Cal. Code Regs. Tit. 10, § 6506 - Termination of Coverage in a QHP
(a)
Enrollee-initiated terminations shall be conducted in accordance with the following
process:
(1) An enrollee may terminate their
coverage in a QHP through the Exchange, including as a result of the enrollee
obtaining other MEC, by notifying the Exchange or the QHP issuer.
(2) An enrollee may choose to remain enrolled in a
QHP at the time of plan selection if they become eligible for other MEC and the
enrollee does not request termination in accordance with subdivision (a)(1) of this
section. If the enrollee does not choose to remain enrolled in a QHP in such a
situation, the Exchange shall initiate termination of their enrollment in the QHP
upon completion of the redetermination process specified in Section
6496.
(3) An individual, including an enrollee's
authorized representative, shall be permitted to report the death of an enrollee to
the Exchange for purposes of initiating termination of the enrollee's coverage in
accordance with the following requirements:
(A)
The individual shall be at least 18 years old.
(B) If the individual reporting the death is the
application filer, the enrollee's authorized representative, or anyone in the
household of the deceased who was included in the initial application, they shall be
permitted to initiate termination of the deceased's coverage.
(C) If the individual reporting the death is not
the application filer, the enrollee's authorized representative, or anyone in the
household of the deceased who was included in the initial application, they shall
submit satisfactory documentation of death to the Exchange before they can initiate
termination of the deceased's coverage. Satisfactory documentation may include a
copy of a death certificate, obituary, medical record, power of attorney, proof of
executor, or proof of estate. The documentation or an attached cover note shall
provide the following information:
1. Full name of
the deceased;
2. Date of birth of the
deceased;
3. The Exchange application ID
or case number (if known) of the deceased;
4. Social Security Number (if known) of the
deceased; and
5. Contact information for
the person submitting the documentation, including full name, address, and phone
number.
(4) The
Exchange shall permit an enrollee to retroactively terminate or cancel their
coverage or enrollment in a QHP if the enrollee demonstrates to the Exchange that:
(A) They attempted to terminate their coverage or
enrollment in a QHP and experienced a technical error that did not allow the
enrollee to terminate their coverage or enrollment through the Exchange, and
requests retroactive termination within 60 days after the enrollee discovered the
technical error;
(B) Their enrollment in
a QHP through the Exchange was unintentional, inadvertent, or erroneous and was the
result of the error or misconduct of an officer, employee, or agent of the Exchange
or HHS, its instrumentalities, a QHP issuer, or a non-Exchange entity providing
enrollment assistance or conducting enrollment activities. Such enrollee must
request cancellation within 60 days of discovering the unintentional, inadvertent,
or erroneous enrollment. For purposes of this provision, misconduct, as determined
by the Exchange, includes the failure to comply with applicable standards under this
title, or other applicable Federal or State laws; or
(C) The enrollee was enrolled in a QHP without
their knowledge or consent by any third party, including third parties who have no
connection with the Exchange, and requests cancellation within 60 days of
discovering of the enrollment.
(b) The Exchange may initiate termination of an
enrollee's coverage in a QHP, and shall permit a QHP issuer to terminate such
coverage, provided that the issuer makes reasonable accommodations for all
individuals with disabilities (as defined by the Americans with Disabilities Act)
before terminating coverage for such individuals, under the following circumstances:
(1) The enrollee is no longer eligible for
coverage in a QHP through the Exchange;
(2) The enrollee fails to pay premiums for
coverage, as specified in subdivision (c) of this section, and:
(A) The three-month grace period required for
individuals receiving APTC specified in subdivision (c)(2) of this section has been
exhausted, as described in subdivision (c)(4) of this section; or
(B) Any other grace period required under the
State law not described in subdivision (b)(2)(A) of this section has been
exhausted;
(3) The enrollee's
coverage is rescinded by the QHP issuer because the enrollee has made a fraudulent
claim or an intentional misrepresentation of a material fact in connection with the
plan, in accordance with Section
1389.21
of the Health and Safety Code and Section
10384.17 of the
Insurance Code, after the QHP issuer demonstrates to the Exchange that the
rescission is appropriate due to the enrollee's fraudulent claim or intentional
misrepresentation of a material fact;
(4) The QHP terminates or is decertified as
described in 45 CFR Section
155.1080; or
(5) The enrollee changes from one QHP to another
during an annual open enrollment period or special enrollment period in accordance
with Sections 6502 and
6504.
