Sec. 6470 - Application

§ 6470. Application

(a) A single, streamlined application shall be used to determine eligibility and to collect information necessary for:

(1) Enrollment in a QHP,

(2) Medi-Cal,

(3) CHIP,

(4) APTC, and

(5) CSR.

(b) To apply for any of the programs listed in subdivision (a) of this section, an applicant or an application filer, or their Certified Enrollment Counselor (CEC), Certified Application Counselor (CAC), as defined in Section 6850(a)(2) of Article 11 of this chapter, Medi-Cal Managed Care Plan Enroller, as defined in Section 6900(a)(3) of Article 12 of this chapter, Plan-Based Enroller (PBE), or Certified Insurance Agent shall submit all information, documentation, and declarations required on the single, streamlined application, as specified in subdivisions (c), (d), and (e) of this section, and shall sign and date the application. CECs, CACs, Medi-Cal Managed Care Plan Enrollers, PBEs, and Certified Insurance Agents must obtain the applicant's consent before signing and submitting the application. Before a CEC, PBE, or Certified Insurance Agent can submit the application, they shall comply with the requirements specified in subdivision (h) of this section.

(c) An applicant or an application filer shall provide the following information on the single, streamlined application:

(1) The applicant's full name (first, middle, if applicable, and last).

(2) The applicant's date of birth.

(3) The home and mailing address, if different from home address, for the applicant and for all persons for whom application is being made, the applicant's county of residence and telephone number(s). For an applicant who does not have a home address, only a mailing address shall be provided.

(4) The applicant's SSN, if one has been issued to the applicant, and if the applicant does not have a SSN, the reason for not having one. The applicant's TIN, if one has been issued to the applicant in lieu of a SSN.

(5) The applicant's gender.

(6) The applicant's marital status.

(7) The applicant's status as a U.S. Citizen or U.S. National, or the applicant's immigration status, if the applicant is not a U.S. Citizen or U.S. National and attests to having satisfactory immigration status or lawful presence status.

(8) The applicant's employment status.

(9) Sources, amount, and payment frequency of the applicant's taxable gross income, as well as the following three types of tax-exempt income: foreign earned income, income from interest that the applicant receives or accrues during the taxable year, and income from Social Security benefits. If self-employed, the type of work, and the amount of net income. Exclude income from child support payments, veteran's payments, and Supplemental Security Income/State Supplementary Payment (SSI/SSP).

(10) The applicant's expected annual household income from all sources, as specified in subdivision (c)(9) of this section.

(11) The number of members in the applicant's household.

(12) Whether the applicant is an American Indian or Alaska Native, and if so:

(A) Name and state of the tribe;

(B) Whether the applicant has ever received a service from the Indian Health Service, a tribal health program, or an urban Indian health program or through a referral from one of these programs, and if not, whether he or she is eligible to receive such services; and

(C) The sources, amount, and frequency of payment for any income the applicant receives due to his or her status as American Indian or Alaska Native, if applicable.

(13) The applicant's expected type and amount of the tax deductions that the applicant is allowed to deduct from his or her taxable gross income when calculating the applicant's adjusted gross income on his or her federal income tax return.

(14) Whether the applicant currently has MEC through an employer-sponsored plan, as defined in Section 5000 A(f)(2) of IRC (26 USC § 5000A(f)(2)), and if so, the amount of monthly premium the applicant pays for self-only coverage through his or her employer and whether it meets the minimum value standards, as defined in Section 6410 of Article 2 of this chapter.

(15) Whether the applicant currently has MEC through any government sponsored programs, as defined in Section 5000 A(f)(1)(A) of IRC (26 USC § 5000A(f)(1)(A)).

(16) Whether the applicant has any physical, mental, emotional, or developmental disability.

(17) Whether the applicant needs help with long-term care or home and community-based services.

(18) Pregnancy status, if applicable, and if pregnant, the number of babies expected and the expected delivery date.

(19) The applicant's preferred written and spoken language.

(20) The applicant's preferred method of communication, including telephone, mail, and email, and if email has been selected, the applicant's email address.

(21) Whether the applicant is 18 to 20 years old and a full-time student.

(22) Whether the applicant is 18 to 26 years old and lived in foster care on his or her 18th birthday or whether the applicant was in foster care and enrolled in Medicaid in any state.

(23) Whether the applicant is temporarily living out of state.

(24) Whether the applicant intends to file a federal income tax return for the year for which he or she is requesting coverage, and if so, the applicant's expected tax-filing status.

(25) Whether the applicant is a primary tax filer or a tax dependent. If the applicant is a tax dependent, the non-applicant primary tax filer shall provide the information in subdivision(c)(1) through (13) of this section, except for the information in subdivision (c)(7) regarding citizenship, status as a national, or immigration status.

