text: The board shall ensure that the Internet Web site maintained under subdivision (c) of Section 100502 provides a direct link to the formulary, or formularies, for each qualified health plan offered through the Exchange that is posted by the carrier pursuant to Section 1367.205 of the Health and Safety Code or Section 10123.192 of the Insurance Code.

history: (History: Added by Stats. 2014, Ch. 575, Sec. 1. (SB 1052) Effective January 1, 2015.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


kind: section

code: GOV

text: The board shall use the information received pursuant to Section 12712.5 of the Insurance Code to provide an individual a notice that he or she may be eligible for reduced-cost coverage through the Exchange or no-cost coverage through Medi-Cal. The notice shall include information on obtaining coverage pursuant to those programs.

history: (History: Added by Stats. 2013, Ch. 442, Sec. 1. (SB 28) Effective January 1, 2014.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE

path: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) The Exchange, in consultation with stakeholders and the Legislature, shall develop options for providing financial assistance to help low- and middle-income Californians access health care coverage. On or before February 1, 2019, the Exchange shall report those developed options to the Legislature, Governor, and Council on Health Care Delivery Systems, established pursuant to Section 1001 of the Health and Safety Code, for consideration in the 2019–20 budget process.

(b) In developing the options, the Exchange shall do both of the following:

(1) Include options to assist low-income individuals who are paying a significant percentage of their income on premiums, even with federal financial assistance, and individuals with an annual income of up to 600 percent of the federal poverty level.

(2) Consider maximizing all available federal funding and, in consultation with the State Department of Health Care Services, determine whether federal financial participation for the Medi-Cal program would otherwise be jeopardized. The report shall include options that do not require a federal waiver authorized under Section 1332 of the federal act, as defined in subdivision (e) of Section 100501, from the United States Department of Health and Human Services.

(c) The Exchange shall make the report publicly available on its Internet Web site.

history: (History: Added by Stats. 2018, Ch. 34, Sec. 2. (AB 1810) Effective June 27, 2018.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) Upon receipt of an individual’s electronic account pursuant to subdivision (h) of Section 15926 of the Welfare and Institutions Code from the insurance affordability program coverage, as specified in subparagraphs (A) and (B) of paragraph (3) of subdivision (a) of Section 15926 of the Welfare and Institutions Code, the Exchange shall use the available information to enroll the individual or individuals in the lowest cost silver plan available, unless the Exchange has information from the county, State Department of Health Care Services, managed care plan, or another plan as determined by the Exchange that enables the Exchange to enroll the individual with the individual’s previous managed care plan within the timeframe required by subdivision (b).

(b) Plan enrollment shall occur before the termination date of coverage through the insurance affordability program.

(c) The plan’s premium due date shall be no sooner than the last day of the first month of enrollment.

(d) The Exchange shall provide an individual who is enrolled in a plan pursuant to this section with a notice that includes the following information:

(1) The plan in which the individual is enrolled.

(2) The individual’s right to select another available plan and any relevant deadlines for that selection.

(3) How to receive assistance to select a plan.

(4) The individual’s right not to enroll in the plan.

(5) Information for an individual appealing their previous coverage through an insurance affordability program.

(6) A statement that services received during the first month of enrollment will only be covered by the plan if the premium is paid by the due date.

(e) This section shall be implemented no later than July 1, 2021.

history: (History: Added by Stats. 2019, Ch. 845, Sec. 1. (SB 260) Effective January 1, 2020.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) The Exchange shall provide payments equaling the cost of providing coverage of services described in Section 18023(b)(1)(B)(i) of Title 42 of the United States Code to individuals enrolled in a qualified health plan through the Exchange in the individual market. The payments shall not be less than one dollar ($1) per enrollee per month.

(b) The Exchange shall make the payments required under subdivision (a) directly to the qualified health plan issuers on behalf of the enrollees.

(c) The payments required under subdivision (a) shall be made upon appropriation by the Legislature. The payments shall not be made from the California Health Trust Fund established by Section 100520.

(d) Subject to appropriation, the payments shall be made for months beginning on or after January 1, 2022.

(e) For purposes of this section, “qualified health plan” does not include a qualified dental plan offered through the Exchange.

(f) This section does not create an entitlement program of any kind, appropriate any funds, require the Legislature to appropriate any funds, or increase or decrease taxes owed by a taxpayer.

history: (History: Added by Stats. 2021, Ch. 143, Sec. 10. (AB 133) Effective July 27, 2021.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) If a qualified health plan is required to cover state-mandated gender-affirming care benefits determined to be in addition to essential health benefits pursuant to Section 18031(d)(3)(B) of Title 42 of the United States Code, the Exchange shall provide payments to issuers of qualified health plans offered through the Exchange to defray the costs of offering those benefits to qualified health plan enrollees.

(b) In accordance with Section 155.170 of Title 45 of the Code of Federal Regulations, the payments required by subdivision (a) shall equal the cost of the additional required benefits reported to the Exchange.

(c) The payments required under subdivision (a) shall only be made upon appropriation by the Legislature. The payments shall not be made from the California Health Trust Fund established by Section 100520.

(d) Subject to an appropriation by the Legislature, the payments shall be made for plan years beginning on or after January 1, 2026.

(e) This section does not create an entitlement program of any kind, appropriate any funds, require the Legislature to appropriate any funds, or increase or decrease taxes owed by a taxpayer.

(f) The Director of the Department of Managed Health Care may issue guidance regarding gender-affirming care benefits subject to this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).

history: (History: Added by Stats. 2025, Ch. 105, Sec. 11. (AB 144) Effective September 17, 2025.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) (1) If the board requires, or has previously required in its contracts with qualified health plans, a qualified health plan to report on cost reduction efforts, quality improvements, or disparity reductions, the board shall make public on the internet website of the Exchange plan-specific data on cost reduction efforts, quality improvements, and disparity reductions.

(2) Data and information posted on the internet website of the Exchange pursuant to paragraph (1) shall be posted in a way that demonstrates the compliance and performance of a qualified health plan with respect to cost reduction efforts, quality improvement, or disparity reduction reporting, but protects the personal information of an enrollee. Comparison among qualified health plans shall contribute to the understanding of the data and progress in achieving goals established by the Exchange through qualified health plan contracts.

(3) The board shall post information on the internet website of the Exchange pursuant to paragraphs (1) and (2) no less than annually.

(b) (1) A qualified health plan shall provide data on enrollees to the Exchange in a form, manner, and frequency specified by the Exchange.

(2) Data and information made public by the Exchange shall be disclosed in a manner that protects the personal information of an enrollee, pursuant to state and federal privacy laws, including the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191).

(3) Records that reveal contracted rates paid by qualified health plans to providers and enrollee coinsurance that can be used to determine contracted rates paid by plans to providers shall not be subject to public disclosure.

(c) (1) A qualified health plan shall provide to the Exchange information that the board identifies as necessary to conduct its duties or exercise its oversight powers.

(2) The information shall be furnished in the form, manner, and frequency specified by the Exchange.

(d) (1) A qualified health plan shall provide enrollee data and other information on quality measures, including contract compliance with measures that affect individual and population health, as well as improvements in care coordination and patient safety, in a manner that allows for an analysis by demographic subpopulations.

(2) A qualified health plan shall provide enrollee data, encounter data, and other information on quality measures, performance improvement strategies, payment methods, and other information necessary to monitor adherence to contract provisions designed to improve health equity and reduce health disparities on an individual and population health basis.

(3) A qualified health plan shall also provide financial data and information, including cost detail, claims data, encounter data, and payment methods to evaluate cost and utilization experience for enrollees. Enrollment data and information shall include demographic, coverage, premium, product, network, and benefit design detail for each enrollee.

(e) A health care service plan or health insurer contracted with the Exchange to offer a qualified health plan shall disclose to the board the following information:

(1) Nongrandfathered individual market products, whether offered through the Exchange or otherwise.

(2) Nongrandfathered small group products, whether offered through the Exchange or otherwise.

(f) A health care service plan or health insurer contracted with the Exchange to offer a qualified health plan shall also disclose to the board, at the request of the board, quality and disparity data and information for all of the enrollees and insureds of the carrier in the individual and small group markets, but not including large group, Medi-Cal, or Medicare.

(g) In order to permit the Exchange to implement the provisions of subdivision (c) of Section 100503 and Section 2 of Chapter 655 of the Statutes of 2010, a health care service plan or health insurer contracted with the Exchange to offer a qualified health plan shall also disclose to the board data and information required by this section for each of the plan years in which the qualified health plan is or has been contracted with the Exchange, including prior years.