(6) The enrollee was enrolled in a QHP without
their knowledge or consent by a third party, including by a third party with no
connection with the Exchange.
(7) Any
other reason for termination of coverage described in
45 CFR Section
147.106 (December 22, 2016), hereby incorporated
by reference.
(c) In the case
of termination of enrollee's coverage due to non-payment of premium, as specified in
subdivision (b)(2) of this section, a QHP issuer shall:
(1) Provide the enrollee, who is delinquent on
premium payment, with notice of such payment delinquency;
(2) Provide a grace period of three consecutive
months for an enrollee who, when first failing to timely pay premiums, is receiving
APTC;
(3) During the grace period
specified in subdivision (c)(2) of this section:
(A) Pay all appropriate claims for services
rendered to the enrollee during the first month of the grace period;
(B) Notify the Exchange and HHS of such
non-payment;
(C) Continue to collect
APTC on behalf of the enrollee from the IRS; and
(D) Comply with any other applicable State laws
and regulations relating to the grace period specified in subdivision (c)(2) of this
section; and
(4) If an
enrollee receiving APTC exhausts the three-month grace period specified in
subdivision (c)(2) of this section without paying all outstanding premiums:
(A) Terminate the enrollee's coverage on the
effective date described in subdivision (d)(6) of this section, provided that the
QHP issuer meets the notice requirements specified in subdivision (e)(1) and (2) of
this section; and
(B) Return APTC paid
on behalf of such enrollee for the second and third months of the grace
period.
(d) If an
enrollee's coverage in a QHP is terminated for any reason, the following effective
dates for termination of coverage shall apply.
(1)
For purposes of this subdivision, reasonable notice is defined as 14 days before the
requested effective date of termination.
(2) Changes in eligibility for APTC and CSR,
including terminations, shall adhere to the effective dates specified in
subdivisions (j) through (l) of Section
6496.
(3) In the case of a termination in accordance
with subdivision (a)(1) through (3) of this section, the last day of coverage shall
be:
(A) The termination date specified by the
enrollee, if the enrollee provides reasonable notice;
(B) Fourteen days after the termination is
requested by the enrollee, if the enrollee does not provide reasonable
notice;
(C) On a date on or after the
date on which the termination is requested by the enrollee if the enrollee's QHP
issuer agrees to effectuate termination in fewer than 14 days, and the enrollee
requests an earlier termination effective date;
(D) If the enrollee is newly eligible for
full-scope Medi-Cal or CHIP, the last day of the month during which the enrollee is
determined eligible for full-scope Medi-Cal or CHIP; or
(E) The retroactive termination date requested by
the enrollee, if specified by applicable State laws.
(4) In the case of a retroactive termination in
accordance with subdivision (a)(4) of this section, the following termination dates
apply:
(A) For a termination in accordance with
subdivision (a)(4)(A) of this section, the termination date shall be no sooner than
14 days after the date that the enrollee can demonstrate they contacted the Exchange
to terminate their coverage or enrollment through the Exchange, unless the QHP
issuer agrees to an earlier effective date as set forth in paragraph (d)(3)(C) of
this section.
(B) For a termination or
cancellation in accordance with subdivision (a)(4)(B) or (C) of this section, the
cancellation or termination date shall be the original coverage effective date or a
later date, as determined appropriate by the Exchange on a case-by-case basis, based
on the circumstances of the cancellation or termination.
(5) In the case of a termination in accordance
with subdivision (b)(1) of this section, the last day of QHP coverage shall be the
last day of eligibility, as described in Section
6496(k) unless the
individual requests an earlier termination effective date per subdivision (a) of
this section.
(6) In the case of a
termination in accordance with subdivision (b)(2)(A) of this section, the last day
of coverage shall be the last day of the first month of the three-month grace
period.
(7) In the case of a termination
in accordance with subdivision (b)(2)(B) of this section, the last day of coverage
shall be consistent with existing California laws regarding grace periods.
