Sec. 6500 - Enrollment of Qualified Individuals into QHPs

§ 6500. Enrollment of Qualified Individuals into QHPs

(a) A qualified individual may enroll in a QHP (and an enrollee may change QHPs) only during, and in accordance with the coverage effective dates related to, the following periods:

(1) The initial open enrollment period, as specified in Section 6502;

(2) The annual open enrollment period, as specified in Section 6502; or

(3) A special enrollment period, as specified in Section 6504, for which the qualified individual has been determined eligible.

(b) The Exchange shall accept a QHP selection from an applicant who is determined eligible for enrollment in a QHP in accordance with Section 6472, and shall:

(1) Notify the applicant of her or his initial premium payment method options and of the requirement that the applicant's initial premium payment shall be received by the QHP issuer on or before the premium payment due date, as defined in Section 6410 of Article 2 of this chapter, in order for the applicant's coverage to be effectuated, as specified in Section 6502(g);

(2) Notify the QHP issuer that the individual is a qualified individual and of the applicant's selected QHP and premium payment method option;

(3) Transmit to the QHP issuer information necessary to enable the issuer to enroll the applicant within three business days from the date the Exchange obtains the information; and

(4) Transmit eligibility and enrollment information to HHS promptly and without undue delay, in a manner and timeframe as specified by HHS.

(c) The Exchange shall maintain records of all enrollments in QHPs through the Exchange.

(d) The Exchange shall reconcile enrollment information with QHP issuers and HHS no less than once a month.

(e) A QHP issuer shall accept enrollment information specified in subdivision (b) of this section consistent with the federal and State privacy and security standards specified in 45 CFR Section 155.260 (September 6, 2016), hereby incorporated by reference, and the Information Practices Act of 1977 (Cal. Civ. Code, § 1798 et seq.) and in an electronic format that is consistent with 45 CFR Section 155.270 (August 30, 2013), hereby incorporated by reference, and shall:

(1) Acknowledge receipt of enrollment information transmitted from the Exchange upon the receipt of such information;

(2) Enroll a qualified individual during the periods specified in subdivision (a) of this section;

(3) Notify a qualified individual of his or her premium payment due date;

(4) Abide by the effective dates of coverage established by the Exchange in accordance with Section 6502(c) and (f) and Section 6504(g) and (h);

(5) Notify the Exchange of the issuer's timely receipt of a qualified individual's initial premium payment and his or her effective date of coverage;

(6) Notify a qualified individual of his or her effective date of coverage upon the timely receipt of the individual's initial premium payment; and

(7) Provide new enrollees an enrollment information package that is compliant with accessibility and readability standards specified in Section 6452 of Article 4 of this chapter.

(f) If an applicant requests assistance from a QHP issuer for enrollment through the Exchange, the QHP issuer shall either:

(1) Direct the individual to file an application with the Exchange, or

(2) Ensure the applicant received an eligibility determination for coverage through the Exchange through the Exchange Internet Web Site by assisting the applicant to apply for and receive an eligibility determination for coverage through the Exchange through CalHEERS, provided that the QHP issuer:

(A) Complies with the federal and State privacy and security standards specified in 45 CFR Section 155.260 and the Information Practices Act of 1977 (Cal. Civ. Code, § 1798 et seq.);

(B) Complies with the consumer assistance standards specified in 45 CFR Section 155.205(d) (December 22, 2016), hereby incorporated by reference;

(C) Informs the applicant of the availability of other QHP products offered through the Exchange and displays the Web link to, and describes how to access, the Exchange Web site; and

(D) Complies with the requirements of Article 9 of this chapter.

(g) In accordance with the following premium payment process established by the Exchange, a QHP issuer shall:

(1) Accept, at a minimum, for all payments, paper checks, cashier's checks, money orders, EFT, and all general-purpose pre-paid debit cards as methods of payment and present all payment method options equally for a consumer to select their preferred payment method.

(2) Effectuate coverage upon receipt of an initial premium payment from the applicant on or before the premium payment due date. In cases of retroactive enrollment dates, the initial premium shall consist of the premium due for all months of retroactive coverage through the first month of coverage following the plan selection date. If only partial premium for less than all months of retroactive coverage is paid, only prospective coverage shall be effectuated, in accordance with the regular coverage effective dates specified in Section 6504(g).

(3) Acknowledge receipt of qualified individuals' premium payments by transmitting to the Exchange information regarding all received payments.

(4) Initiate cancellation of enrollment if the issuer does not receive the initial premium payment by the due date.

(5) Transmit to the Exchange the notice of cancellation of enrollment no earlier than the first day of the month when coverage is effectuated.

(6) Send a written notice of the cancellation to the enrollee within five business days from the date of cancellation of enrollment due to nonpayment of premiums.

(h) A QHP issuer shall reconcile enrollment and premium payment files with the Exchange no less than once a month.

(i) The premium for coverage lasting less than one month shall equal the product of:

(1) The premium for one month of coverage divided by the number of days in the month; and

(2) The number of days for which coverage is being provided in the month described in subdivision (i)(1) of this section.

(j) If individuals in the tax filers' tax households are enrolled in more than one QHP, and one or more APTC are to be made on behalf of a tax filer (or two tax filers covered by the same plan(s)), that portion of the APTC that is less than or equal to the aggregate adjusted monthly premiums, as defined in 26 CFR Section 1.36B-3(e), properly allocated to the essential health benefits (EHB) for the QHP policies, shall be allocated among the QHP policies as follows:

(1) The APTC shall be apportioned based on the number of enrollees covered under the QHP, weighted by the age of the enrollees, using the default uniform age rating curve established by the Secretary of HHS under 45 CFR Section 147.102(e) (April 17, 2018), hereby incorporated by reference;

(2) The portion allocated to any single QHP policy shall not exceed the portion of the QHP's adjusted monthly premium properly allocated to EHB; and

(3) If the portion of the APTC allocated to a QHP under this subdivision exceeds the portion of the same QHP's adjusted monthly premium properly allocated to EHB, the remainder shall be allocated evenly among all other QHPs in which individuals in the tax filers' tax households are enrolled.

(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, including new subsections (i)-(i)(2) and amendment of Note, 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 subsections (f)(2)(D), (f)(5) and (f)(6), 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 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. 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 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 (g)(2) and (i), repealer of subsections (i)(1) and (i)(2)-(i)(2)(C) and redesignation of former subsections (i)(1)(A)-(C) as new subsections (i)(1)-(3), 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 (including amendment of subsections (b)(1), (g)(2) and (g)(4)) 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 subsection (g)(2)) 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 further amendment of subsection (g)(2), new subsections (i)-(i)(2), subsection relettering and amendment of Note) 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; 45 CFR Sections 147.102, 155.205, 155.240, 155.270, 155.340, 155.400, 156.260, 156.265, 156.1230 and 156.1240; and 26 CFR Section 1.36 B-3(e).

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

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