(h) For purposes of this section:

(1) “Disparity reduction” means a reduction in variation in disease occurrence, including communicable diseases and chronic conditions, as well as health outcomes between population groups by age, geographic area, primary language, race, ethnicity, sex, gender identity, sexual orientation, and disability status.

(2) “Financial data and information” means cost detail, including enrollee cost sharing, allowed amounts, fee schedules, and fee-for-service equivalent amounts.

(3) “Personal information” has the same meaning as set forth in Section 1798.3 of the Civil Code.

history: (History: Added by Stats. 2019, Ch. 812, Sec. 2. (AB 929) Effective January 1, 2020.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text: The board shall engage in health oversight activities relating to Exchange operations, including, but not limited to, audits, investigations, inspections, evaluations, analyses, data collection through routine reporting, and any other activities for oversight of the Exchange, including qualified health plan contracts with health care service plans and health insurers. In performing those duties, the board may exercise its authority directly or through its designees, and shall be acting as a health oversight agency, as defined in Section 164.501 of Title 45 of the Code of Federal Regulations.

history: (History: Added by Stats. 2019, Ch. 812, Sec. 3. (AB 929) Effective January 1, 2020.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) (1) Beginning no later than September 1, 2023, and at least monthly thereafter, subject to the restrictions in paragraph (5) of subdivision (b), the Exchange shall request from the Employment Development Department the following information of each new applicant for unemployment compensation, state disability, and paid family leave:

(A) Last name.

(B) First name.

(C) Middle initial.

(D) Social security number.

(E) Date of birth.

(F) Race or ethnicity, to the extent available.

(G) Preferred language.

(H) Gender.

(I) All mailing addresses, including city, state, and ZIP Code.

(J) All telephone numbers, including home, work, and cellular.

(K) Email address, to the extent available.

(L) Date of most recent job loss, to the extent available.

(M) Wages or prior wages.

(N) The Employment Development Department program for which the applicant filed.

(O) Date the claim was filed.

(P) Claimant eligibility status.

(Q) Date initial payment was approved by the Employment Development Department.

(R) The weekly benefit amount.

(S) The benefit period start date.

(T) The benefit period end date.

(2) The Employment Development Department shall provide the information pursuant to paragraph (1) in a manner prescribed by the Exchange.

(3) The Employment Development Department may provide the information pursuant to paragraph (1) more frequently than monthly during periods of high unemployment.

(b) (1) Consistent with subdivision (k) of Section 100503, the Exchange shall market and publicize the availability of health care coverage through the Exchange, and shall engage in outreach activities, to the individuals whose information the Exchange receives pursuant to subdivision (a).

(2) The Exchange may use any contact method that is intended to reach the person at their residence or other personal contact channel to communicate with and inform an individual whose information the Exchange receives pursuant to subdivision (a) of available health care coverage options through the exchange and to assist those individuals in obtaining health care coverage.

(3) (A) The Exchange may disclose information obtained from the Employment Development Department to outreach and marketing vendors under contract to the Exchange.

(B) The Exchange shall not disclose information obtained from the Employment Development Department to a certified insurance agent, a certified enrollment counselor, or any other entity without the consent of the applicant, except as provided in subparagraph (A).

(4) Any outreach and marketing conducted pursuant to this section shall include, in a conspicuous and easy to access manner, the ability for individuals to decline all future outreach and marketing.

(5) The Exchange shall take all necessary measures to safeguard the confidentiality of any information obtained from the Employment Development Department and shall at no time use or disclose that information for any purpose other than to market and publicize the availability of health care coverage through the Exchange to individuals whose information the Exchange receives pursuant to paragraph (1) of subdivision (a). The Exchange shall at all times only request from the Employment Development Department, use, or disclose the minimum amount of information necessary to accomplish the purposes for which it was obtained.

(6) A person or entity that receives information from the Exchange pursuant to this section shall take all necessary measures to safeguard the confidentiality of any information obtained from the Exchange and shall at no time use or disclose that information for any purpose other than to market and publicize the availability of health care coverage through the Exchange to individuals, as directed by the Exchange. A person or entity shall at all times only request from the Exchange, use, or disclose the minimum amount of information necessary to accomplish the purposes for which it was received.

(7) Information received by the Exchange from the Employment Development Department shall both:

(A) At all times be subject to applicable privacy and information security-related requirements arising under both federal and state law.

(B) Be destroyed in a manner that maintains confidentiality.

(8) The Exchange shall ensure that information disclosed to outreach and marketing vendors or any other entity pursuant to this section shall comply with paragraph (7).

history: (History: Amended by Stats. 2023, Ch. 492, Sec. 1. (SB 595) Effective January 1, 2024.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) The board may do the following:

(1) With respect to individual coverage made available in the Exchange, collect premiums and assist in the administration of subsidies.

(2) Enter into contracts.

(3) Sue and be sued.

(4) Receive and accept gifts, grants, or donations of moneys from an agency of the United States, an agency of the state, and a municipality, county, or other political subdivision of the state.

(5) Receive and accept gifts, grants, or donations from individuals, associations, private foundations, and corporations, in compliance with the conflict of interest provisions to be adopted by the board at a public meeting.

(6) (A) Adopt rules and regulations, as necessary. Until January 1, 2030, necessary rules and regulations, except those implementing Section 1043, may be adopted as emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2). The adoption of emergency regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2, including subdivisions (e) and (h) of Section 11346.1, an emergency regulation adopted pursuant to this section shall be repealed by operation of law unless the adoption, amendment, or repeal of the regulation is promulgated by the board pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 within five years of the initial adoption of the emergency regulation. A rule or regulation adopted pursuant to this section shall be discussed by the board during at least one properly noticed board meeting before the board meeting at which the board adopts the rule or regulation. Notwithstanding subdivision (h) of Section 11346.1, until January 1, 2035, the Office of Administrative Law may approve more than two readoptions of an emergency regulation adopted pursuant to this section.

(B) The amendments made to this paragraph by the act that added this subparagraph also shall apply to a regulation adopted pursuant to this section before January 1, 2025.

(7) Collaborate with the State Department of Health Care Services and the Managed Risk Medical Insurance Board, to the extent possible, to allow an individual the option to remain enrolled with the individual’s carrier and provider network if the individual experiences a loss of eligibility of premium tax credits and becomes eligible for the Medi-Cal program, or loses eligibility for the Medi-Cal program and becomes eligible for premium tax credits through the Exchange.

(8) Share information with relevant state departments, consistent with the confidentiality provisions in Section 1411 of the federal act, necessary for the administration of the Exchange.

(9) Require carriers participating in the Exchange to make available to the Exchange and regularly update an electronic directory of contracting health care providers so that individuals seeking coverage through the Exchange can search by health care provider name to determine which health plans in the Exchange include that health care provider in their network. The board may also require a carrier to provide regularly updated information to the Exchange as to whether a health care provider is accepting new patients for a particular health plan. The Exchange may provide an integrated and uniform consumer directory of health care providers indicating which carriers the providers contract with and whether the providers are currently accepting new patients. The Exchange may also establish methods by which health care providers may transmit relevant information directly to the Exchange, rather than through a carrier.

(10) Make available supplemental coverage for enrollees of the Exchange to the extent permitted by the federal act, provided that General Fund money is not used to pay the cost of that coverage. Supplemental coverage offered in the Exchange shall be subject to the charge imposed under subdivision (n) of Section 100503.

(b) The Exchange shall only collect information from individuals or designees of individuals necessary to administer the Exchange and consistent with the federal act.

(c) (1) The board shall have the authority to standardize products to be offered through the Exchange. A product standardized by the board pursuant to this subdivision shall be discussed by the board during at least one properly noticed board meeting before the board meeting at which the board adopts the standardized products to be offered through the Exchange.

(2) The adoption, amendment, or repeal of a regulation by the board to implement this subdivision is exempt from the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).

history: (History: Amended by Stats. 2024, Ch. 236, Sec. 1. (AB 2435) Effective January 1, 2025.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) To the extent approved by the appropriate federal agency, for the purpose of implementing the option in paragraph (7) of subdivision (a) of Section 100504, the Exchange shall make available bridge plan products to individuals specified in Section 14005.70 of the Welfare and Institutions Code. In implementing this requirement, the Exchange, using the selective contracting authority described in subdivision (c) of Section 100503, shall contract with, and certify as a qualified health plan, a bridge plan product that is, at a minimum, certified by the Exchange as a qualified bridge plan product. For purposes of this section, in order to be a qualified bridge plan product, the plan shall do all of the following:

(1) Be a health care service plan or health insurer that contracts with the State Department of Health Care Services to provide Medi-Cal managed care plan services pursuant to Section 14005.70 of the Welfare and Institutions Code.