(8) In the case of a termination in accordance
with subdivision (b)(5) of this section, the last day of coverage in an enrollee's
prior QHP shall be the day before the effective date of coverage in their new QHP,
including any retroactive enrollments effectuated under Section
6504(h)(4) when an
enrollee is granted a special enrollment period to change QHPs with a retroactive
coverage effective date.
(9) In the case
of a cancellation of enrollment in accordance with subdivision (b)(6) of this
section, the Exchange may cancel the enrollee's enrollment upon its determination
that the enrollment was performed without the enrollee's knowledge or consent. The
cancellation date shall be the original coverage effective date.
(10) In the case of a termination due to the
enrollee's death, the last day of coverage is the date of death.
(11) In cases of retroactive termination dates,
the Exchange shall ensure that:
(A) The enrollee
receives the APTC and CSR for which they are determined eligible;
(B) The enrollee is refunded any premiums owed to
the enrollee by the QHP issuer after the retroactive termination date;
(C) If the enrollee enrolls in a new QHP:
1. The enrollee's premium and cost sharing are
adjusted to reflect the enrollee's obligations under the new QHP; and
2. Consistent with
45 CFR Section
156.425(b) (February 27, 2015),
hereby incorporated by reference, in the case of a change in the level of CSR (or a
QHP without CSR) under the same QHP issuer during a benefit year, any cost sharing
paid by the enrollee under the previous level of CSR (or a QHP without CSR) for that
benefit year is taken into account in the new level of CSR for purposes of
calculating cost sharing based on aggregate spending by the individual, such as for
deductibles or for the annual limitations on cost
sharing.
(e) If an enrollee's coverage in a QHP is
terminated in accordance with subdivision (a)(1) or (b)(2) and (3) of this section,
the QHP issuer shall:
(1) Provide the enrollee,
within five business days from the date of the termination, with a written notice of
termination of coverage that includes:
(A) The
termination effective date;
(B) The
reason for termination; and
(C) The
notice of appeals right, in accordance with the requirements specified in Section
6604 of Article 7 of this
chapter.
(2) Notify the
Exchange of the termination effective date and reason for termination;
(3) Abide by the termination of coverage effective
dates described in subdivision (d) of this section; and
(4) Maintain electronic records of termination of
coverage, including audit trails and reason codes for termination, for a minimum of
ten years.
(f) If an
enrollee's coverage in a QHP is terminated for any reason other than terminations
pursuant to subdivision (b)(2) and (3) of this section, the Exchange shall:
(1) Send termination information to the QHP issuer
within three business days from the date of the termination;
(2) Send termination information to HHS promptly
and without undue delay, in the manner and timeframe specified by HHS; and
(3) Retain records of termination of coverage for
a minimum of ten years in order to facilitate audit functions.
Notes
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; Section 1389.21, Health and Safety Code; Section 10384.17, Insurance Code; and 45 CFR Sections 147.106, 147.128, 155.430, 155.1080, 156.270 and 156.425.
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; and 45 CFR Sections 147.106, 147.128, 155.430, 155.1080, 156.270 and 156.425.
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, including amendments, 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. Refiling of 6-30-2014 action on 9-30-2014, including further amendments, 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. Refiling of 9-30-2014 action on 12-12-2014, including further amendments, 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, including amendment of subsections (f) and (f)(3), 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 (d)(2) and (f), 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 with amendments 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 (including amendment of subsections (d)(3)(C)-(D)) and (d)(11)(C)) 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 (including subsequent amendments and amendment of subsection (b)(3)) 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
17. Amendment of subsections (a)(1), (b)(3) and (d)(11)(B) and new subsections (d)(11)(C)-(d)(11)(C)2. filed 10-7-2019 as a deemed emergency pursuant to Government Code section 100504; operative
18. Amendment of subsections (a)(1), (b)(3) and (d)(11)(B) and new subsections (d)(11)(C)-(d)(11)(C)2. refiled 9-9-2022 as a deemed emergency pursuant to Government Code section 100504; operative
19. Amendment refiled 10-13-2023 as a deemed emergency pursuant to Government Code section 100504, including further amendment of section; operative
20. Certificate of Compliance as to 10-13-2023 order, including amendment of subsection (d)(4)(B) and NOTE, transmitted to OAL 6-11-2024 and filed 7-24-2024; amendments effective
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.
