Cal. Code Regs. tit. 10 § 6914

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 6914 - Eligibility Standards for Exemptions Through the Exchange

(a) Except as specified in subdivisions (c) and (d) of this section, the Exchange shall determine an applicant eligible for and issue a certificate of exemption for any month if the Exchange determines that the applicant meets the requirements for one or more of the exemptions described in this section for at least one day of the month.

(b) The Exchange shall proceed in accordance with the following process for a religious conscience exemption:

(1) The Exchange shall determine an applicant eligible for the religious conscience exemption for any month if, for that month, the applicant is either of the following:

(A) A member of a recognized religious sect or division described in Section 1402(g)(1) of the Internal Revenue Code (26 USC § 1402(g)(1)) and adheres to the established tenets or teachings of such sect or division.

(B) A member of a religious sect or division that is not described in Section 1402(g)(1) of the Internal Revenue Code (26 USC § 1402(g)(1)), relies solely on a religious method of healing, the acceptance of medical health services would be inconsistent with the religious beliefs of the individual, and who includes an attestation that the individual has not received medical health services during the preceding taxable year. For purposes of this paragraph, the term "medical health services" does not include routine dental, vision, and hearing services, midwifery services, vaccinations, necessary medical services provided to children, services required by law or by a third party, and other services as the Secretary of United States Department of Health and Human Services may provide in implementing Section 1311(d)(4)(H) of the federal Patient Protection and Affordable Care Act (42 USC § 18031(d)(4)(H)). An individual who claims this exemption, but received medical health services during the coverage year, shall lose eligibility for the religious conscience exemption.

(2) The Exchange shall grant a certificate of exemption to an applicant who meets the standard provided in subdivision (b)(1) of this section for a month on a continuing basis, until the last day of the month after the month of the individual's 21st birthday, or until such time that an individual reports that the individual no longer meets the standard provided in subdivision (b)(1) of this section, whichever comes first.

(3) If the Exchange granted a certificate of exemption for religious conscience to an applicant before reaching the age of 21, the Exchange shall send the applicant a notice upon reaching the age of 21 informing the applicant that the applicant must submit a new exemption application to maintain the certificate of exemption.

(4) The Exchange shall make an exemption in this category available prospectively or retrospectively.

(c) Except as specified in subparagraph (D) of paragraph (1) of this subdivision, the Exchange shall grant an exemption for general hardship to an applicant eligible for an exemption for at least the month before, the month or months during, and the month after a specific event or circumstance, if the Exchange determines that the applicant meets at least one of the requirements specified in paragraph (1) of this subdivision.

(1) To qualify for a hardship exemption, the applicant or qualified individual shall meet at least one of the following criteria:

(A) The applicant experienced financial or domestic circumstances, including an unexpected natural or human-caused event, such that the applicant had a significant, unexpected increase in essential expenses that prevented the applicant from obtaining coverage under a QHP.

(B) The expense of purchasing a QHP would have caused the applicant to experience serious deprivation of food, shelter, clothing, or other necessities.

(C) The applicant has experienced other circumstances that prevented the applicant from obtaining coverage under a QHP. Such circumstances shall be determined by the Exchange on a case-by-case basis.

(D) The qualified individual is an Indian eligible for services through an Indian health care provider, as defined in 42 CFR Section 447.51 (January 1, 2014), hereby incorporated by reference, and not otherwise eligible for an exemption under subdivision (c)(5) of Section 100705 of the Government Code, or an individual eligible for services through the Indian Health Service (IHS), in accordance with 25 USC Section 1680c(a), (b), or (d)(3). A qualified individual who meets the standards specified in this subparagraph shall be:

1. Deemed eligible for a hardship exemption without submitting an exemption application and obtaining a certificate of exemption through the Exchange; and

2. Exempt for a month on a continuing basis, until such time that the qualified individual no longer meets such standards.

(2) General hardship includes, but is not limited to, the following circumstances where the applicant:

(A) Experienced homelessness;

(B) Was evicted or is facing eviction or foreclosure;

(C) Received a shut-off notice from a utility company due to inability to pay the utility bills;

(D) Recently experienced domestic violence;

(E) Recently experienced the death of a close family member;

(F) Recently experienced a fire, flood, or other natural or human-caused disaster;

(G) Filed for bankruptcy;

(H) Incurred unreimbursed medical expenses that resulted in substantial debt;

(I) Recently experienced an unexpected increase in essential expenses or decrease in household income due to divorce or separation, unexpected or sudden disability, or caring for an ill, disabled, or aging family member;

(J) Is a child who has been determined ineligible for Medi-Cal and CHIP, and for whom a party other than the party who expects to claim the child as a tax dependent is required by court order to provide medical support. This exemption shall only be provided for the months during which the medical support order is in effect; or

(K) As a result of an eligibility appeals decision, is determined eligible for enrollment in a QHP or financial assistance through the Exchange for a period of time during which the applicant was not enrolled in a QHP through the Exchange. This exemption shall only be provided for the period of time affected by the appeals decision.

