Cal. Code Regs. Tit. 10, § 6492 - Inconsistencies
(a) Except as
otherwise specified in this Article, for an applicant for whom the Exchange
cannot verify information required to determine eligibility for enrollment in a
QHP, or for APTC and CSR, including when electronic data is required in
accordance with this section but data for individuals relevant to the
eligibility determination are not included in such data sources or when
electronic data from IRS, DHS, or SSA is required but it is not reasonably
expected that data sources will be available within one day of the initial
request to the data source, the Exchange:
(1)
Shall make a reasonable effort to identify and address the causes of such
inconsistency, including through typographical or other clerical errors, by
contacting the application filer to confirm the accuracy of the information
submitted by the application filer;
(2) If unable to resolve the inconsistency
through the process described in subdivision (a)(1) of this section, shall:
(A) Provide notice to the applicant regarding
the inconsistency; and
(B) Provide
the applicant with a period of 95 days from the date of the notice described in
subdivision (a)(2)(A) of this section to either present satisfactory
documentary evidence through the channels available for the submission of an
application, as described in Section
6470(j), except
by telephone, or otherwise resolve the inconsistency.
(3) May extend the period described in
subdivision (a)(2)(B) of this section for an applicant if the Exchange
determines on a case-by-case basis that the applicant has demonstrated that
they have made a good-faith effort to obtain the required documentation during
the period.
(4) During the periods
described in subdivisions (a)(1) and (a)(2)(B) of this section, shall:
(A) Proceed with all other elements of
eligibility determination using the applicant's attestation, and provide
eligibility for enrollment in a QHP if an applicant is otherwise
qualified;
(B) Ensure that APTC and
CSR are provided within this period on behalf of an applicant who is otherwise
qualified for such payments and reductions, as described in Section
6474, provided that the tax filer
attests to the Exchange that the tax filer understands that any APTC paid on
their behalf are subject to reconciliation; and
(C) Clear the inconsistencies for which the
Exchange receives satisfactory documentary evidence from the applicant or the
enrollee. For income inconsistencies, the Exchange shall clear the
inconsistency if the income shown on the documents provided by the applicant or
enrollee is within 10% of the applicant's or enrollee's attestation.
(5) If, after the period described
in subdivision (a)(2)(B) of this section, the Exchange remains unable to verify
the attestation, shall:
(A) Determine the
applicant's eligibility based on the information available from the data
sources specified in Sections
6478 through
6492, unless such applicant
qualifies for the exception provided under subdivision (b) of this section;
and
(B) Notify the applicant of
such determination in accordance with the notice requirements specified in
Section 6476(h),
including notice that the Exchange is unable to verify the
attestation.
(6) When
electronic data to support the verifications specified in Section
6478(d) or
Section 6480 is required but it is not
reasonably expected that data sources will be available within one day of the
initial request to the data source, the Exchange shall accept the applicant's
attestation regarding the factor of eligibility for which the unavailable data
source is relevant.
(7) The
Exchange shall extend the period described in subdivision (a)(2)(B) of this
section by a period of 60 days for an applicant with an income inconsistency
who is required to present satisfactory documentary evidence to verify
household income.
(b)
The Exchange shall provide an exception, on a case-by-case basis, to accept an
applicant's attestation as to the information which cannot otherwise be
verified and the applicant's explanation of circumstances as to why the
applicant does not have documentation if:
(1)
An applicant does not have documentation with which to resolve the
inconsistency through the process described in subdivision (a)(2) of this
section because such documentation does not exist or is not reasonably
available;
(2) The Exchange is
unable to otherwise resolve the inconsistency for the applicant; and
(3) The inconsistency is not related to
citizenship or immigration status.
(c) An applicant shall not be required to
provide information beyond the minimum necessary to support the eligibility and
enrollment processes of the Exchange, Medi-Cal, and CHIP.
Notes
2. New section, including amendment of subsection (a)(2)(B), 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 subsection (a)(5)(B) and repealer of subsection (a)(5)(C), 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 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 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 (a)(4)(B) and new subsection (a)(4)(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, including further amendment of section, 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, 100503 and 100504, Government Code; and 45 CFR Section 155.315.
2. New section, including amendment of subsection (a)(2)(B), 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 subsection (a)(5)(B) and repealer of subsection (a)(5)(C), 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.
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.
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 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 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 (a)(4)(B) and new subsection (a)(4)(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, including further amendment of section, transmitted to OAL 8-10-2018 and filed 9-24-2018; amendments effective
17. Amendment refiled 10-13-2023 as a deemed emergency pursuant to Government Code section 100504, including further amendment of subsections (a)(3) and (a)(4)(B) and new subsection (a)(7); operative
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.