(a) Enrollee-initiated terminations shall be conducted in accordance with the following process:
(1) An enrollee may terminate their coverage in a QHP through the Exchange, including as a result of the enrollee obtaining other MEC, by notifying the Exchange or the QHP issuer.
(2) An enrollee may choose to remain enrolled in a QHP at the time of plan selection if they become eligible for other MEC and the enrollee does not request termination in accordance with subdivision (a)(1) of this section. If the enrollee does not choose to remain enrolled in a QHP in such a situation, the Exchange shall initiate termination of their enrollment in the QHP upon completion of the redetermination process specified in Section 6496.
(3) An individual, including an enrollee's authorized representative, shall be permitted to report the death of an enrollee to the Exchange for purposes of initiating termination of the enrollee's coverage in accordance with the following requirements:
(A) The individual shall be at least 18 years old.
(B) If the individual reporting the death is the application filer, the enrollee's authorized representative, or anyone in the household of the deceased who was included in the initial application, they shall be permitted to initiate termination of the deceased's coverage.
(C) If the individual reporting the death is not the application filer, the enrollee's authorized representative, or anyone in the household of the deceased who was included in the initial application, they shall submit satisfactory documentation of death to the Exchange before they can initiate termination of the deceased's coverage. Satisfactory documentation may include a copy of a death certificate, obituary, medical record, power of attorney, proof of executor, or proof of estate. The documentation or an attached cover note shall provide the following information:
1. Full name of the deceased;
2. Date of birth of the deceased;
3. The Exchange application ID or case number (if known) of the deceased;
4. Social Security Number (if known) of the deceased; and
5. Contact information for the person submitting the documentation, including full name, address, and phone number.
(4) The Exchange shall permit an enrollee to retroactively terminate or cancel their coverage or enrollment in a QHP if the enrollee demonstrates to the Exchange that:
(A) They attempted to terminate their coverage or enrollment in a QHP and experienced a technical error that did not allow the enrollee to terminate their coverage or enrollment through the Exchange, and requests retroactive termination within 60 days after the enrollee discovered the technical error;
(B) Their enrollment in a QHP through the Exchange was unintentional, inadvertent, or erroneous and was the result of the error or misconduct of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, a QHP issuer, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities. Such enrollee must request cancellation within 60 days of discovering the unintentional, inadvertent, or erroneous enrollment. For purposes of this provision, misconduct, as determined by the Exchange, includes the failure to comply with applicable standards under this title, or other applicable Federal or State laws; or
(C) The enrollee was enrolled in a QHP without their knowledge or consent by any third party, including third parties who have no connection with the Exchange, and requests cancellation within 60 days of discovering of the enrollment.
(b) The Exchange may initiate termination of an enrollee's coverage in a QHP, and shall permit a QHP issuer to terminate such coverage, provided that the issuer makes reasonable accommodations for all individuals with disabilities (as defined by the Americans with Disabilities Act) before terminating coverage for such individuals, under the following circumstances:
(1) The enrollee is no longer eligible for coverage in a QHP through the Exchange;
(2) The enrollee fails to pay premiums for coverage, as specified in subdivision (c) of this section, and:
(A) The three-month grace period required for individuals receiving APTC specified in subdivision (c)(2) of this section has been exhausted, as described in subdivision (c)(4) of this section; or
(B) Any other grace period required under the State law not described in subdivision (b)(2)(A) of this section has been exhausted;
(3) The enrollee's coverage is rescinded by the QHP issuer because the enrollee has made a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan, in accordance with Section 1389.21 of the Health and Safety Code and Section 10384.17 of the Insurance Code, after the QHP issuer demonstrates to the Exchange that the rescission is appropriate due to the enrollee's fraudulent claim or intentional misrepresentation of a material fact;
(4) The QHP terminates or is decertified as described in 45 CFR Section 155.1080; or
(5) The enrollee changes from one QHP to another during an annual open enrollment period or special enrollment period in accordance with Sections 6502 and 6504.
(6) The enrollee was enrolled in a QHP without their knowledge or consent by a third party, including by a third party with no connection with the Exchange.
(7) Any other reason for termination of coverage described in 45 CFR Section 147.106 (December 22, 2016), hereby incorporated by reference.