(3) The Exchange shall make an exemption in this category available prospectively or retrospectively, subject to the limitation described in Section 6916(h).

(d) The Exchange shall determine an applicant eligible for a hardship exemption for a month or months during which the applicant, or another individual the applicant attests will be included in the applicant's tax household, is unable to afford coverage through the Exchange or an employer.

(1) Eligibility for this exemption shall be based on the applicant's projected household income for the taxable year.

(2) An individual cannot afford coverage in a month if the individual's required contribution, determined on an annual basis, for coverage for the month exceeds 8.3 percent of the individual's projected household income for the taxable year. An individual's projected household income shall include any amount of the required contribution made through a salary reduction arrangement that is excluded from gross income. An eligible employer-sponsored plan is only considered under subdivision (d)(3) of this section if it meets the minimum value standard described in 45 CFR Section 156.145 (February 27, 2015), hereby incorporated by reference.

(3) For an individual who is eligible to purchase coverage under an eligible employer-sponsored plan, the required contribution for coverage shall be determined as follows:

(A) The required contribution for an employee who is eligible to purchase coverage under an eligible employer-sponsored plan sponsored by the employee's employer is the portion of the annual premium that the employee would pay (whether through salary reduction or otherwise) for the lowest cost self-only coverage.

(B) The required contribution for an individual who is eligible for coverage under an eligible employer-sponsored plan by reason of a relationship to an employee, is the portion of the annual premium that the employee would pay (whether through salary reduction or otherwise) for the lowest cost family coverage that would cover the employee and all other individuals who are included in the employee's family who have not otherwise been granted an exemption through the Exchange.

(C) Nondiscriminatory wellness program incentives, within the meaning of 26 CFR Section 54.9802-1(f) (February 24, 2014), hereby incorporated by reference, offered by an eligible employer-sponsored plan that affect premiums are treated as earned in determining an employee's required contribution for purposes of affordability of an eligible employer-sponsored plan to the extent the incentives relate exclusively to tobacco use. Wellness program incentives that do not relate to tobacco use or that include a component unrelated to tobacco use are treated as not earned for this purpose. For purposes of this paragraph, the term "wellness program incentive" has the same meaning as the term "reward" in 26 CFR Section 54.9802-1(f)(1)(i).

(4) The required contribution for an individual who is only eligible to purchase minimum essential coverage in the individual market is the annual premium for the lowest cost bronze plan available in the individual market through the Exchange serving the rating area in which the individual resides (without regard to whether the individual purchased a QHP though the Exchange), reduced by the maximum amount of any premium assistance for the taxable year determined as if the individual was covered for the entire taxable year by a QHP offered through the Exchange. All members of the individual's tax household who have not otherwise been granted an exemption through the Exchange and who are not treated as eligible to purchase coverage under an eligible employer-sponsored plan shall be included to determine the required contribution.

(5) In the case of plan years beginning in any calendar year after 2019, this subdivision shall be applied by substituting "8.3 percent" specified in subdivision (d)(2) of this section with an amount equal to 8 percent increased by the amount the United States Secretary of Health and Human Services determines reflects the excess of the rate of premium growth between the preceding calendar year and 2013 over the rate of income growth for that period.

(6) The applicant shall apply for this exemption prior to the last date on which the applicant may enroll in a QHP through the Exchange for the month or months of a calendar year for which the exemption is requested.

(7) The Exchange shall make this exemption available prospectively and provide it for all remaining months in a coverage year, notwithstanding any change in an individual's circumstances.

Cal. Code Regs. Tit. 10, § 6914

Note: Authority cited: Sections 100504 and 100725, Government Code. Reference: Sections 100502, 100705, 100715 and 100800, Government Code; 26 USC Sections 1402 and 5000A; 42 USC Section 13031; 26 CFR Sections 1.5000A-3 and 54.9802-1; 42 CFR Section 447.51; and 45 CFR Sections 155.605 and 156.145.

1. New section filed 10-7-2019 as a deemed emergency pursuant to Government Code section 100725(c); operative 1/1/2020 (Register 2019, No. 41). A Certificate of Compliance must be transmitted to OAL by 1-1-2025 pursuant to Government Code section 100725 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 5-11-2020 as a deemed emergency pursuant to Government Code section 100725(c), including amendment of section and Note; operative 5/11/2020 (Register 2020, No. 20). A Certificate of Compliance must be transmitted to OAL by 1-1-2025 pursuant to Government Code section 100725or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 5-11-2020 order, including amendment of subsections (b)(1)(A), (c)(2)(B) and (c)(2)(G)-(H), new subsection (c)(3) and amendment of subsection (d)(2), transmitted to OAL 5-20-2024 and filed 7-2-2024; amendments effective 7/2/2024 pursuant to Government Code section 11343.4(b)(3) (Register 2024, No. 27).