Cal. Code Regs. tit. 10 § 6472

Current through Register 2024 Notice Reg. No. 48, November 29, 2024

Section 6472 - Eligibility Requirements for Enrollment in a QHP Through the Exchange

(a) An applicant who is seeking enrollment in a QHP that is not a catastrophic plan shall meet the requirements of this section, except for the requirements specified in subdivision (f) of this section, regardless of the applicant's eligibility for APTC or CSR. For purposes of this section, an applicant includes all individuals listed on the application who are seeking enrollment in a QHP through the Exchange. An applicant who is seeking enrollment in a catastrophic QHP shall also meet the requirements specified in subdivision (f) of this section. An applicant who is seeking enrollment in a QDP shall also meet the requirements specified in subdivision (g) of this section.

(b) An applicant who has a SSN shall provide their SSN to the Exchange.

(c) An applicant shall be a citizen or national of the United States, or a non-citizen who is lawfully present in the United States, and is reasonably expected to be a citizen, national, or a non-citizen who is lawfully present for the entire period for which enrollment is sought.

(d) An applicant shall not be incarcerated, other than incarceration pending the disposition (judgment) of charges.

(e) An applicant shall meet one of the following applicable residency standards:

(1) For an individual who is age 21 and over, is not living in an institution as defined in 42 CFR Section 435.403(b) (March 23, 2012), hereby incorporated by reference, is capable of indicating intent, and is not receiving Supplemental Security Income/State Supplemental Program payments as defined in Title 22, Division 3, Section 50095 of CCR, the service area of the Exchange of the individual is the service areas of the Exchange in which the individual is living and:

(A) Intends to reside, including without a fixed address; or

(B) Has entered with a job commitment or is seeking employment (whether or not currently employed).

(2) For an individual who is under the age of 21, is not living in an institution as defined in 42 CFR Section 435.403(b), is not eligible for Medi-Cal based on receipt of assistance under title IV-E of the Social Security Act, is not emancipated, and is not receiving Supplemental Security Income/State Supplementary Payment (SSI/SSP) as defined in Title 22, Division 3, Section 50095 of CCR, the Exchange service area of the individual is:

(A) The service area of the Exchange in which the individual resides, including without a fixed address; or

(B) The service area of the Exchange of a parent or caretaker, established in accordance with subdivision (e)(1) of this section, with whom the individual resides.

(3) For an individual who is not described in subdivisions (e)(1) or (2) of this section, the Exchange shall apply the residency requirements described in 42 CFR Section 435.403 with respect to the service area of the Exchange.

(4) Special rule for tax households with members in multiple Exchange service areas.

(A) Except as specified in subdivision (e)(4)(B) of this section, if all of the members of a tax household are not within the same Exchange service area, in accordance with the applicable standards in subdivisions (e)(1), (2), and (3) of this section, any member of the tax household may enroll in a QHP through any of the Exchanges for which one of the tax filers meets the residency standard.

(B) If both spouses in a tax household enroll in a QHP through the same Exchange, a tax dependent may choose to enroll in a QHP either through that Exchange or through the Exchange that services the area in which the dependent meets a residency standard described in subdivisions (e)(1), (2), or (3) of this section.

(5) The Exchange shall not deny or terminate an individual's eligibility for enrollment in a QHP through the Exchange if the individual meets the standards in subdivision (e)(1)-(4) of this section but for a temporary absence from the service area of the Exchange and intends to return when the purpose of the absence has been accomplished.

(f) The eligibility standards specified in this subdivision shall only apply to the eligibility determination for enrollment through the Exchange in a QHP that is a catastrophic plan, as defined in Section 1302(e) of the Affordable Care Act.

(1) The Exchange shall determine an applicant eligible for enrollment in a catastrophic QHP through the Exchange if the applicant:

(A) Has not attained the age of 30 before the beginning of the plan year; or

(B) Has a certification in effect for any plan year that the applicant is exempt from the requirement to maintain MEC under section 5000 A of IRC (26 USC § 5000A) by reason of:

1. Section 5000 A(e)(1) of IRC (26 USC § 5000A(e)(1)) relating to individuals without affordable coverage; or

2. Section 5000 A(e)(5) of IRC (26 USC § 5000A(e)(5)) relating to individuals with hardships.

(2) APTC shall not be available to support enrollment in a catastrophic QHP through the Exchange.

(g) The eligibility standards specified in this subdivision shall only apply to the eligibility determination for enrollment in a QDP through the Exchange. The Exchange shall determine an applicant eligible for enrollment in a QDP if the applicant meets both of the following requirements:

(1) At least one adult in the applicant's family who is enrolled in a non-catastrophic QHP through the Exchange is enrolled in the QDP. The family may continue enrollment in the QDP even if the adult later ceases enrollment in the non-catastrophic QHP through the Exchange.

(2) To enroll one child in a family in a QDP, all children in the family under 19 years of age shall also enroll in the same QDP.

Cal. Code Regs. Tit. 10, § 6472

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 42 CFR Section 435.403; and 45 CFR Section 155.305.

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; 42 CFR 435.403; and 45 CFR Section 155.305.

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 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 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 subsection (a) and new subsections (g)-(g)(2)) 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 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 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).
17. Amendment refiled 10-13-2023 as a deemed emergency pursuant to Government Code section 100504, including further amendment of subsections (b), (e)(1) and (e)(2)(A); operative 10/13/2023 (Register 2023, No. 41). A Certificate of Compliance must be transmitted to OAL by 10-7-2024 pursuant to Government Code section 100504(a)(6)or the language in the emergency order of 10-7-2019 will be repealed by operation of law on the following day.
18. Certificate of Compliance as to 10-13-2023 order, including amendment of NOTE, transmitted to OAL 6-11-2024 and filed 7-24-2024; amendments effective 7/24/2024 pursuant to Government Code section 11343.4(b)(3) (Register 2024, No. 30).