be changed nor can the qualified
employer terminate coverage until after the first month of coverage;
(16) That the qualified employer agrees to
inform its qualified employees of the availability of child and family dental
plans and that qualified employees may choose to enroll only in a QDP even if
the qualified employee does not choose to enroll in a health plan;
(17) That the qualified employer has provided
or will provide to its qualified employees an initial open enrollment period
beginning at least 20 days prior to the employee application due date described
in subdivision (d).
(18) That the
qualified employer understands that the attestations in this section are
subject to audit by the SHOP at any time; and
(19) That the qualified employer agrees to
maintain compliance with the attestations in this section in order to continue
eligibility for coverage through the SHOP.
(c) A qualified employer must provide the
SHOP with its most recent Quarterly Contribution Return and Report of Wages
(Form DE-9C), as filed with the California Employment Development Division, on
which the qualified employer must identify on the face of the form whether each
employee listed on the DE-9C is a full-time employee, part-time eligible
employee, ineligible employee and whether the employee is still employed by the
qualified employer. If there is not sufficient space on the face of the Form
DE-9C for the qualified employer to add the required information, the qualified
employer may attach additional sheets of paper to the Form DE-9C as necessary.
A qualified employer must provide the SHOP with additional or other documents
in the following circumstances:
(1) For a
qualified employer who is a sole proprietor in business less than three (3)
months, a California business license or Fictitious Business Name Filing and a
DE-9C or payroll records for 30 days;
(2) For a qualified employer who is a sole
proprietor who is in business three (3) months or more, a DE-9C. If the owner
is not listed as earning wages on the DE-9C and wishes to enroll for coverage,
a current IRS Form 1040 Schedule C Profit or Loss From Business (Sole
Proprietorship) or, if a Form 1040 Schedule C is not available, a California
business license or Fictitious Business Name filing may be
substituted;
(3) For a qualified
employer who is a corporation in business less than three (3) months, Articles
of Incorporation, filed and stamped by the Secretary of State, and a Statement
of Information or corporate meeting minutes listing all officers' names and a
DE-9C or payroll records for 30 days;
(4) For a qualified employer who is a
corporation in business three (3) months or more, a DE-9C, and, if officers who
are not listed on DE-9C enroll for coverage, a Statement of
Information;
(5) For a qualified
employer who is a partnership in business less than three (3) months, a
Partnership Agreement, a Federal Tax Identification appointment letter, and a
DE-9C or payroll records for 30 days;
(6) For a qualified employer who is a
partnership in business three (3) months or more, a DE-9C and a current IRS
Form 1065 Schedule K-1, if the partners are not listed on DE-9C and want to
enroll for coverage. If an IRS Form 1065 Schedule K-1 is not yet available, the
Partnership Agreement and the Federal Tax Identification appointment letter can
be substituted;
(7) For a qualified
employer who is a limited partnership in business less than three (3) months, a
Partnership Agreement, a Federal Tax Identification appointment letter, and a
DE-9C or payroll records for 30 days;
(8) For a qualified employer who is a limited
partnership in business three (3) months or more, a DE-9C. If general partners
are not listed on DE-9C and wish to enroll in coverage, then a current IRS Form
1065 Schedule K-1. If an IRS Form 1065 Schedule K-1 is not available, the
Partnership Agreement and a Federal Tax Identification appointment letter can
be substituted. Limited partners are not eligible for coverage unless they
appear on a DE-9C;
(9) For a
qualified employer who is a limited liability partnership in business less than
three (3) months, a Partnership Agreement or a Federal Tax Identification
appointment letter, and a DE-9C or payroll records for 30 days;
(10) For a qualified employer who is a
limited liability partnership in business three (3) months or more, a DE-9C. If
partners are not listed on the DE-9C and wish to enroll in coverage, then a
current IRS Form 1065 Schedule K-1. If the IRS Form 1065 Schedule K-1 is not
yet available, the Partnership Agreement and the Federal Tax Identification
appointment letter can be substituted;
(11) For a qualified employer who is a
limited liability company in business less than three (3) months, Articles of
Organization with the Operating Agreement or the Statement of Information and a
DE-9C or payroll records for 30 days;
(12) For a qualified employer who is a
limited liability company in business three (3) months or more, a DE-9C. If
managing members are not listed as earning wages on the DE-9C and wish to
enroll for coverage, a current IRS Form 1065 Schedule K-1 for a partnership or
IRS Form 1040 Schedule C for a sole proprietorship. If an IRS Form 1065
Schedule K-1 is not yet available, a Statement of Information or Articles of
Organization with the Operating Agreement may be substituted; and
(13) For a qualified employer who was
previously insured outside of the SHOP, the SHOP may waive or alter any
additional documentation submission requirements in Section
6520(c)(1)-(12),
if as determined by the SHOP on a case-by-case basis, the proof of coverage is
sufficient to satisfy these requirements.