(2) Meet minimum requirements to contract with the Exchange as a qualified health plan pursuant to Section 1301 of the federal Patient Protection and Affordable Care Act (Public Law 111-148) and Sections 100502, 100503, and 100507 of this code.

(3) Enroll in the bridge plan product only individuals who meet the requirements of Section 14005.70 of the Welfare and Institutions Code.

(4) Comply with the medical loss ratio requirements of Section 1399.864 of the Health and Safety Code or Section 10961 of the Insurance Code.

(5) Demonstrate the bridge plan product has, at minimum, a substantially similar provider network as the Medi-Cal managed care plan offered by the health care service plan or health insurer.

(b) The Exchange shall provide information on all of the available Exchange-qualified health plans in the area, including, but not limited to, bridge plan product options for selection by individuals eligible to enroll in a bridge plan product.

(c) Nothing in this section shall be implemented in a manner that conflicts with a requirement of the federal act.

(d) This section shall become inoperative on the October 1 that is five years after the date that federal approval of the bridge plan option occurs, and, as of the second January 1 thereafter, is repealed, unless a later enacted statute that is enacted before that date deletes or extends the dates on which it becomes inoperative and is repealed.

history: (History: Added by Stats. 2013, 1st Ex. Sess., Ch. 5, Sec. 6. (SB 3 1x) Effective September 30, 2013. Conditionally inoperative, on date prescribed by its own provisions. Repealed, by its own provisions, on second January 1 after inoperative date.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) The Exchange shall have the authority to adopt regulations to implement the provisions of Section 100504.5. Prior to the adoption of regulations, the board and its staff shall meet the requirement of subdivision (t) of Section 100503 in implementing the bridge plan option. Until January 1, 2016, the adoption, amendment, or repeal of a regulation authorized by this section shall be exempted from the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).

(b) This section shall become inoperative on the October 1 that is five years after the date that federal approval of the bridge plan option occurs, and, as of the second January 1 thereafter, is repealed, unless a later enacted statute that is enacted before that date deletes or extends the dates on which it becomes inoperative and is repealed.

history: (History: Added by Stats. 2013, 1st Ex. Sess., Ch. 5, Sec. 7. (SB 3 1x) Effective September 30, 2013. Conditionally inoperative, on date prescribed by its own provisions. Repealed, by its own provisions, on second January 1 after inoperative date.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) The board shall establish and use a competitive process to select participating carriers and any other contractors under this title. Any contract entered into pursuant to this title shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services. The board shall adopt a Health Benefit Exchange Contracting Manual incorporating procurement and contracting policies and procedures that shall be followed by the Exchange. The policies and procedures in the manual shall be substantially similar to the provisions contained in the State Contracting Manual.

(b) The adoption, amendment, or repeal of a regulation by the board to implement this section, including the adoption of a manual pursuant to subdivision (a) and any procurement process conducted by the Exchange in accordance with the manual, is exempt from the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).

history: (History: Amended by Stats. 2015, Ch. 323, Sec. 6. (SB 102) Effective September 22, 2015.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) The board shall establish an appeals process for prospective and current enrollees of the Exchange that complies with all requirements of the federal act concerning the role of a state Exchange in facilitating federal appeals of Exchange-related determinations. Once the federal regulations concerning appeals have been issued in final form by the United States Secretary of Health and Human Services, the board may establish additional requirements related to appeals, provided that the board determines, prior to adoption, that any additional requirement results in no cost to the General Fund and no increase in the charge imposed under subdivision (n) of Section 100503.

(b) The board shall not be required to provide an appeal if the subject of the appeal is within the jurisdiction of the Department of Managed Health Care pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) and its implementing regulations, or within the jurisdiction of the Department of Insurance pursuant to the Insurance Code and its implementing regulations.

history: (History: Amended by Stats. 2019, Ch. 38, Sec. 4. (SB 78) Effective June 27, 2019.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
An applicant or enrollee has the right to appeal any of the following:

(a) Any action or inaction related to the individual’s eligibility for or enrollment in an insurance affordability program, or for advance payment of premium tax credits and cost-sharing reductions, or the amount of the advance payment of the premium tax credit and level of cost sharing, or eligibility for affordable plan options, or eligibility for state financial assistance, or the amount of the advanced premium assistance subsidy.

(b) An eligibility determination for an exemption from the individual responsibility penalty pursuant to Section 1311(d)(4)(H) of the federal act or an eligibility determination for an exemption from the Minimum Essential Coverage Individual Mandate, as specified in Section 100715.

(c) A failure to provide timely or adequate notice of an eligibility determination or redetermination or an enrollment-related determination.

history: (History: Amended by Stats. 2019, Ch. 38, Sec. 5. (SB 78) Effective June 27, 2019.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) The entity making an eligibility or enrollment determination described in Section 100506.1 shall provide notice of the appeals process at the time of application and at the time of eligibility or enrollment determination or redetermination.

(b) The entity making an eligibility or enrollment determination described in Section 100506.1 shall also issue a combined eligibility notice after the Director of Health Care Services determines in writing that the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) has been programmed for the implementation of this section, but no later than July 1, 2017. The combined eligibility notice shall contain all of the following:

(1) Information about eligibility or ineligibility for Medi-Cal, premium tax credits and cost-sharing reductions, state financial assistance, and, if applicable, for the Medi-Cal Access Program, for each individual, or multiple family members of a household, that has applied, including all of the following:

(A) An explanation of the action reflected in the notice, including the effective date of the action.

(B) Any factual bases upon which the decision is made.

(C) Citations to, or identification of, the legal authority supporting the action.

(D) Contact information for available customer service resources, including local legal aid and welfare rights offices.

(E) The effective date of eligibility and enrollment.

(2) Information regarding the bases of eligibility for non-modified adjusted gross income (MAGI) Medi-Cal and the benefits and services afforded to individuals eligible on those bases, sufficient to enable the individual to make an informed choice as to whether to appeal the eligibility determination or the date of enrollment, which may be included with the notice in a separate document.

(3) An explanation that the applicant or enrollee may appeal any action or inaction related to an individual’s eligibility for or enrollment in an insurance affordability program or state financial assistance with which the applicant or enrollee is dissatisfied by requesting a state fair hearing consistent with this title and the provisions of Chapter 7 (commencing with Section 10950) of Part 2 of Division 9 of the Welfare and Institutions Code.

(4) Information on the applicant or enrollee’s right to represent themselves or to be represented by legal counsel or an authorized representative as provided in subdivision (f) of Section 100506.4.

(5) An explanation of the circumstances under which the applicant’s or enrollee’s eligibility shall be maintained or reinstated pending an appeal decision, pursuant to Section 100506.5.

(c) This section shall be implemented only to the extent it does not conflict with federal law.

history: (History: Amended by Stats. 2019, Ch. 38, Sec. 6. (SB 78) Effective June 27, 2019.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) The board shall enter into a contract with the State Department of Social Services to serve as the Exchange appeals entity designated to hear appeals of eligibility or enrollment determination or redetermination for persons in the individual market, or exemption determinations within the Exchange’s jurisdiction. To the extent applicable, the provisions of this title, Subpart F of Part 155 of Title 45 of the Code of Federal Regulations, and Article 7 of Chapter 12 of Title 10 of the California Code of Regulations shall govern the Exchange hearing process. If those provisions are not applicable, the Medi-Cal hearing process established in Chapter 7 (commencing with Section 10950) of Part 2 of Division 9 of the Welfare and Institutions Code shall govern the Exchange hearing process.

(b) This section shall be implemented only to the extent it does not conflict with federal law.

history: (History: Added by Stats. 2014, Ch. 869, Sec. 4. (AB 617) Effective January 1, 2015.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) (1) Except as provided in paragraph (2), the State Department of Social Services, acting as the appeals entity, shall allow an applicant or enrollee to request an appeal within 90 days of the date of the notice of an eligibility or enrollment determination, or exemption determination within the Exchange’s jurisdiction, unless there is good cause as provided in Section 10951 of the Welfare and Institutions Code.

