Cal. Code Regs. Tit. 10, § 6530 - Special Enrollment Periods for Qualified Employees and Dependents
(a) The
SHOP must provide special enrollment periods consistent with this section,
during which certain qualified employees or a dependent of a qualified employee
may enroll in QHPs and enrollees may change QHPs.
(b) A qualified employee, or their dependent,
may enroll in a QHP or change QHPs during special enrollment periods outside of
the initial and annual open enrollment periods in the following situations:
(1) A qualified employee, or their dependent,
experiences an event described in subdivision (a)(1) of Section
6504 of Article 5 of this chapter,
other than subdivision (a)(1)(B) of Section
6504 of Article 5 of this
chapter.
(2) A qualified employee,
or their dependent, experiences an event described in subdivision (a)(2) of
Section 6504 of Article 5 of this
chapter.
(3) A qualified employee,
or their dependent, experiences an event described in subdivision (a)(3) of
Section 6504 of Article 5 of this
chapter.
(4) A qualified employee,
or their dependent, experiences an event described in subdivision (a)(5) of
Section 6504 of Article 5 of this
chapter.
(5) A qualified employee,
or their dependent, experiences an event described in subdivision (a)(6) of
Section 6504 of Article 5 of this
chapter.
(6) A qualified employee,
or their dependent, experiences an event described in subdivision (a)(9) of
Section 6504 of Article 5 of this
chapter.
(7) The qualified
employee, or their dependent, was released from incarceration.
(8) The qualified employee, or their
dependent, is a member of the reserve forces of the United States military
returning from active duty or a member of the California National Guard
returning from active duty service under Title 32 of the United States
Code.
(9) A qualified employee who
is an Indian, as defined by Section 4 of the Indian Health Care Improvement Act
(25 U.S.C. Section
1603(c)), and their
dependent who is enrolled or is enrolling in a QHP through an Exchange on the
same application as the qualified employee, may enroll in a QHP or change from
one QHP to another one time per month.
(10) A qualified employee, or their
dependent, demonstrates to the Exchange, in accordance with guidelines issued
by HHS and as determined by the Exchange on a case-by-case basis, that the
individual meets other exceptional circumstances. Such circumstances may
include, but are not limited to, the following:
(A) If a child who has been determined
ineligible for MediCal and CHIP, and for whom a party other than the party who
expects to claim them as a tax dependent is required by court order to provide
health coverage for the child, the child shall be eligible for a special
enrollment period if otherwise eligible for enrollment in a QHP.
(11) A qualified employee or
dependent demonstrates to the Exchange, with respect to health plans offered
through the Exchange, or to the applicable regulator, with respect to health
plans offered outside the Exchange, that they did not enroll in a health plan
during the immediately preceding enrollment period available to the employee or
dependent because they were misinformed that they were covered under
MEC.
(12) A qualified employee, or
their dependent, is receiving services from a contracting provider under a
health plan, as defined in Section
1399.845(f)
of the Health and Safety Code or Section
10965(f)
of the Insurance Code, for one of the conditions described in Section
1373.96(c)
of the Health and Safety Code or section
10133.56(a)
of the Insurance Code, and that provider is no longer participating in the
health plan.
(13) A qualified
employee, or their dependent, loses eligibility for health coverage under a
Medi-Cal plan under title XIX of the Social Security Act or a state child
health plan under title XXI of the Social Security Act.
(14) A qualified employee, or their
dependent, becomes eligible for assistance, with respect to health coverage
under a SHOP, under such Medi-Cal plan or a state child health plan (including
any waiver or demonstration project conducted under or in relation to such a
plan).
(15) A qualified employee,
or their dependent, experiences an event described in subdivision (a)(12) of
Section 6504 of Article 5 of this
chapter.
(16) A qualified employee
or dependent experiences an event described in subdivision (a)(13) of Section
6504 of Article 5 of this
chapter.
(17) The qualified
employee, or their dependent experiences an event described in subdivision
(a)(14) of Section
6504 of Article 5 of this
chapter.
(18) The qualified
employee or their dependent experiences any other triggering events identified
in California Insurance Code section
10753.05(b)(3)
and California Health and Safety Code section
1357.503(b).
(c) A qualified employee, or their
dependent, who experiences one of the situations described in subdivision (b)
of this section has:
(1) 30 days from the
date of the event described in paragraphs (b)(1)-(11) and (b)(15)-(18) of that
subdivision in this section to select a QHP through the SHOP.
(2) 30 days from the date of the event
described in paragraphs (b)(12) or (g)(1) of this section to select a QDP
through the SHOP.
(3) 60 days from
the date of the event described in paragraphs (b)(13) and (b)(14) of that
subdivision in this section to select a QHP through the SHOP.
(d) A dependent of a qualified
employee is not eligible for a special enrollment period if the qualified
employer does not extend the offer of health coverage or dental coverage to
dependents.