(26) For each person for whom the applicant is applying for coverage:

(A) The relationship of each person to the applicant; and

(B) The information in subdivision(c)(1) through (25) of this section.

(27) Whether the applicant designates an authorized representative, and if so, the authorized representative's name and address, and the applicant's signature authorizing the designated representative to act on the applicant's behalf for the application, eligibility and enrollment, and appeals process, if applicable.

(d) An applicant or an application filer shall declare under penalty of perjury that he or she:

(1) Understood all questions on the application, and gave true and correct answers to the best of his or her personal knowledge, and where he or she did not know the answer personally, he or she made every effort to confirm the answer with someone who did know the answer;

(2) Knows that if he or she does not tell the truth on the application, 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;

(3) Knows that the information provided on the application shall be only used for purposes of eligibility determination and enrollment for all the individuals listed on the application who are requesting coverage, and that the Exchange shall keep such information private in accordance with the applicable federal and State privacy and security laws;

(4) Agrees to notify the Exchange if any information in the application for any person applying for health insurance changes, which may affect the person's eligibility; and

(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.

(e) An applicant or an application filer shall indicate that he or she understands his or her rights and responsibilities by providing, on the single, streamlined application, a declaration that:

(1) The information the applicant provides on the application is true and accurate to the best of his or her knowledge, and that the applicant may be subject to a penalty if he or she does not tell the truth.

(2) The applicant understands that the information he or she provides on the application shall be only used for purposes of eligibility determination and enrollment for all the individuals listed on the application.

(3) The applicant understands that information he or she provides on the application shall be kept private in accordance with the applicable federal and State privacy and security laws and that the Exchange shares such information with other federal and State agencies in order to verify the information and to make an eligibility determination for the applicant and for any other person(s) for whom he or she has requested coverage on the application, if applicable.

(4) The applicant understands that to be eligible for Medi-Cal, the applicant is required to apply for other income or benefits to which he or she, or any member(s) of his or her household, is entitled, including: pensions, government benefits, retirement income, veterans' benefits, annuities, disability benefits, Social Security benefits (also called OASDI or Old Age, Survivors, and Disability Insurance), and unemployment benefits. However, such income or benefits do not include public assistance benefits, such as CalWORKs or CalFresh.

(5) The applicant understands that he or she is required to report any changes to the information provided on the application to the Exchange.

(6) The applicant understands that the Exchange shall not discriminate against the applicant or anyone on the application because of race, color, national origin, religion, age, sex, sexual orientation, marital status, veteran's status, or disability.

(7) The applicant understands that, except for purposes of applying for Medi-Cal, the applicant and any other person(s) the applicant has included in the application shall not be confined, after the disposition of charges (judgment), in a jail, prison, or similar penal institution or correctional facility.

(8) If the applicant or any other persons the applicant has included in the application qualifies for Medi-Cal, the applicant understands that if Medi-Cal pays for a medical expense, any money the applicant, or any other person(s) included in the application, receives from other health insurance, legal settlements, or judgments covering that medical expense shall be used to repay Medi-Cal until the medical expense is paid in full.

(9) The applicant understands that he or she shall have the right to appeal any action or inaction taken by the Exchange and shall receive assistance from the Exchange regarding how to file an appeal.

(10) The applicant understands that any changes in his or her information or information of any member(s) in the applicant's household may affect the eligibility of other members of the household.

(f) If an applicant or an application filer selects a health insurance plan or a QDP, as applicable, in the application:

(1) He or she shall provide:

(A) The name of the applicant and each family member who is enrolling in a plan; and

(B) The plan information, including plan name, metal tier, metal number, coverage level and plan type, as applicable; and

(2) All individuals, responsible parties, or authorized representatives, age 18 or older who are selecting and enrolling into a health insurance plan shall agree to, sign, and date the agreement for binding arbitration, as set forth below:

(A) For an Exchange Plan: "I understand that every participating health plan has its own rules for resolving disputes or claims, including, but not limited to, any claim asserted by me, my enrolled dependents, heirs, or authorized representatives against a health plan, any contracted health care providers, administrators, or other associated parties, about the membership in the health plan, the coverage for, or the delivery of, services or items, medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), or premises liability. I understand that, if I select a health plan that requires binding arbitration to resolve disputes, I accept, and agree to, the use of binding arbitration to resolve disputes or claims (except for Small Claims Court cases and claims that cannot be subject to binding arbitration under governing law) and give up my right to a jury trial and cannot have the dispute decided in court, except as applicable law provides for judicial review of arbitration proceedings. I understand that the full arbitration provision for each participating health plan, if they have one, is in the health plan's coverage document, which is available online at CoveredCA.com for my review, or, I can call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500) for more information."