(2) The appeals entity shall establish and maintain a process for an applicant or enrollee to request an expedited appeals process where there is immediate need for health services because a standard appeal could seriously jeopardize the appellant’s life, health, or the ability to attain, maintain, or regain maximum function. If an expedited appeal is granted, the decision shall be issued as expeditiously as possible, but no later than five working days after the hearing, unless the appellant agrees to a delay to submit additional documents for the appeals record. If an expedited appeal is denied, the appeals entity shall notify the appellant within three days by telephone or through other commonly available secure electronic means, to be followed by a notice in writing, within five working days of the denial of an expedited appeal. If an expedited appeal is denied, the appeal shall be handled through the standard appeal process.

(b) Appeal requests may be submitted to the appeals entity by telephone, by mail, in person, through the internet, through other commonly available electronic means, or by facsimile.

(c) The staff of the Exchange, the county, or the State Department of Health Care Services or its designee shall assist the applicant or enrollee in making the appeal request.

(d) (1) Upon receipt of an appeal, the appeals entity shall send timely acknowledgment to the appellant that the appeal has been received. The acknowledgment shall include information relating to the appellant’s eligibility for benefits while the appeal is pending, an explanation that advance payments of the premium tax credit and advanced premium assistance subsidy while the appeal is pending may be subject to reconciliation if the appeal is unsuccessful, an explanation that the appellant may participate in informal resolution pursuant to subdivision (g), information regarding how to initiate informal resolution, and an explanation that the appellant shall have the opportunity to review the appellant’s entire eligibility file, including information on how an income determination was made and all papers, requests, documents, and relevant information in the possession of the entity that made the decision that is the subject of the appeal at any time from the date on which an appeal request is filed to the date on which the appeal decision is issued.

(2) Upon receipt of an appeal request, the appeals entity shall send, via secure electronic means, timely notice of the appeal to the Exchange and the county, and the State Department of Health Care Services or its designee if applicable.

(3) Upon receipt of the notice of appeal from the appeals entity, the entity that made the determination of eligibility or enrollment being appealed shall transmit, either as a hardcopy or electronically, the appellant’s eligibility and enrollment records for use in the adjudication of the appeal to the appeals entity.

(e) A member of the board, employee of the Exchange, a county, the State Department of Health Care Services or its designee, or the appeals entity shall not limit or interfere with an applicant’s or enrollee’s right to make an appeal or attempt to direct the individual’s decisions regarding the appeal.

(f) An applicant or enrollee may be represented by counsel or designate an authorized representative to act on the applicant’s or enrollee’s behalf, including, but not limited to, when making an appeal request and participating in the informal resolution process provided in subdivision (g).

(g) An applicant or enrollee who files an appeal shall have the opportunity for informal resolution, prior to a hearing, that conforms to all of the following:

(1) A representative of the entity that made the eligibility or enrollment determination shall contact the appellant or the appellant’s appropriately authorized representative and offer to discuss the determination with the appellant if the appellant agrees.

(2) The appellant’s right to a hearing shall be preserved if the appellant is dissatisfied with the outcome of the informal resolution process. The appellant or the authorized representative may withdraw the hearing request voluntarily or may agree to a conditional withdrawal that shall list the agreed-upon conditions that the appellant and the Exchange, county, or the State Department of Health Care Services or its designee shall meet.

(3) If the appeal advances to a hearing, the appellant shall not be required to provide duplicative information or documentation that the appellant previously provided during the application, redetermination, enrollment, or informal resolution processes.

(4) The informal resolution process shall not delay the timeline for a provision of a hearing.

(5) The informal resolution process is voluntary and neither an appellant’s participation nor nonparticipation in the informal resolution process shall affect the right to a hearing under this section.

(6) For eligibility or enrollment determinations for insurance affordability programs based on modified adjusted gross income (MAGI) or state financial assistance under Title 25, the appellant or the appellant’s appropriately authorized representative may initiate the informal resolution process with the entity that made the determination, except that all of the following shall apply:

(A) The Exchange shall conduct informal resolution involving issues related only to the Exchange, including, but not limited to, exemption from the individual responsibility penalty pursuant to Section 1311(d)(4)(H) of the federal act, offers of affordable employer coverage, special enrollment periods, and eligibility for affordable plan options.

(B) Counties shall conduct informal resolution involving issues related to non-MAGI Medi-Cal eligibility or enrollment decisions.

(C) The State Department of Health Care Services or its designee shall conduct informal resolution involving issues related to eligibility or enrollment determinations for programs when the State Department of Health Care Services is the entity making the determination.

(7) The staff involved in the informal resolution process shall try to resolve the issue through a review of case documents, in person or through electronic means as desired by the appellant, and shall give the appellant the opportunity to review case documents, verify the accuracy of submitted documents, and submit updated information or provide further explanation of previously submitted documents.

(8) The informal resolution process set forth by the State Department of Social Services for Medi-Cal fair hearings shall be used for the informal resolutions pursuant to this subdivision and shall require the Exchange, county representative, or the State Department of Health Care Services or its designee to do the following:

(A) Review the file to determine the appropriateness of the action and whether a hearing is needed.

(B) Attempt to resolve the matter if the action was incorrect.

(C) Determine whether a dual agency appeal is required to resolve the matter at hearing and notice the other agency if not already included.

(D) Determine whether interpretation services are necessary and arrange for those services accordingly.

(E) Inform appellants of other agencies that may also be available to resolve the controversy.

(h) (1) A position statement, as required by Section 10952.5 of the Welfare and Institutions Code, shall be made available at least two working days before the hearing on the appeal. The position statement shall be made available electronically by the entity that determined eligibility if the entity has the capacity to send information electronically in a secure manner.

(2) The appeals entity shall send written notice, electronically or in hard copy, to the appellant of the date, time, and location of the hearing no later than 15 days prior to the date of the hearing. If the date, time, and location of the hearing are prohibitive of participation by the appellant, the appeals entity shall make reasonable efforts to set a reasonable, mutually convenient date, time, and location. The notice shall explain what format the hearing shall be held in, via telephone or video conference or in person, and include the right of the appellant to request that the hearing be held via telephone or video conference or in person. The notice shall include instructions for submitting the request on the notice, by telephone or through other commonly available electronic means.

(3) The hearing format may be held via telephone or video conference, unless the appellant requests the hearing be held in person pursuant to paragraph (2).

(4) The hearing shall be an evidentiary hearing where the appellant may present evidence, bring witnesses, establish all relevant facts and circumstances, and question or refute any testimony or evidence, including, but not limited to, the opportunity to confront and cross-examine adverse witnesses, if any.

(5) The hearing shall be conducted by one or more impartial officials who have not been directly involved in the eligibility or enrollment determination or any prior appeal decision in the same matter.

(6) The appellant shall have the opportunity to review the appellant’s appeal record, case file, and all documents to be used by the appeals entity at the hearing, at a reasonable time before the date of the hearing as well as during the hearing.

(7) Cases and evidence shall be reviewed de novo by the appeals entity.

(i) Decisions shall be made within 90 days from the date the appeal is filed and shall be based exclusively on the application of the applicable laws and eligibility and enrollment rules to the information used to make the eligibility or enrollment decision, as well as any other information provided by the appellant during the course of the appeal. The content of the decision of appeal shall include a decision with a plain language description of the effect of the decision on the appellant’s eligibility or enrollment, a summary of the facts relevant to the appeal, an identification of the legal basis for the decision, and the effective date of the decision, which may be retroactive at the election of the appellant if the appellant is otherwise eligible.

(j) Upon adjudication of the appeal, the appeals entity shall transmit the decision of appeal to the entity that made the eligibility or enrollment determination via a secure electronic means.

(k) If an appellant disagrees with the decision of the appeals entity, the appellant may make an appeal request regarding coverage in a qualified health plan through the Exchange to the federal Department of Health and Human Services within 30 days of the notice of decision through any of the methods in subdivision (b).

(l) An appellant may also seek judicial review to the extent provided by law. Appeal to the federal Department of Health and Human Services is not a prerequisite for seeking judicial review, nor shall seeking an appeal to the federal Department of Health and Human Services preclude a judicial review.

(m) Upon final exhaustion of administrative or judicial review, whichever is later, that affects the amount of advance payment of the premium tax credit or the amount of advanced premium assistance subsidy, or both, for a taxable year that has been reconciled previously, the appellant shall file an amended return for that taxable year to reconcile the advanced premium assistance subsidy pursuant to subdivision (a) of Section 100810.

(n) Nothing in this section, or in Sections 100506.1 and 100506.2, shall limit or reduce an appellant’s rights to notice, hearing, and appeal under Medi-Cal, county indigent programs, or any other public programs.