(e) Loss of MEC, as
specified in subdivision (b)(1) of this section, includes:
(1) Loss of eligibility for health coverage,
including but not limited to:
(A) Loss of
eligibility for health coverage as a result of:
1. Legal separation;
2. Divorce;
3. Cessation of dependent status (such as
attaining the maximum age to be eligible as a dependent child under the health
plan);
4. Death of an
employee;
5. Termination of
employment; and
6. Reduction in the
number of hours of employment;
(B) Loss of eligibility for coverage through
Medicare, Medicaid, or other government-sponsored health care programs, other
than programs specified as not MEC under
26 CFR Section
1.5000A-2(b)(2) (November
26, 2014), hereby incorporated by reference;
(C) In the case of health coverage offered
through an HMO or similar program in the individual market that does not
provide health coverage to individuals who no longer reside, live, or work in a
service area, loss of health coverage because an individual no longer resides,
lives, or works in the service area (whether or not within the choice of the
individual);
(D) In the case of
health coverage offered through an HMO or similar program in the group market
that does not provide health coverage to individuals who no longer reside,
live, or work in a service area, loss of health coverage because an individual
no longer resides, lives, or works in the service area (whether or not within
the choice of the individual), and no other benefit package is available to the
individual;
(E) A situation in
which a health plan no longer offers any health coverage to the class of
similarly situated individuals that includes the individual; and
(F) Loss of that coverage due to the
circumstances described in Section 1163 of Title 29 of the United States
Code. "Loss of minimum essential coverage" also includes loss of
that coverage for a reason that is not due to the fault of the
individual.
(2)
Termination of qualified employer contributions toward the qualified employee's
or dependent's health insurance coverage that is not COBRA continuation
coverage, including contributions by any current or former employer that was
contributing to health coverage for the qualified employee or
dependent;
(3) Exhaustion of COBRA
or Cal-COBRA continuation health coverage, meaning that such coverage ceases
for any reason other than a reason specified in subdivision (e)(4) of this
section. An individual is considered to have exhausted COBRA continuation
coverage if such coverage ceases:
(A) Due to
the failure of the employer or other responsible entity, but not of the
employee or dependent receiving COBRA benefits, to remit premiums on a timely
basis;
(B) When the individual no
longer resides, lives, or works in the service area of an HMO or similar
program (whether or not within the choice of the individual) and there is no
other COBRA continuation coverage available to the individual; or
(C) When the individual incurs a claim that
would meet or exceed a lifetime limit on all benefits and there is no other
COBRA continuation coverage available to the individual.
(4) Loss of MEC, as specified in subdivision
(b)(1) of this section, does not include termination or loss due to:
(A) The employee's or dependent's failure to
pay premiums on a timely basis, including COBRA premiums prior to expiration of
COBRA coverage; or
(B) Subject to
Section
10384.17 of
the Insurance Code and Section
1365
of the Health and Safety Code, termination of coverage due to a carrier
demonstrating fraud or an intentional misrepresentation of material fact under
the terms of the policy by the policyholder, contractholder, or
employer.
(f)
If requested by a QHP Issuer or SHOP, an employee or a dependent of an employee
who experiences a triggering event that gives rise to a special enrollment
period pursuant to this section must provide verification of the triggering
event to SHOP for review.
(g) A
qualified employee or their dependent may enroll in a QDP during a special
enrollment period outside of the initial and annual open enrollment periods in
the following situations:
(1) Loss of
eligibility for dental coverage. Loss of eligibility for dental coverage shall
be consistent with any of following situations specified in subdivisions
(b)(11) or (e)(1)-(3) of this section. The date of the loss of dental coverage
shall be the date of the last day the qualified employee, or their dependent,
would have dental coverage under their previous plan or coverage.
(2) Loss of eligibility for dental coverage
does not include termination or loss of dental coverage due to any of the
situations specified in subdivisions (e)(4)(A)-(B).
(3) A qualified employee, or their dependent,
loses eligibility for pediatric dental coverage subsequent to turning nineteen
(19) years of age and wishes to continue dental coverage under a standalone
dental plan offered by a QDP Issuer in the SHOP;
(h) The effective dates of coverage are
determined using the provisions of Section
6534.
(i) Limitation. Qualified employees will not
be able to enroll unless the employer group meets any applicable minimum
participation rules under Section
6522(a)(4).
Notes
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 10503, Government Code; 26 CFR Sections 1.36B-2, 1.5000A-2 and 54.9801-2; 45 CFR Sections 147.104, 155.420, 155.725, 155.1080 and 156.285; Sections 1357.503 and 1399.849, Health and Safety Code; and Sections 10753.05, 10753.063.5 and 10965, Insurance Code.
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 10503, Government Code; 26 CFR Sections 1.36B-2, 1.5000A-2 and 54.9801-2; 45 CFR Sections 147.104, 155.420, 155.725, 155.1080 and 156.285; Sections 1357.503 and 1399.849, Health and Safety Code; and Sections 10753.05, 10753.063.5 and 10965, Insurance Code.
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 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. New section, including amendment of subsections (a)(2) and (e), refiled 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 and amendment of Note, 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, 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.
10. Certificate of Compliance as to 4-20-2018 order, including amendment of section and Note, transmitted to OAL 8-3-2018 and filed 9-17-2018; amendments effective
11. Amendment filed 9-7-2021 as an emergency; operative
12. 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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