Cal. Code Regs. Tit. 10, § 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.
Notes
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.
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.
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
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
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