(o) This section shall be implemented only to the extent it does not conflict with federal law.

history: (History: Amended by Stats. 2019, Ch. 38, Sec. 7. (SB 78) Effective June 27, 2019.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text: For appeals of redetermination of Exchange advance premium tax credits, cost-sharing reductions, or state financial assistance, upon receipt of notice from the appeals entity that it has received an appeal, the entity that made the redetermination shall continue to consider the applicant or enrollee eligible for the same level of advance premium tax credits, cost-sharing reductions, or state financial assistance while the appeal is pending in accordance with the level of eligibility immediately before the redetermination being appealed.

history: (History: Amended by Stats. 2019, Ch. 38, Sec. 8. (SB 78) Effective June 27, 2019.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) Notwithstanding any other provision of law, the Exchange shall not be subject to licensure or regulation by the Department of Insurance or the Department of Managed Health Care.

(b) Carriers that contract with the Exchange shall have a license or certificate of authority from, and shall be in good standing with, their respective regulatory agencies.

history: (History: Added by Stats. 2010, Ch. 655, Sec. 11. (AB 1602) Effective January 1, 2011.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) Notwithstanding subdivision (b), records of the Exchange that reveal either of the following shall be exempt from disclosure under the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1):

(1) The deliberative processes, discussions, communications, or any other portion of the negotiations with entities contracting or seeking to contract with the Exchange, entities with which the Exchange is considering a contract, or entities with which the Exchange is considering or enters into any other arrangement under which the Exchange provides, receives, or arranges services or reimbursement.

(2) Records that reveal claims data, encounter data, cost detail, information about payment methods, contracted rates paid by qualified health plans to providers, and enrollee coinsurance or other cost sharing that can be used to determine contracted rates paid by plans to providers.

(b) Subject to subdivision (a), the following records of the Exchange shall be exempt from disclosure under the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1) as follows:

(1) Contracts with participating carriers entered into pursuant to this title on or after October 1, 2013, shall be open to inspection one year after the effective dates of the contracts.

(2) If contracts with participating carriers entered into pursuant to this title are amended, the amendments shall be open to inspection one year after the effective date of the amendments.

(c) Notwithstanding any other law, entire contracts with participating carriers or amendments to contracts with participating carriers shall be open to inspection by the Joint Legislative Audit Committee. The committee shall maintain the confidentiality of the contracts and amendments until the contracts or amendments to a contract are open to inspection pursuant to subdivision (b).

history: (History: Amended by Stats. 2021, Ch. 615, Sec. 219. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) No individual or entity shall hold himself, herself, or itself out as representing, constituting, or otherwise providing services on behalf of the Exchange unless that individual or entity has a valid agreement with the Exchange to engage in those activities.

(b) Any individual or entity who aids or abets another individual or entity in violation of this section shall also be in violation of this section.

history: (History: Added by Stats. 2012, Ch. 876, Sec. 1. (AB 1761) Effective January 1, 2013.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) The California Health Trust Fund is hereby created in the State Treasury for the purpose of this title, Title 24 (commencing with Section 100700), and Title 25 (commencing with Section 100800). Notwithstanding Section 13340, all moneys in the fund shall be continuously appropriated without regard to fiscal year for the purposes of this title, Title 24 (commencing with Section 100700), and Title 25 (commencing with Section 100800). Any moneys in the fund that are unexpended or unencumbered at the end of a fiscal year may be carried forward to the next succeeding fiscal year.

(b) Notwithstanding any other provision of law, moneys deposited in the fund shall not be loaned to, or borrowed by, any other special fund or the General Fund, or a county general fund or any other county fund.

(c) To the extent permitted by federal law, moneys deposited in the Federal Trust Fund established pursuant to Section 16360 may be transferred to the California Health Trust Fund if the money is made available by the United States federal government for expenditure by the state for purposes consistent with the implementation of this section.

(d) The board of the California Health Benefit Exchange shall establish and maintain a prudent reserve in the fund.

(e) The board or staff of the Exchange shall not utilize any funds intended for the administrative and operational expenses of the Exchange for staff retreats, promotional giveaways, excessive executive compensation, or promotion of federal or state legislative or regulatory modifications.

(f) Notwithstanding Section 16305.7, all interest earned on the moneys that have been deposited into the fund shall be retained in the fund and used for purposes consistent with the fund.

(g) Effective January 1, 2016, if at the end of any fiscal year, the fund has unencumbered funds in an amount that equals or is more than the board approved operating budget of the Exchange for the next fiscal year, the board shall reduce the charges imposed under subdivision (n) of Section 100503 during the following fiscal year in an amount that will reduce any surplus funds of the Exchange to an amount that is equal to the agency’s operating budget for the next fiscal year.

(h) Notwithstanding subdivision (a), moneys in the fund shall not be used to fund the minimum essential coverage individual mandate pursuant to Title 24 (commencing with Section 100700) or the financial assistance program authorized pursuant to Title 25 (commencing with Section 100800), except for the Exchange’s operational costs necessary to administer the individual mandate and financial assistance program.

(i) The Legislature finds and declares that the Exchange’s operations of the programs in Title 24 (commencing with Section 100700) and Title 25 (commencing with Section 100800) are necessary and directly related to furthering the Exchange’s purposes pursuant to this title and the federal act.

history: (History: Amended by Stats. 2022, Ch. 738, Sec. 1. (AB 204) Effective September 29, 2022.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) The Health Care Affordability Reserve Fund is hereby created in the State Treasury.

(b) Notwithstanding any other law, the Controller may use the funds in the Health Care Affordability Reserve Fund for cashflow loans to the General Fund as provided in Sections 16310 and 16381.

(c) Upon the enactment of the Budget Act of 2021, and upon order of the Director of Finance, the Controller shall transfer three hundred thirty-three million four hundred thirty-nine thousand dollars ($333,439,000) from the General Fund to the Health Care Affordability Reserve Fund.

(d) Upon appropriation by the Legislature, the Health Care Affordability Reserve Fund shall be utilized, in addition to any other appropriations made by the Legislature for the same purpose, for the purpose of health care affordability programs, benefit programs pursuant to Section 100503.6, and payments authorized pursuant to Section 100503.5, operated by the California Health Benefit Exchange.

(e) (1) The California Health Benefit Exchange shall, in consultation with stakeholders and the Legislature, develop options for providing cost sharing reduction subsidies to reduce cost sharing for low- and middle-income Californians. On or before January 1, 2022, the Exchange shall report those developed options to the Legislature, Governor, and the Healthy California for All Commission, established pursuant to Section 1001 of the Health and Safety Code, for consideration in the 2022–23 budget process.

(2) In developing the options, the Exchange shall do all of the following:

(A) Include options for all Covered California enrollees with income up to 400 percent of the federal poverty level to reduce cost sharing, including copays, deductibles, coinsurance, and maximum out-of-pocket costs.

(B) Include options to provide zero deductibles for all Covered California enrollees with income under 400 percent of the federal poverty level and upgrading those with income between 200 percent and 400 percent, inclusive, of the federal poverty level to gold-tier cost sharing.

(C) Address any operational issues that might impede implementation of enhanced cost-sharing reductions for the 2023 calendar year.

(D) Maximize federal funding and address interactions with federal law regarding federal cost-sharing reduction subsidies.

(3) The Exchange shall make the report publicly available on its internet website.

(4) The Exchange shall submit the report in compliance with Section 9795 of the Government Code.

(f) Upon order of the Department of Finance, a loan of six hundred million dollars ($600,000,000) is authorized from the Health Care Affordability Reserve Fund to the General Fund in the 2023–24 fiscal year. The loan shall be repaid in annual installments of two hundred million dollars ($200,000,000) over the 2026–27, 2027–28, and 2028–29 fiscal years.

history: (History: Amended by Stats. 2026, Ch. 27, Sec. 6. (SB 164) Effective June 29, 2026.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) The board shall ensure that the establishment, operation, and administrative functions of the Exchange do not exceed the combination of federal funds, private donations, and other non-General Fund moneys available for this purpose. No state General Fund moneys shall be used for any purpose under this title without a subsequent appropriation. No liability incurred by the Exchange or any of its officers or employees may be satisfied using moneys from the General Fund.

(b) The implementation of the provisions of this title, other than this section, Section 100500, and paragraphs (4) and (5) of subdivision (a) of Section 100504, shall be contingent on a determination by the board that sufficient financial resources exist or will exist in the fund. The determination shall be based on at least the following:

(1) Financial projections identifying that sufficient resources exist or will exist in the fund to implement the Exchange.