(c) In the case of termination of enrollee's coverage due to non-payment of premium, as specified in subdivision (b)(2) of this section, a QHP issuer shall:
(1) Provide the enrollee, who is delinquent on premium payment, with notice of such payment delinquency;
(2) Provide a grace period of three consecutive months for an enrollee who, when first failing to timely pay premiums, is receiving APTC;
(3) During the grace period specified in subdivision (c)(2) of this section:
(A) Pay all appropriate claims for services rendered to the enrollee during the first month of the grace period;
(B) Notify the Exchange and HHS of such non-payment;
(C) Continue to collect APTC on behalf of the enrollee from the IRS; and
(D) Comply with any other applicable State laws and regulations relating to the grace period specified in subdivision (c)(2) of this section; and
(4) If an enrollee receiving APTC exhausts the three-month grace period specified in subdivision (c)(2) of this section without paying all outstanding premiums:
(A) Terminate the enrollee's coverage on the effective date described in subdivision (d)(6) of this section, provided that the QHP issuer meets the notice requirements specified in subdivision (e)(1) and (2) of this section; and
(B) Return APTC paid on behalf of such enrollee for the second and third months of the grace period.
(d) If an enrollee's coverage in a QHP is terminated for any reason, the following effective dates for termination of coverage shall apply.
(1) For purposes of this subdivision, reasonable notice is defined as 14 days before the requested effective date of termination.
(2) Changes in eligibility for APTC and CSR, including terminations, shall adhere to the effective dates specified in subdivisions (j) through (l) of Section 6496.
(3) In the case of a termination in accordance with subdivision (a)(1) through (3) of this section, the last day of coverage shall be:
(A) The termination date specified by the enrollee, if the enrollee provides reasonable notice;
(B) Fourteen days after the termination is requested by the enrollee, if the enrollee does not provide reasonable notice;
(C) On a date on or after the date on which the termination is requested by the enrollee if the enrollee's QHP issuer agrees to effectuate termination in fewer than 14 days, and the enrollee requests an earlier termination effective date;
(D) If the enrollee is newly eligible for full-scope Medi-Cal or CHIP, the last day of the month during which the enrollee is determined eligible for full-scope Medi-Cal or CHIP; or
(E) The retroactive termination date requested by the enrollee, if specified by applicable State laws.
(4) In the case of a retroactive termination in accordance with subdivision (a)(4) of this section, the following termination dates apply:
(A) For a termination in accordance with subdivision (a)(4)(A) of this section, the termination date shall be no sooner than 14 days after the date that the enrollee can demonstrate they contacted the Exchange to terminate their coverage or enrollment through the Exchange, unless the QHP issuer agrees to an earlier effective date as set forth in paragraph (d)(3)(C) of this section.
(B) For a termination or cancellation in accordance with subdivision (a)(4)(B) or (C) of this section, the cancellation or termination date shall be the original coverage effective date or a later date, as determined appropriate by the Exchange on a case by case basis, based on the circumstances of the cancellation or termination.
(5) In the case of a termination in accordance with subdivision (b)(1) of this section, the last day of QHP coverage shall be the last day of eligibility, as described in Section 6496(k) unless the individual requests an earlier termination effective date per subdivision (a) of this section.
(6) In the case of a termination in accordance with subdivision (b)(2)(A) of this section, the last day of coverage shall be the last day of the first month of the three-month grace period.
(7) In the case of a termination in accordance with subdivision (b)(2)(B) of this section, the last day of coverage shall be consistent with existing California laws regarding grace periods.
(8) In the case of a termination in accordance with subdivision (b)(5) of this section, the last day of coverage in an enrollee's prior QHP shall be the day before the effective date of coverage in their new QHP, including any retroactive enrollments effectuated under Section 6504(h)(4) when an enrollee is granted a special enrollment period to change QHPs with a retroactive coverage effective date.
(9) In the case of a cancellation of enrollment in accordance with subdivision (b)(6) of this section, the Exchange may cancel the enrollee's enrollment upon its determination that the enrollment was performed without the enrollee's knowledge or consent. The cancellation date shall be the original coverage effective date.
(10) In the case of a termination due to the enrollee's death, the last day of coverage is the date of death.
