Sec. 6486 - Alternate Verification Process for APTC and CSR Eligibility Determination for Decreases in Annual Household Income or If Tax Return Data Is Unavailable

§ 6486. Alternate Verification Process for APTC and CSR Eligibility Determination for Decreases in Annual Household Income or If Tax Return Data Is Unavailable

(a) A tax filer's annual household income shall be determined based on the alternate verification procedures described in subdivisions (b) and (c) of this section if:

(1) An applicant attests to projected annual household income in accordance with Section 6482(e)(2);

(2) The tax filer does not meet the criteria specified in Section 6484;

(3) The Exchange has not verified the applicant's MAGI-based income to be within the applicable Medi-Cal or CHIP MAGI-based income standard, in accordance with the process specified in Medicaid regulations at 42 CFR Sections 435.945, 435.948, and 435.952 and CHIP regulations at 42 CFR Section 457.380; and

(4) One of the following conditions is met:

(A) The IRS does not have tax return data that may be disclosed under Section 6103 (l)(21) of IRC (26 USC § 6103 (l)(21)) for the tax filer that is at least as recent as the calendar year two years prior to the calendar year for which APTC and CSR would be effective;

(B) The applicant attests that the tax filer's applicable family size has changed, or is reasonably expected to change (or the members of the tax filer's family have changed, or are reasonably expected to change), for the benefit year for which the applicants in his or her family are requesting coverage;

(C) The applicant attests that a change in circumstances has occurred, or is reasonably expected to occur, and so the tax filer's annual household income has decreased, or is reasonably expected to decrease, from the income obtained from the data sources described in Section 6482(b)(1) for the benefit year for which the applicants in his or her family are requesting coverage;

(D) The applicant attests that the tax filer's filing status has changed, or is reasonably expected to change, for the benefit year for which the applicants in his or her family are requesting coverage; or

(E) An applicant in the tax filer's family has filed an application for unemployment benefits.

(b) If a tax filer qualifies for an alternate verification process based on the requirements specified in subdivision (a) of this section and the applicant's attestation to projected annual household income, as described in Section 6482(e)(2), is no more than 25 percent below the annual household income computed in accordance with Section 6482(e)(1), the applicant's attestation shall be accepted without further verification.

(c) If a tax filer qualifies for an alternate verification process based on the requirements specified in subdivision (a) of this section and the applicant's attestation to projected annual household income, as described in Section 6482(e)(2), is greater than 25 percent below the annual household income computed in accordance with Section 6482(e)(1), or if the data described in Section 6482(b)(1) is unavailable, the Exchange shall verify the applicant's attestation of the tax filer's projected annual household income in accordance with the following procedures:

(1) The Exchange shall use:

(A) Annualized data from the MAGI-based income sources, as specified in Section 6482(c); and

(B) Other HHS-approved electronic data sources.

(2) If the applicant's attestation indicates that the information described in subdivision (c)(1) of this section represents an accurate projection of the tax filer's household income for the benefit year for which coverage is requested, the Exchange shall determine the tax filer's eligibility for APTC and CSR based on the household income data in subdivision (c)(1) of this section.

(3) If electronic data are unavailable or the applicant's attestation to projected annual household income, as described in Section 6482(e)(2), is more than 25 percent below the annual household income computed using data sources described in subdivision (c)(1) of this section, the Exchange shall follow procedures specified in Section 6492(a)(1) through (4).

(4) Except as specified in subdivision (c)(5) of this section, the Exchange shall accept the applicant's attestation without further verification if:

(A) The applicant's attestation to projected annual household income, as described in Section 6482(e)(2), indicates that a tax filer's annual household income has increased, or is reasonably expected to increase, from the data described in subdivision (c)(1) of this section for the benefit year for which the applicant(s) in the tax filer's family are requesting coverage; and

(B) The Exchange has not verified the applicant's MAGI-based income to be within the applicable Medi-Cal or CHIP MAGI-based income standard, in accordance with the process specified in Medicaid regulations at 42 CFR Sections 435.945, 435.948, and 435.952 and CHIP regulations at 42 CFR Section 457.380.

(5) The Exchange shall follow the inconsistency procedures specified in Section 6492(a)(1) through (4) if:

(A) The Exchange finds that the applicant's attestation of a tax filer's annual household income is not reasonably compatible with other information provided by the application filer; or

(B) The data described in subdivision (c)(1) of this section indicates that the projected annual household income is under 100 percent of the FPL; and

(C) The applicant's attestation to projected annual household income, as described in Section 6482(e)(2), is equal to or greater than 100 percent but no more than 400 percent of the FPL for the benefit year for which coverage is requested; and

(D) The applicant's attestation to projected annual household income, as described in Section 6482(e)(2), is more than 25 percent above the annual household income computed using data sources described in subdivision (c)(1) of this section.

(6) The applicant shall not be eligible for APTC or CSR if:

(A) The applicant has not responded to a request for additional information from the Exchange following the 95-day period specified in Section 6492(a)(2)(B); and

(B) The data sources specified in Section 6482(b)(1) and (c) indicate that the applicant is eligible for full-scope Medi-Cal or CHIP.

(7) If, at the conclusion of the 95-day period specified in Section 6492(a)(2)(B), the Exchange remains unable to verify the applicant's attestation, the Exchange shall:

(A) Determine the applicant's eligibility based on the information described in Section 6482(e)(1);

(B) Notify the applicant of such determination in accordance with the notice requirements specified in Section 6476(h); and

(C) Implement such determination in accordance with the effective dates specified in Section 6496(j) through (l).

(8) If, at the conclusion of the 95-day period specified in Section 6492(a)(2)(B), the Exchange remains unable to verify the applicant's attestation for the tax filer and the information described in Section 6482(e)(1) is unavailable, the Exchange shall:

(A) Determine the tax filer ineligible for APTC and CSR;

(B) Notify the applicant of such determination in accordance with the notice requirements specified in Section 6476(h); and

(C) Discontinue any APTC and CSR in accordance with the effective dates specified in Section 6496(j) through (l).

(1. New 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 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 refiled 9-30-2014 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 section, including amendment of subsections (c)(3)(C) and (c)(4)(C), 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 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 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 section, including amendment of subsections (c)(3)(C) and (c)(4)(C), 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 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 with amendments 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) 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 9-24-2018 pursuant to Government Code section 11343.4(b)(3) (Register 2018, No. 39).)

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 42 CFR Sections 435.945, 435.948, 435.952 and 457.380; and 45 CFR Section 155.320.

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

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