(2) A comparison of the projected resources available to support the Exchange and the projected costs of activities required by this title.

(3) The financial projections demonstrate the sufficiency of resources for at least the first two years of operation under this title.

(c) The board shall provide notice to the Joint Legislative Budget Committee and the Director of Finance that sufficient financial resources exist in the fund to implement this title.

(d) If the board determines that the level of resources in the fund cannot support the actions and responsibilities described in subdivision (a), it shall provide the Department of Finance and the Joint Legislative Budget Committee a detailed report on the changes to the functions, contracts, or staffing necessary to address the fiscal deficiency along with any contingency plan should it be impossible to operate the Exchange without the use of General Fund moneys.

(e) The board shall assess the impact of the Exchange’s operations and policies on other publicly funded health programs administered by the state and the impact of publicly funded health programs administered by the state on the Exchange’s operations and policies. This assessment shall include, at a minimum, an analysis of potential cost shifts or cost increases in other programs that may be due to Exchange policies or operations. The assessment shall be completed on at least an annual basis and submitted to the Secretary of California Health and Human Services and the Director of Finance.

history: (History: Amended by Stats. 2011, Ch. 296, Sec. 136. (AB 1023) Effective January 1, 2012.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) (1) The Exchange shall apply to the United States Department of Health and Human Services for a waiver authorized under Section 1332 of the federal act as defined in subdivision (e) of Section 100501 in order to allow persons otherwise not able to obtain coverage by reason of immigration status through the Exchange to obtain coverage from the Exchange by waiving the requirement that the Exchange offer only qualified health plans solely for the purpose of offering coverage to persons otherwise not able to obtain coverage by reason of immigration status.

(2) The waiver of the requirement that the Exchange offer only qualified health plans as described in paragraph (1) shall be limited to requiring the Exchange to offer California qualified health plans consistent with this section only and shall not be construed to authorize the Exchange to offer any other nonqualified health plan.

(b) The Exchange shall require an issuer that offers a qualified health plan in the individual market through the Exchange to concurrently offer a California qualified health plan that meets all of the following criteria:

(1) Is subject to the requirements of this title, including all of those requirements applicable to qualified health plans.

(2) Is subject to the requirements of subdivisions (a), (b), and (d) of Section 1366.6 of the Health and Safety Code and subdivisions (a), (b), and (d) of Section 10112.3 of the Insurance Code in the same manner as qualified health plans.

(3) Is identical to the corresponding qualified health plan, except for the eligibility requirements set forth in subdivision (c).

(c) Persons eligible to purchase California qualified health plans shall pay the cost of coverage and shall not:

(1) Be eligible to receive federal advanced premium tax credit, federal cost-sharing reduction, or any other federal assistance for the payment of premiums or cost sharing for a California qualified health plan.

(2) Otherwise be eligible for enrollment in a qualified health plan offered through the Exchange by reason of immigration status.

(d) An applicant for coverage under this section shall be required to provide only the information strictly necessary to authenticate identity and determine eligibility under this section. Any person who receives information provided by an applicant under this section, whether directly or by another person at the request of the applicant, or receives information from any agency, shall use the information only for the purposes of, and to the extent necessary for, ensuring the efficient operation of the Exchange, including verifying the eligibility of an individual to enroll through the Exchange. That information shall not be disclosed to any other person except as provided in this section.

(e) Subdivisions (b) to (d), inclusive, shall become operative on January 1, 2018, for coverage effective for California qualified health plans beginning January 1, 2019, contingent upon federal approval of the waiver pursuant to subdivision (a).

history: (History: Added by Stats. 2016, Ch. 22, Sec. 1. (SB 10) Effective June 10, 2016.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
(a) Beginning July 1, 2023, the Exchange shall administer a program of financial assistance to help Californians obtain and maintain health benefits through the Exchange if they lose their employer-provided health care coverage as a result of a labor dispute.

(1) An individual who has lost minimum essential coverage from an employer or joint labor management trust fund as a result of a strike, lockout, or labor dispute is a qualified individual for purposes of financial assistance, including premium assistance and cost-sharing reduction subsidies, provided that the individual meets all eligibility requirements specified in Section 36B of the Internal Revenue Code and Section 18071 of Title 42 of the United States Code, except for the income requirements of those sections. Any household income of the qualified individual above 138.1 percent of the federal poverty level for a family of the qualified individual’s size shall not be taken into account for the qualified individual and the members of their tax household. Consistent with existing federal law and rules, an individual shall be screened for eligibility for the federal Medicaid program.

(2) An individual described in paragraph (1) shall receive subsidies for health insurance premiums and cost-sharing reductions that provide the same assistance that is provided to other individuals with household incomes of 138.1 percent of the federal poverty level who qualify for financial assistance through the Exchange. The cost-sharing reductions shall use a standard benefit design that has an actuarial value of 94 percent or greater, and, effective January 1, 2024, the program design shall have zero deductibles for any covered benefit if the standard benefit design for this income has zero deductibles.

(3) An individual shall be a qualified individual for purposes of financial assistance, including premium assistance and cost-sharing reduction subsidies, under this section if all of the following are met:

(A) The individual loses minimum essential coverage from an employer as a result of a strike, lockout, or labor dispute.

(B) The employer that provided the minimum essential coverage to the individual is involved in the strike, lockout, or labor dispute.

(C) The individual provides a self-attestation confirming that they lost minimum essential coverage from an employer as a result of a strike, lockout, or labor dispute, and that the employer that provided them the minimum essential coverage is involved in the strike, lockout, or labor dispute.

(4) If further documentation is required, the Exchange shall contact the affected collective bargaining agent and may contact the employer.

(b) Notwithstanding Sections 1399.848 and 1399.849 of the Health and Safety Code, and Sections 10965.3 and 10965.4 of the Insurance Code, the effective date of coverage shall be the first day of the month of application submission and plan selection or the first day of the following month, at the discretion of the qualified individual.

(c) (1) The Exchange, on a monthly basis, shall notify an enrollee receiving financial assistance pursuant to this section that the enrollee is required to notify the Exchange if their household income changes or minimum essential coverage provided by the enrollee’s employer is reinstated. The notice shall include information on the potential state and federal income tax consequences of any amount received as a subsidy provided under this section.

(2) Upon resolution of a strike, lockout, or labor dispute, an individual shall no longer be eligible for financial assistance under this section when the Exchange verifies that employer-provided minimum essential coverage from the employer has been reinstated for that individual and dependents and only after prior notification to the qualified individual of loss of financial assistance under this section.

(d) An employer or labor organization shall notify the Exchange before employer-provided coverage is affected by a strike, lockout, or labor dispute pursuant to a process established by the Exchange. The Exchange may contact an employer, labor organization, or other appropriate representative to determine the status of a strike, lockout, or labor dispute, its impact to coverage, and any other information necessary to determine eligibility for financial assistance under this section.

(e) (1) The Exchange shall maximize federal affordability assistance for an individual enrolled pursuant to this section and shall use state affordability assistance funds for financial assistance not otherwise available under federal law.

(2) Financial assistance provided pursuant to this section shall be funded upon appropriation by the Legislature.

(f) Gross income, as defined in Section 17071 of the Revenue and Taxation Code, does not include any amount received as a state subsidy provided under this section.

(g) The following definitions apply for purposes of this section:

(1) “Employer-provided coverage” means coverage provided by an employer, a “multiemployer health plan,” as defined in Section 1002(37)(A) of Title 29 of the United States Code, or a joint labor-management trust.

(2) “Labor dispute” has the same meaning as set forth in clauses (i), (ii), and (iii) of paragraph (4) of subdivision (b) of Section 527.3 of the Code of Civil Procedure.

(3) “Labor organization” has the same meaning as defined in Section 1117 of the Labor Code.

(4) “Lockout” has the same meaning as defined in Section 1132.8 of the Labor Code.

(5) “Strike” has the same meaning as defined in Section 1132.6 of the Labor Code.

history: (History: Amended by Stats. 2024, Ch. 841, Sec. 1. (AB 2749) Effective January 1, 2025.)

title: 22. CALIFORNIA HEALTH BENEFIT EXCHANGE


text:
The Legislature finds and declares all of the following:

(a) The individual mandate imposed by this title, and the penalty imposed by Part 32 (commencing with Section 61000) of the Revenue and Taxation Code, are necessary to protect the compelling state interests of:

(1) Protecting the health and welfare of the state’s residents.

(2) Ensuring access to affordable health care coverage in this state.