(11) In cases of retroactive termination dates, the Exchange shall ensure that:
(A) The enrollee receives the APTC and CSR for which they are determined eligible;
(B) The enrollee is refunded any premiums owed to the enrollee by the QHP issuer after the retroactive termination date;
(C) If the enrollee enrolls in a new QHP:
1. The enrollee's premium and cost sharing are adjusted to reflect the enrollee's obligations under the new QHP; and
2. Consistent with 45 CFR Section 156.425(b) (February 27, 2015), hereby incorporated by reference, in the case of a change in the level of CSR (or a QHP without CSR) under the same QHP issuer during a benefit year, any cost sharing paid by the enrollee under the previous level of CSR (or a QHP without CSR) for that benefit year is taken into account in the new level of CSR for purposes of calculating cost sharing based on aggregate spending by the individual, such as for deductibles or for the annual limitations on cost sharing.
(e) If an enrollee's coverage in a QHP is terminated in accordance with subdivision (a)(1) or (b)(2) and (3) of this section, the QHP issuer shall:
(1) Provide the enrollee, within five business days from the date of the termination, with a written notice of termination of coverage that includes:
(A) The termination effective date;
(B) The reason for termination; and
(C) The notice of appeals right, in accordance with the requirements specified in Section 6604 of Article 7 of this chapter.
(2) Notify the Exchange of the termination effective date and reason for termination;
(3) Abide by the termination of coverage effective dates described in subdivision (d) of this section; and
(4) Maintain electronic records of termination of coverage, including audit trails and reason codes for termination, for a minimum of ten years.
(f) If an enrollee's coverage in a QHP is terminated for any reason other than terminations pursuant to subdivision (b)(2) and (3) of this section, the Exchange shall:
(1) Send termination information to the QHP issuer within three business days from the date of the termination;
(2) Send termination information to HHS promptly and without undue delay, in the manner and timeframe specified by HHS; and
(3) Retain records of termination of coverage for a minimum of ten years in order to facilitate audit functions.
Notes
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, including amendments, 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. Refiling of 6-30-2014 action on 9-30-2014, including further amendments, 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. Refiling of 9-30-2014 action on 12-12-2014, including further amendments, 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, including amendment of subsections (f) and (f)(3), 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 (d)(2) and (f), 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 with amendments 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 (including amendment of subsections (d)(3)(C)-(D)) and (d)(11)(C)) 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 (including subsequent amendments and amendment of subsection (b)(3)) 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 of subsections (a)(1), (b)(3) and (d)(11)(B) and new subsections (d)(11)(C)-(d)(11)(C)2. filed 10-7-2019 as a deemed emergency pursuant to Government Code section 100504; operative 10-7-2019 (Register 2019, No. 41). A Certificate of Compliance must be transmitted to OAL by 10-7-2024 pursuant to Government Code section 100504 or emergency language will be repealed by operation of law on the following day.
18. Amendment of subsections (a)(1), (b)(3) and (d)(11)(B) and new subsections (d)(11)(C)-(d)(11)(C)2. refiled 9-9-2022 as a deemed emergency pursuant to Government Code section 100504; operative 9-9-2022 (Register 2022, No. 36). 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.
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; and 45 CFR Sections 147.106, 147.128, 155.430, 155.1080, 156.270 and 156.425.
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, including amendments, 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. Refiling of 6-30-2014 action on 9-30-2014, including further amendments, 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. Refiling of 9-30-2014 action on 12-12-2014, including further amendments, 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, including amendment of subsections (f) and (f)(3), 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 (d)(2) and (f), 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 with amendments 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 (including amendment of subsections (d)(3)(C)-(D)) and (d)(11)(C)) 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 (including subsequent amendments and amendment of subsection (b)(3)) 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
17. Amendment of subsections (a)(1), (b)(3) and (d)(11)(B) and new subsections (d)(11)(C)-(d)(11)(C)2. filed 10-7-2019 as a deemed emergency pursuant to Government Code section 100504; operative
18. Amendment of subsections (a)(1), (b)(3) and (d)(11)(B) and new subsections (d)(11)(C)-(d)(11)(C)2. refiled 9-9-2022 as a deemed emergency pursuant to Government Code section 100504; operative
19. Amendment refiled 10-13-2023 as a deemed emergency pursuant to Government Code section 100504, including further amendment of section; operative