(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, 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 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 himself or herself 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.
(Added by Stats. 2014, Ch. 869, Sec. 3. (AB 617) Effective January 1, 2015.)
Last modified: October 8, 2018