(3) Ensuring a stable and well-functioning health insurance market in this state.

(b) There is compelling evidence that, without an effective mandate on individuals to secure health coverage, there would be substantial instability in health insurance markets, including higher prices and the possibility of areas without any insurance available.

(c) Ensuring the health of insurance markets is a responsibility reserved for states under the federal McCarran-Ferguson Act (15 U.S.C. Sec. 1011 et seq.) and other federal law.

history: (History: Added by Stats. 2019, Ch. 38, Sec. 10. (SB 78) Effective June 27, 2019.)

title: 24. MINIMUM ESSENTIAL COVERAGE INDIVIDUAL MANDATE


text:
(a) For each month beginning on or after January 1, 2020, a California resident shall be enrolled in and maintain minimum essential coverage for that month, except as provided in subdivision (c).

(b) For each month beginning on or after January 1, 2020, a California resident shall ensure and maintain minimum essential coverage for any person who qualifies as that California resident’s applicable spouse or applicable dependent, except as provided in subdivision (c).

(c) The following individuals shall be exempt, with respect to any month, from the requirements imposed by subdivisions (a) and (b):

(1) An individual who has in effect a certificate of exemption for hardship or religious conscience issued by the Exchange under Section 100715 for that month.

(2) An individual who is a member of a health care sharing ministry for that month. “Health care sharing ministry” has the same meaning as the term was defined in Section 5000A(d)(2)(B) of the Internal Revenue Code on January 1, 2017.

(3) An individual who is incarcerated for that month, other than incarceration pending the disposition of charges.

(4) An individual who is not a citizen or national of the United States and is not lawfully present in the United States for that month.

(5) An individual who is a member of an Indian tribe, as defined in Section 45A(c)(6) of the Internal Revenue Code of 1986, during that month.

(6) An individual for whom that month occurs during a period described in subparagraph (A) or (B) of Section 911(d)(1) of the Internal Revenue Code of 1986 that is applicable to the individual.

(7) An individual who is a bona fide resident of a possession of the United States, as determined under Section 937(a) of the Internal Revenue Code of 1986, for that month.

(8) An individual who is a bona fide resident of another state for that month.

(9) An individual who is enrolled in limited or restricted scope coverage under the Medi-Cal program or another health care coverage program administered by and determined to be substantially similar to limited or restricted scope coverage by the State Department of Health Care Services for that month.

(d) The requirements of subdivisions (a) and (b) shall be referred to as the Minimum Essential Coverage Individual Mandate.

(e) An Individual Shared Responsibility Penalty shall be imposed for failure to meet the requirement of the Minimum Essential Coverage Individual Mandate pursuant to Part 32 (commencing with Section 61000) of the Revenue and Taxation Code.

path: 24. MINIMUM ESSENTIAL COVERAGE INDIVIDUAL MANDATE


text:
For the purposes of this title, the following definitions shall apply:

(a) “Applicable dependent” means a dependent, with respect to an applicable individual, who meets all of the following criteria:

(1) The dependent is an applicable individual.

(2) The dependent is generally eligible for enrollment for health care coverage purposes, including, but not limited to, because of the applicable individual’s employment status or status as the head of household, parent, spouse, or domestic partner.

(3) With respect to a given month, the dependent is not covered by other minimum essential coverage for that month.

(b) “Applicable individual” means, with respect to any month, an individual who is subject to the Minimum Essential Coverage Individual Mandate, pursuant to Section 100705.

(c) “Applicable spouse” means a spouse or domestic partner of an applicable individual who meets all of the following criteria:

(1) The spouse or domestic partner is an applicable individual.

(2) The spouse or domestic partner is generally eligible for enrollment for health care coverage purposes, including, but not limited to, because of the applicable individual’s employment status or status as the head of household, parent, spouse, or domestic partner.

(3) With respect to a given month, the spouse or domestic partner is not covered by other minimum essential coverage for that month.

(4) The spouse or domestic partner files a joint return with the individual under Chapter 2 (commencing with Section 18501) of Part 10.2 of the Revenue and Taxation Code.

(d) “California resident” has the same meaning as in Section 17014 of the Revenue and Taxation Code.

(e) “Dependent” has the same meaning as in Section 17056 of the Revenue and Taxation Code.

(f) “Exchange” means the California Health Benefit Exchange, also known as Covered California, established pursuant to Title 22 (commencing with Section 100500).

(g) “Minimum essential coverage” has the same meaning as defined in Section 1345.5 of the Health and Safety Code.


text:
(a) The Exchange shall grant an exemption for reason of hardship from the Minimum Essential Coverage Individual Mandate established in Section 100705 for a given month upon determining that an individual has suffered a hardship with respect to the capability to obtain minimum essential coverage.

(b) The Exchange shall grant an exemption for reason of religious conscience from the Minimum Essential Coverage Individual Mandate established in Section 100705 for a given month upon determining that an individual for that month is either of the following:

(1) A member of a recognized religious sect or division thereof, as described in Section 1402(g)(1) of the Internal Revenue Code of 1986, and is an adherent of established tenets or teachings of that sect or division.

(2) A member of a religious sect or division thereof that is not described in Section 1402(g)(1) of the Internal Revenue Code of 1986, who relies solely on a religious method of healing, for whom 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. An individual who claims this exemption, but received medical health services during the coverage year, shall lose eligibility for the religious conscience exemption, is liable for the cost of the care, and is liable for the Individual Shared Responsibility Penalty.

(c) The Exchange shall establish a process for determining whether an individual is entitled to an exemption pursuant to subdivisions (a) and (b), issuing a certificate of exemption to an individual, and notifying the individual and the Franchise Tax Board of the determination in a time and manner as the Exchange, in consultation with the Franchise Tax Board, determines is feasible and prompt. The Exchange may contract with a third party or another entity, including a state or federal agency, to administer this section.


text:
(a) In addition to the efforts required by subdivision (b) and any other outreach and enrollment efforts required by law, the Exchange shall annually conduct outreach and enrollment efforts to individuals who did not indicate on their individual income tax returns that they and their dependents were enrolled in and maintained minimum essential coverage for the preceding taxable year or who indicated that they or their dependents were exempt from the Minimum Essential Coverage Individual Mandate for that year.

(b) In addition to the efforts required by subdivision (a) and any other outreach and enrollment efforts required by law, the Exchange shall annually conduct outreach and enrollment efforts to individuals who indicate on their individual income tax returns that they are interested in no-cost or low-cost health care coverage by checking the box required pursuant to Section 18543 of the Revenue and Taxation Code.

(c) For purposes of the efforts required by subdivisions (a) and (b), the Franchise Tax Board shall provide the Exchange with individual income tax return information, as authorized by Sections 19548.8 and 19548.9 of the Revenue and Taxation Code, in a form and manner determined by the Franchise Tax Board, in consultation with the Exchange.

history: (History: Amended by Stats. 2022, Ch. 170, Sec. 1. (SB 967) Effective January 1, 2023.)


text:
(a) The Exchange may, in consultation with the Franchise Tax Board, promulgate rules and regulations to implement this title.

(b) The Franchise Tax Board may, in consultation with the Exchange, promulgate rules and regulations to implement this title to the extent that those regulations do not conflict with regulations promulgated by the Exchange pursuant to subdivision (a).

(c) Until January 1, 2022, any rules and regulations necessary to implement this title may be adopted as emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2). The adoption of emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2, including subdivisions (e) and (h) of Section 11346.1, an emergency regulation adopted pursuant to this section shall be repealed by operation of law unless the adoption, amendment, or repeal of the regulation is promulgated by the board pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 within five years of the initial adoption of the emergency regulation. An emergency regulation adopted pursuant to this section shall be discussed by the board during at least one properly noticed board meeting before the board meeting at which the board adopts the regulation. Notwithstanding subdivision (h) of Section 11346.1, until January 1, 2027, the Office of Administrative Law may approve more than two readoptions of an emergency regulation adopted pursuant to this section.

(d) It is the intent of the Legislature that, in construing this title, the regulations promulgated under Section 5000A of the Internal Revenue Code as of December 15, 2017, shall apply to the extent that those regulations do not conflict with this title or regulations promulgated pursuant to subdivision (a) or (b).


text:
(a) The Exchange shall administer a program of financial assistance to help low-income and middle-income Californians access affordable health care coverage through the Exchange.

(b) The program may provide financial assistance to California residents with household incomes at or below 600 percent of the federal poverty level, and may provide other appropriate subsidies designed to make health care coverage more accessible and affordable for individuals and households.

