Sec. 6710 - Roles and Responsibilities

§ 6710. Roles and Responsibilities

(a) A Certified Plan-Based Enrollment Entity (PBEE) and its Certified Plan-Based Enrollers (PBEs) shall perform the following functions:

(1) Maintain expertise in eligibility, enrollment, and PBE Program specifications.

(2) Provide enrollment assistance to consumers in a manner considered to be through the Exchange pursuant to 45 C.F.R. § 156.265(b)(2) and Section 6500(f) of Article 5 of this chapter.

(3) Provide information and services in a fair and accurate manner. Such information and services shall include assistance with other Insurance Affordability Programs (e.g., Medi-Cal).

(4) Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under Section 2793 of the Public Health Service (PHS) Act, 42 U.S.C. § 300gg-93, or any other appropriate State agency or agencies, for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan or coverage.

(5) Comply with the privacy and security requirements in 45 CFR § 155.260.

(6) Comply with any applicable federal or state laws and regulations.

(7) Inform all applicants of the availability of other QHP products or stand-alone dental plans offered through the Exchange through an HHS-approved universal disclaimer and display the Web link to access the Exchange Web Site on the PBEE's Web Site, and describe how to access the Exchange Web Site or the Service Center of the Exchange. The PBE can refer an applicant to any individual or entity certified through Articles 8, 11, 12 of this chapter, or to any Agents certified by the Exchange.

(8) Facilitate enrollment and renewal in a QHP offered in the Individual Exchange by the PBEE affiliated with the PBE.

(A) The QHP Issuer must be able to provide applicants standardized information for its available QHPs in the Individual Exchange, including at a minimum the following data elements:

(i) Premium and cost-sharing information;

(ii) The summary of benefits and coverage established under Section 2715 of the PHS Act;

(iii) Identification of whether the QHP is a bronze, silver, gold or platinum level plan as defined by Section 1302(d) of the Affordable Care Act (ACA), 42 U.S.C. § 18022(d), or a catastrophic plan as defined by Section 1302(e) of the ACA, 42 U.S.C. § 18022(e);

(iv) The results of the enrollee satisfaction survey, as described in Section 1311(c)(4) of the ACA, 42 U.S.C. 18031, when available;

(v) Quality ratings assigned in accordance with Section 1311(c)(3) of the ACA, 42 U.S.C. 18031;

(vi) Medical loss ratio information as reported to HHS in accordance with 45 C.F.R. § 158;

(vii) Transparency of coverage measures reported to the Exchange during certification with 45 C.F.R. § 155.1040;

(viii) The provider directory made available to the Exchange in accordance with 45 C.F.R. § 156.230;

(ix) Potential total cost, including premium and out-of-pocket expenses; and

(x) Participation of the preferred provider of the consumer in the QHP Issuer's available QHPs.

(9) Clearly distinguish between QHPs for which the consumer is eligible and other non-QHPs that the Issuer may offer, and indicate that advance payments of the premium tax credit and cost sharing reductions apply only to QHPs offered through the Exchange.

(10) Allow applicants to select and attest to an APTC amount, if applicable, in accordance with 45 C.F.R. § 155.310(d)(2) and Section 6476(c) of Article 5 of this chapter.

(11) If the consumer is determined to be eligible for Medi-Cal, the PBE shall either transfer the consumer to the county of residence for enrollment in Medi-Cal or transmit all eligibility information to DHCS consistent with 45 C.F.R. § 155.310 and Section 6476(e) of Article 5 of this chapter. A PBE shall not facilitate Medi-Cal plan selection until the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) has been programmed to allow a beneficiary to select a Medi-Cal managed care plan, as defined in Section 6410 of Article 2 of this chapter, pursuant to subdivision (p) of Section 14016.5 of the Welfare and Institutions Code.

(12) Advise all consumers found ineligible for Insurance Affordability Programs of their appeal rights, including the time limits and methods for filing appeals, in accordance with Sections 6604 and 6606 of Article 7 of this chapter.

(13) Advise all consumers found ineligible for Insurance Affordability Programs that there may be other health insurance products outside of the Individual Exchange that may be suitable to their needs. The PBE shall offer to transfer the consumer to a Captive Agent or Solicitor, as defined in Health and Safety Code Section 1345(m), affiliated with the PBEE capable of offering the consumer the full range of health plans offered by the Issuer in the Individual Market and Individual Exchange.

(b) To ensure that information provided as part of any enrollment assistance is culturally and linguistically appropriate to the needs of the population being served, including individuals with limited English proficiency, all PBEEs and PBEs shall:

(1) Develop and maintain general knowledge about the racial, ethnic, and cultural groups in their service area, including each group's diverse cultural health beliefs and practices, preferred languages, health literacy, and other needs;

(2) Collect and maintain updated information to help understand the composition of the communities in the service area, including the primary languages spoken;

(3) Provide consumers with information and assistance in the consumer's preferred language, at no cost to the consumer, including the provision of oral interpretation of non-English languages and the translation of written documents in non-English languages when necessary to ensure meaningful access. Use of a consumer's family or friends as oral interpreters can satisfy the requirement to provide linguistically appropriate services only when requested by the consumer as the preferred alternative to an offer of other interpretive services;

(4) Provide oral and written notice to consumers with limited English proficiency informing them of their right to receive language assistance services and how to obtain them;

(5) Receive ongoing education and training in culturally and linguistically appropriate service delivery; and

(6) Implement strategies to recruit, support, and promote a staff that is representative of the demographic characteristics, including primary languages spoken, of the communities in their service area.

