Cal. Code Regs. tit. 10 § 6602

Current through Register 2024 Notice Reg. No. 44, November 1, 2024

Section 6602 - General Eligibility Appeals Requirements

(a) In accordance with Section 6510 of Article 5 and Section 6922 of Article 13, an applicant or enrollee shall have the right to appeal:

(1) An eligibility determination made in accordance with Article 5 of this chapter, including:

(A) An initial determination of eligibility, including the amount of APTC and level of CSR, made in accordance with the standards specified in Sections 6472 and 6474 of Article 5 of this chapter;

(B) A redetermination of eligibility, including the amount of APTC and level of CSR, made in accordance with Sections 6496 and 6498 of Article 5 of this chapter; and

(C) A determination of eligibility for an enrollment period, made in accordance with Section 6476(c) of Article 5 of this chapter;

(2) An eligibility determination or redetermination for the State financial assistance, including the amount of the State advance premium assistance subsidy, made in accordance with Title 25 (commencing with Section 100800) of the Government Code and Article 5 of this chapter.

(3) An eligibility determination or redetermination for a hardship or religious conscious exemption made in accordance with Article 13 of this chapter;

(4) The Exchange's failure to provide a timely eligibility determination in accordance with Section 6476(f) of Article 5 of this chapter or failure to provide timely notice of an eligibility determination or redetermination in accordance with Sections 6476(h), 6496(h)(2), or 6498(j)(2) of Article 5 of this chapter; and

(5) A denial of a request to vacate a dismissal made by the Exchange appeals entity in accordance with Section 6610(d)(2) to the HHS.

(b) The Exchange appeals entity shall conduct all eligibility appeals, including appeals of an eligibility determination for a hardship or religious conscious exemption made in accordance with Article 13 of this chapter.

(c) For purposes of this Article, an administrative law judge designated by the appeals entity shall determine, on a case-by-case basis:

(1) The validity of all appeal requests received by the Exchange, the appeals entity, or the counties; and

(2) Whether good cause exists, including, but not limited to, good cause for an untimely appeal request and continuance.

(d) An applicant or enrollee may request an appeal of any of the actions specified in subdivision (a) of this section to HHS upon exhaustion of the Exchange appeals process.

(e) During the appeal, an appellant may represent themselves, or be represented by an authorized representative, as provided in Section 6508 of Article 5 of this chapter, or by legal counsel, a relative, a friend, or another spokesperson.

(f) Appeals processes established under this Article shall comply with the accessibility and readability requirements specified in Section 6452 of Article 4 of this chapter.

(g) An appellant may seek judicial review to the extent it is available by law.

(h) When an appellant seeks review of an adverse MAGI Medi-Cal or CHIP determination made by the Exchange, the appeals entity shall transmit the eligibility determination and all information provided as part of the appeal via secure electronic interface, within three business days from the date the appeal request is received to DHCS, as applicable, unless the appeal request is for an expedited appeal, in which case, the appeals entity shall follow the procedure provided in Section 6616.

(i) For any eligibility appeal decisions issued by the appeals entity on or after January 1, 2024, the appellant may request, within 14 days of the date of the decision, an administrative review of the decision by the CMS Administrator, in accordance with the process specified in 45 CFR Section 155.505(g)(1) (April 27, 2023), hereby incorporated by reference.

(j) The appeals entity shall:

(1) Ensure all data exchanges in the appeals process comply with the federal and State privacy and security standards specified in 45 CFR Section 155.260, and the Information Practices Act of 1977 (Cal. Civ. Code, § 1798 et seq.) and are in an electronic format consistent with 45 CFR Section 155.270; and

(2) Comply with all data sharing requests made by HHS.

(k) The Exchange shall provide the appellant with the opportunity to review their entire eligibility file, including all papers, requests, documents, and relevant information in the Exchange's possession at any time from the date on which an appeal request is filed to the date on which the appeal decision is issued pursuant to Section 6618.

Cal. Code Regs. Tit. 10, § 6602

Note: Authority cited: Sections 100504, 100506.1 and 100506.3, Government Code. Reference: Sections 100503 and 100506, Government Code; and 45 CFR Sections 155.260, 155.270, 155.505, 155.510 and 155.605.

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100503 and 100506, Government Code; and 45 CFR Sections 155.260, 155.270, 155.505, 155.510 and 155.605.

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, with amendments, 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. Refiling of 6-30-2014 action on 9-30-2014, including amendment of subsection (i)(1), 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 subsections (a)(1)(A)-(B), new subsection (a)(1)(C) and amendment of subsections (a)(2) and (a)(4)) 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 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 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. New subsection (a)(2), subsection renumbering and amendment of newly designated subsection (a)(3) and subsection (b) 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. New subsection (a)(2), subsection renumbering and amendment of newly designated subsection (a)(3) and subsection (b) 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.
19. Amendment refiled 10-13-2023 as a deemed emergency pursuant to Government Code section 100504, including further amendment of subsection (e), new subsection (i) and subsection relettering; 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.
20. Certificate of Compliance as to 10-13-2023 order, including amendment of subsection (a) and 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).