(c) Upon appropriation by the Legislature, the Exchange shall adopt, and may amend, an annual program design for each coverage year to implement this section by resolution of the board of the Exchange. The resolution shall be adopted at a duly noticed meeting.

(1) A resolution adopted pursuant to this section shall not take effect until 10 days after notification in writing to the Joint Legislative Budget Committee.

(2) The requirements of paragraph (1) may be waived by the written consent of the Chair of the Joint Legislative Budget Committee to adopt a resolution that is deemed urgent. A resolution adopted pursuant to this paragraph shall take immediate effect.

(3) The Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) shall not apply to the program design or a resolution adopted pursuant to this section.

(d) The program design adopted for a coverage year shall be based on funds appropriated to the program for that coverage year. An appropriation made for the program shall contain provisional language directing the Exchange to provide a certain proportion of the funds to specified income ranges as determined by the Legislature and may provide other parameters guiding the design of the program.

(1) Pursuant to the Budget Act of 2023, the program shall be funded at an amount up to eighty-two million five hundred thousand dollars ($82,500,000) for coverage year 2024.

(2) It is the intent of the Legislature, beginning in the 2024–25 fiscal year, to appropriate up to one hundred sixty-five million dollars ($165,000,000) in the annual Budget Act to the program for each coverage year of the program after coverage year 2024.

(e) The Exchange shall provide appropriate opportunities for stakeholders and the public to consult in the design of the program.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 10. (AB 118) Effective July 10, 2023.)

title: 25. INDIVIDUAL MARKET ASSISTANCE

path: 25. INDIVIDUAL MARKET ASSISTANCE


text:
(a) A premium assistance subsidy provided by the program shall be able to be advanced to program participants and shall be remitted by the Exchange to a qualified health plan issuer, based on the program participant’s projected household income, family size, and other factors determined pursuant to the program design and subject to reconciliation against actual household income, family size, and other factors determined pursuant to the program design as provided in Section 100810.

(b) A premium assistance subsidy provided by the program shall be provided only to a California resident who is eligible for the federal premium tax credit authorized under Section 36B of the Internal Revenue Code, except that premium assistance subsidy shall not be subject to the income requirements of that section.

(c) Gross income, as defined in Section 17071 of the Revenue and Taxation Code, does not include an amount received as a premium assistance subsidy provided by the program.

history: (History: Added by Stats. 2019, Ch. 38, Sec. 11. (SB 78) Effective June 27, 2019.)

title: 25. INDIVIDUAL MARKET ASSISTANCE


text:
(a) A responsible individual shall reconcile premium assistance subsidies advanced pursuant to subdivision (a) of Section 100805 to the responsible individual or the responsible individual’s dependents with the premium assistance subsidies allowed based on actual household income, family size, and other factors determined pursuant to the program design for a coverage year during which the responsible individual or the responsible individual’s dependents received an advanced premium assistance subsidy, as follows:

(1) If a program participant’s allowed premium assistance subsidies for the taxable year exceed the program participant’s advanced premium assistance subsidies, the program participant may receive the excess as a premium assistance subsidy reconciliation refund. The Franchise Tax Board shall remit the refund to the program participant, less any taxes, fees, and penalties the program participant owes to the state. If a program participant is a dependent, the Franchise Tax Board shall remit the refund to the responsible individual, less any taxes, fees, and penalties the responsible individual or program participant owes to the state.

(2) If a program participant’s advanced premium assistance subsidies for the taxable year exceed the program participant’s allowed premium assistance subsidies, the program participant shall have a liability in the amount equal to the excess of the advanced premium assistance subsidies over the program participant’s allowed premium assistance subsidies as a reconciliation liability, up to a limit specified by the program design. The program design may vary that limit based on household income.

(3) The responsible individual shall reconcile premium assistance subsidies in accordance with this section, and shall include the liability imposed by this section or the premium assistance subsidy reconciliation refund on a return filed pursuant to Chapter 2 (commencing with Section 18501) of Part 10.2 of the Revenue and Taxation Code for the taxable year.

(4) If a program participant with a liability imposed by this section is a dependent, the responsible individual shall be solely liable for that liability of the dependent.

(5) If a responsible individual with a liability imposed by this section files a joint return for the taxable year, the responsible individual and the spouse or domestic partner of the responsible individual shall be jointly and severally liable for that liability.

(6) Notwithstanding the return filing thresholds requirements in Chapter 2 (commencing with Section 18501) of Part 10.2 of the Revenue and Taxation Code, a responsible individual shall file a California income tax return with the Franchise Tax Board for the purpose of reconciliation as required under this section.

(b) The Franchise Tax Board’s civil authority and procedures for purposes of compliance with notice and other due process requirements imposed by law to collect income taxes shall be applicable to the collection of the premium assistance subsidy reconciliation liability due pursuant to subdivision (a). The amount due shall be paid upon notice and demand by the Franchise Tax Board and shall be assessed and collected pursuant to Part 10.2 (commencing with Section 18401) of the Revenue and Taxation Code.

(c) The Franchise Tax Board shall integrate enforcement of the liability imposed pursuant to subdivision (a) into existing activities, protocols, and procedures, including audits, enforcement actions, and taxpayer education efforts.

title: 25. INDIVIDUAL MARKET ASSISTANCE


text:
For purposes of this title:

(a) “Coverage year” means a calendar year in which a program participant, or the program participant’s spouse, domestic partner, or dependent, received financial assistance pursuant to this title.

(b) “Dependent” means a dependent, as defined in Section 17056 of the Revenue and Taxation Code

(c) “Exchange” means the California Health Benefit Exchange, also known as Covered California, established pursuant to Title 22 (commencing with Section 100500).

(d) “Family size” shall be defined in the program design adopted pursuant to Section 100800.

(e) “Federal poverty level” shall be defined in the program design adopted pursuant to Section 100800.

(f) “Household income” shall be defined in the program design adopted pursuant to Section 100800.

(g) “Modified adjusted gross income” shall be defined in the program design adopted pursuant to Section 100800.

(h) “Program” means Individual Market Assistance established pursuant to Section 100800.

(i) “Program participant” means an individual eligible to receive financial assistance pursuant to this title.

(j) “Qualified health plan” has the same meaning as defined in Section 1301 of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).

(k) “Responsible individual” means a program participant or an individual with a dependent who is a program participant. With respect to a dependent, “responsible individual” means the individual who claims the dependent as a dependent.

(l) With respect to a program participant’s household income or size:

(1) “Actual” means the household income or family size determined to have applied for the coverage year in accordance with the program design adopted pursuant to Section 100800.

(2) “Projected” means the household income or family size projected for the coverage year in accordance with the program design adopted pursuant to Section 100800.

title: 25. INDIVIDUAL MARKET ASSISTANCE


text:
(a) The Exchange may, in consultation with the Franchise Tax Board, promulgate rules and regulations as necessary to implement this title that are consistent with the program design adopted pursuant to Section 100800.

(b) The Franchise Tax Board may, in consultation with the Exchange, adopt regulations that are necessary and appropriate to implement Section 100810 and that are consistent with the program design adopted pursuant to Section 100800 and regulations adopted by the Exchange pursuant to this section.

(c) The Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) shall not apply to a regulation, standard, criterion, procedure, determination, rule, notice, guideline, or any other guidance established or issued by the Exchange or Franchise Tax Board pursuant to this title.

(d) In construing this title, the regulations promulgated by the Exchange under Title 10 of the California Code of Regulations shall apply to the extent that those regulations do not conflict with this title, the program design adopted pursuant to Section 100800, regulations promulgated by the Exchange pursuant to this section, and regulations promulgated by the Franchise Tax Board pursuant to this section.

(e) It is the intent of the Legislature that, in construing this title, the regulations promulgated under Section 36B of the Internal Revenue Code shall apply to the extent that those regulations do not conflict with this title or regulations promulgated by the Exchange pursuant to subdivision (a) or Franchise Tax Board pursuant to subdivision (b).

history: (History: Amended by Stats. 2022, Ch. 47, Sec. 5. (SB 184) Effective June 30, 2022.)

title: 25. INDIVIDUAL MARKET ASSISTANCE


text: This title shall not be construed to create an entitlement program of any kind, to appropriate any funds, to require the Legislature to appropriate any funds, or to increase or decrease taxes owed by a taxpayer.

history: (History: Amended by Stats. 2022, Ch. 47, Sec. 6. (SB 184) Effective June 30, 2022.)

title: 25. INDIVIDUAL MARKET ASSISTANCE


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title: GENERAL

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