(c) To ensure that enrollment assistance is accessible to people with disabilities, all PBEEs and PBEs shall:

(1) Ensure that any consumer education materials, Web sites, or other tools utilized for consumer assistance purposes are accessible to people with disabilities, including those with sensory impairments, such as visual or hearing impairments, and those with mental illness, addiction, and physical, intellectual, and developmental disabilities;

(2) Provide auxiliary aids and services for individuals with disabilities, at no cost, where necessary for effective communication. Use of a consumer's family or friends as interpreters can satisfy the requirement to provide auxiliary aids and services only when requested by the consumer as the preferred alternative to an offer of other auxiliary aids and services;

(3) Provide assistance to consumers in a location and in a manner that is physically and otherwise accessible to individuals with disabilities;

(4) Ensure that legally authorized representatives are permitted to assist an individual with a disability to make informed decisions; and

(5) Acquire sufficient knowledge to refer people with disabilities to local, state, and federal long-term services and supports programs when appropriate.

(d) All PBEEs and PBEs shall provide the same level of service to all individuals regardless of age, disability, culture, race, ethnicity, income, sexual orientation, or gender identity and seek advice or experts when needed.

(e) If capacity necessitates, for those culturally and linguistically appropriate services in this Section which are not otherwise required of the PBEE in federal or state law, a PBE may transfer consumers seeking those services under this Section to other Exchange resources including the Exchange Service Center and describe how to access Exchange-provided services.

(f) All PBEs shall complete the PBEE and PBE Section of a consumer's application to the Exchange, including the following:

(1) Name, certification number of the PBE, signature or electronic signature, date, and PBE PIN number, if applicable; and

(2) Name of the PBEE.

(g) PBEs that do not meet the definition of a Captive Agent, as defined in Section 6410 of Article 2 of this chapter, shall report to the Exchange any criminal convictions, administrative actions taken by any other agency, and arrests for which the individual is out on bail or his or her own recognizance, within 30 days of the date of the conviction, action, or arrest.

(h) PBEs that are Captive Agents shall be licensed in good standing through the California Department of Insurance.

(i) Prohibited Activities for PBEEs and PBEs.

(1) All PBEEs and their Contractors and Employees that are PBEs may not:

(A) Conduct door-to-door marketing;

(B) Employ marketing practices or offer information and assistance only to certain members in a manner that will have the effect of enrolling a disproportionate number of the Issuer's non-QHP members with significant health needs in QHPs offered in the Individual Exchange;

(C) Cold-call non-member target populations;

(D) Mail the paper application for the consumer;

(E) Advise the consumer to provide inaccurate information on the application regarding income, residency, immigration status and other eligibility criteria;

(F) Select a QHP for the potential applicant while providing application assistance;

(G) Solicit or accept any consideration from an applicant in exchange for application assistance;

(H) Pay any part of the premium or any other type of consideration to or on behalf of the consumer;

(I) Sponsor a person eligible for the program by paying family contribution amounts or co-payments;

(J) Offer applicants any inducements such as gifts or monetary payments to apply for coverage in a QHP or Medi-Cal Managed Care Plan represented by the PBE;

(K) Intentionally create multiple applications from the same household, as defined in 45 C.F.R § 435.603(f);

(L) Invite, influence, or arrange for an individual whose existing coverage through an eligible-employer sponsored plan is affordable and provides minimum value, as described in 26 U.S.C. § 36B(c)(2)(C) and in 26 C.F.R. §§ 1.36B-2(c)(3)(v) and (vi), to separate from employer-based group health coverage;

(M) Request, view or obtain claims data information while providing application assistance;

(N) Request, view or obtain health status information including any pre-existing conditions for purposes other than connecting the consumer to the appropriate IAP;

(O) Violate conflict of interest standards in Section 6712;

(P) Be a Certified Insurance Agent through the Exchange pursuant to Section 6800 of Article 10 of this chapter, or any other enrollment assistance function of the Exchange, including those certified through Article 8 of this chapter; or

(Q) Retain any information related to income, citizenship, immigration status, or disability.

(R) Employ, be employed by, be in partnership with, or receive any remuneration arising out of the functions performed under this Article, from any individual or entity certified through Article 8 or Article 11 of this chapter or from any Agents certified by the Exchange.

(1. New section filed 9-30-2013 as an emergency; 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 amendment of subsection (a)(8)(A)(iii), repealer of subsection (a)(8)(A)(iv), subsection renumbering and amendment of subsections (f)(1)-(2), refiled 4-1-2014 as an emergency; 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 6-26-2014 as an emergency; operative 7-1-2014 (Register 2014, No. 26). 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 with amendments 10-2-2014 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31); operative 10-2-2014 (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 3 (Register 2014, No. 51). 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. Certificate of Compliance as to 10-2-2014 order, including further amendment of subsections (a)(5), (a)(8), (a)(11), (f)(1) and (i)(1)(P), transmitted to OAL 4-12-2016 and filed 5-23-2016; amendments effective 5-23-2016 pursuant to Government Code section 11343.4(b)(3) (Register 2016, No. 22). 8. Amendment of subsection (a)(7) and new subsection (i)(1)(R) filed 1-29-2018; operative 1-29-2018 pursuant to Government Code section 11343.4(b)(3) (Register 2018, No. 5).)

Note: Authority cited: Section 100504, Government Code. Reference: Section 100503, Government Code; and 45 Code of Federal Regulations, Sections 155.205(d), 155.260, 155.415, 156.265 and 156.1230.

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