(B) For a Kaiser Medi-Cal health plan: "I have read the plan description. I understand that Kaiser requires the use of binding neutral arbitration to resolve certain disputes. This includes disputes about whether the right medical treatment was provided (called medical malpractice) and other disputes relating to benefits or the delivery of services, including whether any medical services provided were unnecessary or unauthorized, or were improperly, negligently, or incompetently rendered. If I pick Kaiser as my Medi-Cal health plan, I give up my constitutional right to a jury or court trial for those certain disputes. I also agree to use binding neutral arbitration to resolve those certain disputes. I do not give up my right to a state hearing of any issue, which is subject to the state hearing process."

(g) The Exchange may request on the application that the applicant authorizes the Exchange to obtain updated tax return information, as described in Section 6498(b), for up to five years to conduct an annual redetermination, provided that the Exchange inform the applicant that he or she shall have the option to:

(1) Decline to authorize the Exchange to obtain updated tax return information; or

(2) Discontinue, change, or renew his or her authorization at any time.

(h) If a CEC, PBE, or a Certified Insurance Agent assists an applicant or an application filer in completing the application, he or she shall:

(1) Provide his or her name;

(2) Provide his or her certification or license number, if applicable;

(3) Provide the name of the entity with which he or she is affiliated;

(4) Certify that he or she assisted the applicant complete the application free of charge;

(5) Certify that he or she provided true and correct answers to all questions on the application to the best of his or her knowledge and explained

to the applicant in plain language, and the applicant understood, the risk of providing inaccurate or false information; and

(6) Date and sign the application.

(i) To apply for an eligibility determination and enrollment in a QHP through the Exchange without requesting any IAPs, an applicant or an application filer shall, for the applicant and each person for whom the applicant is applying for coverage, submit all information, documentation, and declarations required in:

(1) Subdivision (c)(1), (2), (3), (4), (5), (6), (7), (12)(A), (19), (20), (26)(A), and (27) of this section;

(2) Subdivision (d) of this section;

(3) Subdivision (e)(1), (2), (3), (5), (6), (7), (9), and (10) of this section;

(4) Subdivision (f)(1) and (2)(A) of this section; and

(5) Subdivision (h) of this section.

(j) An applicant or an application filer may file an application through one of the following channels:

(1) The Exchange's Internet Web site;

(2) Telephone;

(3) Facsimile;

(4) Mail; or

(5) In person.

(k) The Exchange shall accept an application from an applicant or application filer and make an eligibility determination for an applicant seeking an eligibility determination at any point in time during the year.

(l) If an applicant or application filer submits an incomplete application that does not include sufficient information for the Exchange to conduct an eligibility determination for enrollment in a QHP through the Exchange or for an IAP, if applicable, the Exchange shall proceed as follows:

(1) The Exchange shall provide notice to the applicant indicating that information necessary to complete an eligibility determination is missing, specifying the missing information, and providing instructions on how to provide the missing information;

(2) The Exchange shall provide the applicant with a period of 90 calendar days from the date of the notice described in subdivision (l)(1) of this section, or until the end of an enrollment period, whichever date is earlier, to provide the information needed to complete the application to the Exchange. In no event, shall this period be less than 30 calendar days from the date of the notice described in subdivision (l)(1) of this section.

(3) During the period specified in subdivision (l)(2) of this section, the Exchange shall not proceed with the applicant's eligibility determination or provide APTC or CSR, unless the applicant or application filer has provided sufficient information to determine the applicant's eligibility for enrollment in a QHP through the Exchange, in which case the Exchange shall make such a determination for enrollment in a QHP.

(4) If the applicant fails to provide the requested information within the period specified in subdivision (l)(2) of this section, the Exchange shall provide notice of denial to the applicant, including notice of appeals rights in accordance with Section 6604 of Article 7 of this chapter.

(1. New article 5 (sections 6470-6510) and 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 article 5 (sections 6470-6510) and section, with amendments, 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 (c)(25), (f) and (j)(1), 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 article 5 (sections 6470-6510) and section refiled 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. 5. Editorial correction of History 4 (Register 2014, No. 45). 6. Editorial correction of History 4 (Register 2014, No. 50). 7. New article 5 (sections 6470-6510) and 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. 8. New article 5 (sections 6470-6510) and 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. 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 article 5 (sections 6470-6510) and new section 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 article 5 (sections 6470-6510) and new section, including amendment of subsection (d)(4), new subsection (d)(5) and subsection renumbering, 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 article 5 (sections 6470-6510) and new section, including amendment of subsection (f), refiled 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 article 5 (sections 6470-6510) and 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. 15. New article 5 (sections 6470-6510) and new section refiled, including repealer of subsections (d)(6)-(d)(6)(B), 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, 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). 17. Amendment of subsections (b), (c)(9), (d)(4) and (d)(5) 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 100504 or emergency language will be repealed by operation of law on the following day.)

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; and 45 CFR Sections 155.310 and 155.405.

The adopted version of this section by Register 2021, No. 26, effective 6/14/2021 is not yet available.

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