Statutes, codes, and regulations
California Code Of Regulations
Title 10 - InvestmentChapter 12 - California Health Benefit Exchange
Article 7 - Appeals Process for the Individual Exchange
Section 6618 - Appeal Decisions

Cal. Code Regs. tit. 10 § 6618

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Current through Register 2024 Notice Reg. No. 48, November 29, 2024
Section 6618 - Appeal Decisions
(a) Appeal decisions shall:
(1) Be based exclusively on the information and evidence specified in Section 6614(e) and the eligibility requirements under Article 5 of this chapter;
(2) State the decision, including a plain language description of the effect of the decision on the appellant's eligibility;
(3) Include a summary of the facts relevant to the appeal;
(4) Identify the legal basis, including the regulations that support the decision;
(5) State the effective date of the decision, if applicable; and
(6) Explain the appellant's right to pursue the appeal before the HHS appeals entity, including the applicable timeframe and instructions to file, if the appellant remains dissatisfied with the eligibility determination;
(7) Indicate that the decision of the Exchange appeals entity is final, unless the appellant pursues the appeal before the HHS appeals entity; and
(8) Provide information about judicial review available to the appellant pursuant to Section 1094.5 of the California Code of Civil Procedure.
(b) The appeals entity shall:
(1) Issue a written appeal decision to the appellant within 90 days of the date on which a valid appeal request is received;
(2) If an appeal request submitted under Section 6616 is determined by the appeals entity to meet the criteria for an expedited appeal, issue the appeal decision as expeditiously as possible, but no later than five business days after the hearing, unless the appellant agrees to delay to submit additional documents for the appeals record; and
(3) Provide the appeal decision and instructions to cease the appellant's pended eligibility, if applicable, via secure electronic interface, to the Exchange or the DHCS, as applicable.
(c) Upon receiving the appeal decision described in subdivision (b) of this section, the Exchange shall promptly, but no later than 30 days from the date of the appeal decision:
(1) Implement the appeal decision effective, at the option of the appellant:
(A) Prospectively, on the first day of the month following the date of the appeal decision or consistent with the effective dates specified in Section 6496(j) through (l) of Article 5 of this chapter, as applicable; or
(B) Retroactively, to the coverage effective date the appellant did receive or would have received if the appellant had enrolled in coverage under the incorrect eligibility determination that is the subject of the appeal.
(2) Redetermine the eligibility of household members who have not appealed their own eligibility determinations but whose eligibility may be affected by the appeal decision, in accordance with the standards specified in Section 6472 and 6474 of Article 5 of this chapter.

Cal. Code Regs. Tit. 10, § 6618

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 amendment of subsections (a)(5)-(6) and (b)(1)-(2), 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 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, including amendment of subsections (b)(1)-(c)(1)(B) and new subsection (c)(1)(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 (including amendment of subsection (c)(1)(B)) 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 2-16-2017 as an emergency pursuant to Government Code section 100504(a)(6), as modified by 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 amendment of subsection (c)(1)(A)-(B) and repealer of subsection (c)(1)(C), 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 transmitted to OAL 8-10-2018 and filed 9-24-2018 (Register 2018, No. 39).

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100503 and 100506, Government Code; and 45 CFR Section 155.545.

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 amendment of subsections (a)(5)-(6) and (b)(1)-(2), 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 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, including amendment of subsections (b)(1)-(c)(1)(B) and new subsection (c)(1)(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 (including amendment of subsection (c)(1)(B)) 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 2-16-2017 as an emergency pursuant to Government Code section 100504(a)(6), as modified by 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 amendment of subsection (c)(1)(A)-(B) and repealer of subsection (c)(1)(C), 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 transmitted to OAL 8-10-2018 and filed 9/24/2018 (Register 2018, No. 39).