(d) To participate in the SHOP, a qualified
employee must submit the following information to the SHOP no later than five
days prior to the requested effective date:
(1) The employer's business name and business
phone number;
(2) The qualified
employee's first and last name, SSN or Taxpayer Identification Number, date of
birth, home address, mailing address (if different from home address),
telephone number, email address, and if the employee is newly hired;
(3) Whether the employee is applying for
Cal-COBRA or COBRA continuation coverage pursuant to the following conditions:
(A) The COBRA coverage is currently in effect
under the qualified employer's health plan; or
(B) The employee has had a qualifying event
that renders the employee eligible for continuation of coverage and is applying
for that coverage; and,
(C) If
applicable, the effective date of coverage, the qualifying event that triggered
that coverage, and the date of the qualifying event;
(4) If the qualified employer is offering
coverage for dependents and the employee elects to offer their dependents
coverage, the marital or domestic partnership status of the qualified
employee;
(5) If the qualified
employer is offering coverage for spouses, registered domestic partners, or
non-registered domestic partners, and/or dependent children, and the employee
elects to offer their dependents coverage, then information about the qualified
employee's spouse, registered domestic partner, or non-registered partner,
and/or dependent children, which includes:
(A)
The first and last name of each spouse, registered domestic partner, or
non-registered domestic partner, and/or each dependent child, their
relationship to the qualified employee, SSN or taxpayer identification number,
date of birth, age, gender, home address, and mailing address (if different
from home address); and
(6) The
names of the health plans and dental plans, if applicable, selected by the
qualified employee and dependents.
(e) To participate in the SHOP, a qualified
employee must do all of the following:
(1)
Agree to mandatory arbitration if the QHP Issuer selected by the employee
requires arbitration, which would require the employee and their dependents to
arbitrate all claims relating to their QHP;
(2) Disclose whether the employee used an
insurance agent and, if so, the agent's name, general agency name (if
applicable), and whether the agent is an insurance agent certified by Covered
California. If the employee uses an insurance agent, the employee must have
that agent certify that they understand they may be subject to a civil penalty
for providing false information under Health and Safety Code Section
1389.8
and Insurance Code Section
10119.3.
(3) Sign the application under penalty of
perjury, that all information contained in the employee application is true and
correct to the best of the employee's knowledge.
(4) Acknowledge that the employee understands
that they may be subject to penalties under federal law if they intentionally
provide false or untrue information pursuant to
45 CFR Section
155.285 (September 6, 2016), hereby
incorporated by reference.
(f) If a qualified employee declines
coverage, the employee must sign the declination of coverage, which is part of
the application, and state other sources of coverage, if any.
(g) The SHOP must keep all information
received pursuant to this section private in accordance with applicable federal
and state privacy and security laws pursuant to
45 CFR Section
155.260 (September 6, 2016), hereby
incorporated by reference, and the Information Practices Act of 1977 (Cal. Civ.
Code, commencing with Section
1798). The SHOP may not provide to
the qualified employer any information collected on the employee application
with respect to the qualified employees or dependents of qualified employees,
other than the name, address, birth date, and health plan or dental plan
selection of the spouse or dependent. The SHOP may only share information from
an employee application with the QHP Issuer or employer that is strictly
necessary for the purposes of eligibility and enrollment. Information obtained
by the SHOP pursuant to this section may not be used for purposes other than
eligibility determinations and enrollment in health or dental coverage through
the SHOP.
Notes
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; and 45 CFR Sections 155.260, 155.705, 155.715, 155.725, 155.730, 156.140 and 156.285.
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; and 45 CFR Sections 155.260, 155.705, 155.715, 155.725, 155.730, 156.140 and 156.285.
2. New article 6 (sections 6520-6538) and section, including amendment of subsection (d)(3), 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)(10)(B), 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 order, including further amendment of section, on 10-2-2014 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats.
5. Editorial correction of History 3 and History 4 (Register 2014, No. 45).
6. 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 10-2-2014 will be repealed by operation of law on the following day (Register 2015, No. 38).
7. 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 10-2-2014 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.
8. Refiling of 9-30-2016 order, including further amendment of section, on 11-28-2016 as a deemed emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 833 (Stats. 2016, c. 30); operative 11-28-2016 (Register 2016, No. 49). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
9. Refiling of 11-28-2016 order, including further amendment of section, on 4-17-2017 as a deemed emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 833 (Stats. 2016, c. 30); operative 4-17-2017 (Register 2017, No. 16). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
10. Refiling of 4-17-2017 order, including further amendment of section, filed 4-20-2018 as a deemed emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 833 (Stats. 2016, c.30); operative 4-20-2018 (Register 2018, No. 16). A Certificate of Compliance must be transmitted to OAL by 10-1-2018 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 4-20-2018 order, including amendment of subsections (a) and (a)(12)(B), repealer of subsection (a)(12)(D), subsection relettering, amendment of subsections (b)(2), (b)(7), (b)(12) and (g)(4) and amendment of Note, transmitted to OAL 8-3-2018 and filed 9-17-2018; amendments effective
12. Amendment filed 9-7-2021 as an emergency; operative
13. Certificate of Compliance as to 9-7-2021 order, including further amendment of section, transmitted to OAL 8-22-2024 and filed 9-23-2024; amendments effective
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